WB 100 G677a 1885 ^ 32230410R n iiiniii h mi m uni mil m t 3noi<33w do Aavagn ivnouvn N snoiosw do Aavagn ivnouvn 3NOia3w do Aav NLM051515797 \f\i&S NOiasw do Aavagn ivnouvn 3NOiaaw do Aavaan ivnouvn 3NIDIQ3W do Aavagn tvnoiiv V\ I /ViV\ THE AMERICAN PRACTICE OF MEDICINE. INCLUDING THE DISEASES OF WOMEN AND CHILDEEN. BASED UPON THE PATHOLOGICAL INDICATION OF THE REMEDIES ADVISED. BT , I. jrMrGOSS, A.M., M.D., // / PROFESSOR OF THE PRACTICE OF MEDICINE IN THE ECLECTIC MEDICAL COLLEGE / OF GA., AUTHOR OF MATERIA MEDICA AND THERAPEUTICS ; / NEW REMEDIES, ETC. U Magna est Veritas et prevalebit ! SECOKH EDTTIQK PHIL ACKLPHIA :" SAMUEL M. MILLER, M.D., MEDICAL PUBLISHER. 1885- Ow 1 66 G-iVï7î DEDICATIOK To my associâtes, and students, and ail lovers of "Scientific Medicine," this volume is respectfuUy dedicated by o The Author. n D COPYRIGHT SECURED. SAMUEL M. MILLEB, M.D., Pbiladelphia, Pa., 1885. A HAND BOOK OF TREATMENT. 15th Edition, 8vo. 740 pages. 20,000 COPIES SOLD. Priée, in cloth 4$; m sheep.85; in Full Russia, 85.50. " I would not part with your Hand-Book of Treatment for any price. It has been of in- estimable value to me." H. M. Kaigler, M.D., Georgetown, Ga, The Hand-Book of Treatment CONTAINS Masterly Papers on DIPHTHERIA BY Roberts Bartholow, Ahraham Jacobi, J. Solis Cohen. 800 Oiseases. 600 Formula. TEE AUTHORS OF THE Hand-Book of Treatment A.BB Alonzo Clark, J. Lewis Smith, J. M. DaCosta, Wm. Goouell, S. Weir Mitchell, Fordvce Barker, Samuel D. Gross, Wm. Hammond, Richard J. Levis, Alfred Loomis, Horatio C. Wood, Austin Flint, Lewis A. Sayre, Alfred Stille, 1). Hayes Aguew, Francis Lelafîeld, Fes.seixlen N. Otis, E. C. Seguin, Samuel W. Gros>s, Montrose Fallen, Wm. Van Buren, E. L. Keyes, K. A. F. Penrose, J. H. Hutchinson, J. Forsyth Meigs, Joseph A. Howe, Henry G. Pirhird, Wm. Pepper, Geo. Straw bridge, Thos. G. Morton, Frank Hamilion, D. B. St. J. Roosa, Ellerslie Wullace, J. Solis Cohen, Wm. Thomson, Alfred Post, The Treatment ol THE FEVERS, BY Alonzo Clark, William Pepper, Austin Flint, Alfred Lomis, J. M. DaCosta, The Treatment ol FRACTURES. BY F. H. Hamllton, 1). Hayes Agnew, Lewis A. Sayre, Richard J. Levis, Thos. G. Morton, The Treatment ot HERV0US OISEASES BY S. Wier Mitchell, E. C. Seguin, A. Met'. Hamilton H. C. Wood, Wm. Hammond. The Treatment ol DISEASE OF WOMEN BY Fordyce Barker, William Goodell, T. G. Thomas, R. A. F. Penrose, A. J.C. Skene. " You give me better value for money sent you than any other firm with whom I hâve dealt." W. J. Gibson, M. D., Belleville, Ont PREFACE. When I was elected several years ago to the chair which I now occupy, I could find no work on the Theory and Practice of Medicine or Spécial Therapeutics, which gave the pathological indications for remédies, except those written by Homœopaths. I hâve therefore been induced to attempt the préparation of a work with spécial référence to that much needed feature ; and I leave it to the reading physican to décide how well or how poorly I hâve succeeded in this particular réquisition. I claim nothing new in pathology. I acknowledge my indebted- ness to the récent works of Raue, Green, Virchow, Vogel, liasse, Simon, Bamberger, Niemeyer, Wagner, Koch, Skoda, Hebra, Haie, Da Costa, Bryan, Hammond, Wood, Bartholow, and others, from whom I hâve extracted, whenever it has suited me to con- sult them upon any diflicult pathological question. And while I hâve been educated in the Universities of Georgia and Phila- delphia, and was first taught the time honored System of Parcel- sus, I hâve not allowed exclusive dogmas to govern my judgment either in practice or theory. I hâve tried to steer between ex- trêmes on ail sides ; and hâve given that treatment for diseases which I hâve found successful by expérience. I do not prétend that this volume is a perfect exposition of the science and art of healing, but an humble attempt to add something to the long accumulated fund of médical knowledge. For many years, as épidémie visitations hâve occurred under my observa- tion, I hâve noticed that the old method of treating diseases by name was quite unsuccessful, and that it required a spécial récogni- tion of existing pathological peculiarities, and of spécial remédies to meet thèse several indications. The remédies required in one épidémie will not produce the same effects in another épidémie of the same clisease, hence the necessity for spécial patholoical indi- cations for certain remédies. I hâve generally given remédies singly for a pathological condition, or in some cases, alternated two or three remédies at one time.* This will be objected to by some, until they study disease and remédies closely, when they will see the propriety and necessity for this plan of trcating diseases. I hâve generally given a smaller dose than most writers recommend, and this is in accordance with forty years, expérience in thé healing art. So too *See the Author's New Remédies. [v] VI THE AMERICAN PRACTICE OP MEDICINE. I use the saturated tinctures or fluid extracts, as being most uni- form in strength, and of course, the most certain in action. As re- gards the dose, there can be no certain rules laid down. I hâve ïound that medicines produce their therapeutical effect in doses short of those causing their toxical effect ; and that it is not always that any certain dose is absolutely required to produce curative affects, but that medicinss, having a spécifie aftinity for certain parts or organs, will act upon said organs, tissues or parts, in a given away in therapeutic doses, but quite differently generally, in toxical doses. I hâve seen medicines cure diseases in various sized doses, provided the dose was below that required to produce the toxical effect. This volume does not teach a dogmatical proscriptive System of therapeutics, but the author aims to add his expérience to that of other honest laborers in the field of médical science. I claim that I hère give a guide, imperfect though it be, to the administration of remédies that will greatly aid the practitioner in selecting his remédies iu each case, if he studies pathology well. There is much wrangling among médical men in regard to the " law of cure." Such has been the zeal with which some men hâve advocated their own cherished theory upon this subject, that they hâve been induced to discard and abuse ail who differed from them. But it is now apparent to ail sound pathologists, that there can never be a " System of cure in medicine" that is, there cannot be a definite law by which ail medicines shall act, but each remedy acts according to its own peculiar law. Some after the law of " Similia Similibus Curanter" and others upon the law of u Contra- ria Contrariis Curantur, or Opponenda." Ko remedy should ever be given until the pathological indications calling for it, is well understood and pointed out by the symptoms in the case. The action of our remédies must be well understood, or we hâve no rightto prescribe them; and if we prescribe remédies routinely which we do not understand well, we are quacks. Every man is a quack who gives a remedy without knowing why he gives it, no matter what is his "pathy." The Author. ttfTRODTÎCTIOtf. The definite action of medicine is denied by a large majority of the physicians of Europe and America ; and this déniai has orgin- ated solely from the fact that we hâve hitherto ignored the patho- logical indications for our remédies. Furthermore, we hâve not singly tested (proven) our remédies, so asto get the précise aflinity of each one, together with the remédiai effects. The old rule of treating diseases by name, regardlessof any pathological indications for the spécifie remedy, has been a blighting curse to humanity, and in this era of light and advancing science should be abandoned, with other relies of ignornace and blind-guessing. The mor tality tables show how very unsuccessful this old routine plan of treating diseases has proven. And the sad results following this unscientific method in practice, should induce every man to investigate for himself, and try the more rational practice, based upon pathology. Some of the leading men of England, such as Ringer, and a few in America, such as Bartholow, acknowledge the fact that some of the remédies now used according to their pathological indications, are invaluable, viz : belladonna, for con- gestion of the venous capillaries ; aconite, for an excited heart with fever, etc.; but neither of them hâve given us the " spécifie" use of our other remédiai agents. They do not mention the cura- tive effects of baptisia in a septic diathesis ; sesculus in hsemor- rhoids ; hamamelis in varicosus ; apocynum canab. in dropsy ; convallaria and cactus in hypertrophy and valvular insuflâciency of the heart ; actaea rac. in lithic acid diathesis ; chionanthus in jaundice ; oil of pepo in hsemorrhoids (this remedy has lately been suggested to me as à spécifie in piles, by Dr. M. A. Baldwin, of Cutnbert, Ga.) ; lycopus in hsemorrhage of the lungs ; coto bark and mangifera indica in chronic diarrhœa ; rhamus purschiana in constipation ; kava-kava in urethral inflammation ; ipecac and euphorbia in the vomiting and purgiug of choiera infantum and choiera morbus ; small doses of tincture of colocynth in colic ; small doses of podophyllum in dysentery and summer complaint ; nor do they even acknowledge the gênerai law of affinity of reme- edies for organs and tissues. By the spécifie application of our remédies in accordance with their spécifie affinity, and the pathological indications calling for them, we do not mean to say, that a certain remedy will cure ail cases of a certain disease. We deny the old dogma, that groups diseases by name, into certain classes, and prescribes for them [vii] Vlll THE AMERICAN PRACTICE OP MEDICINE. merely by name, regardless of pathology. Disease may consist ot one pathological déviation from a normal state, and be met by one remedy, or it may,and often does, consist of many pathological dé- viations from health, each of which abnormal déviations will demand a " spécifie" agent to correct it. If there are various lésions in a case, dépendent upon one first lésion as a cause, then the relief of the first lésion may be followed by relief of ail the lésions in the case. It is clear then that we must be thoroughly versed in the précise action of our remédies, and in the pathological indications ealling for them. We must know in what our lésion consista, that is: whether it be excess of action, deficiency of action, or a mère per- verted action. Without this knowledge ail our prescribing is doue in the dark—it is unmitigated quackery. Our diagnosis must not be based upon the old generalization, or genus of disease, but upon a clear knowledge of the various pathological peculiari- ties pointed out by the symptoms in each case. This is the only way to treat disease successfully in gênerai. We do not say that by this method it is possible to reach absolu te success in every case, that is an utter impossibility, but we simply say that this method is a much nearer approach to gênerai success than the old guessing System of the past. This is the distinguishing peculiarity of that class of physicians called " Eelectic ;" but there are many who sail under this title who are really utterly unacquainted with the principles of modéra " Eclectism." We do not assert that there is any one law by which ail our remédies act, but that remé- dies act upon their own law. "And ail physicians should prove ail things, and hold to the good." What is the différence between this pathological System of prac- tice and the homœopathic System of practice ? Although we acknowledge the dual action in a great many remé- dies, such as ipecacuanha, curing dysentery and vomiting under certain pathological conditions ; podophyllum in dysentry and certain forms of diarrhœa ; ergot in arresting threatened abortion, and some other similiar instances of the dual action of our remé- dies, yet we do not say that ail remédies thus act, nor do we hold the dogma of the infinitésimal dilution of remédies increasing their action. This is a very material différence. We believe that there is & spécifie afiinity of certain remédies for certain organs or tissues, and that a certain drng has a certain action upon an organ or tissue in a given dose, but that action is changea by greatly increasing the quantity. Its action may be quite différent under différent pathological conditions. We are also convinced that there are pathogenetic powers in our remédies, hence the necessity for small dose. While we regard symptoms as a guide to diag- nosis, we are well satisfied that it will not do as a rule in diagnosis. INTRODUCTION. ix For instance, we regard a great many diseases as of germ origin, as diphtheria, catarrh, phthisis, fevers, and many others ; hence it will not do to confine our treatment to the mère fébrile élément or manifestation of thèse disease; butwe mustmeetthe first morbid cause of the organic or functional disturbance. There is a certain septic élément in the blood that causes many diseases, as typhus, and typhoid fever, choiera, yellow fever, rémittent and intermit- tent fever ; hère our remédies must be selected to meet this septic élément, instead of the mère fébrile manifestations, and after re- moving this septic condition, then the mère lésions may be easily met. We also oppose the old hobby of prescribing mercurials in disease. But some members of our school admit that the binio- dide of mercury, with iodide of potassium added, so as to prevent constitutional injury,may do good service ; others deny even that, and ignore mercurials entirely. We do not deny but that the dual action of our remédies does furnish the key to scientific thera- peutics, Each case should be carefully examinecl, and the pecu- liar pathological condition made out, then the remedy (in its médi- cal, and not letheal dose) prescribed in sufficient quantity to meet the indication according to the expression of the grouped symp- toms. In many cases, there doubtless is a similarity between the drug's pathogenesis and the morbid éléments of the disease to be met by the drug. And we admit the fact that the empiric use of remédies has been followed by success in many cases, simply from the fact that they were prescribed from the knowledge of their affînity for certain organs and tissues. There must be a relation- ship between the diseased or morbid condition—the pathological lésion, and the remedy. Haller's law of cure prevails in most cases,but Hahneman's chimera in regard to dynamization of medi- cines belongs to the old superstitions that clung to medicine in the bygone âges, and not to science. A HAND-BOOK OF OPERATIVE SURGERY. •th Edition, 8vo. 700 pages. 7.000 COPIES SOLD. By STEPHEN SMITH, M. D., Surgeon to Bellevue Hospital, N. Y. Price ia. Cloth. «4.00 ; in Sheep, 85.00 ; in Full Russia, f6.00.____________________________ Tùis volume is a handy book for the practitioner, and by means of a full index is adapted for instant référence to ail the détails of opérations. The work has been carefully prepared, with a view to combine in the most compact and availaole form al) the es- sential matter of the larger works on Surgery. It is encyclopédie in character, treat- ing a vast range of subjects, and in- cluding the methods and Systems of the most eminent practitioners, many of whom hâve expressedly authorized this use of their highly valuable expé- rience and eminent professional skill. Though of great value to ail profess- ional surgeons, the book is peculiarly usefttl for physicians who rarely hâve surgical cases, and who will flnd the explicit directions and illustrative cuts in this work instantly helpful in emergenciesandspeciaHydiflficult cases. Illustrations form a very important feature. Thèse hâve been prepared with spécial care, for the purpose of rendenng the text clear, and of pre- senting distinctly to the eye the more obscure points of surgical opérations. A LETTER FROM Prof. Samuel D. Gross TO THE AUTHOR. "Are you aware that you bave pro- duced a great book? If not, let me assure you of the fact. I beiieve I am perfectly familiar with the literature of surgery, and if there is any work of the kind equal to yours In any lan- guage, I am Dot acquainted with It. This is saying a great deal, but only what is strictly true. The work, con- sidered as a whole, does you infinité crédit, and cannot but be regarded as a most valuable, addition to the surgi- cal literature of our country." "The book has no equal in Ameri- ca."—D. Hayes Agnew, M. D., Phila- delphia, Pa. "It is splendidly adapted to the wants of the profession."—Edmund Andrews, M. D., Chicago, III. " Like eyerything which cornes from Dr. Stephen Smith, it is well done."— Frank H. Hamilton, M. D., N. Y. " A large quantity of knowledge in a small space."—Sir James Paget, London, Eno. "I talce ail your publications, and like them ail very much in- deed." R. S. Greene, M.D., Newcastle, Ala. TABLE OF CONTENTS. Chapter I.—Diseases of the Blood. Cyanosis,...........- 21 Ansemia, ... -....... 21-22 Oligocythaemia,..........- 22 Luksemia, .......... 22-23 Chlorosis,............ 23 Scurvy, ........... 23-24 Purpura Hœmorrhagica,......... 24-25 Scrofula,........... 25 Chapter II.—Fevers : The Exanthemata. Typhoid Fever, ..... .... 26-29 Typhus Fever, .......- - 29-32 Measles,............ 32-34 Scarlatina,.....-..... 34-37 Small Pox : Varioloid.......... 37-40 Vaccinia, - - ........ 40 Intermittent Fever,........- - 40-43 Rémittent Fever, ......... 43-45 Yellow Fever, - - ...... 45-47 Chapter III.—Diseases of the Respiratory Organs. Bronchitis,.......... 48-50 Whooping Cough,.......... 50-51 Asthma,..........- 52-53 Pneumonia,........... 53-56 Phthisis,........... 56-59 Emphysema, -.......... 59-61 Pleurisy,........... 61-63 Hœmoptysis, - ....... 63-64 Pneumothorax,.......... 64-65 Hydrothorax,........... 65-66 Chapter IV.—Diseases of the Heart. Pericarditis, .......... 68-70 Hydropericardium,.......... 70-71 Insufficiency of the Mitral or Bicuspid Valves, ... 71-72 Constriction of the Left Auriculo-Ventricular Opening, - 72 Defective Aortic Valves,........ 72 Constriction of the Aortic Opening,....... 73 Defective Tricuspid Valves,-........ 73 Endocarditis, .......... 74-75 Hypertrophy and Dilatation of the Heart,..... 75-76 Nervous Palpitation of the Heart,......- 76-77 Angina Pectoris,.......... 77-78 Diaphragmitis,........... 78 [xi] xii THE AMERICAN PRACTICE OF MEDICINE. Chapter V.—Diseases of the Digestive Organs. Dyspepsia,........- 83_83 Acute Gastritis,.......- 83-84 Chronic Gastritis, -------- ~ g. Gastralgia,.......- 84_g6 Perforating Ulcer of the Stomach, - " 86-87 Cancer of the Stomach,......" 87-88 Hsematemesis,......... ™ Gastromalacia, ---------- Chapter VI—Diseases of the Intestinal Canal. Intestinal Catarrh, .....- 89-90 Chronic Intestinal Catarrh, -------- qi oo Typhlitis and Peri-typhlitis,.....- *1_™ Proctitis,........- - " - »*-JJ Dysentery,.........- - »f»J Choiera,............ «5-97 Choiera Morbus,........- oa Choiera Infantum,........- oa Chronic Constipation,....... - 98-99 Intestinal Hsemorrhage,......... 99 Haemorrhoids,.......... 99-102 Peritonitis,........... 102-103 Enteralgia, - - ......- 103-105 Ascites,............105-106 Intestinal Worms,......... 106-109 Chapter VII.—Diseases of the Liver. Hyperœmia,........... 110 Hepatitis,.........- 111-112 Cirrhosis of the Liver,.........112-113 Acute Yellow Atrophy of the Liver,...... 113-114 Cholecystitis,........... 114-116 Jaundice,..........- 116-118 Chapter VIII.—Diseases of the Spleen. Splenitis, ---..........119-120 Chapter IX.—Diseases of the Pancréas. Pancreatitis,........... 121 Chapter X.—Diseases of the Kidneys. Diabètes Mellitus, , ...... 124-125 Hsematuria,.......... 125-126 Acute Bright's Disease,.........126-127 Chronic Bright's Disease,.....: - - 127-128 Interstitial Nephritis, - - '...... - 128-129 Rénal Colic, .......... 129-130 Chapter XI.—Diseases of the Bladder. Cystitis, ------......131-132 Vesical Calculus,.......... 132-133 Chapter XII.—Diseases of the Maie Organs of Génération. Gonorrhœa, - ........134-136 Vesical Gonorrhœh,......... 136 Bubo,............ Stricture of the Urethra,........ Syphilis,............ Constitutional Syphilis,......... TABLE OF CONTENTS. Xlii Chapter XIII.—Diseases of the Testes. Hydrocele,........... 142 Orchitis, ........... 142-143 Varicocele,...........143-144 Impotence,........... 144 Chapter XIV.—Diseases of the Prostate. Prostatitis,...........145-146 Onanism : Prostatorrhœa : Spermatorrhœa,..... 146-147 Chapter XV.—Diseases of the Female Generative Organs. Ovaritis,............153-154 Ovarian Dropsy,.......... 154-156 Leucorrhœa,...........156-157 Acute Parenchymatous Metritis,....... 157-159 Chronic Parenchymatous Metritis,.......159-160 Puerpéral Fever,.......... 160-161 Anteversion of the Womb,........ 161 Rétroversion of the Womb, - -...... 161-162 Prolapse of the Womb,.........162-163 Polypus of the Womb,......... 163-164 Cancer of the Womb,.........164-165 Metrorhagia,........... 165-166 Menorrhagia,........... 166 Amenorrhœa,........... 166-167 Dysmenorrhœa,...........167-169 Pruritus Vulvœ,.......... 169 Mastitis, -----.......169-170 Scirrhus, or Cancer of the Mammse, ...... 170 Chapter XVI.—Diseases of the Spine. Anaemia, . ........ 171 Hyperœmia,........... 171 SpinaBifida,.......... - 171-172 Spinal Meningitis, ........ . 172-173 Myelitis.....:.......173-174 Mult.ple Sclerosis: Chronic Myelitis, -..... 174 Chapter XVII.—Diseases of the Motory Apparatus. Rheumatism, ,......... 176 Acute Rheumatism, . . •...... 176-177 Chronic Rheumatism,.........177-179 Goût,............ 179-181 Chapter XVIII.—Diseases of the Osseous System. Rachitis, . ..........182-183 Osteitis: Exostosis,......... 183-184 White Swelling,.......... 184 Coxalgia,........... 184-186 Genu Album,...........186-187 Chapter XIX.—Diseases of the Nervous System. Neuritis,........... 188 Neuralgia, ...........188-189 Tic Douloureux,.......... 189-190 Cervico-Occipital Neuralgia,........190-191 Ansesthesia,.......» . • • 191-192 Trigeminal Anaesthesia,......... 192 XIV THE AMERICAN PRACTICE OF MEDICINE. Morbid Affections of the Motory Nerves, Spasms: Convulsions: Cramps. Chorea, .... Hysteria, .... Trismus : Tetanus, . . • Trismus Neonatorum, Catalepsy, Epilepsy, .... Acute Eclampsia : Puerpéral Convulsions, Paralysis Agitans, Paralysis, . Hydrophobia, Chapter XX.—Diseases of the Acné, Alopecia, Icthyosis, Dermatitis Contusiformis, Herpès, . Urticaria, Eczéma, Chronic Eczéma, Impétigo Contagiosa, Ecthyma, Pemphigus, Rupia, Furuncle, Carbuncle, Malignant Pustule, Èpithelioma, . Paronychia, Félon, Psoriasis, Lichen Planus : Lichen Simplex, Prurigo : Pruritus, Itch, Prairie Itch, Chapter XXI.—Diseases of the Dropsy of the Scalp, Erysipelas of the Scalp and Face, Eczéma of the Scalp, Dandruff, Seborrhœa Capillii : Vernix Caseosa, Favus, .... Ringworm, Vascular Naevus, Baldness, . Chapter XXII.—Diseases of the Ansemia, ..... Hyperœmia, . • . . Congestion, ..... Vertigo, ..... Insomnia, ..... Tubercular Meningitis, Acute Meningitis, Cerebro-Spinal Meningitis, Sunstroke, Skin Scalp Head and Brain. TABLE OF CONTENTS. XV Apoplexy, .... Thrombosis : Embolism, Aphasia, .... Thrombosis of the Cérébral Sinuses, . Dementia paralytica, Senile Dementia, Delirium Tremens, . Dipsomania, .... Opium and Morphia Poisoning, Tumors of the Brain and its Membranes, Chapter XXIII Diplopia, Hyperaemia of the Conjunctiva Conjunctivitis, Catarrhal Conjunctivitis, . Purulent Conjunctivitis, Military Ophthalmia, Ophthalmia Neonatorum? Gonorrhœal Conjunctivitis, . Diphtheritic Conjunctivitis, Acute Granular Conjuctivitis, Chronic Granular Conjunctivitis, Scrofulous Conjunctivitis, . Phlyctsenular Conjunctivitis, Phlyctsenular Corneitis, Ulcération of the Cornea, Corneitis, Anterior Staphyloma, Episcleritis, . Hyperaemia of the Iris, Simple Iritis, Suppurative Iritis, Serous Iritis, Choroidal Hyperaemia, Simple Choroiditis, . Suppurative Choroiditis, Hyalitis, Muscae Volitantes, Glaucoma, Retinal Hyperaemia, Retinitis, Optic Neuritis, Atrophy of the Optic Nerve, Amblyopia, Chapter XXIV Inflammations, Boils in the Ear, Abscess of the Ear, Eczéma of the Ears, Simple Otorrhœa, Aspergillus, HardenedWax, Foreign Bodies in the Ear, Insects in the Ear, Catarrh of the Ear, Chronic Otorrhœa, -Diseases of the Eye. Diseases of the Ear, xvi THE AMERICAN PRACTICE OF MEDICINE. Chapter XXV—Diseases of the Nose. Catarrh: Coryza, Chronic Catarrh: Ozœna, Influenza, Rose Cold: Hay Fever, Epistaxis, Chapter XXVI—Diseases of the Face. Erysipelas, , Milk Crust, Acné Punctata Lupus, Acné Rosacea, 298-299 299 300 300-301 301-302 302 304 304-305 305 305-307 Chapter XXVII.—Diseases of the Mouth and Throat. Glossitis, Cancer of the Tongue, . Inflammation of the Gums, Dentition, Decay of the Teeth, . Odontalgia, Parotitis, Symptomatic Parotitis, . Tonsilitis, Uvulitis, . Sore Throat, . Chronic Sore Throat, Retro-Pharyngeal Abscess, Angina Ludovici, The Mucous Membrane of the Mouth Thrush, .... Ulcerative Stomatitis, Diphtheria, Noma, .... 309-310 310-311 311-312 312 312 312 312-313 314 314-315 315-316 316 317 317-318 318-319 319 319-320 320-321 321-325 326 Chapter XXVIII.—Diseases of the Larynx and Œsophagus. Bronchocele : Goitre, Œsophagitis, . Stenosis Œsophagi, Acute Laryngitis, Chronic Catarrhal Laryngitis, Croupous Laryngitis, Œdema of the Larynx, . Tubercular Ulcération, Spasm of the Glottis, . 327 327-328 328 328-329 329-330 330-331 331-332 332-333 333 GENERAL REMARKS UPON THE LEADING AND MOST PROMINENT SYMPTOMS OF DISEASE. The Pulse.—The puise is produced by the expulsion of the blood from the heart through the aorta, and thence into the various arteries of the body, by each contraction of the left ventricle of the heart, and by the innate contractility of the arterial walls. Hence the character of the puise will be modified by the condition of the heart and also by that of the blood-vessels, and of the blood itself. Gentleness should be observed in feeling the puise, so as not to excite the action of the heart, especially in children and nervous persons. In ordinary cases, the puise may be examined at the wrist. In examining the puise, the pressure upon the artery must be very gentle, and must be made by three Angers. The frequency of the puise may be measured by the second hand of a watch, and its peculiar characteristics, as indicating diseased conditions, can only be appreciated by the educated hand of the careful examiner. Its rhythm, its fulness, or its softness should be noted ; whether compressible, strong, bounding, hard, soft, or small and wiry, intermittent, or regular in beat. The healthy puise is uniform, equal and moderately full, and swells slowly un- der the Angers ; it is smaller and quicker in children, and ordi- narily also in women. In old âge there is a structural change in the arterial coats, and hence, the puise becomes somewhat harder than in the young and vigorous. In health, the average number of puise beats in a minute, at différent âges, is as foïlows : at birth, 140 ; during infancy, 120 to 130 ; in childhood, 100 ; in youth, 90 ; in adult âge, 70 to 72 ; in old âge, 65 to 70 ; in décrépitude, 75 to 80. It is quickened by exertion or excitement ; it is more fréquent in the morning, and just after meals; it is somewhat faster when standing than when sitting, and in sitting than lying ; but is retarded by sleep, cold, fatigue, hunger, and by arterial sédatives, such as digitalis or ve- ratrum. -,.-,. A rapid puise, especially when it is strong, full and hard, îndi- cates fever or inAammation ; if very rapid and small, it indicates debility or dépression, as is the case frequently in enteric fever. A jerking puise, with quick and forcible beat, followed by abrupt cessation for one or two beats, indicates structural lésion of the valves of the heart. The puise may, however, be intermittent, owing to obstruction to the circulation of the blood in the heart and lungs, or from softening of the brain, or from inAammation 2 [xvii] XVÎii THE AMERICAN PRACTICE OF MEDICINE. of the brain, or from apoplexy. Ilernia, enteritis, and gangrené of the intestines may producejintermittency in the puise, so may it also be produced by prolonged or over exertion, watchiug, want of rest or sleep, and anxiety. Indigestion with flatulence may produce it in a less marked degree. A weak puise indicates îm- poverished blood and debility, and a full puise dénotes plethora, or the early stage of acute disease. The Température of the Body.—The normal température of sheltered parts of the body is 98.4° or a few tenths more or Jess, and a persistent rising above 99.5° or a fall below 97.3° are indi- cations of a diseased condition. A normal température gives^assu- rance of the absence of anything except local and very triAing disturbances of health ; but any very acute disease very socn éle- vâtes the température above the normal standard. By the clinical thermometer we readily diagonise between an inAammatory and a non-inflammatory form of disease, and the thermometer helps us to détermine the intensity of the inAammation, by the number of degrecs the bodily heat rises above the normal standard. Hysteria, for instance, often simulâtes inAammatory dis^ ase ; température in hysteria, however, is always nearly or quite natural, but never in inAammation. In typhoid fever, the thermometer not only indicates the fever, but also reveals changes that are about to take place in the patient's condition. In consumption, even when other symptoms are obscupe, the thermometer will show that the tem- pérature is about 102.3°, or even higher, and the température will increase in proportion to the tubercular deposit. This increase of the température of the body often exists for several weeks prior to the loss of weight or before the physical signs indicate tubercle in the lungs. In measles, the thermometer is the best means of deterniining that pneumonia is settmg in. In acute rheumatism, if the température runs up to 104°, it indicates grave complica- tions. Respiration.— Healthy inspiration and expiration are per- formed with ease. Au adult breathes about twenty times in a minute. Breathing is quickened by exertion and by disease, es- pecially fevers. Dyspnœa, or diflicult breathing, may he the resuit of loss of lung substance ; adventitious deposits in the luno-s ; for- mations of false menbranes in the air passages, as in croup or diphtheria, in tonsilitis and glossitis, also in asthnia, which is a spasm of the muscles of the air tubes. Effusion of Anid into the pleura or pericardium (the serous membranes surroundino- the lungs and heart,) causes dyspnœa from compression of the îuno-s. Organic diseases of the heart, and functional diseases of this organ also cause dyspnœa. Diseases of the nerves of resporation or thir centres, may cause serious dyspnœa. Fracture of a rib ' or fracture of several ribs, apoplexy, or great exhaustion, an insufli- GENERAL REMARKS. xix cient supply of blood to the nérve centre of the brain, ail may cause dyspnœa. The Tongue.—The tongue is an important means of diagnosis. A dry tongue indicates diminished sécrétion, and is common in most acute and fébrile diseases ; a moist condition of this organ is regarded as a favorable sign, especially when it foliows a furred and dry condition. A very red tongue is common in eruptive fevers and in rémittent and intermittent fevers, especially when the stomach is involved ; it also is indicative of indigestion, in which case the edges are more red. If the tongue is Assured, it indicates typhus or typhoid fever. A purple orlivid tongue indi- cates defective oxygénation of the blood. A heavy fur on the tongue indicates irritation or inAammation of the mucous mem- branes ; it is also common in diseases of the brain, in ail varieties of fever, and in most acute and dangerous diseases. Tobacco smok- ers usually hâve a furred tongue when well. A yellow coat upon the tongue is regarded as an indication of disordered liver ; and a brown or black coat dénotes a low state of vitality, or contamina- tion of the blood. A tendency to health, after an attack of sick- ness, is indicated by a graduai cleaning of the tongue, which indi- cates a clearing up of the intestinal tract. If the tongue becomes a browner, drier and dirtier, each day, the nervous system grows graduglly feebler, and the hope of recovery less. When the fur i-eparates in patches, leaving a glossy, red surface, the prospect of recovery is also unfavorable ; so too in cases where a crust is rap- idly removed. This rule is subject however to exceptions. Pain.—A throbbing sensation with pain, and a sensation of tightness is a pulsative pain. A nervous pain generally intermits, or remits. A spasmodic pain is mitigated by pressure, or by fric- tion, and by the application of warmth. Pain from inAammation is constant, attended by a quickened puise and heat, and is încrea- sed by movement of the affected part, or by pressure. Pain occurs sometimes in a part distant from the seat of disease, as when in- Aammation of the liver gives rise to pain in the right shoulder ; so too inAammation of hip-joint may give rise to pain in the knee- joint ; stone in the bladder is accompanied by pain in the pénis ; and disease of the heart gives rise to pain shooting down the left arm. The Skin.—In health, the skin feels moist, elastic, soft, smooth, warm and neither very tense nor loose. A harsh, dry, burning heat of the skin, indicates fever and inAammation. If perspiration takes place, and the improvement is gênerai otherwise, it is a fav- orable sign. Partial or local perspiration indicates a deranged condition of the nervous system, or an affection of the organs beneath the sweating surface. When perspiration occurs after slight exercise, it indicates great weakness or debility. Night- XX THE AMERICAN PRACTICE OF MEDICINE. sweats occur in debility, in hectic and in consumption, or chronic bronchitis. The color of the skin is also diagnostic. A bluish tint of the skin indicates structural disease of the heart. A yellow color points to biliary affections. A rich blush of the cheeks, es- pecially if it be conflned to a limited part, and the surrounding parts remain pale, indicates an irritable condition of the nervous system, or a diseased state of the lungs. The face will often blanch from sudden émotion, and Aush from a sudden fit of anger or shame. I hâve seen persons who were subject to occasional Aushes of the face from a morbid state of the capillaries. The Urine.—By the healthy activity of the kidneys the blood is relieved of many impurities, which, if retained, would produce disease in some part of the organic structure. Healthy urine is of a yellow or amber color, of slight ammoniacal smell, and pré- cipitâtes very little, if any, deposit on standing. The average speciAc gravity in healthy urine is between 1020 and 1025. It présents varieties in disease, and furnishes valuable indications to the physician. In jaundice it is of a dark yellow or saffron color. In fevers it is generally red or high colored, and scanty in quan- tity. It may be bloody and slimy in affections of the kidneys and bladder. It is pale and copious when less urea is excreted, or when metamorphosis is checked, as in nervous and hysterical af- fections. It may be heavy, muddy, or of a purple color in some peculiar conditions of the system ; or it may be very dark or black, indicating its putridity. In chronic or acute inAammation of the bladder, the urine is passed with more or less pain. Sometimes there is very fréquent désire to micturate, with burning and scald- ing pain in passing the urine, especially the last drop, as in calcu- lus. Diabetic urine is usually pale and copious, and its speciAc gravity is from 1025 to 1060. In hysteria the speciAc gravity may be as low as 1007. In rheumatism the urine is usuallv acid, but in nervous affections it is alkaline. CHAPTER I. DISEASES OF THE BLOOD. As the blood is the life of the body it must necessarily produce great disturbance in the body when this vital Auid becomes changed in its character and composition. In health, the blood consists of sérum and two kinds of corpuscles—the red and white. The sérum contains water, Abrin, albumen, salts, fatty or oily sub- stances, and extractive materials. If thèse constituents be diminished, increased, or altered, it causes an abnormal condition of the blood. This Auid may al- so be poisoned by the admixture of obnoxious substances, such as uric acid, oxalic acid, ammonium, sulphurretted hydrogen, urates, bile, pus, and even sugar. Cyanosis.—The blood having a natural afflnity for oxygen, absorbs it while it is in contact with the air in the lungs. Any cause that prevents this absorption of oxygen by the blood corpus- cles, hinders the transformation of venous into arterial blood, which causes cyanosis. This disease consists in deflciency of oxygen in the blood corpuscles. Its causes are numerous, and may be ar- rangea under various heads as mentioned hereafter. Causes.—It may be the resuit of imperfect respiration, in consé- quence ofspasms, or œdema, or croup, or inflammation of the larynx and glottis, or any obstacle that may prevent the air from entering the air-cells of the lungs freely. Emphysema, hepatization, hydrotho- rax, or paraly tic affections of the respiratory muscles, or distention of the abdomen with gas or water, so as to impede respiration, may give rise to it. Diseases of the heart may cause it, and so may obstructions within the pulmonary vessels. immédiate transmission of the venous blood into the left ventricle, by non- closure at birth of the foramen ovale, is often the cause of this disease. Irrespirable gases, as carbonic acid gas, may cause cyano- sis. Sometimes in typhus fever, choiera, pysemia and tuberculosis, the blood is so changed that its corpuscles are unable to absorb oxygen. Symptoms.—Cyanosis is to be distinguished by the bluishness of the skin, especially of the face andlips; coldness of the surface and extremities; sopor; and finally, asphyxia. Treatment.—I find that cactus will give as great relief as any remedy we hâve, gtt. 5 every two or three hours. Collinsonia may alternate. Cyanosis is usually fatal. Ansemia.—This may be defined as a poverty of the blood, or, [21] 22 THE AMERICAN PRACTICE OF MEDICINE. pathologically speaking, it may be defined as a diminution of plastic albuminates, and red corpuscles. That impoverished state of the blood that follows hœmorrhage, from wounds, or other- wise, is not what is meant by true anœmia. Causes.—A déficient supply of nourishing food may cause this disease. A want of air and exercise, too high or too low a tem- pérature, excessive loss of semen, too long continued lactation, too profuse menstruation, mental over-work, albuminuria, excessive mucous discharges, diarrhœa, or dysentery, excessive suppuration, infiltrations into the pericardial sac, or into the pleural or perito- neal cavities, malignant growths, malarial infections, certain min- erai poisons, such as arsenic and mercury, diseases of the lym- phatics and spleen may ail cause anaemia, under certain condi- tions. Symptoms.—Paleness of the skin and mucous membranes, drop- sical effusion in conséquence of deficiency of albumen in the blood, emaciation, marasmus, or atrophy of tissue, a tendency to hœm- orrhage, low température, dyspnœa, and palpitation of the heart. Treatment.—Fowler's Solution in gtt. | doses, or iron in mod- erate doses, with helonias dioica, gtt. 30, three times a day, will generally cure this disease. Oligocythaemia.—In some diseases more corpuscles die than are generated, in a given time, and this causes a state of the blood which is called oligocythœmia. It is characterized by weakness of the muscles ; a tired feeling ; nervousness ; palpitation of the heart, and a murmur in the jugular veins. So rapid is this dissolution of the blood corpuscles in some cases that the blood-serum becomes surcharged with the constituents of the dead corpuscles, and is thus discolored. Sometimes the excrétions of the body assume a bloody hué. The skin and mucous membrane may become colored with hsematin, so as to render it yellowish, creatiug an appearance of jaundice. The dissolution of blood-corpuscles may be confined to a certain portion of the circulation, and constitute an essential élément of local gangrené. A gênerai putrid dissolution may take place throughout the system, and produce gênerai gangrené or sep- ticsemia. This is the case sometimes in scurvy and typhus fever, puerpéral fever and yellow fever, and other tropical forms of fever. Treatment.—Baptisia, alternated with gtt. 1 of Fowler's Solu- tion every three hours, are the remédies. Leukœmia—Is caused by a great prédominance of the white corpuscles, ànd often occurs in connection with hypertrophy of the spleen, or tumors of the lymphatic glands in gênerai. Symptoms.—The patient complains of great prostration, dull pains in the splenic région, headache, dizziness in the ears, palpi- tation of the heart, shortness of breath, with enlargement of the lymphatic glands of the entire body, but especially of the cervical DISEASES OF THE BLOOD. 23 jugular, axillar and inguinal régions. There may be tumors of the spleen without leuksemia, and so of the lymphatics. Treatment.—Thuja oc, in doses of gtt,, 1 to 2, three times a day, often relieves this disease quickly. The sulphate of sodium in small doses is also a good remedy ; dose gr., 1 to 2, three times a day. If there is debility, bad digestion, constipation, or a want of nervous power, then nux vomica may be given, in doses of gtt., 1 to 2, three times a day. In some cases gtt., 1 to 2 of arsenic, in the shape of Fowler's solution, has been given with good effect. Menespermin, in doses of gr. 1 to 2, may be given with the best effects in many cases. The nitrate of sodium is also a good rem- edy, dose gr. 1 to 2, three times a day. The acétate of sodium will often answer as well, and in some cases even better. Nitrate of potassium, in 1 to 2 gr. doses, is also a good remedy. The car- bonate of limeis a valuable remedy. The phosphate of magnésium is often useful. Ghlorosis.—This is a diminution of haemoglobin in the blood. The albuminates and leucocytes are not affected, and this fact must be regarded as a pathological distinction between this disease and ansemia. This'disease seems to be limited to the female sex, be- tween the fourteenth and twenty-fourth years of âge. There may exist a constitutional tendency to this disease. Symptoms.—Paleness of the skin, which is either clear or yel- lowish, greenish, or waxy. The lips and mucous membranes are pale, with dark rings around the eyes, œdema of the face, eyslids and feet, decreased température, and great sensitiveness to cold. The puise is slow, compressible and small, and there is generally palpitation of the heart. There is great debility, headache, noises in the ears, pains in the body, especially in the stomach and back, sadness, want of energy, nightmare, sometimes mania. • Treatment.—Iron is a valuable remedy, and may be alternated with helonias dioica. Arsenic is also indicated in many cases. Hypophosphite of lime, alternated with nux-vomica, is useful where the digestion is feeble. Pulsatilla in doses of gtt. 5 is re- quired where in females the menstrual flow is deAcient, and this may be alternated with senecio aureus gtt. 30 to the dose. Scurvy.—This disease resembles septicsemia, and is very grad- ually developed. There is gênerai debility, sleeplessness, dépres- sion of mind, cachectic face, with blue rings around the eyes, the puise is slow and soft, and the appetite poor, urine scan- ty, skin dry and harsh, and frequently constipation. The gums become bluish, swollen, spongy, and generally bleed at the slight- est tpuch. The breath becomes fetid, and there is a bad taste in the mouth. The debility increases, the extremities suffer pain, ecchymosed spots appear on the body or limbs, and finally ail over, from the size of a lentil seed to that of half a dollar. At first they 24 THE AMERICAN PRACTICE OF MEDICINE. look purple, and in severe cases they are black. Very frequently there is epistaxis, and hsemorrhages from other parts of the body. The debility may become so great that the patient faints upon slight exertion, and there may flow from the gums and mouth a fœtid, ichorous, bloody fluid; the ecchymosed spots on the skin may change into blisters, filled with an ichorous fluid and form- ing ulcers. The pain of the limbs may greatly intensify, and the joints and bones may become enlarged, and an effusion of fibrin take place under the skin. A thin ichorous diarrhœa may set in, with colicky pains. The spleen usually becomes greatly enlarged and often very tender to the touch. There may be hœmorrhage from the kidneys as well as from the nose and bowels. There may also be an extra vasation of bloody serummto the pleura, thepericar- dium, the lungs, or brain or its membranes, and the patient may die suddenly ; or slow convalescence may take place and the pa- tient gradually recover his health. It has been divided into sea and land scurvy, but there is no es- sential différence between thèse two forms of scurvy. Causes.—A want of vegetable food and the exclusive use of sal- ty provisions generally gives rise to this disease ; but exposure to damp, cold weather, bad drinking water, rancid méat, depressing mental émotions, fear and anxiety may aid in its development— ceteris paribus. Treatment.—Where the skin is pale, the gums swollen and bleeding, dark purple blotches upon the limbs or body, limbs swol- len, hard, and painful, with constipation of the bowels, the agave Americana, in the form of an extract, in doses 5 \ every two or three hours, has made many cures, and so hâve lemon juice and vegetables. Purpura Haemorrhagica.—This is a sporadic hœmorrhage, of rather a brief du ration, the etiology of which is not known. It differs from scurvy in not having any of those affections of the gums that attend scurvy. It may begin suddenly, without any premonitory symptoms. There appear petechiœ upon the skin, or there may be epistaxis. It may commence with rheumatic pains in the legs, especially in the knees and ankles. Hœmoragic ex- anthema may extend over the entire body, which may vary in size from the size of a lentil seed to that of a large pea. There may be vesicles formed out of the circumscribed hœmorrhao-es into the rete Malpighi from capillary loops of the papillae of the skin. If a mère cutaneous éruption constitute the disease, it is called purpura hœmorrhagica. Hœmorrhage may take place from the mucous membrane of the nose, mouth, stomach, intestines urethra bronchi, or from the womb in females. Treatment.—Phosphorus, in tincture, may be required in some cases. Hamamelis is one of onr best remédies, and may be given DISEASES OF THE BLOOD. 25 in doses of gtt. 5 to 10 of the tincture of fluid extract every two hours. Arsenic may be required in some cases. Scrofula.—Scrofulosis is a peculiar cachexia, which manifests itself in the form of a nutritive disturbance in the skin, mucous membranes, joints, bones, organs of sensé, lymphatic glands, and sometimes in other glands, as the submaxillary. The subject may hâve a large head, coarse features, thick upperlip, broad cheek bones, large abdomen, swollen glands on the neck, and soft flabby muscles, and there may be whiteness of the skin, showing the ves- sels plainly ; redness of the lips and cheeks, languid eyes, flabby appearance of the whole make up of the body. So, too, there may be éruptions on the face, as eczéma or impétigo, or porrigo, or tinia. And in some cases lupus may take place. There may be scrofulous conjunctivitis, otitis, or oft occurring coryza, and even bronchitis. It may affect the joints, in the form oîwhite swellings, or cause sup- purating abscesses, such as caries of the bones and destruction of the capsular ligaments. There may be ostitis or periostitis or ne- crosis of the bones. The lymphatics generally show the greatest nutritive disturbances. And the cellular tissue may become in- volved, causing suppuration and abscesses, which progress general- ly very slowly, and heal with great diffieulty, and always leave ugly cicatrices. Thèse glandular abscesses are mostly on the neck. Sometimes the glands are greatly enlarged, but the microscope shows their enlargement to consist of pure hypertrophy of their own cells, and not of any foreign éléments. When^ they inflame and suppurate, they form abscesses which break or else the puri- form matter becomes dessicated into a cheesy mass, and may then be transformed into a chalky substance. Thèse chalky substances may so irritate the adjacent tissues, as to give rise to inflamma- tion and suppuration of glands. The most common location of thèse swollen glands is the neck, especially behind the cars and under the lower jaws. The mesenteric and bronchial glands may also be aflected. This disease may be inherited as well as acquired. Treatment.—In children, the alnus rub. in doses of J to 15 of the fluid extract or tincture three times a day, alternated with the iodide of barium (as an ointment,) will often make a decided im- pression on the disease. I hâve used the syrup of the hypophos- phites with fine effect. Cistus canadensis and menispernium, (the tincture,) in doses of 5 J each, three times a day, do good generally. The common black walnut, in the form of a syrup of the leaves, is a valuable remedy. When the bones are attacked, then the chloride of gold, in doses of -fa of a grain, three times a day, may be used, alternated with pot. iod. If it manilests itself upon the skin, the iodide of arsenic, in doses of -^ of a grain, often acts ad- mirably. CHAPTER II. FEVERS: THE EXANTHEMATA. Typhoid Fever.—Enteric fever is a continued, slightly infectious fever, continuing about twenty-eight days and often bnger. Its pathological effects are évident in the bowels. It is accompanied with an éruption of a few rose-colored spots on the chest, abdomen or back, with great feebleness, and abdominal pains and tender- ness, and almost always with diarrhœa. The diarrhœa increases as the disease advances; the discharges being copious, liquid, putrid, and of a lighl-ochre color. Typhoid {jôtpoç and elàoç) signifies like typhus ; but while thèse two forms of fever hâve many similar symptoms in common, y et typhoid is an entirely différent disease, and it is necessary to be able to distinguish one from the other. The nature and cause of thèse two forms of fever are essentially différent. Enteric fever is regarded as contagious, but less so than typhus. That we may be able to differentiate between them, we should contrast the symptoms of the two fevers. Typhus fever cornes on quickly ; typhoid fever cornes on slowly. Typhus attacks persons at any âge ; typhoid fever is most common in youth, rarely occurs after forty. In typhus, the éruption is of a mulberry-color ; cornes out in a single crop about the fourth or fifth day, and lasts until the disease terminâtes. The éruption generally appears upon the extremities, is slightly elevated, and remains after death. In typhoid fever, the éruptions are rose-colored, few in number, and generally on the abdomen, occurring in successive crops, which in their turn fade and disappear. In typhus fever the brain is affec- ted, but the bowels are but little, if at ail affecter], the abdomen being often natural, and the discharges being dark, but never bloody. In typhoid fever the bowels are always affected, and the évacuations are of an ochre-color, and watery, with congestion of the mucous membrane of the bowels: very often there is also hœmorrhage, and the abdomen is tumid and tender to the touch. In typhus, there is a dusky Aush on the face and shoulders and the eyes are injected, and the pupils are contracted generally. In typhoid lever, the expression is bright, with a blush on the cheeks and the pupils are generally dilated. Typhus runs its course in about fourteen days. Typhoid continues from four weeks to three months, unless it be checked. In typhus, relapses are of rare oc- currence. In typhoid, relapses are of fréquent occurrence especi- ally in certain épidémies. In typhus, death occurs from coma or FEVERS: THE EXANTHEMATA. 27 congestion of the lungs. In typhoid, death may resuit from asth- enia, pneumonia ''hsemorrhage, or from perforation of the intestines. Typhus generally occurs from over-crowding, and defective venti- lation, typhoid from bad drainage, poisoned drinking water, or decaying animal and vegetable matter under certain electriaal con- ditions. Causes.—There is a peculiar poison that produces this form of fever, which has its origin in a certain state of fermentation from bad drainage, or from want of cleanliness about the p remises. Anywhere there is filth undergoing fermentation or décomposition, the poison of typhoid fever may beproduced,provided the air isina condition to aid the resuit. There is a certain state of putrescence in matter, either vegetable or animal, in which this zymotic poison is generated, and its gaseous émanations are borne to us upon the gentle zéphyr or in our drinking water, and having, per se, anaffinity for certain parts of the organization, produce this disease. Symptoms.—When the poison is not very highly concentrated, there is a period of incubation, varying from eight to ten days, after the expiration of which time the disease cornes on slowly and progresses gradually. The patient at first complains of languor and indisposition to move about ; is chilly ; the limbs and back ache ; the appetite fails ; there is nausea and sometimes even vomiting; the tongue has a white coating on it; the breath is offensive ; the bowels are relaxed ; and the puise is quick- ened. The symptoms gradually intensify daily, until the patient is seized with a rigor, then more or less fever, severe head- ache, and great muscular debility. This is the stage of accession, to be followed by the other stages. During the first week the prominent symptoms are, vascular excitement and nervous oppression, with' a bounding puise, about 90 or 100 per minute, great heat of the surface, thirst, and obscured mental faculties ; often delirium at night. The abdomen now enlarges, is résonant upon percussion, and there is pain on pressure, especially in the right iliac fossa, where a gurgling sen- sation is conveyed to the fingers on pressure. About the second week, emaciation and debility become well marked, the fiesh wastes away rapidly ; the urine is scanty, being loaded with urea from the rapid wasting of the nitrogenized tissues. And about this time diarrhœa sets in, if not before, which is copious m most cases. The discharges are fluid, pale-ochre colored, or of a drab color, with a putrid odor, sometimes flocculent débris in them. The third week the emaciation becomes extrême ; the patient lies extended upon his back, sinking toward the foot of the bed. There is generally a bright pinkish flush upon the cheeks ; sordes on the lips, gums and teeth ; the tongue is dry, brown, or red 28 THE AMERICAN PRACTICE OF MEDICINE. and glazed ; the urine is often retained from inaction of the blad- der ; the fieces pass off involuntarily ; the patient picks at tne bed-clothes, or grasps at black-spots—like Aies before his perverted vision, and finally becomes deaf and delinous. In fatal cases, death occurs about this time. The Eruption.—About the ninth day, or between the seventh and fourteenth day, the éruption begins to appear on the sternum and epigastrium, in the form of rose-colored dots, which are few in number, round, scareely elevated, and soon fade away into the hue of the skin, to be replaced by another crop, and this continues for some time. Occasionally very minute vesicles appear, looking like drops of sweat (sudamina), chiefly on the neck, chest, or over the abdomen. Température.—The température affords very important infor- mation in enteric fever, and materially aids the physician in his diagnosis. In this form of spécifie fever the température is grad- ually elevated, but in others it often abruptly rises. This gradu- ai élévation of température is one of the diagnostic sjTnptoms of typhoid fever. The température generally reaches 103.5° or 104° about the fourth or fifth day in this form of fever. The rash not occurring before the sixth, or sometimes not until the tenth or twelfth day, the diagnosis is somewhat diflicult without noticing this graduai rise of température. It is also a means of prognosis. If the température varies, that is, if the température is low in the morning and attains its maximum degree in the evening at the end of the second week, the attack will prove milder and of shorter duration; and if the température falls considerably in the morning, even'though the rise may be considérable in the evening, the prog- nosis may still be favorable. But should the température remain continuously high during the second week then the attack will will prove long and severe or fatal. One of the first indications of improvement in cases of persistent élévation of température is a décline in the morning température, notwithstanding the evening élévation may still be considérable. Sudden fall of température may resuit from diarrhœa or hœmorrhage. The décline of tem- pérature in enteric fever is more graduai than that of typhus. Complications.—Hœmorrhage is one of the complications of enteric fever, and may occur at any period of the attack. If large vessels are involved the hœmorrhage is apt to prove fatal at once, and if it does not it so exhausts the patient that he has no power to bear up against the fever. Diarrhœa also may so exhaust the patient that he cannot long survive. Ulcération of the bowels may progress until the coats of* the bowels are perforated and cause fatal peritonitis. This may happen the second or third week or during tedious and imperfect convalescence. The symptoms' of perforation of the bowels are pain and tenderness in the abdomen fevers: the exanthemata. 29 with swelling, nausea and vomiting. Congestion of the lungs is a complication that may occur; so may bronchitis. Treatment.—The treatment for the first few days should be antiseptic. Baptisia, in doses of from 3 to 5 gtt. (of the tincture) should be given every two or three hours. This remedy greatly modifies the disease. Such remédies as aconite and varatrum ex- ercise no influence over the disease in the outset. No remedy will control the fever while the spécifie poison is affecting the system. Antiseptic treatment should be well carried out at first, not only by giving baptisia internally, but also the sulphiteof sodium solu- tion should be used to thoroughly wash the body once or twice a day, tepid, if in cool weather, or cold if in very warm weather. Whenever the brain begins to manifest congestion, by intense headache, or delirium, then drop doses of belladonna should be given every half hour, or 3 or 4 gtt., every two hours until this complication is relieved. If there is great nausea at any time in the attack, ipecac, in doses of one or two drops of a good tincture, should be given every half hour until this trouble is relieved. In cases where there is extrême prostration, phosphoric acid, (diluted) should be used in small doses, say 15 to 30 gtt., in half a glass of water, every two or three hours. Where there is restlessness, sleeplessness, and t witching of the muscles, then scutellarin, in 2 grain doses will relieve that trouble. And if there be slight hœmorrhage from the capillaries, then sulphuric acid should be given, largely diluted in water, say two or three gtt. in a wine glass of water, three or four times a day. Towards the end of the second week, if the tongue becomes of a bright red color, then an emulsion of turpentine may be used, say five gtt., to a drachm of gum or elm mucilage, to be given every two hours. After the zymotic poison is removed from the blood, by antisep- tics, then aconite may be given in small doses, every hour, to con- trol local inflammations, or venous stasis of the blood in the bowels, lungs or brain. I usually add 20 to 30 gtt., to a glass of water, and give a teaspoonfull every half hour, or every hour. Where there is diarrhœa, with meteoristic gurgling of wind in the intest- ines, and a cadaverous odor about the body, then vegetable char- coal, in doses of 3 to 5 grains in water, every two hours should be given. The patient should hâve a nourishing diet ail through the attack, such as rice water, chicken broth, and if there is rapid loss of strength, boiled milk should be given-. In cases of great prostration, with feeble circulation, wine whey should be used as a diet. As soon as convalescence is fully established, the diet may then consist of beef tea or essence, toasted bread, rice and milk, but in small quantifies at a time. Typhus Fever.—Typhus is a spécifie form of acute fever, very highly infectious and contagious, and generally continues, under 30 THE AMERICAN PRACTICE OF MEDICINE. ordinary treatment, from fourteen to twenty-one days. It is at- tended with a confused léthargie condition of the faculties ot the mind, and a peculiar mulberry-colored éruption. It is often tne resuit of over-crowding, defective ventilation, and privation, hence cdlleà jail fever, ship and camp fever. Symptoms.—The precursory stage is usually short, causing the patient to take to his bed in three or four days. In this it differs from Enteric or Typhoid fever. The patient complains of soreness, fatigue, loss of appetite, frontal headache, and disturbed sleep. He is often seized with a chill or rigor, usually succeeded by dry heat of the skin, thirst, quick puise, dry, white, often tremulous tongue, scanty and high-colored urine, sometimes nausea and vomiting, heavy stupor, great prostration, and muscular pains (myalgia), irritability or restlessness, especially towards night, and if sleep occurs it is disturbed by dreams, and unrefreshing to the patient. The patient generally lies prostrate on his back, with a dull and weary expression of the face, his eyes appear heavy, and a dusky color is spread uniformly over his cheeks. In the advanced stao-e of a severe attack he lies with his eyes shut, or half closed, moan- ing, and too prostrate to answer questions. If requested to pro- trude his tongue he does it with an effort, incompletely, and the muscles are trembling and half rigid. The mouth soon becomes dry,sordesformonthelips, gums and tongue, the skin becomes mor- bidly hot (calor mordax) and dry, hearing grows very dull and is sometimes suspended for a time. During the first week the patient complains much of headache, noises in the ears, and finally becomes doaf, the conjunctivœ are injected, the pupils contracted, eyes very sensitive to light and generally closed. Ile becomes irritable and fretful. And about the eighth or ninth day the mind passes from a state of excitement to one of delirium. This symptom is usually more severe, and appears earlier in persons of cultivated mind than in those of a more common order of intellect. In the culti- vated, the delirium may become wild and maniacal, or low and muttering. Sometimes there is subsultus tendinurn: but in favor- able cases this symptom passes off in three or four days Conva- lescence may set m suddenly. From the fourteenth to the seven- teenth days the patient may fall into a long, deep, quiet sleep, and awake m twelve or sixteen hours quite refreshed. The powers of the mind gradually begin to dawn again, the countenance to assume a more tranquil aspect, sleep becomes natural, and conval- escence fui y established. Diarrhœa may occur in this disease but generally the bowels are confined, and the discharo-es are dark (not yellow ochre colored as m enteric fever), but may pass involunta- The PuLSE.-The puise in this feyer is very rarelv under 100 beats per minute, and very frequently we meet with * cases where FEVERS: THE EXANTHEMATA. 31 it runs up as high as 120, 130, or even to 140 per minute. Where it runs up as high as 140 per minute, in adults, it indicates great danger. As a gênerai rule, the puise gradually increases in fre- quency up to the ninth or twelth day, and in favorable cases, then gradually, or suddenly déclines. If the puise become more and more rapid after the ninth or twelfth day a fatal resuit may be prognosed. A falling puise is one of the first and most reliable indications of convalescence, the decreasing température is also a reliable indication of amendment. If the puise becomes slower, stronger and fuller we may know that the patient is convalescent. The fall of the température and the décline of the puise often take place without marked perspiration, or critical diarrhœa, or altération of the urine, or any very remarkable change othef- wise. The Eruption.—The éruption appears between the fourth and seventh days, and consists of slightly elevated spots, of a mulberry color, which disappear on pressure ; they are often scattered and minute, or they may be numerous, and large, and two or more may coalcsce. Thèse spots usually appear first on the abdomen, then upon the chest and limbs. Thèse spots remain with some changes of color, until the disease terminâtes. Pressure will temporarily obliterate thèse spots the first three days, but after that time they remain indelible, thus distinguishable from spots occurring in enteric fever, which disappear under pressure at any time during their existence. In fatal cases the spots of typhus fever remain after death. There is always a characteristic odor about the typhus patient, and his discharges; it is pungent, ammoniacal, and very offensive. Nervous Symptoms.—The name typhus (rù minister a few drops of tincture of ipecacuanha. If there is a bronchial cough and pain in the chest, bryonia, in doses of 2 to 5 gtt. every two hours, will relieve this complication. For the cough, if excessive, I give drosera rotundiflora (15 to 4§of simple syrup), dose 15, every three hours. The sequelse must be met upon the pathological indications. Treatment of Sequel^:.—Diarrhœa is apt to continue after the entire disappearance of the other symptoms of this disease. Il diarrhœa should be very troublesome, the tincture of pulsatilla, in doses of 3 to 5 gtt., every two hours often will suffice for this complication. If the eyes should be much affected by measles and remain so after the main force of the disease passes off, and there should be photophobia, then gtt. 3 of belladonna should be given every four hours, and that alternated with the tincture of euphrasia, in doses of gtt. 1 to 3. If there is an harrassing cough left after the measles hâve passed off, then gtt. 10 to 15 of the tincture of sticta pulmonacea may be given, alternated with dros- era rotundiflora. If the cough does not cease in a few days under thèse remédies, then from J to J gr. of bicromate of potassium may be given three times a day, alternated with a grain of sub- limed sulphur. For œdema, which often occurs in children who hâve been exposed too soon after measles, the acétate of potassium is useful in doses of gr. 2 to 3, every hour or two, until the kidneys act well, and if it fails to act, then gtt. 5 or 6, of the tincture of apocynum cannabinum should be given every two hours. Scarlatina.—Scarlatina, like the preceding diseases, is infec- tious and contagious. And such has been its mortality that it is much to be dreaded when in its most malignant type. It mostly affects children and young persons, and is not apt to attack them the second time. In point of mortality, scarlatina is second only to small-pox and typhus fever. In the year of 1863, the mortality in London, England, was 4982. In 1870, the rate of mortality in London alone was 108 per week. It is to be hoped the nature and cause of this dreaded scourge will be more thoroughly studied FEVERS: THE EXANTHEMATA. 35 and better understood, so that this alarming fatality among our children may be much curtailed at least. Varieties.—This disease may be properly divided into three varieties, or degrees of intensity, as scarlatina simplex, scarlatina anginosa, and scarlatina maligna. Thèse distinct degrees in the intensity of scarlatina dépend doubtless, in part, upon the consti- tution of the patient. Exposure to the contagion of scarlatina sim- plex may produce scarlatina anginosa or maligna. Scarlatina sim- plex is a scarlet rash with redness of the throat, but without ulcér- ation. This form will terminate favorably if properly treated. Scarlatina anginosa is a more severe form of the disease, with red- ness and ulcération of the throat, and a tendency to abscesses in the neck. In this form the température is high and the circula- tion is very rapid. The danger arises from the complications in this form of the disease, such as ulcérations of the throat, and ab- scesses of the neck, &c. In scarlatina maligna there is an extrême dépression of the vital powers, and great cérébral disturbance, added to the affection of the throat and skin ; the fever soon as- sumes a malignant type ; the tongue has a brown coating ; there is often low muttering delirium ; the throat présents a dark livid or sloughy appearance ; the éruption cornes out imperfectly or ir- regularly, or first appears, and then recèdes; and is of a dark color instead of a bright scarlet color. This form of the disease is very fatal. General Symptoms.—Scarlatina commences with a chill, to be succeeded by a hot fever, nausea, or vomiting, very rapid puise, thirst, frontal headache, and sore throat. In about forty-eight hours after the occurrence of thèse symptoms, the characteristic rash makes its appearance, first on the breast, and then gradually extends to the neck, face, trunk, and thence over the limbs. The éruption is of a bright scarlet color, and consists of numerous red points or spots. Thèse spots diffuse themselves uniformly over the skin, or appear in large patches, more or less irregular, on différent parts of the body. The color of the skin disappears on pressure, but returns again. The tongue is characteristic ; it is first coated, the tip and edges are red, the papillœ are red and rather elevated, and after a time it becomes clean and rather raw looking. A diffused redness, sometimes of a dark claret color, covers the mouth, faces and throat, and disappears as the fever subsides. About the fifth day, the efflorescence generally begins to décline, and disappears'entirely about the eighth day, or at most, about the ninth day. In most cases, desquamation of the cuticle takes place in the form of a scurf from the face and trunk ; but in large Aakes from the hands and feet, occasionally coming away entire like a glove or slipper. The disease, however, does not always pursue this uniform course, It sometimes occurs without 36 THE AMERICAN PRACTICE OF MEDICINE. the rash, or sore throat, and the éruption is livid and partial, and attended with such extrême prostration that the patient succumbs in a few hours under its violence. _, Distinctive Features.—The rash, already descnbed.-—Ihe high température of the body, which is frequently 105 or 106 F. —The prominent papillœ and redness of the tongue, which is comparai to the strawberry in color.—A peculiar glistening stare of the eyes, easily distinguished from the liquid eye of measles.— The sore throat, which is swollen around the soft palate and ton- sils. Thèse are the diagnostic peculiarities of scarlatina, but they vary in intensity in every épidémie Visitation of the disease. Cause and Modes of Propagation.—The earliest source of scar- let fever is traceable to Arabia. The nature of the poison is subtle. It is doubtless transmitted by formations in the clothes, bedding, carpet, or in dry goods, and physicians often convey it from fam- ily to family. Disinfection and thorough ventilation tend to des- troy this poison, and a température of 205° Far., will kill it. The primary fever gives rise to the infection, which continues until complète desquamation takes place. Treatment.—This disease requires very early and prompt treatment, the neglect of which by the physician gives rise to the worst cases we meet with. Cases of a mild type, left to them- selves, may terminate in mortification of the throat, nose, cheek, or sometimes the limbs. In scarlatina simplex, from 3 to 5 gtt. of belladonna should be given to adults every four hours, and 1 to 2 gtt. of tincture of aconite every one or two hours, according to the amount of fever. From children from | to 1 gtt. of belladonna, and \ to \ gtt. of aconite is sufficient. If tnere is burning and itching of the skin it may be relieved by rubbing it well with a salty bacon skin. If there is constant and violent vomiting ; severe headache ; intolérance of light ; virtigo ; very hot red face ; rapid small puise ailanthus, in doses of 1 to 2 gtt. of the tincture every two hours, will be of material service. The above symptoms show a malignant tendency, whi^h, if not arrested by the ailanthus, may be combated with baptisia, in doses of 1 to 5 gtt., according to the âge, etc. In the anginose form, if there is rapid swelling of the throat and stinging pain, apismel, in doses of 1 to 2 o-tt. every two hours should not be forgotten. If there is great rest- lessness and a tendency to convulsions, then gelseminum in doses of 5 to 8 gtt. according to âge, should be given three or four times a day. Where there is great prostration of stren«;th, carb. of am- monium, in doses to suit the âge of the patient, should be'admin- istered every two hours. If the throat is very sore, and the breath fœtid, the patient should gargle with a solution of sulphite of so- dium, and alternate with a tea-spoonful of cayenne everv two hours. In the malignant form, small doses of belladonna must FEVERS: THE EXANTHEMATA. 37 not be forgotten, say J to J gtt. for children, and 1 to 2 gtt. adults, every four hours, to protect the brain and skin, and to aid in con- trolling the fever, as it exerts a controlling power over this dis- ease. Where there is rapid prostration or emaciation, cold, clammy sweats, weak puise, with burning heat, a few doses of Fowler's Solution should be given, to aid in eliminating the poison through the kidneys. At times, from 2 to 5 gtt. of tincture of camphor, according to âge, may be used. to support the patient's waning strength. If typhoid symptoms appear, then rhus tox. should be administered in small doses. Small Pox : Varioloid.—Thèse are highly infectious diseases, the infectious material being contained in the pustules as well as in the exhalations from the patient's body. Ail we know of this infectious virus is its effects upon the organism. It is readily re- produced again whilst it develops its peculiar phenomena, and thus propagated from person to person. Infection takes place by immédiate contact with the patient, also by remote means. The viris is often carried in clothes or goods that hâve been exposed to the exhalations from the body of a small-pox patient. This infection is very persistent in its nature, and often retains its in- fectious power for several years, if it be excluded from the open atmosphère; and not exposed to intense heat. I knew a case in which small-pox was communicated to some persons engaged in cleaning out an old cellar, under a house where small-pox patients had been kept some two years previously. There appears to be no great différence between the virus of small-pox and that of varioloid, except in their intensity, either may cause the one or the other form of disease. This doubtless dépends very much upon the susceptibility of the subject, and the adaptation of the virus for a greater or less development of its ef- fects under certain favorable or unfavorable circumstances. Vac- cination seems to destroy, to a great extent, the prédisposition to the disease ; if not completely, at least partially. Course and Symptoms.—After some nine days of incubation, the first stage begins with severe chill, or repeated chilly sensations, which are followed by a high fever, headache, sometimes delirium ; a thickly furred tongue, generally white ; a deep flush upon the face ; a hard fréquent puise ; a severe bruise-like pain over the body, especially in the back and loins ; more or less pain and ten- derness in the epigastric ; thèse are premonitory symptoms, and are very seldom absent. And when the pain and vomiting are excessive and continuous, they indicate that there will be a severe form of the disease. On the third or fourth day, the éruption often is so minute as to escape notice, it appears in the form of red spots, or small hard pimples, which feel like shot in the skin. This érup- tion appears first on the face, neck and wrist, then on the body 38 THE AMERICAN PRACTICE OF MEDICINE. and Anally on the lower extremities. Upon examination, the érup- tion may be seen upon the palate, and is sometimes found upon mucous membrane of the larynx, trachea, and bronchi, giving nse to soreness of the throat, salivation, cough, painful expectoration, and to great hoarseness of voice. Thèse little pimples gradually increase in size until about the eighth day from the Arst invasion of the fever ; the contents, at first watery and transparent, change to a yellowish matter as the pimples become ripened into pustules. Thèse pustules are depressed in the centre, and are surrouuded for a short distance by a rose-red areola. While the pustules are filling up, therc is swelling of the eyelids and face, sometimes so much so as to deform or obliterate the features. About this time there arises from the patient a peculiar disagreeable odor, which is char- acteristic of this disease, so much so the disease might be known by this odor alone. There are always more papulœ comparatively on the face than on any other part of the body, and when they are so nu mérous as to coalesce, they coalesce in the face ; rarely, if ever, on the rest of the body. Variolœ confiuentes can only be seen on the face, whilst elsewhere the papulœ are isolated—variolœ dis- cretœ ; or merely touch each other—variolœ cohérentes. In from nine to ten days from the first invasion the pustules are matured. And simultaneously with this éruption on the skin, an éruption appears on the mucous membranes, and that on the conjunctiva causes a flow of tears, photophobia, and in some cases a total clos- ure of the eyes for several days, and sometimes total blinduess. When the éruption is fully developed, the pains lessen, the fever decreases and the patient is much relieved. But in cases of vari- ola confluens only, the relief is not marked. When the pustules are maturing they eularge, the surrounding skin intiames and swells, and a red areola forms around each pustule. The redness and swelling coalesce from ail directions, and constitute a diflused erysipelatous appearance of the whole face, greatly clisfiguring the patient. This process gradually spreads over the en tire body, in* the same order in which the éruption spreads. The patient com- plains of tension andburning of the skin, and the affections of the eyes, mouth, throat, larynx, and genitals increase in the same order. The heat of the body now rises again, and is frequently alternated with chilly sensations ; it rises according to the inten- sity of the inAammation of skin, and does not abate until the der- matitis reaches its acme. This is the secondary or suppurative fever. It may assume a typhoid type. In other cases it may combine with a hœmorrhagic diathesis, and the pustules become bloody, and bloody extravasations take place in the skin or hse- morrhages may take place from mucous membranes, constituting hœmorrnagic or septic small-pox, and Anally portions of the inAamed parts may mortify, constituting gangrenous small-pox. There FEVERS: THE EXANTHEMATA. 39 may be a localising of the virus in the serous membranes, produc- ing stitching pains in the side, cough, bloody expectoration, pneu- monia, pluritis, and other effects. Ln extrême cases, there is peri- carditis, menigitis, suppurative inAammation of the joints, perios- titis, abscesses, suppuration of the lymphatic glands, suppuration of the eyes, and croupous exudations on the larynx and trachea. About the twelfth day the pustules burst and discharge their con- tents, which dry and form hard, brownish crusts. The fever then gradually lessens, and ail the painful symptoms disappear. The crusts of the pustules gradually drop off; they usually leave dark red somewhat elevated spots, which, after some time disappear. But where there hâve been deep-seated ulcérations, they leave uueven scars, which, at Arst are red, but finally become white. In some grave cases of confluent small-pox the scars are larger and deeper, and resemble the scars of bad burns. This is the usual course of variola. Varioloid runs a similar course, but ail the symptoms are much milder ; and its stages are much shorter ; and its suppurative pro- cess is so mild, that it seldom leaves distinct scars. But even varioloid is milder at times than at others ; like variola, it is influenced much by the diet of the patient, his peculiar condition at the time, and the température and other atmospherical peculi- arities at the time of invasion. Treatment.—At the beginning, if there is high fever, with alternate chills, dryness of the skin, rapid puise, headache, nausea and vomiting, pain in the back, aconite, in small and repeated doses, will do great good, 20 gtt. to 4 5, of water ; dose, a tea- spoonfull every hour through the course of the disease, when fever is prominent. If the puise is very full and rapid, veratrum viride may be substituted for aconite. Digitalis, in doses of 10 to 15 gtt., and 1-1 Oth gr., sulphate of zinc, has answered me in many cases. In ail cases, where there is a severe headache, delirium, intolérance of light, I give a dose of belladonna, say 3 gtt., every three hours until thèse symptoms are subdued. Where there is excessive swelling of the face and eyelids, with erysipelatous red- ness, stinging and burning pain, apismel, in doses of 3 to 5 gtt, every one or two hours, will do good service in ail cases. In those dangerous cases, where the swelling suddenly sinks in and the pustules suddenly dry up, showing a low state of the vital forces, tincture of camphor in doses of 5 gtt., every half hour or hour, will aid in sustaining the patient. Where there is great soreness of the throat, with redness and itching, hydrastis is a val- uable remedy. It is said to prevent pitting to a marked degree. The Auid extract may be given in doses of 5 to 10 gtt., every hour, or l to | gr. of hydrastis as often. Sarracenia—the pitcher plant, is believed to shorten the course of the disease considerably. It 40 THE AMERICAN PRACTICE OF MEDICINE. may be used freely in the form of infusion. Where there are glandular swellings about the neck, sore throat, and hœmorrnages, the muriate of ammonium, in small doses, will aid in controlhng thèse complications. Where there is asthenia, with great debility, burning heat, fréquent small puise, intense thirst, restlessness, îr- regularly developed variola, with a typhoid tendency, or a great tendency to hsemorrhage, with a livid areola, then Fowler s solu- tion, in doses of 2 to 4 gtt., every four hours, will aid in bringing such cases to a favorable termination ; and this remedy should not be forgotten in those grave cases. Where there are other distinct typhoid symptoms, besides those above described, such as great fetor of the body and breath, the pustules thick upon the palate, tonsils, uvula and in the nasal cavities, but very scanty upon the skin, profuse salivation great prostration and excessive pains across the loins, then baptisia will be of good service, in doses of 2 gtt., every three hours. This may be alternated with rhus tox. in doses of 2 gtt., of the tincture every three hours. Where there is great nervousness, with con- vulsions, or a tendency thereto, gelseminum, in doses of 8 or 10 gtt., every three hours, will be demanded. The patient's diet must be strictly guarded until well. Vaccinia.—Vaccinia is a disease of the cow, which by inocu- lation, was discovered by Jenner, a century ago. It protects against small-pox generally. By vaccination the disease vaccinia is artifically introduced into the human system, for the purpose of protecting it against small-pox. According to statistics, in Sweden, forty years before Jenner discovered the prophylactic power of vaccination, about 2,050 persons died annually with small-pox ; after vaccination only 158 died annually. In Berlin, before vaccination was introduced, 3,422 ; but since vaccination was instituted, about 176 die annually. In Paris, prior to the introduction of this prophylactic measure, about 80 out of every one hundred died of small-pox ; since its introduction, about 14 to 16 die out of every hundred cases. The British army scattered ail over the world, is of course, greatly exposed to this disease, but is so protected by vaccination, that but one in one thousand is at- tacked, and less than one in ten thousand die of the disease. (See the London Lancet, August 15th, 1863.) Vaccination, to be pro- tective, must be properly performed, and good, fresh lymph from the cow or from a child, free from any constitutional taint must be used. It should be put in with a clean lancet or ivory point, which must make four or five scratches, so as to leave at least four good scars ; this is important, as one or two scars is not a certain protection. m Intermittent Fever.—This type of lever is caused by a pecu- liar poison, which, under certain conditions, originated in marshy FEVERS: THE EXANTHEMATA. 41 lands, swamps, low régions near rivers, newly-settled places which arc being cleared and cultivated, the vicinity of canals newly dug, and régions which seemingly lie dry, but contain a great deal of water underground ; the drier the surface the greater the effluvia from underneath the porous and cracked soil. This poison is usually called swamp-miasm or malaraia. Its nature is unknown, and its effects differ according to certain atmospheric conditions at the time of its production. Although swamps and damp low régions are necessary for its development, yet thèse seem not the only conditions that can generate this peculiar poison. Intense heat, decaying vegetable matter, and alluvium, do not explain the présence or absence of this poison, for there are sections of country where thèse conditions do exist where a sunicient quantity of this miasma is not produced to generate fever ; on the other hand, we find certain districts in which this fever prevails frequently, where there are no swamps or alluvium. Occasionally, there are sporadic cases of fever in places where there is no apparent cause of miasma. This fact is difficult to explain. One peculiarity of this poison is its gênerai invasion. ISTo âge or sex is exempted from its influence ; the liability to repeated attacks increases with every invasion, and persons who hâve had fréquent attacks are subject to chronic en- largement of the spleen, and malarial cachexia. In regard to the stage of incubation, it varies according to the intensity of the poi- son, and the stronger or weaker résistive force of the constitution of the subject. In some cases the disease is developed at once, in others it seems to linger in the system some ten or fifteen days, or longer. There is most generally a period of gênerai malaise, and a disturbance of différent functions, before the apyrexia and par- oxysm of fever manifest themsel ves. This period of indisposition also differs in différent individuals. This form of fever has three distinct stages, the chill, the hot stage—fever, and the sweat. The chilly stage may last but a few minutes, or it may be prolonged three or four hours, or even longer. It is a stage of great dépres- sion, in which the blood seems to leave the surface and crowd the internai organs, and in which the venous blood is stagnated in the capillaries. This causes the chill. The skin is cold, shriveled— cutis anserina. The internai température is increased one or two degrees, or even more. The patient is apt during this stage to suffer from headache, thirst, pain in the back and limbs, and op- pression. The hot stage—the stage of fever, creeps on slowly, still intermingled with chilly sensations, until finally the whole surface is in a glow of heat, the température rising several degrees. This stage lasts from two or three, to as much as eight and even to twelve hours in some rare cases. The third stage, that of sweat, finally ends the paroxysm, greatly to the relief of the suffering patient, who now feels comparatively comfortable. But this apy- 42 THE AMERICAN PRACTICE OF MEDICINE. rexia is seldom free from ail morbid feelings and manifestations. When an intermittent fever develops its regular paroxysms in thèse three well marked stages, and in regular order, it is term€*j intermittens compléta ; when one of thèse is wauting^it is called intermittens incompleta ; and if the order of its stages is reversed, that is if the paroxysm commences with the sweating stage, and ends with the chill, it is termed intermittens inversa. When the paroxysms come on every twenty-four hours, the attack is called a quotidian fever ; if twice in twenty-four hours, it is called a tertian fever ; and if three times in twenty-four hours it is called a quartan fever. When it occurs every seventh day, it is called intermittens septima. Sometimes it changes from one type to another, that is, a quotidian changes into a tertian, or a tertian into a quotidian. The disease, if neglected, may terminate in dropsy. Treatment.—While the préparations of cinchona are valuable in certain stages of this disease they are not spécifie against it, and had better be dispensed with in many cases, rather than be indis- criminately used in ail instances as they hâve been. There are functional and structural lésions in many cases, which demand spé- cial treatment at the outset. Each of thèse lésions should receive its appropriate treatment at once. For the simple élément of pe- riodicity—as an antagonist against the malarial poison, we may use the sulphate of cinchona or of cinchonidia, not in toxical doses, as has too often been done, but in moderate médical doses, of say gr. 5 to 8, in divided doses, ofgr. 2 every hour. During the chill ■ but little can be done, except to keep the patient as warm as pos- sible with hot packs, &c. As soon as the hot stage sets in, the ad- ministration of the tincture of gelseminum, in doses of gtt. 10 to 15, every two hours should be commenced and continued until the fever subsides. If this does not producc a remission of the fever, after the second dose, one drop of aconite (tinct.) should be added to each dose of gelseminum. In some cases the tincture of ipecac, in doses of gtt. 1 to 2, may be given until the complication is con- trolled.* The above course will usually meet the indications at the outset of an attack of intermittent fever, but it often happens that the physician will hâve cases that hâve been maltreated, or neglected, and which hâve resulted in chronic intermittent fever, with gênerai debility, prostration, anœmia and diarrhœa. In such cases the tincture of alstonia constricta, in doses of gtt. 5, every two hours, during the interval, is useful. In old chronic cases, where the liver and spleen hâve become involvedas they frequently do, I find that an occasional dose of euonymin podophyllin, say gr. \ of the former and gr. | of the latter, every six hours, 'until a mild aperient effect is produced, is necessary. I find that the *See Author's New Remédies. FEVERS: THE EXANTHEMATA. 43 euonymin is not only one of the most powerful stimulants to the liver, but is also a mild anti-pcriodic and tonic. Where amenda exists, I use iron and helonin, until the blood is enriched to its normal standard. In some cases of long standing, in addition to iron, I find Fowler's solution, in doses of gtt. 3 to 5 three times a day bénéficiai, in fact some cases are very slow to yield to any other remedy. As tonics, afteï the fever lias been broken up, I find gtt. 20 of the tincture ptelea and sabbatia stellaris, three times a day, valuable in restoring the patient's strength. Thèse drugs are also efl'ective in some chronic cases, in breaking up the fever, as they are both mild anti-periodics as well as superior tonics. In some old chronic enlargements of the spleen, causing fréquent re- lapses of this form of fever, I hâve given the comp. tincture of iodine, in doses of gtt. 5 to 6, three times a day, and hâve thus succeeded in making a final cure. Prof. Roberts Bartholow praises the anti-pyrelie powers of resorcin. It is doubtless a val- uable anti-fermentive, and as such, will prove valuable in this and other d iseases. The dose is, in ordinary cases, gr. 5, every two hours. Benzoate of sodium is also a valuable anti-pyretic and has proved effective in this, as well as in many other diseases. Dr. Klebs, of Germany, used this^article as an antiseptic in several diseases. Pilocarpine is also highly extolled as a diaphoretic, in eliminating the malaria. Apiol is also used by some writers. I hâve used euca- lyptus in chronic malarial poisoning, with good effect, in doses of l to 15, three times a day. The carbazotate or picrate of ammo- nium has been highly thought of as an anti-periodic* in doses of gr. £ four times a day, or about one grain per day. In chronic cases I hâve often used ptelea trifoliata, in doses of 15 three times a day with success, for keeping the liver and bowels regular in ac- tion. Rémittent Fever.—Rémittent fever differs from intermittent fever in this, that it has no apyrexia, but in place of it there is merely a réduction of the fever, which is again succeeded by an- other exacerbation. In very grave casées the remission is so slight as often to be mistaken for continued fever. Rémittent fever may be separated into three types, that is, the lightest form, the grave form, and the gravest form. The lighest form commences after the expiration of a stage of incubation, with a chill which is fol- lowed by a violent fever and some gastric symptoms, enlarged spleen, in some cases more or less jaundice, herpès labialis, head- ache, pain in the limbs, dizziness, ringing in the ears, epistaxis, great debility, and sometimes bronchial irritation. This fever may last for three weeks, or it may change, as it often does, into the intermittent type, for thèse are but degrees of one and the same *See Author's New Remédies, Page 113. 44 THE AMERICAN PRACTICE OF MEDICINE. disease. The graver form is characterized by the remissions grad- ually ceasing and the fever becoming continuons, which causes the disease to resemble typhus fever. The patient becomes dehr- ious or lies in a profound stupor, his tongue becomes dry and his spleen is very much enlarged, and often tender upon pressure. This form lasts from ten to fifteen. days. It may get better, and if so, it terminâtes in intermittent fever. If the disease does not get better the patient is apt to die in a comatose state, or diarrhœa or dysentery set in. The gravest form is characterized by a very high degree of adynamia. The patient rapidly sinks into a col- lapse. This form very soon gives rise to functional disturbances in almost ail the vital organs. In some cases there is jaundice, in others, epistaxis, hsematemisis, hœmaturia, or albuminaria, or sup- pression of urine; in others there are discharges from the bowels resembling choiera. The liver and spleen are much enlarged, ter- minating sometimes in inflammation and suppuration. The se- rous tissues show exudations upon them, and the skin may become gangrenous and slough off in places. There is a form of malignant rémittent fever now styled typho malarial fever, which is the con- gestive fever of some of the old authors. This is however a new name for an old disease. This pernicious intermittent is charac- terized by greater violence of symptoms and longer duration. The stagnation of the venous circulation is greater, causing collapse, which resemble the appearance of choiera. This form prevails where there is great solar heat and an exubérant supply of marsh exhalation, out of which is elaborated this intensely poisonous ef- Auvium, which is so depressing to the whole vital system. Treatment.—The treatment must be prompt to be successful. If there is a comatose condition, one or two drops of belladonna must be given every hour until the symptom is removed. In the adynamic form arseniate of quinia should be given in doses of or. J every two hours, alternated with gtt. 5 of saturated tincture^f camphor to support the vital powers. If thèse fail to arouse the circulation, then gtt. 30 of tincture of xanthoxylum should be given every hour alternated with gr. 5 of ciuchonidia. The skin should be well rubbed with mustard-water, in which powdered cayenne is thickly sprinkled, to keep up the capillary circulation, thereby relieving the internai organs as much as possible ; other- wisedeath may resuit. In the so called "typho-malarial fever" an antiseptic treatment should alternate with other indicated reme- dies.^ The sulphite of sodium, sulphurous acid and baptisia should be given at the outset, to counteract the septic tendency. If there is sordes on the teeth then muriatic acid, in doses of gtt 1 to 2 every two hours, may be given in half a wine glass of water If the fœces are slimy and very offensive, gtt. 5 of baptisia should be given every three hours, or gtt. 2 every hour until the stools cease fevers: THE EXANTHEMATA. 45 to be offensive. In convalescence, the patient's diet must be nour- ishin°-, but of easy digestion and unheating. In cases where the system is so profoundly affected by the poison that there is a want of reactive force, and hence the internai organs are liable to be- come congested, it is often necessary to apply strong washes of mustard and cayenne to the skin, to stimulate the capillary cir- culation. At the same time some internai stimulant may be given, such as the tincture of xanthoxylum fraxineum and nux vomica, say, gtt. 30 to 60 of the Arst named, and gtt. 5 of the nux vomica every two or three hours. In many cases that I treated in mala- rious régions, some years ago, I found it diflicult to get a complète remission, in order safely to give the antiperiodics. In thèse cases I usually gave gtt. 1 of tincture of aconite and gtt. 25 to 30 of tincture of gelseminum, every three hours until I procured the desired remission, then I proceeded to give quinia, or one of the other préparations of the bark, in doses to suitthe patient's con- dition. I hâve found cinchonidia mnch less liable to affect the hearing and sight than quinia. I hâve also found the sulphate of cinchpnia a milder remedy than quinia, but slower to act. Yellow Fever.—Yellow fever obtains epidemically, but only duriuo- the hot season, and rarely, if ever, in localities over six hundred feet above the level of the océan. It generally prevails in low, level land near the sea-coast, and mostly in very hot ch- mates. It may break out on board of ships, if they bave been long at sea and are condition to favor its production, such as want of cleanliness, foui water, badly ventilated sleeping-rooms, easily de- composable freight, or excessive overcrowding with passengers. The virus producing this form of fever is altogher différent from ordinary swamp miasma, as it is portable from person to person and from place to place, in ships, etc. Those most subject to this fever are the strong, young, full in habit, and such as are not ac- climated. Whites are more liable than Créoles, and Créoles are more so than Xegroes ; Indians are the least liable of ail races. The stage of incubation is generally short, sometimes lasting only a few days, and agaiu twelve or fourteen days. The disease itself runs an acute "course, lasting from three to ten days. There are three distinct stages of this fever: (1) The fever paroxysm ; (2) the period of remission, with icteros and slownessof puise; (3) the anyretic stage, with hamiorrhage, suppression of urine and col- lapse. The disease is generally ushered in suddenly by a chill, which is due to the depressing effects af the virus. This fever soon reaches a very high degree, to be followed by dryness of the skin or sweat. This sweat, however, does not lessen the heat, or the hardness of the puise. Violent headache and pain in the eyes attend this stage; the eyes are red, watery, and of glassy appear- ance. There is also, at this time severe pain in the lumbar régions 46 THE AMERICAN PRACTICE OF MEDICINE. and extremities. The patient is restless and has nausea, vomiting, and great thirst, with soreness in the epigastrium. The discharges from the bowels are retarded, and often ofa light color,sometimes becoming soft, prof use and bloody ; the urine also is scanty and of a dark red color. In some cases there is epistaxis. Mental dé- jection and physical prostration with great restlessness are also symptoms. This stage may last but one or two days, or it may continue four or five days ; then follows the second stage. The patient now feels better. Ail the very distressing symptoms cease and the puise falls to seventy or eighty per minute. In favorable cases this is the commencement of convalescence. In grave cases, however, the nausea and soreness in the stomach continue, and the skin and eyes begin to assume the characteristic icteroid hue. The puise sinks below its normal standard, and the patient feels ex- hausted, and wears a stupid expression of countenance. Thèse symptoms ail increase in the third stage. In a day or two the soreness at the pit of the stomach turns into a severe burning sen- sation; the tongue becomes dry, the thirst violent, and the nausea and vomiting grow more violent. At first there may be nothino- thrown up but a sour fluid, but gradually the contents of the stom- ach become mixed with blood, and at last the vomit consists only of pure, decomposed black blood, (the characteristic black vomit.) At the same time blood passes from the bowels, and, in some cases, from the nose, mouth, kidneys and capillary vessels under the skin, forming petechial spots upon the surface. The sécrétion of urine is now scanty, or ceases entirely. The patient is in great agony ; there is either clear consciousness, or a state of delirium. This exhaustion increases very rapidly, the skin becomes darker and the température of the body rapidly déclines, until the patient either dies suddenly in a comatose state, with delirium and con- vulsions, or retains his sensés to the latest moment of extrême ex- haustion and agony, and dies gradually. This is the ordinary course of yellow fever, but there are cases, which at first are so mild that the patient only feels unwell, and is not sick enouo-h to take to his bed. Finally, ail at once, he is seized with vomitino-of blood, and rapidly sinks into a collapse. Treatment.—Treatment should commence with antiseptics. Baptisia, in doses of gtt. 2 to 5 shonld be given every two hours, as soon as the first symptoms appear, and continued throughout the attack. To control the fever, there is nothino- better than small doses of aconite, gtt. £ to 1, every hour. As soon as nausea and vomiting set in, Fowler's solution, in doses of gtt. 5 should be given every six hours, or gtt. 1, every hour. If there is menin- geal symptoms, such as headache and pain in the back of the neck then gtt. 3 of tincture of belladonna, should be given every three' hours, until they are relieved. If there is great dépression and FEVERS: THE EXANTHEMATA. 47 coldness of the surface and extremities, gtt. 2 or 3 of the saturated tinct. of camphor, should be given every hour, until its stimula- ting effects arouse the circulation, and thereby prevent the col- lapse. In some cases in Southern Georgia, pure alcohol, well di- luted with water, given so as to stimulate the patient, has proved the most successful of any treatment yet tried. CHAPTER III. DISEASES OF THE RESPIRATORY ORGANS. Bronchitis.—This catarral inflammation is characterized by a hyperœmic state of mucous tissue of the bronchial tubes, giving rise to excessive sécrétion, and when long continued, causing a graduai change of the texture. The mucous membrane appears ecchymosed, injected, infiltrated, opaque, swollen, and covered with abnormal sécrétion. The finest tubes are not unfrequently completely closed, so that the ingress of air into the air-cells is obstructed, and the blood as a natural conséquence becomes poisoned with the uneliminated carbon. Especially is this the case when the disease attacks infants, or very young children who are unable to clear the obstructed air-tubes. In chronic cases, hy- pertrophy of the mucous membrane takes place, the muscular fibres lose their elasticity; and the bronchial tubes enlarge, some- times evenly, or in other instances only in short sac-like tracts, which is called Bronchiectasis. Inflammation may attack only the larger bronchi, or only the smaller oues. If the former be the case, there will be a tickling under the sternum, and a burning or sore feeling ; whilst where the smaller tubes are affected, thèse symptoms do not exist. This disease is attended with more or less fever, whether the larger or smaller bronchi are involved. The fever, in many cases is of a high grade. The disease is usually preceded by more or less chilliness, alternated with burning heat. without much increase in the thermometrical indications ; thus it may be distinguished from inflammatory fever, which commences with an increase of thermometrical heat. This disease like catarrhal fever, often assumes a typhoid form, especially in weak children and very old persons. The patient soon becomes deliri- ous and comatose ; the tongue is dry, puise small and fréquent; and an exhausting perspiration cornes on. There is a character- istic rattling in the trachea, which is caused by the inability of the patient to throw off the phlegm, resulting from paralysis of the muscular fibres of the bronchi. This is theso called death-rattle; and is a certain indication of a fatal termination. This form of bron- chitis is called by old writers pneumonia notha. There is another form of bronchitis, which attacks children, especially those at the breast. It involyes the smallest branches of the bronchial tubes and is called capillary bronchitis. This is a dangerous form of catarrhal bronchitis, and often terminâtes fatally under the best devised treatment. As the smaller air-tubes are attacked they be- DISEASES OF THE RESPIRATORY ORGANS. 49 corne impervious to air, and, consequently, the carbon is not ex- pelled, and an insufficient supply of oxygen is inhaled. In thèse cases the respiration becomes very diflicult, with hissing and rattling noises in the chest, and painful coughing spells, driving the blood to the face, and drawing up the lower ribs as in croup. When new-born infants are the subjects of this form of bronchitis it soon develops itself into a higher stage. The child is too feeble to detach the accumulating mucous, the lungs become closed up, and the skin grows blue and gray in color ; the nose becomes pointed, the eyes dull ; the respiration quite superficial, and there is great danger of the disease terminating fatally. Physical Signs.—Percussion reveals but little in this affection; the sound is similar to that of health. Auscultation shows a vesicular murmur, which soon becomes loud, harsh and coarse. The expiratory murmur (scarcely audible in health), now becomes louder than the inspiratory murmur. When the disease is con- fined to the larger bronchi, the vesicular murmur is hidden by the louder bronchial breathing. As soon as the mucous membrane becomes covered with the sécrétion, there is a fine bubbling, hiss- ing aud whistling sound. When the sécrétion is in the larnyx, trachea, or the larger bronchial tubes, the rattling noise is heard ail over the chest, and, consequently, we cannot well judge of the extent of the sécrétion by the noise in respiration. If the finer bronchi only are involved, and the respiration is feeble, the rattling noise is not heard. In vigorous respiration, if the vesicu- lar murmur is absent, it dénotes either a large quantity of mucus in the bronchi, or else she closure of the finer tubes by the swell- ing, which prevents the air from passing into the air-cells, Bronchitis is generally not attended with severe pain, but is ac- companied by a sore, raw, and sometimes burning sensation in the chest. The sputa may be slightly streaked with blood in cases of a grave type, but is not bloody as in pneumonia. We meet with every grade of this disease, from the most severe form to the mildest. It often prevails in a mild form, and is called catarrh, influenza or grippe. Again it appears in a grave form, attended with high fever, and proves fatal to old people and young children. It prevails epidemically in some localities, and thèse visitations generally prove severe in the southern parts of the United States. It is especially rife in localities infested with malarious diseases, and in such localities is generally very severe. Treatment.—In the commencement of catarrhal bronchitis, with high fever, dry skin, restlessness, headache, burning and soreness in the chest, I hâve fonnd aconite in closes of gtt. f to 1 every hour for adults, and gtt. £ to \ for children, according to their âge, very useful. It bas a controlling effect over ail catarrhal fevers and inflaml^iftrfô,c^9^$t>ld never be forgotten. 4 (£&?nâZ L'*4 50 THE AMERICAN PRACTICE OF MEDICINE. In children, if the disease is attended with a hot skin, a tendency to perspire, a painful cough, causing the child *° 9J7» sieeploss- ness or starting in sleep, then administer a drop of belladonna once in four hours, until the child becomes quiet. In very young infants gtt. £ to J is sufficient for the dose. If the pain in the chest is severe, the cough dry and tight, or if there be pain at the epigastrium, in the pleura, or about the chest generally, then bryonia, in doses of gtt. 1 to 2, may be used with good effect. Where there is much rattling in the chest, convulsive cough, with vomiting of phlegm, dyspnœa or nausea, with pale face, then I give gtt. 1 tincture of ipecac, to children, and gtt. 3 or 4 to adulte, every half hour, until the symptoms are controlled. If there is croupous inflammation, a dry, hoarse, barking, hollow cough, then the tincture of sponge, in drop doses, every two hours, will be found effective. If there is great anguish, suffocation, palpita- tion of the heart, oppression of the chest, diflicult breathing from tightness of the chest, and spasmodic cough with thick yellow sputa, I prescribe digitalis in doses of gtt. 1 to 2, alternated with gtt. 2 or 3 of cereus grandiflorus, every one or two hours, accord ing to the urgency of the symptoms. Adults may take gtt. 5 to 10 ofdigtalis, and gtt. 10 to 15 of cereus. In capillary bronchitis with diflicult respiration, rattling of mucus in the chest, short fits ofcoughing, and bright yellow thin stools, showing inaction of the liver, give a few drops of tincture of chelidonium every hour. If the sputa is very diflicult to cough up chelidonium may be alternated with gtt. 1 to 2 of incture of sanguinaria, gtt. 4 to 6 is the proper dose for adults, well diluted with simple syrup. I usually give the syrup of sanguinaria, made by adding 1 % of tincture to 9 3 of simple syrup. The dose for children is from gtt. 8 to 12, and for adults gtt. 30 to 60 in water. This is one ol the most certain and harmless expectorants we hâve, as in médical doses, it does not irritate the stomach as squills and senega are known to do, but acts as a tonic. In the advanced stage, attend with excessive accumulation of phlegm, small doses of tart. emetic are indicated, gr. ^ to \. The hypophosphites are also valuable in this disease. Whooping Cough.—This is also a specie of bronchitis, but of a purely épidémie nature, not a mère nervous affection, as has been stated by some old writers. In the incipient stage it is difli- cult to distinguish it from the ordinary bronchial catarrh ; but later on, the paroxysms of coughing are accompanied by the char- acteristic whoop, which consists of a crowing inspiration caused by a spasmodic closure of the glottis, followed by quick, short, expir- ations in succession, which generally end in the éjection of masses of tough phlegm. Thèse paroxysms come on as often as the phlegm collects in the bronchi. Respiration is so much obstructed DISEASES OF THE RESPIRATORY ORGANS. 51 that cyanotic symptoms supervene, and swell the veins ; in some cases, the brain is so congested, that convulsions take place. Oc- casionally epistaxis occurs, and the ears and mouth may also bleed more or less. Whooping cough has been divided into three stages: the catarrhal, the convulsive, and the critical. The catarrhal stage much resembles ordinary catarrh, the convulsive stage is sui generis, and the critical stage is similar to an attack of ordinary catarrh, and soon wears off. The disease if properly treated generally terminâtes in two or three weeks, but when neglected, may go on for several months and then prove fatal. Its physical signs do not materially differ from those of bronchitis. It may terminate in pneumonia or emphysema, or by its morbid effects upon the circulation, may bring about œdema of the brain and its membranes, and thus prove dangerous. This disease usually attacks children and but once ; it is regarded as more or less contagions. Treatment.—If the disease is attended with congestion of the brain, red face, hot head, fever, drowsiness and disturbed sleep, with starting and jerking of the muscles, then belladonna, alter- nated with small doses of aconite, gtt. 1 or 1|, and gtt. \ to \ of aconite, every hour will be sufficient. If the cough becomes very fréquent, and there is a sensé of constriction in the chest, then gtt. 5 to 10, of drosera rot. may be administered every hour or two, until the symptoms are completely relieved. If there be constipa- tion, vomiting, gagging or choking spells, with bluish face, and severe pain in the umbilical régions, small doses of nux vomica will be of material service, and I give gtt. J to 1, once every four hours in water. If convulsions supervene, let gtt. 5 or 10 of lo- belia be given every hour, until the convulsions cease. The diet may be moderate. Recently the Auid extract of castanea vesca (chestnut leaves) has been used in whooping cough, in doses of gtt. 5 to 10, every one or two hours, according to the severity of the cough. To relieve the sudden, deep spasmodic cough attending some cases of this disease, the bromide of ammonium has proven to be a prompt remedy, in doses of gr. \ to 1, every one or two hours through the day. Picrate of ammonium has shown itself to be very reliable in this affection. It is quite bitter, and is best given in the form of a saturated tincture, made by adding 15 to 15 of alcohol, and then gtt. 3 to 5, of that tincture may be added to 15 of simple syrup. Give from J to 1 teaspoonful of this mixture, overy two hours, in about an equal quantity of water. Some writers highly commend sticta pulmonacea in whooping-cough. Eriodyction is also highly extolled in whooping-cough. Trifolium pratense (red clover blooms) has acquired considérable réputation in whooping cough, given in the form of a saturated tincture, in doses of gtt. 5 to 10, every two hours. 52 THE AMERICAN PRACTICE OF MEDICINE. Asthma.— Asthma resembles spasm of the glottis, and like it, is caused by an irritation of the vagus nerve. It may be either central, peripheral, or a mère reAex from other nerves. _ Asthma, when purely nervous, exhibits upon post mortem examination, no abnormal condition of the air passages. Irritation of the vagus nerve causes a spasmodic contraction of the transverse muscular fibres of the bronchi, and, hence, the great difficulty of inspira- tion. How this irritation upon the vagus is produced, however, we cannot tell. In some cases I hâve seen changes of weather produce it, in others, dust will give rise to it. In some cases in- deed I hâve seen asthma associated with heart disease, and in others associated with emphysema, and still again connected with lésions of the liver, stomach and other organs, as the utérus, &c. Its exciting causes are various. In some persons it is produced and kept up by living in a certain locality ; in some by smelling certain drugs, especially ipecacuanha ; in some by sexual excesses and mental excitement, and sometimes it is diflicult to trace it to any cause, save the impressionability of the patient's nervous system. It generally occurs in paroxysms every week, two weeks, or even every month. Treatment.—For relief of the paroxysms, several remédies are used, such as ipecac, lobelia, gelseminum, and the inhalation of nitrite of amyl, &c. I hâve frequently relieved paroxysms by hav- ing the patient breathe the smoke of soft brown paper steeped in a strong solution of pure nitrite of potassium, and then dried. This paper should be burned near the patient, in order that he or she may inhale the smoke freely. The curative treatment consists in giving such remédies as counteract the spasmodic tendency of the bronchial tubes. In old people, or where asthma is connected with emphysema, or heart disease, arsenic is one of our chief remédies, and should be given in small doses, say gtt. 1 to 2 of what is called Fowler's solution, three times a day. This is a remedy also for asthma complicated with dyspepsia, as it tones up the stomach. I hâve used the bromide of lithium in some cases with good effect, alternated with gelseminum 2 5 ; grindelia robusta 2 5 ; ptelea 2 5 ; eriodyction Californicum 2 5 ; silphium gummiferum 2 5 ; prescribed in doses of one or two tea-spoonfuls every three hours, so as to keep up the anti-spasmodic efiect upon the nervous system. I use the saturated tinctures with good results. When the paroxysms occur very frequently, and are attended with a quick, small, and weak puise, aconite lu drop doses, three or four times a day, has often aided the above remédies in the radical cure of asthma. When connected with chronic bronchitis, the iodide of antimony, in doses of gr. 5 of the 2 dec. trituration, three times a day, has proved very successful in some cases. The DISEASES OF THE RESPIRATORY ORGANS. 53 cannabis indica (India hemp) in doses of gtt. 3 to 5 of the tincture, has often given relief in extrême cases of this disease. Sumbul (musk root) in the form of a saturated tincture, in doses ofgtt. 30 has proven a good remedy. Quebracho, in doses of gtt. 1 or 2 every ten or fifteen minutes, also gives prompt relief, and is worthyofa trial as a curative remedy. When connected with diseases of the heart, I find gtt. 10 to 15 of cereus grandiflorus, every two hours, is necessary, in alternation with other proper remédies. In some instances I hâve found that the tincture of digitalis, in gtt. 5 to 6 doses, is necessary, alternated with anti- spasmodic remédies. Iberis, too, has proved very successful in some cases of asthma on record. Iberis amara is the " candy tuft " of the gardens. It may be administered in the form of a saturated tincture, in doses of gtt. 4 to 5. Pneumonia.—This complaint consists of a hyperœmia of the pulmonary capillaries, with catarrhal or serous exudation. From the différent morbid products of exudation, this disease has been divided into croupous, catarrhal and serous pneumonia. Catarrhal pneumonia is acute bronchitis, which has been already considerecl, as an inAammation extending into the Anest bronchial tubes, and hence, is called catarrhal capillary bronchitis. It is mostly found in children, associated with the whooping cough, inAuenza or croup. It is usually an extension and aggravation of thèse affec- tions. Serous pneumonia, or acute œdema of the lungs, is charac- terized by a serous exudation, and is generally a secondary dis- ease, the resuit of croupous pneumonia, bronchitis, tuberculosis, heart disease, measles, and typhus or scarlet fever. Croupous pneumonia is the most common form, and consists of a croupous or fibrous exudation, which is susceptible of being vitalized.^ It most generally attacks the inferior lobes of the lungs, especially the right one ; and rarely attacks both lungs. It does not often extend over one whole lung, but is confined to certain portions, which, in some cases, are too small to be detected at first by pur- cussion. It does not often attack the central portion of the lungs alone, but generally extends to the surface. In the aged, and gen- erally in debilitated persons of any âge, the disease attacks the posterior parts of the lungs. Pneumonia usually exhibits three stages: (1) The inflammatory stage, which is hyperœmia of the capil- laries in the lung tissue with exudation of coagulable lymph ; (2) hepatization, or infiltration of the lung tissue with coagulable lymph; and (3) resolution, or purulent infiltration, which is the transformation of lymph into pus. Thèse stages are recognized by their respective symptoms. The first stage sets in gradually with a chill, which is soon followed by high fever, the puise run- ning up to 120° or 130°, according to the âge of the patient. There is apt to be a red flush upon the cheek corresponding to the dis- 54 THE AMERICAN PRACTICE OF MEDICINE. eased lung, and the lips very often become covered with fever blisters. The respiration is much interrupted, being short and labored. There is cough and rusty sputum, which soon becomes mixed with blood. If the plura be involved, there will be a sharp pain in the chest, and if there be a dull, heavy pain the bronchi are also involved. In severe cases there is delirium or stupor. The urine is scanty and highly colored, and gives a precipitate to nitrite of silver. Physical Signs.—There is decreased mobility of the diseased side, and if both lobes are affected in depending portions, the pa- tient moves only the upper part of the thorax while breathing, and the abdomen remains quiet. Palpation shows an increase in the fremitus. The impulse of the heart is very much increased, but normal in position. Percussion yields a short, tympanitic sound over the engorged parts, as long as they contain air, but this condition ceases whenever the hepatization is completed : the sound then is very dull. Auscultation reveals a fine crépitant sound, like the rattling of parchment, or the pressing of hair be- tween the thumb and finger, or like spitting forcibly against a silk cloth. The second stage is characterized by great dyspnœa, cough, pain, brain symptoms, albuminous urine, and strong vocal fremitus. Percussion now reveals a very dull sound over the part. Auscultation gives neither the crépitant sound, nor the vesicular sound, but a bronchial breathing—bronchophony and sometimes pectoriloquy, unless the bronchi are closed up by mucus. If the bronchi be clogged with mucus, varied, rattling sounds will be heard. The third stage is characterized by a relaxation of the violent symptoms. The fever abates, the face becomes pale, the skin moist, the dyspnœa ceases, and the sputum becomes copious, frothy, lighter and more easily expectorated. The urine grows clear, copious, and again throws down a precipitate with nitrate of silver. On inspection, the thoracic walls will be seen to hâve regained their mobility. The percussion sound again becomes tympanitic, and upon auscultation the bronchial sound, the bron- chophony, has become weaker ; the crépitation sound then reap- pears, and finally yields to the natural vesicular respiratory sound. Thèse stages, in the usual course of the disease, occupy about four- teen days. But, in some cases, we observe a new invasion of the disease following the first attack, and a portion of healthy lung becomes œdematous ; that is, it becomes infiltrated by a serous exudation, in which the dyspnœa increases eventually to suffoca- tion. Tbis fatal resuit is brought about by an increased quantity of carbon in the blood. In some instances, the disturbed circula- tion of the lungs causes a hyperœmic condition of the brain and the blood not being sufficiently oxygenized, or beino- retarded in its return from the brain, causes stagnation and death a form of DISEASES OF THE RESPIRATORY ORGANS. 55 apoplexy. Abscesses may form in the third stage, which, if small may lieal. But when the abscesses are large, and form large cav- ities, there will be pectoriloquy, or a metallic tinkling. In some cases, where the upper portion of the lungs are attacked, the hepa- tization may be transformed into tubercular infiltration. If this be the case, the fever does not leave altogether, but shows some increase at night. The dyspnœa, cough and dull sound of hepa- tization continue, and auscultation reveals bronchophony. In some rare instances, the hepatized lung becomes indurated, or cir- rhosed, the interstitial tissue becoming tense, and rendering the air-cells impervious. In such cases convalescence is tedious, and for some time, upon percussion, we discover a very dull sound with bronchial breathing, and there is more or less dépression in the thorax. It occasionally happens that gangrené takes place ; which will show itself by sudden collapse, cadaverous odor of the breath, and by the expectoration growiug very dark, and copious ki quan- tity. Pneumonia, without treatment, or with poor treatment, may continue from twenty to thirty days, but with good care, it is possible to arrest it in either of the three stages. It may with proper treatment be brought to a favorable termination in from 9 to 14 days in most cases, where there is no complication. Treatment.—Where the fébrile symptoms are well marked, and the secreting functions are suspended or imperfectly performed aconite is a most valuable remedy, in closes of gtt. I to |-, every fifteen minutes, or gtt. 1, every hour, when the inflammation does not run so high. If the respiration is short, labored, rapid, and attended with a sharp pain in the side, with a very painful dry cough, give bryonia, in doses of gtt. 1 to 2, every three hours, or in very urgent cases, every hour or two. If the chest is oppressed with excess of sputum, and there is great rattling of mucus, nau- sea, profuse expectoration, violent throbbing of the heart, and a sensé of suffocation, gtt. 1 to 2, of the tincture of ipecac. and gtt. 1 to 2, of tincture of sanguinaria, may be given hourly. If céré- bral complications arise, as indicated by nervousness, delirium, sleeplessness, picking at the bed clothes, flushed face, and congested eyes, then tinct. of belladonna, in gtt. 3 to 5 doses, every three hours, until the mind is entirely relieved, will be found invaluable. If the liver is involved, as indicated by pain under the scapula, then chelidonium, in doses of gtt. 10 to 15, four times a day should be prescribed, until this complication is relieved. After hepatiza- tion takes place, the iodide of potassium may be alternated with the bromide of sodium, or with syrup of sanguinaria. If typhoid symptoms supervene, phosphorus, in the form of saturated tincture, in doses of gtt. | to \, every three hours will act well in sustaining the nervous system. If there is pleuro-pneumonia, the tincture of asclepias syriaca, in doses of gtt. 20 to 30, may be alternated with 56 THE AMERICAN PRACTICE OF MEDICINE. aconite, every hour or two, according to the urgency of the symp- toms. In pneumonia I hâve found hot compresses of much benefit, as well as of much comfort to the patient. They relax the skin, and distend the capillary vessels, thereby inviting a larger quan- tity of blood to the surface, and of course withdrawmg that much from the engorged lungs. Compresses are much better than blis- ters. In the second and third stage ; if attended by extrême dysp- nœa, tough sputum, stitching pain in the chest, and quick, small puise, the tincture of sanguinaria, in doses of gtt. 4 to 6, every hour will aid the other remédies in bringing about a favorable termination of the disease. It may be used where the puise is very quick, full, hard and strong, but not otherwise ; when needed I would use it in small doses, say gtt. \ to 1, every two hours. Phthisis.—Phthisis, or consnmption, is a condition having its remote origin in a peculiar scrofulous diathesis. In this deadly disease certain morbid bodies, called tubercles, are deposited in the lungs, and in thèse bodies there is soon set up a process of suppuration and ulcération looking to their discharge. The dis- ease is not confined to âge or sex, but is most frequently developed in early life, say, from 18 to 30 years of âge. When fully devel- oped it is generally supposed to be incurable, but, in its early stages, remédiai and hygienic measures may be brought to bear upon it with much hope of success. An hereditary tendency or prédispo- sition to this disease exists in many constitutions, but it is possible that an acquired debility of the system (which may be developed by various causes) may at times, give rise to it. Indigestion, masturbation, chlorosis in females, acute eruptive fevers, typhus fever, whooping cough, pleuritis, pneumonia, and a humid atmos- phère may ail aid in developing this disease. Tubercles.—Thèse morbid products are of various sizes, and consist of a yellowish, cheesy substance, which gradually dégénér- âtes into pus or an ichorous material destroying more or less of the lung tissue. In this way are formed abscesses, which, when emptied, form cavities of vomicœ. In new-born infants and young children, tubercles may form in the mesenteric glands and at the base of the brain, causing, in the first case, intestinal tuberculosis, and in the latter, tubercular meningitis, both of which are as fatal, generally, as phthisis. Symptoms.—The early symptoms are often obscure and consist of cough, dyspnœa, irregular wandering pains about the chest, ex- cessive susceptibility to cold, impaired digestion, loss of flesh, de bility without any visible cause, hœmoptysis, flushing of the cheeks, and accélération of the puise in the evenino-, foliowed by disturbed sleep, and morning sweats. It is not uncommon for the first noticed symptoms to be spitting or coughing up blood. As the disease advances, respiration becomes rather distressing the DISEASES OF THE RESPIRATORY ORGANS. 57 sputa become more purulent, and emaciation and exhaustion take place from imperfect digestion. The intestines may be be impli- cated in the tuberculous deposit, and then there may be'diar- rhœa. The mucous membrane of the respiratory organs becomes ulcerated or thickened, the voice grows husky or imperfect, and aphony results from ulcération. Aphthœ of the mouth, pharynx and larynx often form, and the feet and ankles occasionally be- come œdematous. The sub-clavicular région sinks in, and the clavicles become prominent, and the thorax flattened and elongated. The respiratoryr motion decreases or ceases in thèse places, and in advanced cases, the respiratory motion is only seen in the lower portion of the thorax. Emaciation is rapid, the skin is loose, thin and pale, and the finger and toe nails become rounded, from defi- ciency of the hypophosphites in their composition. Palpitation of the sub-clavicular région reveals stronger fremitus. There is impulse in the heart's action. Percussion at the outset of the dis- ease aflbrds no results, as the tubercles, while snall, do not effect the sound ; but when they become large, and in masses so as to lessen the amount of air in the lungs, the sound becomes very dull, especially in the infra-clavicular, acromial and supra-scapular ré- gions. In the advanced stage, after the cavities hâve formed near enough to the thoracic walls to reflect sound, percussion over that part yields a metallic or tympanitic sound. Auscultation in the beginning of the disease gives an increased and rather prolonged expiratory murmur, and sometimes fine rattling noises. After the tubercles dissolve, a clicking sound is heard, and after the lung tissue has become infiltrated with tubercular masses, we hear bron- chial breathing and broncophony, with various rattling sounds. Treatment.—In the incipiency of tuberculosis, use iodine in the form of Lugol's solution, gtt. 3 to 5, three times a day, alter- nated with pure créosote, say gtt. 25 to water 4 5—dose a tea- spoonful three times a day. This aids in preventing indigestion and diarrhœa, and at the same time acts as an antiseptic, prevent- ing décomposition. In some eases I hâve succeeded with the phosphates, alternated with the tinctures of ptelia and euonymus atropurpureus, in moderate doses, twice daily. I use the coni- pound syrup of the phosphates, as given by Churchill. Al ter di- arrhœa sets in, Fowler's solution, in gtt. 1 to 2 doses, three times a day, is of great utility ; often arresting the diarrhœa, and improv- ing the digestion. Where the cough is very excessive, and attend- ed with a purulent expectoration and hectic fever, I hâve found Peruvian balsam, in small doses, to reduce it very much. fn cases where there is a very great tendency to décomposition, great dysp- nœa, diarrhœa, utter prostration, and aphthœ about the mouth or throat, I give iodide of arsenic, in small doses of 1 gr. of the 3 dec. trituration, three times a day. Cod-liver oil, salicin, quinia, or- 58 THE AMERICAN PRACTICE OF MEDICINE. ganic salicylic acid, iodide of iron, iodide of manganèse, carbolic acid, phosphoric acid, hypophosphorus acid, maltine, petroleum and crude mecca oil, hâve ail been highly praised as anti-phthisical remédies. Cod-liver oil has long been used, rather routinely, as a kind of spécifie, but has often failed, as other remédies hâve done, and always will do, until given in accordance with the pathological indications for the remedy. Given where the digestive ^ system is feeble, it does great harm, as it increases the indigestion. This fact accounts for the great diversity of opinion in regard to the utility of this remedy. It will not do either, where there is in- flammatory condition of the system existing, with tuberculosis, as it aggravâtes this condition, and so hastens the anatomical lé- sions. In such a condition, instead of the cod-liver oil, l give gtt. 1 to 2 of aconite, three or four times a day, until the inflammatory symptoms cease. But where there are no actual inflammatory manifestations, I would ad vise 1 5 of the cod-liver oil, with 2 5 of pure maltine, three times a day. In most cases that I hâve treated, there has been more or less inaction of the liver, causing seconda- ry indigestion. Where such is the case, 1 hâve found euonymus atropurpureus in doses of gtt. 20 or 30 of a saturated tincture, or gtt. 15 or 20 of the fluid extract, one of our most trustworthy rem- édies. Petroleum possesses marked antiseptic properties, with which it arrests the blood poison, thereby lessening the tendency to disorganization of tissue. I hâve frequently combined ptelia tri- foliataand euonymus atropurpureus with the hypophosphites, in the form of a syrup, by adding 4 5 of each of the above remédies (in the form of fluid extracts or saturated tinctures) to 8 5 of the hypophosphites as given by Prof. Churchill, of England. I hâve given a tablespoonful of this mixture, three or four times a day. It lias a better effect (in the non-inflammatory form) than anything I hâve lately tried. I hâve a patient now under my treatment, who came from Franklin, Pa., in an advanced stage of phthisis, who is now able to be up ail the time, and is gaining strength and Aesh under the above regimen. Some years ago, perhaps about 1862, I was called to a patient in Buford, Ga., whom I found in the ad- vanced stage of [phthisis pulmonalis, much emaciated, bed-ridden, in child-bed, with hectic fever, night-sweats, and a large vomica in the left lung. The larger portion of both lungs was filled with tubercles. This case presented ail the symptoms of hastenino- dis- solution, but I put her upon the hypophosphites, ptelea, and euon- ymus, and she mended from the first week or two. She finally recovered, and is now a Uving monument of the efficacy of the above remédies. Thèse remédies possess the power of assisting the di- gestive apparatus, and also of the assimilating functions, thereby elaborating aprotoplasm, outof which a much healthiercell-nucleus is formed. DISEASES OF THE RESPIRATORY ORGANS. 59 At the same time, doubtless, they stimulate the excretory organs to eliminate the aplastic or worn-out éléments from the en- tire body. It must not be expected that thèse, or any other remé- dies, can control ail cases, especially those in which the destructive metamorphosis has advanced too far to be arrested, for there is a point in this disease, as well as in many others, where a cure is impossible. Where there is a high degree of inflammatory excite- ment, the hypophosphites are contra-indicated. In this condition aconite should be given, in doses of gtt. 1 to 2, three or four times a day, alternated with mecca oil, or crude petroleum, in moderate doses, of from J to 1 5- Petroleum is of much value in ail cases of catarrhal complications in phthisis, soothing the harrassing cough, and lessening the excessive expectoration that often attends this disease. It exerts no control, however, over the tubercular ca- chexia, and hence we must look to other remédies to prevent and control the primordial lésions of this disease. The phosphates or phosphorus, in the form of oils of the metalloid, alcoholic tinctures, or etherial tinctures cannot possess nu trient properties until they are vitalized so as to assume an organismal power, hence thèse forms of phosphorus are not assimilated until they are vitalized. There exists in the capillaries, a tri-basic phosphate of lime, magnésium, sodium, potassium, and iron, which is very similar to that found in the cereals. It is further noted, that those organic phosphates which are elaborated in vegetables are very active aliments, and readily assimilated. Hygienic Treatment.—The patient's diet should be highly nu, tritious, but such as is easily digested. The tender parts of beef mutton, game and fish, with stale bread, should constitute one or two meals" a day ; milk, eggs, butter and oysters, may also be used if the stomach will digest them easily. Cod-liver oil, in small quantifies, emulsified with maltine, should be taken after each meal. From one to two teaspoonfuls may be taken at each dose provided it does not oppress the stomach. If digestion is feeble, lactopepsin, in doses of gr. 40 to 60, may be taken in water just after each dose. Daily exercise in the open air, should be insisted upon when the weather is favorable. The skin should be bathed daily, and foliowed by a friction with a crash towel. If the wea- ther is cool, the water may be tepid at first and gradually reduced in température until it is cold. In the commencement of the dis- ease (not after the system is too far debilitated to be benifitted) the pa- tient should seek a high, dry, and moderately warm climate, not a hot, humid atmosphère, filled with miasma, but one fllled with ozone, which prevails in altitudes from eight hundred to one thousand feet above the level of the océan. Many consumptives hâve im- proved rapidly by visiting Marietta, Ga., and similar places. Emphysema.—This disease consists of an enlargement of the 60 THE AMERICAN PRACTICE OF MEDICINE. air-cells, either from a coalition of several of them into one, or from mère distension of the cells. It may also be a transmission ot air into the sub-pleural cellular tissue. In emphysema, post-mortem examination shows the lungs swelled out, and a want ot that pe- culiar crépitation of the healthy lung when pressée! between the fingers. The air-cells are widened, sometimes to the size of a par- tridge-egg, or even larger. I saw a very extrême case in the hos- pital at Philadelphia, Pa., in the year 1867, exhibited by Dr. Da Costa, which showed the air-cells as large as a walnut at the apex of each tube of the lungs. This disease may be produced by vio- lent inspiratory effort, as in asthma ; or it may originate in phthi- sis, pneumonia, or bronchitis, (from the tubes being blocked up with tough phlegm). Whooping cough, playing upon wind-instru- ments, and severe straining may also cause emphysema. It pre- vents the oxygénation of the blood, tuircharges it with carbon, and lessens its percentage of oxygen. This deficiency of oxygen and excess of carbon gradually grows greater, until extrême dyspnœa takes place, causing the patient to strain the respiratory muscles so much that the thorax becomes arched and very much dilated. As the air-cells become obliterated, so do the capillaries of the lungs. Consequently, the blood from the right ventricle cannof find space within the lungs, and stagnation of the blood follows, causing hypertrophy of the right ventricle. This is followed by the usual conséquences, which are undulations of the right jugular vein, cyanosis of the face, vancosis of the vessels of the alœ nasi and cheeks, swelling of the liver, scanty urine and hœmorrhoids. Diagnosis.—On inspection, the chest is found arched, barrel shaped and dilated to the sixth rib. This condition, however, is not universal, for emphysema may exist without such marked al- tération. Palpation generally reveals the fact that the heart has been forced lower down towards the pit of the stomach. Percus- sion gives the dull sound over the heart and liver covered with the distended lung, hence we hâve the lung sound over the heart and liver. Auscultation affords but little information. If there is catarrh associated with emphysema, we should hear rattling and bubbling noises. The progress of the disease is slow, and its acute attacks are provoked by bronchial catarrhs. It may end in gênerai dropsy and death, or it may last for years. Treatment.—Like phthisis pulmonalis, emphysema is very diflicult to cure. When the dyspnœa is very great, and the face cyanotic, tinct. of arsenic in doses of gtt. 2 or 3, three times a day, generally affords signal relief. If the circulation is much distur- bed, and there is headache, dizziness, palpitation of the heart, and fulness of the abdomen, gtt. 3 or 5, of tinct, of belladonna, three times a day, will give relief to thèse symptoms. If there are at- tacks of suffocating dyspnœa, attended with cold sweats over the DISEASES OF THE RESPIRATORY ORGANS. 61 body, coming on regularly every morning, I then prescribe small doses of arseniate of quinia. The lst centésimal trituration is as strong as it can be used, as it is highly toxical. The dose of that trituration is gr. J to 1, three times a day. In old cases, where there is hypertrophy of tjie heart, digitalis, in small doses, say gtt. 5 to 10, every four hours, often brings relief. This may be alter- nated with cactus, gtt. 10 to 15. If there is a dry, spasmodic cough, and the sputum is tough and difficult to raise, small doses of the tincture of ipecachuanha and sanguinaria, will produce easy expectoration ; gtt. 1 to 2 of ipecac, and gtt. 5 to 6, of sanguina- ria, is sufïicient. If that fails, the tinct. of lobelia and syrup of senega, may be used. Pleurisy.—In pleurisy, post morte m examination'reveals the fact that the inflammation results in an injection of the pleura, with pinkish stripes and spots hère and there. Thèse consist in enlarge- ment of the capillary vessels ; and in some cases there are irregular, ecchymosed patches of dark red extravasation in the pleura. The surface of this membrane appears dull and swollen, and sometimes rough, villous, and granulated. This is so in many instances, but in some cases, in addition to the above pathological conditions, there is a scanty fibrinous exudation, like a soft, croupous mem- brane, covering the pleura. Where there is recovery, this exuda- tion may be dissolved by fatty metamorphosis, and thus be absor- bed ; but the fine granulations, and new cells which lie underneath, frequently give rise to adhésions of the pleural surfaces. This fibrinous exudative pleurisy also accompanies most cases of croup- ous pneumonia. In some cases a large quantity of a greenish yel- low sérum, and coagulated fibrinous masses, may collect, float in the sérum, and finally adhère to the pleura like croupous mem- branes. There are always more or less pus globules contained in this sécrétion, and so there may be bloody exudation. In cases that recover, this sécrétion may be gradually absorbed, and between the adhésions, there may be left a yellow cheesy material, the resi- due of unabsorbed pus-globules and fibrinous substances. As ob- sorption advances, the lungs regain their normal volume, provided the air-cells be not closed by fibrinous deposits. In some cases where the exudation is purulent ; (that is, so full of pus-globules that it forms an opaque, yellow, thick fluid, called empyema,) it constitutes nyo-thorax. But even in thèse cases, absorption may take place in time, and a cure be the resuit. If the pleura itself becomes involved in the suppurative process, it causes softening and finally perforation of its tissues, and the pus escapes outside, either through the thoracic wall, or through the bronchial tubes, is thereby coughed up, and the patient recovers. ►Symptoms.—In the first form of pleuritis, where there is no exu- dation, there are no well marked symptoms. But in the second 62 THE AMERICAN PRACTICE OF MEDICINE. form, where there is fibrinous exudation, when it is attended by pneumonia or tuberculosis, there is sharp pain, which prevents deep inspiration ; and sneezing and coughing give rise to increase of the pain. If not complicated with either of the above diseases, there is but slight cough attending it. The third form, with abundant sero-fibrinous exudation, usually commences with a chill, followed by high fever. The chill may be repeated, giving rise to the suspicion that there is a complication of intermittent fever. This, like the second form, is accompanied by a violent pain in the side and chest. This pain is usually attended with dyspnœa as long as the fever lasts, and when there is extensive exudation compressing the lung, there may be a cough. Pleurisy reaches its climax in six or eight days, and may then begin to décline. The fever, pain, and cough cease, and absorption of the exudation commences, progresses slowly, and finally, in a few weeks the fluid is removed. Physical Signs.—Upon inspection the thorax is discovered to be enlarged, from the exudation. The intercostal spaces appear level with the ribs, or may in some cases bulge out between them. The respiratory motion is much lessened. Palpation.—This reveals the absence of the vocal fremitus, which is the resuit of the fluid between the thoracic wallsandthe lung. The heart and liver are also found to be moved out of their normal place. Purcussion.—This yields a duller sound, but if the exudation be moderate, so as not to compress the lung and drive ail the air out of it, there will be a tympanitic sound. Auscultation.—This reveals an absence of the natural respira- tory murmur over the part covered with the exudation. In the fourth form, which goes by the name of empyema ovpyo- throax ther are similar physical signs, as above stated. When pus is about to make its way through the throacic walls there will appear an œdematous swelling, between the fourth and fifth ribs, which soon grows hard and tense, and protrudes between the ribs. Finally this tumor becomes soft, and if not opened, will burst and discharge the pus. When it breaks through the bronchial tubes, it may do so suddenly, causing violent paroxysms of coughing, the patient throwing up large quantities of seropus or _ pus. The patient may suffocate or sink under the pyemic poisoning of the blood, or the pus may make its way down through the diaphragm into the abdominal cavity, causing peritonitis, and death thereby. Pleurisy is distinguished from pneumonia by the repeated chills at its outset ; catarrhal sputa ; pain ; enlargement of the throax; dislocation of the heart and liver, and the friction sound. In pneumonia, there are rust-colored sputa, but dull, or no great DISEASES of the respiratory organs. 63 pain unless the bronchiel tubes are involved. There is increased vocal fremitus also, aud a crépitant sound, but no dislocation of the heart and liver. Treatment.—Where there is great thirst, high fever, quick puise, dry skin, pain in the side and chest, inability to lie on the right side, and dry hacking cough, aconite, in doses of gtt. 1 to 2 sohuld commence the treatment. The dose need not be repeated oftener then every hour. Perhaps a better plan would be to give gtt. | or | every fifteen minutes until the puise and fever are both reduced, and then at longer intervais. If the tongue is coated with a white fnr, the pain in the chest is severe, and there is great thirst, bryonia should be alternated with the aconite, in doses of gtt. 2 to 3. There is pleura-pneumonia in some cases, where we bave bloody or rusty sputa and severe cough, which may be treated with tincture of sanguinaria gtt. 3, or gtt. 20 or 30 of the syrup of sanguinaria with the same quantity of wine of antimony given every two hours at the outset, and alternated with tinc. of aconite Where the skin is dry and harsh, I find the tiucture of asclepias, in doses of gtt. 20 or 30 every hour, or in severe cases, frequently repeated, to be one of our safest and most prompt diaphoretics. Warm compresses (made by soaking flan- nel cloths in hot water, and wringing them sufficicntly), applied to the chest, will aid in the relief of the pain, and the internai congestion, by driving the blood to the surface. Haemoptysis.—When the capillary vessels of the bronchial tubes become ruptured, and the blood, either thin or coagulated, is coughed up in large or small quantifies of a bright dark color, it is called hœmoptysis, or blood-spitting. When abscesses, tubercular cavities, etc., cause the rupture of larger vessels, and a profuse flow of blood from the lungs, it is called hsemorrhage of the lungs or pneumorrhagia, Sometimes the blood is not brought up ; in that case, it collects in the parenchyma of the lungs, and forms the so called hœmoptoic infardions, which appear black and shilling, hâve an uneven granulated appearance, and are of various sizes, from that of a pea to that of a walnut ; they contain no air, and sink in water. When infiltration takes place, and the parenchyma of the lung gets torn, the blood fills the opening, and in this way producc pulmonary apoplexy. This pulmonary apo- plexy gives a very dull sound upon percussion. When haernorr- hage of the lungs results from tuberculosis and disorgauization, it is an alarming disease, as it is apt to recur again and again, greatly to the distress of the patient. It often proves fatal, unless ar- rested. The disease may arise from disease of the heart, caused by obstruction in the ostium venosum, and insufficieny of the mitral valve. Treatment.—There is quite a number of remédies reccomended 64 THE AMERICAN PRACTICE OF MEDICINE. for this hsemorrhage, but I hâve found only a few that are reliable în urgent cases. Among them is the tincture, or intusion of lycopus virg. or bugle weed. This plant not only possesses sédative powers, by which it controls the capillary circulation, but is also astringent, and so lessens the caliber of thèse minute vessels, and consequently, reduces the flow of blood in proportion. It is much safer than digitalis, as it is not like it, accumulative in its action. So positive is its action in hœmoptysis, that I hâve seldom bad to use any other remedy to check ordinary cases of of this affection. In the absence of the lycopus, aconite in small repeated doses, alternated with the fluid extract of ergot, in doses of gtt. 15 to 20, every one or two hours, according to the urgency of the case, acts admirably. Vegetable charcoal, properly pre- pared, in small doses, is of utility in cases of slow puise and cold skin attended with proxysms of cough and hoarseness. If the hœmorrhage is associated with piles, collinsonia, in do^es of gtt. 20, three times a day, will be found useful. Where there is anœmia, iron should be in connection with other remédies. If the hœmorrhage is from the venous capillaries, hamamelis, in gtt, doses, every half hour, is very positive in action. Pneumothorax.—Pneumothorax consists of a collection of air or gas within the pleural sac. Air alone does not constitute the disease, but pus, blood or sérum are usually found with it, hence, it is called either pyo, hœmato, or hydro-pneumothorax. Pneu- mothorax is known by the enormous extension of the thoracic wall of the affected side and by the bulging out of the intercostal spaces. When it affects the left side it pushes the heart to the right side, it presses the liver down into the abdominal cavity. The gas consists mostly of carbonic acid and nitrogen, with a small percentage of oxygen. If, however, décomposition has taken place there is sulphuretted hydrogen gas. Thèse substances may be limited to a small space or they may fill the pleural cavity. The entrance of air into this cavity is occasioned by a perforation of the pleura pulmonum, allowing the air to enter from the air- cells of the lungs ; or it may originate from a perforation of the thoracic wall, permitting the air to enter from without. Gaseous substances may, too, resuit from décomposition in pyrothorax. The disease makes itself known by dyspnœa and by the patient being compelled to sit up and keep the sound lung free from pressure. The worst cases occur in connection with tuberculosis, gangrené or cancer. Physical Signs.—Upon inspection enormous enlargement of the diseased side of the thorax will appear, and there will be a bulging of the intercostal spaces and a want of respiratory move- ment. The breathing is suspiratory. Palpation reveals an ab- sente of vocal fremitus. the liver and spleen are. displaced down- FEVERS: THE EXANTHEMATA. 65 wards, and the heart is found much out of place, towards the middle or right side of the thorax. Percussion reveals a tympan- itic sound, unless the thorax be greatly distended, when it be- comes non-tympanitic. Very often the upper part of the lung is so compressed that there is a dull sound. If there be effusion the sound of the lower portion of the thorax is dull when the patient is erect, and changes when he shifts his position. Auscultation reveals a full résonant percussion sound, with a metallic, tinkling sound when the patient coughs, talks, or inhales deeply. Over the Compressed lung there will be broncophony and bronchial breathing. Differential Diagnosis.—This disease differs from emphysema by its dyspnœa coming on suddenly and growing worse regularly and steadily. The one-sided distention of the thorax, the great bulging of the intercostal spaces, the absence of fremitus, the ab- sence of vesicular murmur, and the présence of a tinkling sound, also serve to distinguish between the two diseases. Treatmsnt.—Where the dyspnœa is sudden and very dis- tressing, I use small doses of tincture of arsenic, gtt. 2 or 3, every three hours. If the discase be the resuit of external wounds or iujuries of the chest, aconite in doses of gtt. J to 1, in alternation with gtt. 1 of arnica mon., every two or three hours, will give re- lief. After the inflammatory symptoms are under control by the aconite, give delphinium staphisagria, in doses of gtt. 2, every two hours. If thèse remédies fail to arrest the morbid process, then resort must be had to the aspirator. As a gênerai rule the aspirator should bè made to enter just above the sixth rib, unless the pus be thick, when it may be better to let it out at the auterior portion of the chest. It may be necessary also to puncture this part, and keep the wound open for some time, as the discharge will be kept up probably for nine months. In the anterior por- tion of the chest, there is less danger of the aperture closing. This is the case too when the opening is made in the side. Hydrothorax.—Hydrothorax consists of a collection of sérum in the chest—within the pleural sac—without marked inflamma- tory symptoms in that locality. It is generally on both sides of the chest at the same time, although one side sometimes contains more fluid than the other. The color of the sérum differs in dif- férent cases ; sometimes being clear, as others, yellowish, reddish, or greenish. It never contains fibrinous substances, as is always the case in a pleuritic exudation. There is often, however, albu- men présent. The pleura exhibits no signs of inflammation, but are of a pale and dull color. This disease often follows organic disease of the lungs and heart, which cause obstruction of the venous circulation within the lungs; or it may be the resuit of some morbid condition of the venous or arterial system, causing 5 66 THE AMERICAN PRACTICE OF MEDICINE. the blood to become thin and watery, as is the case in Bright s disease. It may also follow disease of the liver and spleen, and as a resuit ot anœmia and cachexia. It is most frequently, tnerelore, attended by gênerai dropsy. Its symptoms are various, according to the complications attending it. Symptoms.—Dyspnœa, which is always worse when lying down, is one of the most prominent symptoms. When the patient is sitting up the fluid gravitâtes to the lower part of the thoracic cavity, and thus allows space in the upper part of the thorax for a partial expansion of the lungs, while in the reclining position the lung is compressed by the fluid. Where there is a large col- lection of sérum, the patient is compelled to sit up ail the time, or he suffocates. On inspection the chest présents an enlargement visible to the eye. Palpation shows absence of vocal fremitus, and displacement of the heart, liver and spleen. Purcussion gives a dull sound as far as the fluid reaches. Auscultation shows ab- sence of the vesicular breathing over the space occupied by the fluid, but there may be bronchial breathing about the spine, where the lungs are compressed. Treatment.—The treatment must be in accordance with the existing complications. If there is irritability of the stomach, suppression of the urine, and very short breathing, I usually com- mence the treatment by giving gtt. 10 to 30 of apocynum canna- binum every three hours, and alternate that with gr. 10 to 15 of nitrite of potassium in half a glass of water. If thèse fail, I then give digitalis, gtt. 20, thrice daily. The kidneys are frequently hard to manage, and it requires very active diuretics to produce the desired effect. Where the hydrothorax accompanies heart disease, asparagus, in the form of a strong infusion, often acts ad- mirably. I bave found the polytrichum juniperum (haircap moss) to be one of our best diuretics. It may be given freely in the form of infusion. I use pipsissewa, in connection with the above, with good effect. If the stomach and bowels are affected, and there is great dyspnœa, thirst and palpitation of the heart, tinct. of arsenic is a valuable remedy ; it should be given in drop doses, every meal. If there is heart discase, that should also be treated, or a cure cannot be effected. If the liver aud spleen are diseased, they should receive due attention. After the fluid is removed it reqnires the best of treatment to prevent its reaccumulation. I usually put my patients upon iron, alternated with helonias dioica to enrich the blood, and restore the lost balance between sécrétion and excrétion. If the stomach aud liver are at fault, bryonia, in doses of gtt. 2 to 5 three times a day, will aid digestion, and rco-u- late the bowels. Asclepias syriaca is also a valuable remedy in ail forms of dropsy. CHAPTER IV. DISEASES OF THE HEART. The Heart.—Its Examination by Auscultation.—In order to understand the disease of the heart, it is necessary to become ac- quainted with the healthy or normal, and the unhealthy, or abnor- mal sounds of this organ. There are four divisions of the heart, to wit: two auricles and two ventricles—which, from their respective positions, are called right and left auricles, and right and left ven- tricles. Into the right auricle the venœ cavae empty the blood which has been used by the body for its sustenance. From the right auricle, there is au aperture leading into the right ventricle, called the auriculo-ventricular opening. This opening has three triangular" folds, opening inward, which are called the tricuspid valves. The right ventricle has an opening leading into the pulmon- ary artery, which carries the deoxygenized blood into the lungs. This opening is guarded by a set of valves called semi-lunar valves, which open outwards. This arrangement is also repeated in the left auricle and ventricle. The left auricle receives the oxygénât ed blood from the lungs through the pulmonary veins. From the left auricle, there is a like opening leading into the left ventricle, which is also guarded by valves, consistingof two segments. Thèse are called bicuspid or mural valves, and open inwârd. The left ven- trical has also an opening, which leads into the aorta, through which the heart pumps the blood to every part of the body. There are, likewise, in this opening, a set of valves, of the semidunar variety, which open outward. The following is the modus operandi of the heart as soon as the ventricles become fully distended, they simul- taneously begin to contract, and, on account of the direct relation of the several valves to those two cavities of the heart, the blood, under great pressure from the contraction of the ventricles, forcibly shuts the tricuspid and mitral valves, thus closing the auriculo-ven- tricular openings, and the same action opens both sets of semi-lunar valves for the escape of the blood. As before stated, the pulmo- nary artery carries the dark blood to the lungs, from which the pul- monary veins return the blood (oxygenated) to the left auricle, thus forming the pulmonary circulation. Then through the aortic valves and artery, the red blood is propelled through the entire body, from whence it is returned through the venœ cavœ'to the right auricle; forming the systemic circulation. As the two ventricles contract, the two auricles dilate, and vice versa. This contraction of the ven- tricles and simultaneous dilatation of the auricles, constitute the [67] 68 THE AMERICAN PRACTICE OF MEDICINE. heart's systole, and the forcible closure of the auriculo-ventricular valves, produces the first sound of the heart. The dilatation of the ventricles and simultaneous contraction of the auricles, is known as the heart's diastole, which, by forcibly closing the two sets of valves (semi-lunar) produces the second sound of the heart. The first sound then, is caused by the shutting of the tricuspid and mitral valve*. The second sound, by shutting of the semi lunar valves. Being ac- quainted with the position and character of the normal sounds of the heart, the physician is prepared to study the abnormal sounds of the organ in disease. For instance, the normal first sound. heard most clearly at the apex of the heart, is proof that the mitral valves close completely, not allowing any blood to regurgitate into the au- ricle ; and that the aortic valves and orifice offer no obstacle to the direct passage of the blood out of the left ventricle. If then the mitral valves be déficient, so that they cannot shut perfectly during the rush of blood against them, the stream of blood not stopping mère, re enters the auricle, causing a noise, but not* the characteris- tic tick. If the aortic valves be stiffened or roughened, or the aortic opening constricted, so that the stream of blood, in its onward course, is interfered with.it then rubs against this obstacle, and thereby causes a noise or murmur, at the same time, when the closure of the mitral valve would give the first tick. And if the mitral valves be déficient, and, at the same time, the aortic valves stiffened and roughened, or the aortic opening constricted, then the stream of blood must inevitably regurgitate through the, auriculo- ventricular opening, and also rub against the obstacles in the aortic opening and cause a noise, but not the characteristic tick. An in- crease of the second or diastolic sound of the pulmonary artery, is almost always attended with insufficiency of the mitral valves. And, an increase of the second sound of the pulmonary artery, and a noise over the aorta, shows that there is insufficiency of the mitral valves and a constriction of the aortic orifice combined. If we hear a murmur or noise, instead of the second sound, over the aorta, we may know there is insufficiency of the aortic valves. And in case there is a thickening of the mitral valvts, or constriction of the auriculo-ven- tricular opening, the blood accumuluting in the less>.r circuit, causes hypertrophy, with dilatation of the right ventricle. In case the the auriculo-ventricular valves be insufficient, and, at the same time, the auriculo-ventricular opening be constricted, then there would be a see-saw sound. Valvular diseases are rare on the right side of the heart, and when they do occur, it is mostly in connection with diseases of the left side. An anœmir murmur is a soft sound, like the blowing of a pair of bellows, but it is sometimes like that of filing or sawing, and is beard over the aortic valves. Pericarditis.—The internai layer of the pericardium isa serous membrane, like that of the pleura, and hence, when inflamed it DISEASES OF THE HEART. 69 présents similar post mortem appearances. Thèse are injection, exudation, and swelling. During the inflammatory process the in- jected capillaries may become ruptured, which causes bloody exu- dation. If pus globules should form in great abundance the exu- dation becomes purulent, and, should the exudation undergodécom- position; it exhibits a fœtid, discolored, ichorous appearance, as in empyema. A serious exudation is readily absorbed again, but if it be of fibrinous character it gives rise to achesions between the heart and the prericardium. If there be very large quantities of this fluid the heart is pushed back from the thoracic walls ; its movements interfered with, and at the same time the lung very much com- pressed. Congestion of the lungs, brain, and liver may resuit; also œdema of the lower extremities. Pericarditis may be the resuit of idjuries, or it may originate from taking cold; or from acute rheumatism. Pleurisy, pneumonia, or ulcerative processes of the ribs, vertebrœ, œsophagus, stomach, liver, or lungs may also cause it, or it may follow Bright's disease, turberculosis, disease of the valves, cancer, and fevers. Chronic pericarditis may resuit from abuse of spirituous liquors, violent exercise, and gouty affections, or it may follow the acute form of pericarditis, especially in rheu- matic habits. Symptoms.—It is attended with fever, sometimes commencing with chills, and followed by heat and rapid puise. There is also a sharp cutting pain in the région of the heart, which is increased by motion, dçep inspiration, and also by external pressure. Dyspnœa is generally présent; sometimes to such an extent as to prevent the patient's lying down without an extrême sensé of impending suffo- cation. In some cases there is a short, dry, hacking cough, and if the patient can lie down at ail, can only lie on the left side. Physical Signs.—After two or three days, we may hear the friction sound ; which takes place as soon as a deposit of fibrin is formed, within the pericardium. This friction sound is seldom synchronous with the sound of the heart, but précèdes or follows it. Inspection.—In young persons, there may be a perceptible bulging out of the presecordial région, from the quantity of exuda- tion distending the chest. Palpation.—In the beginning of the disease palpation reveals a strong impulse of the heart at its normal place ; but later this be- comes weaker and finally ceases. When the loud friction sound takes place, it feels like the purring of a cat. Percussion.—At the outset percussion reveals nothing. As soon however as exudation takes place the dull percussion sound of the heart extends over a large space, but if the lung happens to cover the filled pericardium, we fail to get the sound at ail. In the beginning exudation is confined to the base of the heart and the origin of the arteries, and hence, we look for the dulness of 70 THE AMERICAN PRACTICE OF MEDICINE. the sound at thèse points. Later the dulness of sound may be found over the long diameter of the heart, and, if the eflusion is considérable, in the transverse diameter. The pericardium con- tains two or three pounds of fluid, and the sound becomes dull from the second left costal cartilage to the lower border of the tho rax, and from the right edge of the sternum to the middle of the left latéral région. Where pericarditis is a mère complication of some other disease, the course is less uniform, although the physi- cal signs are similar to those mentioned above. When the disease is not complicated, it is quite easily cured, but when it is compli- cated with rheumatism, phthisis pulmonalis, goût, chronic bronchi- tis, and confirmed cases of dyspepsia,it is quite diflicult to manage. Our prognosis should always be in accordance with the complica- tions existing in each individual case. Treatment.—At the outset, treat the fever, the pain in the heart, and dyspnœa with aconite, in doses of gtt. 1 every hour; until the puise is controlled. If, after the fever is moderated, there still remains pain in the région of the heart, bryonia in doses of gtt. 1 to 3 every three hours, will generally give relief. If there be a sensation of stricture in the heart, preventing its mobility, and a sensé of suffocation, faintness, cold perspiration on the face, and palpitation, then cereus grandifiorus is one of the main remédies, and I usually give it in doses of gtt. 10 to 20, every fifteen minutes until it brings relief, and then in doses of gtt. 5, every hour for some days after. If there be rheumatism connected with pericardi- tis, a copious exudation of sérum, irregular, intermitting puise, and a brick-dust colored sédiment in the urine, I find digitalis required in doses of gtt. 10 to 15, of the saturated tincture. I carefully watch its efl'ect3, for it is liable to produce dangerous sedation in some sub- jects. I prescribe every two or three hours, until it controls the action of the heart, and acts upon the kidneys. As soon as the frio- tion sound is heard, give small doses of spigelia. Hydropericardium.—This disease consists of a collection of sérum without fibrin. A fibrinous exudation never takes place without an inflammatory process preceding it. The sérum in hy- dropericardium is clear, and of a yellowish color, but if mixed with blood, is brownish or reddish, and of an alkaline reaction. A small quantity of such a fluid is,' generally found in post-mortem ex&mi- nations, and when dropsy of the pericardium exists several ouncea of it are fonnd within the sac. The pericardium is much distended, is without luster, and of a dull whitish color. The fat upon the heart is also gone, the cellular tissue œdematious ; while the heart becomes compressed, and the chest enlarged. This disease takea place generally in conséquence of an hydrœmic condition of the blood, or in conséquence of some other disease which cause j a gên- erai dropsical tendency in the system. Such are enlarged spleen DISEASES OF THE HEART. 71 Bright's disease, cancer, anœmia, dilatation of the right ventricle; and bypertrophy of the heart, etc. It may resuit also from ob- struction of the circulation, (as in emphysema,) cirrhosi» of the lungs, defects of valves of the heart after pleurisy or pneumonia. Hydropericardium generally originatesfrom some other disease. Symptoms.—The symptoms are rather obscure, until there is a large collection of sérum within the pericardium, when there is dispnœa. This prevents the patient from assuming a reclining posi- tion, attempting to do so causing at once a sensé of suffocation. There is apt to be a collection of dropsy in other parts of the body, and the jugular veins enlarge As the dropsical accumulation invades the other portions of the body, the respiration is impeded, the circulation much retarded, and finally the patient falls into a stnpor, which ends in his death. Physical Signs.—There is an absence of friction sound, and a distention of the prsecordial région in young persons. The impulse of the heart is weak or absent; aud precussion sounds are dull and wider in circumference than in a healthy state. Treatment.—This form of dropsy should be met with the remédies advised in hydrothorax. I hâve found small doses of digitalis, alternated with apocynum cannab to be effective in stimu- lating absorption and the acétate of potassium successful as a diu- retic to remove the Auid. Tn some cases that I have^recently treated from my dispensary, I hâve been quite successful with large doses of infusions of pipsissewa, polytrichum juniperum, (hair cap moss) and apocynum cannabinum, alternated with nitrate of potassium, in doses say of gr. 2 to 3, three times a day, in a large quantity of water. This nitrate acts powerfully upon the kidneys, in moder- ate dose, but if given largely it purges, and is liable to irritate the stomach and bowels. In one or two instances, after using other diuretics for some time unsucessfully, I hâve given gtt. 30 to 60 of tincture of senecio aureus with each dose of the diuretics, and hâve succeeded in rapidly removing the sérum. In this form of dropsy, like ail other forms of the disease, to effect a radical cure, we must enrich the blood after removing the sérum. To do this, requires not only iron, but also such other remédies as directly tend to stimulate the blood-making functions. In this class helon- ias dioica stands at the head of the list. I give it alternated with iron. If hydropericardium has followed some disease exhausting the blood, I give tincture of cinchonia, in small doses. Huxham's tincture is also a good préparation for this purpose Insufficiency of the Mitral or Bicuspid Valves.—If there exists a deficiency in the mitral or bicuspid valves, the blood ré- gurgitâtes into the left auricle during the systole, thus checking the full flow of the blood through the pulmonary vein. This deficiency causes an undue accumulation of blood in the lungs, causing the 72 THE AMERICAN PRACTICE OF MEDICINE. blood to be forced backwards into the pulmonary artery, widen- ing its volume, and producing a louder second tick. The increas- ed second-tick of the pulmonary artery ss the characteristic symp- tom of valvular insufficiency. Check of the pulmonary circulation also causes dilatation and dypertropy of the right ventricle. Final- ly this increase of power in the right ventricle diminishes again, the veins of the lungs become overcharged with blood ; the venae cavœ are also surcharged, and in conséquence, the liver, spleen and kidueys become hyperaemic, a condition which finally leads to gên- erai dropsy. This stagnation of the pulmonary circulation may also lead to dyspnœa, bronchitis, periodical hœmorrhages of the lungs hyperœmia of the brain and cyanosis. If valvular insuf- ficiency exists, the diastol c sound will be replaced by a noise at the point where the apex strikes the thoracic wall. The diastolic sound of the pulmonary artery is much increased, and the natural dull percussion sound of the heart extends further in breadth, on account of the dilation of the right ventricle. Constriction of the Left Auriculo Ventricular Opening. —«Constriction of this aperture prevents a due quantity of blood from passing through into the left ventricle, and so causes an ac- cumulation of blood in the left auricle, and there is a check to the flow of blood in the pulmonary vein. This causes an over-filling of the lungs, and a greater pressure backward into the pulmonary artery. The necessary conséquences are detailed in the treatment of mitral valves. The deficiency of blood circulating through the aorta and the left ventricle causes the aorta to become narrowed, and the left ventricle togrow smaller. The sound at the heart's apex, is like the purringof a cat, the diastolic sound of the pulmonary artery is louder, and the dull percussion sound is heard further to the right side of the chest. Defective Aortic Valves.—The aortio valves are liable to become so defective that they do not close up completely, and con- sequently the blood is driven into the aorta during the heart's sys- tole, but rushes back into the left ventricle, and causes an undue quantity to accumulate there. The blood accumulated in the thick- ening, causes it to make a greater effort to expel this blood. This overaction produces dilation and thickening, and so gives rise to ec- centric hypertrophy of the left ventricle. The defective aortic valves are counterbalanced by the increased size of the left ventricle. And for a time there may be neither dropsy nor cyanosis. But there is apt, however, to be more or less congestion of the brain, as shown by dizziness, noise in the ears, flickering before the eyes, headache, red face and at times hallucinations. Signs.—The diastolic sound is louder and more distinct, and there exists great extension of the dull percussion in the heart's long axis. The impulse is lower down, and the puise is short, jerky and wiry, there is strong pulsation in the carotids. DISEASES of the heart. 73 Constriction of the Aortic Opening.—One of the first indica- tions of constriction of the aortic opening is déficient circulation, followed by paleness, small and thread like puise, fits of fainting, coolness of the skin and extremitie?, and anremia of the brain, etc. As the disease advances the veins become overcharged with blood, dyspnœa sets in, and not unfrequently cyanosis supervenes, accom- panied by other symptoms of diseased heart. Physical Signs.—Systolic murmur is one of the prominent phy- sical signs, and can be heard in the carotids. There are dull percus- sion sounds, somewhat extended towards the longitudinal axis of the heart, and in conséquence, dilation and hypertrophy of the left ventricle follow. The displacement of the apex of the heart outside of the nipple'line, and the small, wiry, irregular and thread-like, puise are ail common signs of this affection. Defective Tricuspid Valves.—This defect allows the blood to flow back into the right auricle, when the heart contrac s. The rétrograde stream of blood flows into the venae cavœ and jugular veins and imparts pulsation to thèse veins, simultaneously with the arterial pulsation. This flow of the blood causes overfilling of ail the veins, and this is followed by hyperaemia, cyanosis, and finally, either partial, or complète dropsy. Physical Signs.—In this disease the systolic murmur is heard in the right ventricle ; aud there will be pulsation and enlargement of the jugular veins. Dull percussion sound will now be heard in the direction of the breadth of the heart, from the right auricles having become enlarged. Their affection often results from disease of the other valves, and consequently, it is attended by ail the physi- cal signs and disturbances given above. Treatment of vavular diseases of the heart. —The treat- ment will hâve to be varied to suit each individual peculiarity and complication. Simple disease of the valve may point to certain remédies, and other complications must also be met by proper treatment. The diet must not be stimulating and ail stimulants as coflee and tobacco must be avoided. The most effective remedy for defective valves, is tinc. of arsenic, in doses of gtt. 1 or 2, three times a day. To quiet the heart, small doses of lycopus and cereus grandiflorusjmay be administered every two hours through the day and in extrême cases, at night also. In some instances, in addition to this remedy, I hâve used small doses of belladonna, three times a day, with good results. Aly usual dose is from gtt. 5 to 15, in alterna- tion with convallaria maj. Where there is anœmia, I give the pyrophosphate of iron, in doses of gr. 1 to 2, in the form of a syrup, three times a day. If there be évident signs of congestion ,of the lungs, the tincture of phosphorus, in doses of gtt. 1 to 2, three or four times a day, will be found in valuable. Thèse valvular diseases are generally so soon complicated with others, that it is impossible 74 THE AMERICAN PRACTICE OF MEDICINE. to lay down any positive guide for their treatment. If dropsy supervene, a spécial course of therapeutics will be necessary. If the heart becomes enlarged, that too will require spécial treatment. The disease also is liable to end in dilatation, hypertrophy and softening of the heart's walls, ail of which must in time receivedue attention. Endocarditis.—Post mortem examination shows theliningmern- brane of the heart injected, reddened, swollen and covered with a fine fringe-like substance. Thèse finally change into a papillae and wart-like excrescences, which consist of softened endocardium. The chordœ tendinœ and valves are. often torn loose by this softening process, and in some cases the endocardium itself, is torn at the place where it covers the heart muscles, and the blood» rushing into it, so distends and softens the heart muscles, that it constitutes an acute heart aneurism. Adhésion of the chordœ tendinse and points of the valves, either between themselves or with the walls of the heart, and myocarditis may also resuit from an extension of the in- flammation. Emboli may resuit from particles of coagulated fibri- nous exudation, being driven with the stream of blood into the arteries. Thèse emboli may cause abscesses, apopletic clots. or should they block up the larger vessels of the lower extremities, they may cause gangrené. Endocarditis is generally found in the left ventricle, in conséquence of metastasis during an attack of acute rheumatism of the joints. Especially is this the case where several ofthejoints are affectedat the same time. It may be associated with pericarditis, myo-carditis, with the acute form of Bright's dis- ease, or it may even follow scarlet fever, puerpéral fever, typhus fever, and measles. Its invasion during thèse affections, may may be unnoticed ; for the patient seldom complains of pain in the région of the heart when thus attacked, except in cases of rheuma- tism. Symptoms.—Palpitation of the heart, and a soft, compressible and small puise, are the early indications of this disease. Dyspnœa is a marked symptom, and is severe in proportion to the amount of complication with the respiratory organs. If the lungs are much involved in the morbid process, there may. be quick and unequal respiration, fainting, congestion of the brain, headache, delirium, sleeplessness, stupor,or even coma. Physical Signs.—The sounds of the heart are heard over a larger space than in health, and are stronger than natural at the outset of the disease. In place of the first tick, we hear a murmur from the diseased valves, and the arterial tick is increased. Percussion.—This, at first, reveals nothing to guide us in the diagnosis, but after a few days, there will be a dull sound over a greater space than there is in health, by reason of the dilated con- dition of the right ventricle, from impeded circulation. This dis- DISEASES OF THE HEART. 75 ease can be successfully treated, or it may leave behind diseases of the valves, such as thickening, adhésions, or perforation, and in conséquence, there may be dilation and hypertrophy of the heart. It is a serions disease. Treatment.—If there is rheumatism connected with it, and pain in the pre-cordial régions, causing great anxiety, palpitation, with irregulnr, intermitting puise and dyspnœa, then small doses of the chloride of gold, three times a day, will act well. The dose need not to exceed gr. J. Follow this with gtt. 5 to 10 of the tincture of spig- elia every two hours, or gtt 1, of the tincture of convallaria. If the pain in the région of the heart is of a cutting or cramp like character, gtt. 10 to 15 of tincture of cereus grandiflorus, should be given every ten or fifteen minute^, until the pain is more or less relieved. If there be stagnation of the pulmonary circulation, then the carb. of ammonium is required. Give aconite if there be high fever. Hypertrophy and Dilatation of the Heart.—Hypertrophy of the heart consists of an increase of its muscular mass, or the thickening of the walls, whereby the capacity of the organ is dim- inished. This is the case in what is called concentric hypertrophy. There is still another form, where the muscle is increased in thick- ness, and at the same time the inner cavity enlarged, This is called eccentric hypertrophy. Sometimes only one half of the heart is en- larged or dilated. If the left ventricle is hypertrophied, the heart will be longer, and reach further down the left thorax, but if there is eccentric hypertrophy of the right ventricle, the heart will be broader, and will extend further over into the right thorax. Dis- eases of the valves and arteries, or obstruction of the circulation in the capillaries of the lungs are prime sources of both hypertrophy and dilatation of the heart, Pericarditis and myocarditis, mental excitement, alcoholic spirits, excessive use of tea or coffee, may ail aid in its production. Sigxs.—Percussion, in hypertrophy, gives rise to a dull sound, transmitted in ail directions ; and the heart's puise is so greatly augmented that the chest is shaken by it The apex of the heart is lower and towards the left nipple line. Dilatation and hyper- trophy of the left ventricle gives similiar results. The percussion sound does not extend so far towards the right thorax in hyper trophy and dilatation of the left ventricle as it does in complète dilatation and hypertrophy. In hypertrophy and dilatation of the right ventricle the dull percussion sound is further towards the right side. The jugular veins swell and undulate, and very soon cyanosis takes place, accompanied not unfrequently by bleeding of the lungs, and dropsy. Treatment.—For hypertrophy of the heart from obstruction of the portai circulation, gtt. 3 to 5 of nux vomica three times 76 THE AMERICAN PRACTICE OF MEDICINE. times a day, produce good results. If the disease is from valvular deficiency, give collinsonia, in doses of gtt. 10 to 20, three times a day, alternated with gtt. 2 to 3 of tinct. of arsenic every three hours. To control the palpitation of the heart, I hâve used cereus grandi- florus and lycopus virg., in doses of gtt. 10 to 15 every two hours. If the disease is associated with rheumatism, gtt. 2 to 3 of kalmia augustifolia may be given three or four times a day. If the hyper- trophy and dilatation is from mitral insufficiency or aortic constric tion and there is an irritable heart, then digitalis, in doses of gtt. 5, every three hours, will give tone to the muscles of the heart. If there be valvular disease preceding hypertrophy, the iodide of ar- senic is a valuable remedy, and may be given in doses of gr. 1-10. If the disease has followed acute, or exists with, chronic rheumatism, I then use tincture of colchicum, in doses of gtt. 10 to 15 every three hours, until the pain at the heart is subdued. Should this fail 1 would employ carb. or benzoate of lithium. If there be a sharp pain in the région of the heart, bryonia, in doses of gtt. 2, every two hours, alternated with gtt. 5 of spigelia, will be apt to give re- lief. If the patient suffers from a cramping pain, like a band around the heart, I hâve always found that the tincture of cerous grandi- florus would give quick relief. This is also the remedy for simple nervous palpitation of the heart. If there be a tight cough, con- gestion of the lungs, oversensitiveness to external impressions, palpitation from émotions, great debility, fatty degeneration of the heart, dyspnœa, and thèse in dilatation following endocarditis, then gtt. 1 to 2 of the tincture of phosphorus, three times a day, has a good effect. If dilatation and hypertrophy of the left ventricle, dyspnœa, and very fréquent spells of palpitation exist, very small doses of the acétate of lead may be given three times a day, gr. £ to J. Gr. ^ is enough in most cases. If anaemia, or chlorosis show itself in young girls, I advise the pyrophosphate of iron with other proper remédies. In many cases that I had at my dispeusary, haemorrhage of the lungs was quite fréquent, and I hâve found lycopus virg. one of our most trustworthy remédies. I usually give the infusion, or saturated tincture, according to âge. Nervous Palpitation of the Heart.—This f >rm of palpitation does not occur regularly, but as occasional paroxysms, it often at- tends organic disease of the heart. During the attack, the face may be red, and the puise full and large, or the face pale, and the puise small and irregular. Some hâve dizziness and roaring in the ears, headache, flickering before the eyes, fainting spells, and great dyspnœa, Causes.—One of the most fréquent causes is anaemia or chlorosis. It also often occurs in women about their climateric period ; also, in hysterical women, especially if any utérine disease or irregularity exists. It results often from sexual excesses, or it may be the re- DISEASES OF THE HEART. 77 suit of spinal irritation, or reflex nervous irritation from worms. Occasionally it sets in without any apparent cause. In our exam- ination, we should not dépend upon sounds during a spell of palpit- ation, but examine the heart in the interval between the spells, as there are unusual sounds during palpitation, which do not exist at other times. We must therefore be careful in our examinations, or we may be deceived. Treatment.—Generally in cases of young persons, after excite- ment or fright, aconite, in gtt. £ doses, every half hour, will allay the attacks of palpitation. In women, after suppression of the menses, or in the case of those who are hysterical, médium doses of the tincture of asafœtida, is generally ail that is required, with such other remédies as the gênerai constitutional conditions point out. If there is coldness of the skin and extremities, paleness of the face and great dyspnœa, then use gtt. 3 to 5 of the saturated tincture of camphor, every ten minutes, until relief is afforded. If this affec- tion follows long continued nursing, or loss of blood, small doses of the tincture of bark will often be required. In cases of tremulous palpitation following unusual exertion or mental émotion, cocculus indicus, in doses of gtt. 3 to 5, every two hours, will frequently re- lieve the spells. If the patient be anœmic, then pyrophosphite of iron should be given for some time. If the affection occur in young girls from suppressed menses, I administer gtt. 10 to 15, of pulsa- tilla, until the menses are restored to their normal quantity. Angina Pectoris.—This is a pressing, aching pain in the middle of the sternum, which cornes on suddenly, and almost suspends the breathing. It gradually increases in violence, and spreads from the middle of the sternum, towards the left plexus brachialis, and thence to the hands and feet; but seldom attacks the right side. The pa- tient suflers great pain and dyspnœa ; the countenace becomes pale, the front part of the head is covered with a cold perspiration. Thèse paroxysms may terminate in about half an hour, with éruc- tations of gas from the stomach, and may, or may not return again. In some cases the heart's action is increased, and in others, dimin ished. The spells may occur only occasionally, or they may occur daily. They are generally associated with some organic disease of the heart, such as aneurism of the aorta, fatty degeneration of the heart, and ossification of the coronoid arteries. This is always a grave disease. Treatment.—For the relief of the paroxysm the inhalation of gtt. 5 of nitrite of amyl every few minutes, for two or three doses, is invaluable At the same time the patient should take gtt. 20 of cereus grandiflorus every ten or fifteen minutes, until heis relieved. This remedy seldom fails to quickly relieve the paroxysm. I gave a gentleman in the city of Atlanta, three or four drachms, in the course of a few hours one night, and it relieved him of one of the 78 THE AMERICAN PRACTICE OF MEDICINE. worst cases of angina pectoris I ever witnessed. After relie ving the patient, we should carefully examine him to ascertain what or- ganic heart affection gave rise to the angina. Then, when our diag- nosis is made out, we should treat whatever disease of the heart may exist. If it be ossification of any of the arterial trunks, our treatment can only be palliative. I usually give a course of Fow- ler's solution, alternated with the carbonate of potassium. If there be fatty degeneration of the heart, our prognosis is very grave, and a sparse and low diet should be prescribed. Diaphragmitis.—The tendinous tissue of the diaphragm is seldom ever primarily affected ; but as the serous lining on its upper surface is a continuation ofthe pleura and pericardium, and that on its lower surface, of the peritoneum, it frequently surfers from par- ticipation with the pleura, the pericardium, and the peritoneum. Symptoms.—Dyspnœa is one ofthe direct indications of this dis- ease, also singultus, yawning, risus sardonicus, pain in the shoulders, vomiting, great difficulty in swallowing and a feeling of extrême tightness, etc. Therapeutics.—Where there is a hard, quick. feverish puise, thirst, anxiety, restlessness, painful cough, great dyspnœa, and pain and heat in the région of the diaphragm, I use gtt. 1 or 2 of acon ite, every hour, until the puise is slower and softer, and then half the quantity to keep down the inflammation. If there still be great pain, I give gtt. 1 or 2 of bryonia every one or two hours until the pain ceases. If the pain be of a rheumatic character, gtt. 1 to 2 of rhus tox. should be given every two or three hours, until the pa- tient is relieved. CHAPTER V. DISEASES OF THE DIGESTIVE ORGANS. Dyspepsia.—Indigestion is a common disease of the âge. So common is it, indeed, that almost the entire population are dys- peptics. The disorder includes every grade of severity, from a mild type, to the extrême, torturing soûl beclouding, life-embit- tering disease that converts the bright sunshine of life into the dark shadows of the grave. It sits like an incubus upon the very soûl of man. Indigestion may resuit from anatomical changes in the digestive organs, as inflammation, catarrh, thickening of the coats ofthe stomach, ulcération, éruption upon the mucous tissue, cancer of the stomach, or softening, etc., Again it may be caused by a deficiency of gastric fluid. or chemical constituents of that fluid. It may also originate from a want ofpancreatic fluid, or of biliary sécrétion. An abnormal condition of the nervous system may give rise to it, or it may be the resuit of using stimulating driuks, or of improper food. The use of tobacco is a great factor in the production of this disease. Sedentary habits and excessive mental application, may also combine to produce it. Symptoms.—The symptoms are so various that it is diflicult to enumerate them. I shall therefore only give such as are most promi- nent and common. In some cases there is a want of appetite, and in others a morbid one, with a craving for sour articles of diet and drink. Palpitation of the heart accompanies the disease, especial- ly in those cases characterized by the accumulation of gas upon the stomach. Many cases are accompanied by great and rapid accu- mulation of acid upon the stomach ; the patient haviug more or less rancid éructations, py rosis, or heart burn, and water-brash every day. In some cases of long standing, the patient's digestion becomes so much impaired that nothing seems to digest, and he may hâve vomiting or diarrhœa in conséquence. There is often tenderness over the pit of the stomach, which seems to the patient as if it were full, and sometimes very mnch swollen. The mind is deprcssed, incapacitating the subjects for mental or bodily work, and they become morose and irritable, and are disturbed at night by dreams. The expression is relaxed, tired, weary, and sad, with dull sunken eyes, aud lips generally pale. The flesh diminishes rapidly, the hands and feet are generally cold, and the whole body becomes very sensitive to cold changes. The teeth often decay from excess of acid in the blood, and the patient suffers often from toothache and neuralgia about the face and head. The bowels are [79] 80 THE AMERICAN PRACTICE OF MEDICINE. either loose or constipated. Patients very frequently complain of pain over the région of the stomach and in the neighborhood of the liver, which sometimes radiâtes the left scapula. There is oc- casionly, also, roughness in the throat, causing the patient to hawk up a tough phlegm. If the liver is implicated, which is often the case, there will be a hacking cough. The tongue is furred very frequently ; red at the tip and edges and there is a bad taste in the mouth. Treatment.—One of the first things to be done is to put the pa- tient upon a proper diet. He should be confined to such articles of food as are best suited to his particular case. If he use tobac- co, he must be informed at once that it is violent poison, and the most powerful relaxant in nature. It is the prime factor in the pro- duction of dyspepsia, and he should be advised to relinquish it at once, thus doing much towards curing the disease. Ile should also be prohibited from the use of large quantifies of drinks. A glass of fresh sweet milk is most suitable for the majority of patients. Some can use no other diet but bread and milk, while others can take a small .quantity offish, fowl, tender beef, mutton, or kid, without injury. Whatever the patient digests with the greatest ease should be partaken of in great modération. As much of the cure dépends upon the proper kiud and quantity of foocl, as upon medicine, and without strict dieting, no cure can be ac- complished. Among the vast list of tonics I hâve tried, but few are available in this disease. In récent cases, or in acute dyspep- sia, especially when it occurs in summer, and is caused by high liv- ing, or excessive use of acid fruits ; and where, too the tongue and mouth arc inclined to dryness, and there is yellowish coating on the tongue, accompanied by apththge:,bitter belching ; great sore- ness of the epigastrium ; nausea ; distension of the bowels ; sensa- tion of fulness in the stomach ; water brash ; jaundice; congestive headache; obstinate constipation, and disgust for food, bryonia in doses of gtt. 1 or 2, one hour before meals, will give appetite, tone up the stomach, and act on ail the sécrétions concerned in the di- gestive process. In some cases, where eating is followed by keen pA\n(which is generally due to ulcer of the stomach?) I give"'oxide of bismuth, in doses ofgr, 3 to 5, one hour before meals; should this fail I use gtt. 2 to 3 of the tinct. of arsenic, in a wine glass of wa- ter, before meals. If the bowels are not regulated by the use of bryonia, I give gtt. 3 to 5 ofthe tincture of nux vomira, one hour before each meal. Where the mouth is dry and clammy of a morn- ing, and there is heartburn, berberis vulgaris is a valuable remedy, and has been frequently successful. In females who are feeble, and whose catamenia are irregular or déficient; where there exists nausea; disgust of food; vertigo; slow digestion; constipation; flatulence and sleeplessness, aletris farinosa is a valuable remedy, DISEASES OF THE DIGESTIVE ORGANS. 81 in doses of gtt. 25 to 30 of the fluid extract, every three or four hours. If tîie tongue is white, dry, streaked, narrow and pointed, and there is an aching, gnawing pain in the stomach, with a sensé of constriction, aggravated by pressure, a désire for milk and hot food, colic and wind in the bowels, constipation, morose disposi- tion, and pain in the side, radiating to the left scapula, chelido- nium, in o-tt. 10 to 15 doses, three times a day will soon restore the biliary sécrétion and relieve the above symptoms. Should this fail, the tincture of euonymus atropurpureus may be given in doses of gtt. 20 to 30, three times a day between meals.. This druo- acts finely upon the secretory organs. Cornus cire, is a val- uable remedy where there is constant nausea, a bitter taste in the mouth, and aversion to ail kinds of common food ; the dose is gtt. 30 to 40 of the tincture, before meals. When dyspepsia is attend- ed with prostration, nervous headache, flat taste, craving for cer- tain articles of food, régurgitation and painful bloating after meals, small doses, say gtt, 1 to 2 of ignatia amara may be given before meals. Where there is great lassitude, exhaustion, obstinate con- stipation, dull headache, fréquent désire to urinate, wind in the bowels, large, flabby, slimy tongue, sour éructations, dyspnœa, palpitation of the heart, pyrosis, stitches in the epigastrium, chron- ic mucous discharges and great weakness, gtt, 10 to 15 of hydras- tis canadensis, before each meal will aid digestion. If anœmia ex- ists (as is often the case,) with prostration and albuminuria or dia- bètes, helonias dioica, in doses of gtt. 2 to 5, every three hours is one of our best remédies. Where there is nausea and vomiting, pain in the umbilical région, yellow, watery, corrosive stools and a burning sensation in the rectum, iris versicolor in gtt. 1 to 2 doses three times a day will bring relief. Should the patient hâve a sweet taste in the mouth, or an acid and putrid taste, with con- stant flow of saliva, excessive thirst, aversion to animal diet, sen- sation of emptiness in the stomach and drowsiness, muriatic acid, in doses of gtt. 2 to 3 before meals, diluted with cold water, will do o-ood service ; I hâve used it frequently with happy results. In cases attended by nervous prostration from the loss of vital fluidsY phosphoric acid, (Horsford's Acid Phosphate in doses of gtt. 20 to 30,) is always valuable. For excessive acidity of the stomach, if the above acids do not give relief, robina in gtt, 5 doses, should be tried, as it lessens this tendency very much. Where there is a craving for acids, a changeable appetite, putrid taste, foui breath, dryness of the mouth and throat, white fur on the tongue, pyrosis, sour éructations, régurgitation of the food, vomiting, with canine huno-er, constipation, headache, prolapsus of the rectum after stool, morning diarrhœa, great dépression of mind, tincture of podophyl- lum, in doses of gtt. 1 to 2, four times a day will very materially aid in the cure. Where there is a bitter slimy taste ; a feeling of 6 82 THE AMERICAN PRACTICE OF MEDICINE. tightness after meals; epigastric pains ; a want of appetite; bitter vomiting; flatulence; and wheu breaddisagrees with the patient; where there is water-brash ; hiccough ; colic and pains in the bow- els, gtt. 1 to 2 of tincture of pulsatilla, three times a day, general- ly gives immédiate relief. The hypophostites of lime, sodium, and magnésium in the formof eompound syrup, in several instances hâve done me good service. Many cases of this disease are the re- sults of and exhausted condition of the nerve centres, and contin- ued use of the phosphites is required to restore proper nervous tonicity. Where the gastric, pancreatic and salivary fluids are déficient, I hâve found Lactopeptine of essential service, when given just after meals. Various tonics hâve been known to effect a cure but the above bave proved most successful with me. Acute Gastritis.—Catarrh of the stomach, iu the acute form, is similar, in a pathologieaFpoint of view, to catarrhal inflammation of any other mucous tissue. There is swelling, redness, aud often a tough, transparent, or grayish-white slime over the membrane after death, the mucous membrane is so softened as to be easily scraped off like a mushy covering of the tissues. Causes.—Cold or wetting may cause this inflammation, or very cold or very hot food and drinks may produce the same resuit, so, too, with aleoholic drinks, ice cream and ice water. Symptoms.—In the outset there may be a chill, accompanied by paleness of the face and cold extremities. Later, the chillness alternâtes with flushes of heat, and the face becomes red and hot with high fibrile reaction. The patient then complains of soreness, fulness, and a burning pain at the pit of the stomach. The appe- tite is suspended, but the patient is apt to crave water, and if indulged, will vomit. There is constantly a belching up of gas, although the stomach still feels full. If the bowels are implicated, the stools become fetid and mushy. Treatment.—Where there is great thirst and pain in the stom- ach, with burning nausea and vomiting, gtt. 25 of aconite in % 4 pf water, in doses of a teaspoonful, mayr be alternated with drop doses of tincture of arnica every two hours. If, however, the tongue is dry, without thirst, and there is con- stipation, gtt. 10 or 15 of bryonia should be added to 5 4 of water, and given to the patient in doses of a teaspoonful, every two hours. If constant sour and rancid belching exists, with a bloated condi- tion of the stomach and bowels, vegetable charcoal in small doses acts admirably everyhour. When there is présent a bitter taste in the mouth, vomiting of green bile, constant rumblin give rise to it. Pathology.—This disease consists of hyperaemia ofthe mucous membrane, characterized by swelling, dryness, in the early stage, and afterwards increased sécrétion of mucus. As it becomes chronic, the mucous tissue becomes thickened and hypertrophied, and its surface is frequently found studded with small excres- cences. This issue is of a slate color, and the sécrétion finally becomes more or less purulent. The vaginal follicles become swollen on account of the obstruction in the excretory ducts, whilst their sécrétion is going on inside, and little round bodies of the size of hemp seed form, which are called ovula Nabothi. In some advanced stages of long standing there are diffuse catarrhal érosions for the most part on the posterior lip of the os uteri, or fol- licular ulcers which are caused by the bursting of the ovula Na- bothi. Occasionally granulating ulcers form. Symptoms.—A drawing pain in the small of the back and in the inguinal région, a feeling of fulness and heaviness of the pelvis, together with dysuria and tenesmus, characterize this disease. Pressure over the utérus gives pain, and in acute cases there is more or less fever. In some three to four days the characteristic leucorrhaeal discharge begins, which at first is transparent and sticky, staining the linen a grayish color. As the disease ad- vances this discharge becomes opaque and more or less purulent. In chronic cases it sometimes commences more gradually, and the discharge may be scanty at first. If the diseharge is corrosive it is generally évidence that it is from the vagina. The longer this disease exists, the more the mucous lining is changed in its char- acter, which changes influence the menses, causing either excess, pain or deficiency in the discharge. If conception takes place there is great liability to miscarriage. Chronic catarrh may be endured a long time, but it finally produces debility, relaxation, anaemia and hydraemia. It leads also to hyperaesthesia, neurgalia and spasmodic complaints, such as hysteria. Again it may lead DISEASES OF THE FEMALE ORGANS OF CENERATION. 157 to metritis, displacements of the utérus, closure of the cervical canal, and sterility. Treatment.—Where there is great debility, defective nutrition and anaemia, it is advisable to commence the treatment with aletris farinosa, one of our best tonics for females. It may be given in doses of gtt. 10 to 15 three times a day. If there is great pain in the back and hips, constipation and piles, aesculum hippocastanum may be given in alternation with the aletris farinoso, in doses of gtt. 5 to 6, three or four times a day. If there is great distension of the abdomen, and the discharge is like the white of an egg, muriate of ammonium in doses of gtt. 2, three times a day will aid materially in the cure. If the discharge becomes acrid and cor- roding and passes off when the patient stands on her feet, tincture of arsenic, In doses of gtt. 2 to 3, will hâve a happy effect upon the disease. If the discharge be acrid and fœtid and is attended by ulcération ofthe os uteri and vagina, baptisia, in doses of gtt. 1 to 3, should be ordered three times a day, and the vagina syringed out with a solution of permanganate of potassium, gr. 5 to the 51 of water at first (to be gradually reduced in strength to gr. 2.) If there is pruritus acccompanying the leucorrhœa, gtt. 10 or 15 of tincture of collinsonia should be administered every three hours. Pulsatilla is also an invaluable remedy, in doses of gtt. 3 to 5, three times a day, The fluid extract of hydrastis cana- densis applied locally is a valuable remedy iu vaginal leucorrhœa, and the sulphate of hydrastin, in a saturated solution in water and glycérine, is also a good topical application. Cimicifuga is effective in utérine leucorrhœa, and may be given in doses of gtt, 20 three times a day. For vaginal leucorrhœa, with severe catarrhal inflammation of the mucous membrane, tinct. of yellow marigold, with water and glycérine in equal parts, is valuable for external use. I usually apply it on lint or a soft sponge, renewing the application twice or thrice a day in grave cases. For muco- purulent leucorrhœa, the balsam of Peru in aqueous solution acts very well when locally applied. Where the discharge is very acrid and fœtid, I use carbolic acid as a wash, diluted in water, 1 part to 10 or 20 parts of water, according to the sensibility of the parts. Carbolic acid 5 2, glycérine §1, rose water %1, is also a good combinatiou for this purpose. A wash of a saturated solu- tion of boracic acid is also advisable in vaginal leucorrhœa. A strong solution of alum is an invaluable application where the dis- charge is thin and very profuse. In leucorrhœa of long standing, with inflammation and ulcération, sepia * and pulsatilla are the proper remédies. Acute Parenchymatous Metritis.—In this disease, the utérus * 8epia is made from Cuttle fish, and must be used carefully. 158 THE AMERICAN PRACTICE OF MEDICINE. is hyperœmic, œdematous, enlarged, and présents a dark, red color, often containing exudates of blood, or bloody sérum. In the chronic form, the redness is not so apparent, as from the exubérant growth of the interstitial tissue the small blood vessels become compressed, so that only7 a few of the veins become variocosed on account of the obstruction to the circulation in the organ. The substance of the utérus itself appears pale, dry and tense, and very much thickened. This condition of the parts, either in acute or chronic metritis, is always more or less complicated with inflam- mation of the mucous coat of the utérus, catarrh of the utérus, or an inflammation of the peritoneal coat of the organ, as in puer- péral peritonitis occurring after delivery. Causes.—The causes are the same as those which produce utérine catarrh, except in the case of puerpéral peritonitis, which follows delivery, abortion, or miscarriage. Symptoms.—This form of inflammation, like most others, sets in with a chill, followed by fever and pain in the back, etc. There is generally pain in the inguinal région; pressure in the pelvis; and great soreness over the utérus. If it takes place during the menstrual flow, this suddenly ceases, or may burst forth as metro- rhagia. Metritis is almost always complicated with utérine ca- tarrh, and consequently, is attended with similar characteristic discharges. Prognosis.—In favorable cases the disease may terminate in eight or ten days. Puerpéral metritis, however, is a graver form of the disease, and often proves fatal, especially if not well treated. The most fréquent causes of this form of metritis are operative manipu- lations during parturition, mental excitement or dépression during the puerpéral state, improper diet, taking cold, and, doubtless, there is at times a condition of the atmosphère favorable to it. The épidémie form is usually called puerpéral fever, which is a pe- culiar dissolution of the blood similar to, but not identical with, that of typhus fever. This disease generally commences after de- livery, while the utérus is still in a state of hyperaemia. It also sets in with a chill, followed by a high fever, extrême tenderness over the utérus, great thirst, nausea, and often vomiting, suppres- sion of the lochial discharge and a great tendency to putrescence. This last symptom is evinced by a very offensive odor about the patient and her bed. The disease is often complicated with phleg- masia alba dolens, milk leg, which is a metastatic inflammation of one or more of the large veins of the thigh, causing a shining, white and very painful swelling of the whole limb. The chronic form of metritis is characterized by a heavy feeling often mistaken for prolapse of the utérus. At the outset the menses are generally very profuse ; but later, as the exubérant interstitial tissue com- presses the blood-vessels of the utérus, menstrual discharge becomes DISEASES OF THE FEMALE ORGANS OF GENERATION. 159 scanty or perhaps ceases, and leucorrhœa takes the place of the menses. Treatment.—In the acute form of metritis, I find aconite in- valuable, in doses of from gtt. | to 1, every half hour or hour, ac- cording to the severity of the disease. Belladonna may be given in doses of gtt. 3, every four hours in alternation with the aconite. Both of thèse remédies oppose the inflammatory process, by their direct influence over the capillary, and gênerai circulation. They are both especially applicable in the puerpéral form of inflamma- tion of the utérus and its appendages. If there is constant nausea and vomiting, small doses of ipecacuanha should be given, say gtt. 1 to 2 of the tincture of the fresh root, every half hour until the symptom is relieved. If the fever runs very high in puerpéral metritis, and the puise is full, strong and quick, veratrum viride, in doses of gtt. 2, every two or three hours, has acted well with me in many cases. If there is great soreness over the utérus, I usually apply a cloth wet in spirits of turpentine over the spot. In cases of an adynamic type, where there is great prostration, a bruised feeling ail over, fœtid odor from the body and excrétions, and a dry red tongue, or a brown parched one, baptisia in doses of gtt. 1 to 5, may be given every two hours, until this condition is correeted. The above is the proper treatment for the acute form of metritis, the chronic form requiring other remédies. In chronic metritis, where there is constant désire to urinate and constipation, nux vomica, often does much good in doses of gtt. \ to 1 every 2 hours. If the disease cornes on in a subacute form, from getting the feet wet during the menstrual period, or just after the confinement, pulsatilla, in doses of gtt. 2to 3, every two or three hours, will aid ïn the cure. If, instead of obstruction of the menses, there is haemor- rhage, sabina may be prescribed in doses of gtt. 1 to 2 of the tinc- ture, every three hours, with good effect. If the disease is attended with putrescence of the utérus, and ulcération of the os uteri,gtt. 1 to 2 ofthe tincture of secale cornutum should be administered every two hours, until this state is corrected. Should there be constant tenesmus in the bladder, gtt. 1 to 2 of tincture of cantharides may be given every hour, until the symptom is relieved. Chronic Parenchymatous Metritis.—This is areolar hyperlasia of the utérus, and is one of the most intractable diseases of females. This eomplaint seems to consist in a diffuse growth of connectiye tissue, constituting induration. The whole utérine conneetive tis- sue sometimes proliférâtes, usually without accompanying increase of muscular substance, or if this does occur, the conneetive tissue prédominâtes. This condition is generally called hypertrophy of the utérus, or enlargement of the cervix, by some authors, subin- volution of the utérus, and bv others, chronic enlargement of the utérus and cervix. 160 THE AMERICAN PRACTICE OF MEDICINE. Causes.—Any impairment of the vital forces may tend to the development of this disease, and a tuberculous tendency of consti- tution may also hâve this resuit. Too fréquent parturitions, pro- longea nervous dépressions, attacks of puerpéral inflammation, displacement of the utérus, endometri tis, cardiac disease and neo- plasms, and excessive sexual intercourse may also cause it. Symptoms.—Where the cervix alone is involved, there is pain in the back and loins, pressure on the bladder and rectum, irregular menstruation, nervous disorder, pain with the sexual embrace, dyspepsia and leucorrhœa. If the body of the utérus is affected, there will be a dull, heavy, dragging pain in the pelvis, which is increased by motion. Defacation and sexual intercourse are also attended with more or less pain, and the monthly courses are pre- ceded by a dull pain in the back and utérus. There is apt also to be pain in the mammae just before and during the menstrual flow ; the areolae also around the nipple become darker. In some cases there is nausea and vomiting, and the pressure in the rectum fre- quently results in hœmorrhoids. The utérus is perceptibly en- larged, and is tender to the touch.^ Treatment.—Local depletion, either with leeches or the scarifi- cator may do good in some cases. I hâve depleted with tampons of sponge, saturated with glycérine, applied ail night, and then renewed in the morning. This treatment should be continued for several days, and is of spécial utility in cases of enlarged cervix uteri. Phytolacca in small doses, of gtt. 5 every three hours, will aid in lessening the enlargement. Sepia has done good service for me in several cases ; given in doses of gtt. 1 to 2 three times a day. After using the glycérine a few days, I administer gtt. 10 of Lu- gol's solution to 5 2 or 3 of glycérine and water. This may be alternated with a solution of the tincture of polymnia uvedalia, gtt, 10 to 20 of which may be taken internally, three times a day. It may be applied by adding equal quautities of pure glycérine, or glycérine and water. Puerpéral Fever.—This is a most serious disease in females. Its fréquent causes are, operative manipulations during parturition; great mental excitements or dépressions during the puerpéral state; faulty diet, and taking of cold, etc., during that period. There is a very grave form of puerpéral fever, similar to typhus fever, which consists in a dissolution of the blood. This form of puer- péral fever always commences in the first days of the puerpéral state, even before the utérus regains its normal position and size. It usually sets in with chills, followed by high fever, great tender- ness over the abdomen, urgent thirst, vomiting, suppression of the lochial discharge, and a very marked tendency to putrescence and décomposition. Phlegmasia alba dolens, or milk leg, is a fréquent complication of this form of fever. This seems to be a metastatic DISEASES OF THE FEMALE ORGANS OF GENERATION. 161 inflammation of one or several large veins of the thigh, causing a white, shilling, very painful swelling ol* the whole limb, together with great enlargement of the diseased vein. Parenchymatous metritis, acute and chronic, often occurs, in which there is an hy- peraemic, œdematous enlargement of the substance of the utérus. If this state be attended with a great tendency to putrescence and décomposition in the acute form, it is apt to prove in most cases, intractable to ail kinds of treatment. Treatment.—If there is a great tendency to putrescence, anti- septics should be given at the outset, alternated with arterial séda- tives. I hâve found the tincture of veratrum viride, in doses of gtt. 2 or 3 every two hours, until the rapidity of the puise is mod- erated, then in smaller doses, alternated with aconite, in doses of gtt. 1 every two hours, to answer well in most cases. If there is an offensive odor about the patient, a solution of gtt. 2 to 5 of per- manganate of potassium to the ounce os water, used with a syringe, and thrown up against the os-uteri every two or three hours is effective. I also give from gtt. 3 to 5 of the tinct. of baptisia every two hours. If the inflammation is the resuit of injury from ma- nipulations during parturition, I then administer gtt. 1 of tincture of arnica four times a day. If there is headache or delirium I use gtt. 3 to 5 of tincture of belladonna three times a day. If there is partial paralysis of the lower limbs, restlessness, dry tongue with red edges, red rash on the breast, and any other marked ty- phoid symptoms, rhus toxicodendron in doses of gtt. 1 to 2 every three hours, will be found to act well. If there is constipation, and great distention of the abdomen, headache and thirst, I give gtt, 2 to 3 of bryonia every two hours If there is a very great tendency to gangrené, gtt. 5 of turpentine every hour or two act admirably. Anteversion of the Womb.—Anteversion consists in a dis- placement, in which the fundus of the utérus falls forward and leans upon the bladder and pubis. This condition may be the re- suit of hypertrophy of the anterior wall of the utérus, of peritoneal exudates or tumors within the abdominal cavity pressing it for- ward, and of muscular efforts. Symptoms.—There are no very distinct symptoms, except pres- sure upon the bladder and rectum. Upon introducing the index finger into the vagina, the portio-vaginalis will be felt inclined backwards. Rétroversion of the Womb.—Hère the fundus of the womb inclines back towards the os sacrum, or is even pressed down beneath its promontory. This condition may exist in the early stage of pregnancy, and may be produced by the same abdominal conditions that cause anteversion. Its symptoms are pressure upon the neck of the bladder, sometimes causing great difficulty 11 162 THE AMERICAN PRACTICE OF MEDICINE. in passing the urine, and pressure on the rectum, causing consti- pation, and pain in défécation. Upon examination the neck of the utérus will be felt high up, towards the pubic arch, in a posi- tion just the opposite of that of anteversion. The examination should always be made while the patient is in the erect position, as reclining changes the position of the misplaced utérus. Prolapse of the Womb.—The utérus may descend, more or less, into the pelvis ; from a slight bearing down upon the upper portion of the vagina, to a protrusion of the womb out of the vagina—prolapsus completus, or what is called by some writers, procidenlia uteri. The womb is kept in its normal position by the peritonaeum and the broad ligaments, but can descend when there is a relaxed state of this apparatus. Undue pressure from above, straining and lifting, or standing too much on the feet, while the body is hot, may also cause it to descend. Ail debilitating diseases favor this malposition of the utérus, as leucorrhœa, excessive menstruation, chlorosis, anaemia, poor diet, etc. Symptoms.—There is a peculiar sensation of heaviness in the pelvis, and a feeling of great weight, as if everything within the abdomen would pass through the vagina. This sensation is worse in walking, after standing long on the feet, and after severe exercise. Pressure upon the bladder and rectum, causing constant désire to urinate and defcate, and generally, more or less leucor- rhœa exists. Upon examination with the index-finger, the os uteri will be felt near the outer opening of the vaginal orifice, together with a fold of mucous membrane. Treatment of Utérine Displacements.—In anteversion, the use of pessaries accomplishes but little, except in some exceptional cases. The utérus should first be reduced to its proper position with a utérine sound, and then Thomas' rétroversion pessary should be introduced to keep it in its normal position, until the muscular tone of the parts is toned up. After replacing the utérus, which can be done with the sound, both in cases of ante- version and rétroversion, and after correeting the malposirion, the patient should hâve such direct tonics as hâve a spécial affinity for the utérus, as sepia, in very small doses, say gtt. 1 to 2 of the 3d dec. solution, for it must be remembcred that this drug has power- ful toxical effects. Helonias and cimicifuga are both good utérine tonics, as are also lilium tigrum, in doses of gtt. 2 to 5, three times a day ; œsculum hippo. and ustilago, dose of either gtt. 3 to 5, every three hours ; and aletris. ]S"ux vomica often does well, in small doses. The médical treatment in this affection consists in the admin- istration of such medicines as will relieve the pathological condi- tions upon which the deformity dépends. The disease often exists with chronic congestion of the utérus, which will generally yield DISEASES OF THE FEMALE ORGANS OF GENERATION. 163 to the chloride of gold and sodium, in very small doses of gr. 1- 50 to 1-60, three times a day. Very ofteu this sized dose will prove toxical, Sepia will, also, often correct malposition of the utérus, and should always be tried, in small doses. Nux vomica has a direct tonic effect upon the muscles of the utérus, as it has upon ail the muscles of the body ; and should be used if sepia fail. Cimicifuga, in doses of gtt. 15, three or four times a day, has proved itself valuable in my hands ; and so has lilium tigrum. If there be congestion, ustilago and belladonna are the best remédies ; dose of the former, gtt. 3 to 5, and of the latter, gtt. 1 to 2. ./Esculum and helonias are as applicable in prolapsus as in other malpositions. The use of corsets and heavy skirts must be prohibited ; and, as temporary support, until the utérus can re- gain its usual tone, the soft rubber pessary may be worn. (Dr. Jackson's elastic soft rubber pessary is preferred). In cases of procidentia, the utérus must be replaced before any other treatment is commenced. Some writers recommend amputation of the enlarged and elongated cervix, but I never had a case where I deemed this necessary. In addition to the above tonic treatment, I use an astringent wash, composed of Monsel's sait, 5 1 to aqua 54 or Monsel's solution, 5 1 to 5 1 of water, thrown up with a glass syringe against the os uteri, and retained there ten or fifteen minutes, by elevating the hips. This last is the most powerful astringent in the list, and may be used stronger and stronger, until its astringence begins to contract the muscles of the part so that it produces great soreness ; as it will often do. I would rather hâve this than ail the washes in the Materia Medica. With it, and proper internai tonics, I can effect a cure where ail the pessaries hâve utterly failed. I treated a case, not long since, which had worn a pessary for months, until it had produced such violent ulcération, and leucorrhœa that the woman stankdreadfully. I threw away the pessary, and used for the fœtor and ulcération, the solution of iron as above, alternated with a solution of permanganate of potassium, gr. 5 to the ounce, with proper internai tonic treat- ment. I succeeded so well with this treatment that I hâve aban- doned the pessary entirely in almost ail cases. Polypus of the Womb.—Utérine polypi are soft tumors, growing from the mucous surface on a pedicle or stem, and are generally within the womb, although there are interstitial fibroids, which are imbedded in the parenchyma of the utérus. They seldom exist in females under thirty years of âge, and can only be .diagnosed by a physical examination. The mucous polypi con- sist of an exubérant growth of the utérine mucous lining. They are usually pediculated, and consist either of distended mucous follicles, or are mère vascular bodies. They frequently cause violent haemorrhage, and always excessive leucorrhœal discharge. 164 THE AMERICAN PRACTICE OF MEDICINE. Treatment.—The phosphate of lime, in doses of gr. 3 to 5 three times a day, has much réputation, and so has the sanguin- aria used externally and internally. Staphisagria, in doses of gtt. 1 to 2, three times a day, is recommended by some writers ; and powdered tannin, locally applied, will sometimes destroy a soft polypus. Rhus toxicodendron, gtt. 1 to 2, every four hours, is highly recommended b}7 some, and so is iodine. This affection properly belongs to the domain of surgery. The tumors may he removed by ligature, or torsion, and then the roots destroyed by application of diluted nitric acid. This acid should be so diluted that it will not corrode the sound flesh, which may be protected with oil. Cancer of the Womb.—Cancer of the womb is most generally of the medullary variety ; scirrhous and alveolar cancers occurring less frequently. The disease generally begins at the vaginal portion of the utérus, and very rarely extends to the fundus. It is very apt, however, to spread down the vagina, over the bladder and rectum, causing the most horrid destruction of thèse organs. Symptoms.—One of the first symptoms noticed by the patient, is severe pain in the small of the back,loins and groins, becoming more and more violent. At first there will be haemorrhages at the monthly periods, but as the disease advances, they may occur at any time. A copious leucorrhœa sets in, which becomes more and more offensive and watery7 ; corroding the parts it happens to tonch. Cauliflower excrescence is a cancroid hypertrophy of the papillae at the mouth of the womb, which often attains very great size. It is usually in the shape of a cauliflower. Its color is a bright red, it bleeds very easily, and is very prone to cancerous degeneration. The constitution soon becomes prostrated from the pain and loss of blood. It is similar to cancer of the womb in its symptoms, and can only be certainly diagnosed by the introduc- tion of the spéculum, as is the case with cancer of the utérus. They are both apt to prove fatal. Treatment.—The chloride of gold and sodium is one of our best remédies in this disease. It is indicated when there are very offensive discharges, and stinging, cutting pains in the utérine région. As soon as the disease has exhausted tbe vital powers, and the pains become burning, sharp, and worse at night ; and the discharges grow acrid, corroding, offensive and dark colored ; I find arsenic, or the iodide of arsenic very useful in small doses. I give gtt, 1 to 2 of tincture of arsenic, or gr. 1-30 to 1-20 ofthe iodide of arsenic four times a day. If tne pain is intense and stitching, and there is nausea and vomiting, small doses of conium should be administered, and the cancer dressed with an ointment of the same drug. In cauliflower excrescence, where the menses are irregular and offensive, graphites (plumbago DISEASES OF THE FEMALE ORGANS OF GENERATION. 165 or black lead) in doses of gr. 1 or 2 three or four times a day, will hâve a most excellent effect. At the same time, the excre- scence should be washed in a solution of glycérine, water and créosote, 5 1 of glycérine, 5 1 of créosote, and § 7 of water. Where the tumor is inclined to bleed easily, the tincture of thuja o 1 to wqter 5 3, may be applied on lint, and renewed every three or four hours. Mitigation of the patient's sufferings is ail that need be expected in this disease. Metrorhagia.—This disease consists of a more or less profuse haemorrhage from the womb, between the menstrual periods. It may occur in the non-pregnant state, and seems to resuit from an abnormal flow of blood to the womb or from morbid growths in the utérus. It is very frequently produced by the peculiar physi- ological changes conséquent upon the so-called " change of life "— cessation of the menses. Some of the worst cases that I hâve ever treated occurred at this period. This form of haemorrhage may also set in during pregnancy. Some women menstruate several times after conception, without apparent injury ; but in most women a haemorrhage during pregnancy indicates abortion. A severe haemorrhage, four or five months after conception, indi- cates placenta prœvia, or miscarriage, In cases of abortion, the haemorrhage may be very profuse, and generally occurs from im- perfect contraction of the utérus. Metrorhagia is frequently pre- ceded by a chill, and the hemorrhage cornes in gushes, or in a continued flow of bright red, or dark blood. The face soon bleaches, the hands and feet grow cold, and there may be labor- like pains or colic. After great loss of blood, the patient becomes anaemia Treatment.—Ipecac, in doses of gtt. 1 to 2 of a saturated tincture of the fresh root, has often done good service, especially where the haemorrhage is of a bright red color, and is accompanied by nausea and vomiting. It may be repeated every twenty-five or thirty minutes nntil the haemorrhage is arrested. If this fail, gtt. 3 to 5 of the tincture of cannabis indica should be ordered every half hour until the flow ceases. If the flooding occurs with great relaxation in feeble cachectic women, I give secale cornu- tum, in doses of gtt. 10 to 80 of a good tincture or fluid extract, every .one or two hours, as required. In robust, florid women, where the haemorrhage originates from utérine congestion, or in- flammation, (in which case the discharge is of a bright red color,) the tincture of sabina in doses of gtt. 1 to 3, should be adminis- tered every two or three hours, or repeated oftener in smaller doses. Should this fail to stop the haemorrhage, the oil of erigeron should be alternated, in doses of gtt. 8. There are still other remédies recommended, as apocynum cannabinum, in doses of gtt. 1, every ten or fifteen minutes. I hâve succeeded well with tinc- 166 THE AMERICAN PRACTICE OF MEDICINE. ture trillium pendulum, and also with gr. 4 doses of pure berberine sulphate. Menorrhagia.—This a profuse flow of blood from the utérus at the regular menstrual period. Thèse periods may come too soon, or may last too long ; and, in some cases, the menses are not only too profuse, but come on too early, and last too long, hence prov- ing very exhausting, Causes.—Morbid growths in the utérus, structural changes, etc., may give rise to this haemorrhage, or it may resuit from stagnation of blood in -the utérine veins, and lung and heart dis- eases. Preternatural détermination of blood to the utérus, sexual excesses, sexual excitement, or onanism, may also cause it. Some- times it results from a haemorrhagic diathesis, as in purpura, scurvy, small pox, typhus fever, measles, etc. The blood in this form of haemorrhage of the womb, is either fluid or coagulated, and differs in color. Treatment.—The treatment is similar to that detailed above for metrorhagia. If the discharges be of a bright red color, and there be nausea and vomiting, ipecacuanha is the most reliable remedy, in doses of gtt. 1 to 3, every half hour or hour, according to the severity of the flow. If this drug does not control the haemorrhage in due time, tincture of sabina may be used in alter- nation, every two or three hours. This latter is a most valuable remedy. Should the utérus be relaxed, ergot, in doses of gtt. 30 to 60, every one or two hours, will aid the above remédies in stopping the haemorrhage; or it may alternate with oil of eri- geron. I hâve often succeeded well with cannabis indica, in doses of gtt. 5. Tincture of rue is highly praised by some writers, but I hâve never tried it myself. If the diseharge is black and lumpy, I find the tincture of crocus sativus (saffron,) very useful in doses of gtt. 2 or 3, every two hours, or in smaller doses every half hour. Where there are cardiac complications, and the flow is of a dark color and thick, tincture of cereus grandiflorous may be administered in doses of gtt. 1 to 5, every hour, in alternation with charcoal in small doses, or with the tincture of chamomilla, in doses of gtt. 1 to 2. In cases of vascular excitement, with flushed face, throbbing of the carotids, full, bounding puise, nausea, etc., gtt. 3 to 5 of belladonna, every three hours, will aid other remédies, and is most valuable in alternation with ipecacu- anha. Sometimes small and repeated doses of the bromides hâve done well, especially in rather passive forms. In this form, the tincture of hamamelis, in doses of gtt. 5, every fifteen minutes, has proved very efficient, and so has trillium pendulum. Ustilago maidis is also an invaluable remedy. In the interval I give tonics and senecio aureus. The best tonic is helonias dioica. Amenorrhœa.—This may occur any time between the âges of DISEASES OF THE FEMALE ORGANS OF GENERATION. 167 puberty and the climacteric. After puberty, females should men- strate regularly, except during pregnancy and nursing. Non-ap- pearanee of the menses at the âge of puberty may be from chlo- rosis, scrofula, rachitis, tuberculosis, etc. It may also anse from degeneration of the ovaries, but is oftener from catarrhal affections of the womb. It has occurred from spinal diseases, occlusion of the os uteri, and imperforate hymen. Metritis is a common cause of this obstruction. Sometimes vicarious menstruation will take place. This is a flow of blood, at the monthly period, from some other mucous membrane, as the nose, eyes, bowels or ears, or from wounds. With this obstruction, there may be headache, dyspnœa, dyspepsia, sadness, sleeplessness, œdema, palpitation of the heart, and hœmorrhages of various parts, as above stated. Treatment.—If delayed menstruation occur in rheumatic sub- jects, or from getting the feet wet at the time it should take place, aconite, in doses of gtt. & to 1 three or four times a day, alternated with cimicifuga, will often bring on the flow. Delay of first menses, in mild dispositions, should be treated with gtt. 3 to 5 of pulsatilla, three times a day. If there is anaemia, however, he- lonias and iron will be necessary, alternated with cimicifuga. If the delay, or obstruction, should be the resuit of an atonie condi- tion, the chloride of gold and sodium will arouse the dormant énergies of the system, and aid in bringing on the menses. If, with obstruction, there exists indigestion and constipation, nux vomica in doses of gtt, 2 to 5 three times a day, will hâve excellent results If, in the interval, there exists cérébral irritation, bella- donna in doses of gtt. 1 to 2 may alternate other indicated remé- dies or should there be leucorrhœa instead of the menses, I give sepia, in very small doses, gtt. i to \, three times a day, and not oftener for it is highly toxical. If there be congestion of the head, and delirium, or a tendency to dropsy, the tincture of apis mel., in doses of gtt. 3 to 5 may alternate with aconite or belladonna, every three or four hours, according to the urgency of the symp- toms. I hâve frequently succeeded well with gtt. 30, ot senecio aureus, three times a day. If obstruction is due to rheumatic ex- posure I order bryonia, in doses of gtt. 2 to 3 of a saturated tinc- ture, three times a day. The sitz-bath should always^ be used at and near the menstrual period. In functional mactiyrty, apiol has been highly praised by Prof. Bartholow. Where chlorosis or anaemia existe, iron, aletris farinosa, and helonias dioica are proper remédies, and will always aid in the cure. >Dvsmenorrhœa.-Dysmenorrhœa is usually attended by un usuaTp^îii which may continue only a day or two or the entire menstrual period. It is generally caused by one of four things, ^ viz. • (1) structural changes, or flexions of the utérus, (the mechani- cal dysmenorrhœa of writers) ; (2) congestion of the utérus, (corn- 168 THE AMERICAN PRACTICE OF MEDICINE. mencing with signs of congestion of the pelvic organs, as strong action of the heart, and congestion of the head with fever, which is believed to be produced by a thickening of the peritoneal linino- of the ovaries, and the conséquent difficult perforation of the Graafian follicle) ; (3) the formation of an exudation between the mucous coat and the parenchyma of the utérus, (membranous dys- menorrhœa in conséquence of which, portions of the loosened membrane are thrown off and discharged) ; and (4) a morbid sen- sibility (hyperaesthesia) of the nervous system controlingthe utérine organs, called neuralgic dysmenorrhœa. In this form the menses are attended with extrême pain in the utérus, back, and limbs, and sometimes with neuralgic pains in various parts, cramps, etc. Treatment.—In the congestive form, where the discharge is of a bright red color, aconite in drop doses every hour or two, alter- nated with gtt. 3 of pulsatilla, will be apt to give relief. If it is of the inflammatory order, the above remédies should be relied upon at first, but if they fail, the acétate of ammonium should be administered in doses of % \ to 1 every two hours. If dysmenor- rhœa is complicated with hœmorrhoids, and there be pelvic con- gestion, collinsonia in doses of gtt. 10 to 15 every two hours, may be alternated with other appropriate remédies. If the discharge is scanty, I use sepia (juice of cuttle-fish) in doses of gtt. \ given every two hours. In the spasmodic form we hâve several very positive medicines, as xanthoxylum fraxineum (tincture of the bark and berries), which I give in doses of gtt. 30 every half hour. If this fails in two hours, gtt. 15 to 20 of tincture of gelseminum will be effective. If this does not stop the spasms, tincture of vi- burnum prunifolium may be used in doses of 5 1 every half hour. If this cannot be obtained, the tincture of viburnum opulum may be substituted in the same sized dose. Cimicifuga in doses of gtt. 10 to 15 often readily relieves the congestive form. I hâve also relieved it with gtt. 80 to H0 of the ammoniated tincture of guai- acum every two or three hours. Cannabis indica is the best remedy where the discharge is very profuse ; the dose is gtt. 3 to 5 of the tincture. The treatment in the inter-menstrual period is essential to relieve the paroxysms. The tinctures of senecio aureus and caulophyllum thalictroides are invaluable in the radical cure of this very painful affliction of women. I usually alternate thèse two remédies, and give them in doses of gtt. 30 to 40 each, three times a day. If the patient be of a scrofulous habit, the com- pound tincture of iodine in doses of gtt. 3 to 4 three times a day may be ordered, in alternation with the senecio aureus. If there be any cutaneous disease connected with dysmenorrhœa, sulphur will aid the other indicated remédies in the cure. If, however, the éruption of the skin be inclined to suppurate freely, tincture of arsenic in doses of gtt. 2 three times a day, acts admirably. DISEASES OF THE FEMALE ORGANS OF GENERATION. 169 When the dysmenorrhœa is associated with rheumatism, I hâve found the tinctures of cimicifuga and gum guaiacum to be very efficacious in doses suited to the strength of the patient. In ail cases where the patient is anœmic, iron should be used, alternated with helonias diocia. I prefer the phosphate or p37rophosphate of iron. The patient should avoid ail very sudden changes, and keep the feet warm and dry, bathing them at night in warm water. Pruritus VulvaB.—This is an intolérable itching of the vulvœ ; so severe as to prevent sleep, and to cause other ner- vous affections. Upon examination, the vagina will be found rather dr}7, and with an éruption on the mucous surface and labia. It is believed that this disease is caused by a stagnation of the blood in the vaginal veins, for the subjects of pruritus are often the subjects also of haemorrhoids, or piles. Treatment.—According to the above pathology, collinsonia, in doses of gtt, 10 tolô, three times a day, would be indicated, espe- cially if constipation ofthe bowels existed with the pruritus. If the itching be more severe after the menstrual period, an ointment of conium will usually lessen this symptom. If there be leucorr- hœa with the pruritus, sepia, gtt. J to 1, three times a day, will aid materially in the final cure. If haemorrhoids set in with the pruritus, I prescribe tincture of sulphur in doses of gtt. 5 to 10,or gr. 1 to 2, of pulverized sulphur, three times a day. I hâve tried sulphurous acid, with the very best effects, applying it locally, while I was giving the other indicated remédies internally. Pla- tinum is highly praised by some writers, and so is lycopodium, used locally and internally. The tincture of grindelia robusta, 1 part to 10 of water, is a first-rate application, and so is a lotion of bammamelis, especially if the disease is connected with piles. Mastitis.—This form of inflammation generally takes place at the commencement of lactation. Causes.—It originates from a stagnation of milk in the gland, or a tube of the milk gland. This, in turn, may be from the ina- bility of the child to completely empty the breast, from imperfec- tion of the nipples, or from undue pressure exercised upon the gland by tight dresses. There is first an inflammation of the milk ducts of the mammae, which soon spreads and inflames the whole gland. The inflammation may, in some rare cases, begin in the subcutaneous cellular tissues, (rather an erysipelatous form,) and spreading inward, produce a caking of a portion of the breast. This form may originate from injury of the breast by external bruises, from exposure to intense cold, and from severe pressure on the organ by tight cloth ing. This painful. affection, if not ar- rested in the early stage, will resuit in an abscess, and when it once begins to suppurate, a succession of abscesses may continue for months. 170 THE AMERICAN PRACTICE OF MEDICINE. Treatment.—If the patient can be seen in the early stage of the disease, phytolacca, used both locally and internally, will ar- rest the disease. I poultice the breast with Indian meal wet in a strong tea ofthe root, and give gtt. 5 ofthe tincture of green root, every two hours. This treatment has seldom failed with me. The next best remedy is belladonna, used locally and internally. If ail thèse fail, the abscess should be opened to let out the pus. Scirrhus, or Cancer of the Mammae.—Scirrhus is the most fréquent form of mastitis, and may begin deep in the gland, or near the surface. It can be felt as a round tumor within the breast, small at first, but later, large and very hard. As it in- creases in size, it draws the nipple inward until it présents a navel- like dépression. The progress of this tumor may be slow, but finally suppuration forms a deep ulcer, with callous, elevated edges, diseharging an ichorous fluid, and often having a very offensive odor, especially in very warm weather. This should be disinfec- ted. Medullary Sarcomae.—Thèse appear as one or several tumors, which rapidly destroy the mammary gland, and not unfrequently conglomerate into large masses of irregular shape. Scirrhous can- cer is distinguished from other tumors of the breast by very in- tense pain, which is stinging, burning, and lancinating in character. Cause.—The cause is obscure, and there is some peculiar consti- tutional contamination, the nature of which we do not know. Treatment.—The only successful treatment of the medullary form, is by the surgeon's knife, at an early period. Ail cases that I hâve ever seen hâve proved fatal. The scirrhous form may be treated in the same way, at the commencement, but unless it is done early, I believe that enucleation by proper caustics is better. The chloride of zinc, gold, and bromium hâve ail been successfuUy used. CHAPTER XVI. DISEASES OF THE SPINE. The spinal column may beconsidered as a continuation ofthe head and the spinal cord and its membranes as ans wering to the dura mater, araconoid, and pia mater, they being a continuation of the same membranes, and sending forth branches of nerves to the various parts of the body, like the brain itself. The diseases of the spinal cord correspond with those of the brain. Anaemia.—This state of affairs is due to a deficiency of blood in the cord, and is generally associated with other diseases of the body. It symptoms are obscure, but there is always great weak- ness, dyspnœa, fréquent palpitations of the heart, and gênerai anaemia of the whole body. Hyperaemia.—Hyperaemia of the spinal cord is usually com- binée! with congestion of the brain. It may be the resuit of local disturbances of the circulation of the blood, from haemorrhoids, menstrual affections, pregnancy in women, and tumors. It exists sometimes in fébrile affections, and in severe spasmodic diseases. Symptoms.—There will be difficulty7 in voluntary motion, and pa- ralysis of the lower extremities, and sometimes also of the upper limbs. This paralysis almost always affects both sides, more or less, rarely but one side. Respiration is often diflicult, and the muscles of the bladder and the rectum are affected. Treatment.—The treatment of hyperaemia, in the active form, should consist of aconite, in doses of gtt. 1 every two or three hours, according to the intensity of the disease. This drug may be alternated with gtt. 10 of gelseminum, every three hours. In a passive form, gtt. 10 to 20 of the fluid extract of ergot may be required every three hours. Spina Bifida.—Hydrorrhachis congenita is an analogous affec- tion to hydrocephalus. It consists in an imperfect development of the fœtus, which may hâve been prematurely expelled from the utérus. There are instances, however, in which children are born with spina bifida. Like hydrocephalus congenitus, spina bifida consists of a dropsical effusion of sérum, either between the dura mater and the vertebrae, in the subarachnoidal space, or within the central canal of the cord. Xow when this effusion takes place before the vertebra has closed perfectly, the pressure of the fluid within prevents a final cure, and thus, from deficiency of the ver- tébral arches, the spinal column is posteriorly cleft in two ; thus giving rise to the name, spina bifida. Only one of the vertebrae [171] 172 THE AMERICAN PRACTICE OF MEDICINE. may be unclosed, or it may affect the whole spinal column. Very often, however, it is confined to the lumbar, cervical, or sacral régions. The fluid passes out, and, according to the quantity, forms a large or small tumor. After birth, this tumor rapidly increases and fluctuâtes, and becomes denser and larger when the child cries, or strains in any way. The tumor is painful upon firra external pressure, and may cause convulsions, or, if hydro- cephalus is associated with spina bifida, there will be stupor and gênerai paralytic symptoms. Sometimes, portions of the spinal marrow protrude with the sérum. In this case, the tumors fluc- tuate less than when they are filled with sérum alone. In rare cases, they are ruptured at the birth of the child, or else they burst after birth, and convulsions take place, finally ending in the death of the child. Ail cases are apt to prove fatal before puberty. Treatment.—One of the leading remédies indicated by the pathological condition is carbonate of lime, gr. 1 doses, three times a day, alternated with phosphite of lime, gr. 2, three times a day. Occasionally, it is advisable to tap the tumor, and inject tincture of iodine and glycérine, in equal parts, into the sac. Iodine, gr. \, iodide of potassium, gr. 5, water 5 \, may be used, too, as an injection. Spina bifida, is, generally speaking, a fatal disease ; nevertheless, we should do ail we can to prolong life and effect a cure, where it is possible, although such efforts hâve seldom been successful under my observation. One patient, I recollect, got well, with some curvature of the spine. Spinal Meningitis.—This is an inflammation of the spinal pia mater. Swelling of the dura mater and of the arachnoid is seldom met with as a primary disease. Pathology.—The pia mater is generally of a pale-reddish color, sometimes purple, swollen, and infiltrated, with a jelly-like or bloody exudation. When the redness fades away, the membraue is of a dirty yellowish and greyish color, covered with a dirty, looking exudation. Sometimes the whole membrane is inflamed reaching to the cavity of the cranium. After recovery there are adhésions, hyperaemia, thickening of the membrane, and per- haps hydrorrhachis and atrophy of the spinal marrow. There is an épidémie form, eombined with cérébral meningitis, as in spotted fever, which we will discuss in another place. Symptoms.—If eombined with cérébral affections, there will be such marked brain symptoms as to altogether disguise the spinal affection. If swelling is confined to the spinal pia mater, we find pain in the back, at the point of inflammation, which is aggra- vated by movement. There is also pain in the limbs, whieh is made worse by motion. Stifliiess of the muscles exists, and in some cases episthotonos, especially if the cervical portion is the seat of trouble. The least motion of the spine gives rise to tonic DISEASES OF THE SPINE. 173 spasms, while reflex irritation of the périphérie extremities of the nerves does not produce them. The acute form may terminate in the chronic form, with exudation and paraplegia as a resuit, This discharge may terminate in tubercular degeneration, fol- lowed by œdema of the lungs, catarrh of the bladder, etc. Treatment.—Where the skin is dry and hot, and the puise small, quick, and like a cord or thread, aconite is a valuable remedy, and may be ordered in doses of gtt. 1, every hour, until the puise becomes soft and slower, and then every two hours. If there is a throbbing pain in the spine, drowsiness, with inability to sleep, and spells of nervous starting, gtt. 3, of belladonna, should be given every two hours, until thèse symptoms give way. If the affection is connected with, or proceeds from disease of the bones of the spinal column, the phosphate of lime will be a very good remedy in gr. 2 doses, three times a day. In the chronic form, where there is inability to lift the limbs, I use eocculus indicus, in doses of gtt. 1 to 3, every four hours until relief is given. In chronic cases, when aggravated by cold, changes of weather, dulcamara, in doses of gtt. 5, three times a day, may be given. Myelitis.—Myelitis is of less fréquent occurrence than menin- gitis; and when it exists it generally produces meningitis. Pathology.—Its pathologyT resembles that of encephalitis. There is redness, swelling and softening, either throughout the entire length of the gray substance of the spinal marrow alone, or it is an inflammation extending diagonally7 through a portion of the différent parts of the spinal cord. Myelitis is the resuit of external injuries, and exposure to cold, or it may be associated with inflammation of other adjacent organs. In some rare instances it has been seen during the course of typhus or typhoid fever and pneumonia. Symptoms.—One of the first symptoms is a disorder of sensi- bility and motility. The patient may feel a sensation of coldness, numbness, prickling and pain in the toes and fingers, which gradually extends from the periphery towards the trunk, on one or both sides. There is more or less pain in the spine, which is aggravated by pressure upon the spinal processes, and the parts which are enervated byr the diseased roots are more or less con- stricted, and either very sensitive or the reverse. If the degener- ation of tissue should take place throughout the whole substance of the spinal marrow, there may be complète anœsthesia or insen- sibility of the parts. The deficiency of motion first shows itself in unwieldiness of the périphérie mu clés, and this may terminate in complète paralysis of the lower extremities (this is of very fréquent occurrence); but if the dorsal région is affected, it causes paralysis of the sphincters ani and vesicœ in addition. If the 174 THE AMERICAN PRACTICE OF MEDICINE. trouble be still higher up, there will be great palpitation of the heart. Should the cervical région be affected, the upper ex- tremities, respiratory motion, déglutition and speech will be more or less déficient. If the lésion is confined to the cervical région only the upper extremities are paralyzed. Prognosis.—The lower the seat of inflammation the more slowly it advances to a fatal termination. Patients may live ten or fifteen years with paraplegia, but where the cervical portion of the spinal cord is inflamed, death may take place in a short time from paralysis ofthe respiratory muscles. Where the lésion is limited to one or more of the latéral cords the paralytic symptoms may be confined to one side for awhile, with more or less insensi- bility ; or there may be insensibility on one side, and paralysis on the other side, as in some trumatic wounds. One fréquent symp- tom of myelitis is the érection ofthe pénis, which may remain so for days. Treatment.—As this disease is generally accompanied by meningitis, the same treatment will be required as for that disease. In the active stage aconite, in doses of gtt. 1 every hour, will serve to control arterial excitement. If there is great pain in the sacral régions; ansesthesia of ail the limbs; paralysis of the lower limbs ; convulsive twitching and shocks of the paralyzed limbs ; painful contractions of the flexor muscles ; and paralysis of the rectum and bladder, gtt. 15 of ergot may be administered. If this affection occurs after sexual excess (as it often does) or in connection with an inflammatory condition of the vertebrae hypo- phosphate of lime will be of material service, alternated with other indicated remédies. I usually give it in the form of a syrup, gr. 2 or 3, three times a day. In the chronic form counter-irri- tation may be used, byr vesieating the spine with diluted acetic acid, or croton oil. In the latter form the hypophosphite of lime, sodium and magnésium in small doses, will aid in the radical cure of this disease. If softening ofthe spinal marrow should re- suit, apoplexy will set in, and cause death ; or, it may termiuate in sclerosis medullœ pinalis (hardening of the spinal marrow) ; this also may terminate in apoplexy, and finally in death. In either case medicines exert but slight control over the morbid process. Belladonna, in drop doses, will mitigate the symptoms for a time. Multiple Sclerosis: Chronic Myelitis.—This form of chronic myelitis is often associated with chronic encepalitis, which is characterized by the development of numerons insulated sclerotic nodules of various sizes, and of a chronic inflammatory nature. Thèse nodules are scattered throughout the entire spinal cord, and very often over ail the brain. Occasionally a less intense, but more diffuse sclerosis unités the différent nodules together. Women DISEASES OF THE SPINE. 175 are oftener the subjects of this disease than men, and it rarely oc- curs later in life than thirty years of âge, or earlier than ten years. Causes.—Severe mental or bodily exertion may give rise to this disease, and it may also be caused by eatching cold, traumatic influences, pregnancy, hysteria, and acute diseases. Symptoms.—Disturbance of sensibility is often one of the first marked symptoms. A want of coordination (ataxia) is also often observed, and a peculiar tremor accompanying voluntary motions, which progressively increases. This tremor, which appears at every attempt to move distinguishes sclerosis from paralysis agitans. Altération in speech is another symptom, as is also al- tération of the voice. Speech is more or less indistinct and hesitating, and the voice becomes monotonous and weak. The movement of the tongue and lips is impaired, and mastication and déglutition become very diflicult. The sight is disturbed, there being diplopia, amblyopia, and often blindness, Vertigo, sleeplessness, violent headache, and, occasiorally apoplectiform attacks may be présent, which are apt to be followed by fébrile excitement and hemplegia. The symptoms in each individual vary according to the extent and location of the sclerotic nodules. Treatment.—In cases where the gait is tottering, the legs weak, speech much embarrassed, amaurosis is présent, pupils are widely dilated, and there is deafness, phosphorus, in some form, is indicated, and I prefer the phosphide of zinc, in doses of gr. 1-10 to 1-14 in water, every four hours. Where the palsy is preceded by twitching of the muscles, or trembling, I order physostigma, in doses of gtt. 1 to 3, every four hours. Where there is vertigo, staggering gait, trembling, gênerai debility, cholera-like convul- sions in the limbs, transcient blindness and sleeplessness, nitrate of silver, in very small doses, is indicated. This may be alternated with gtt. 1 of nux vomica (saturated tincture) every four hours. Thèse remédies are also indicated in tabès dorsulis, or gray degene- ration of the posterior calamus. CHAPTER XVII. DISEASES OF THE MOTORY APPARATUS. Rheumatism.—Rheumatism attacks the fibrous tissues, joints, aponeuroses, sheaths of the tendons, neurilemma, periosteum, and the muscles and tendons. It is a very painful affection, caused doubtless by inflammation of a peculiar character, and some nutritive disturbance, not well understood now by the best pathologists. The immédiate cause of this form of inflammation is exposure to cold or wet. Rheumatism ma}7 be acute or chronic. Acute Rheumatism.—This form generally has its seat in the synovial membranes of one or several joints. By some peculiar nutritive disturbance, the joints become inflamed, and yield a scanty exudation, which contains but a small quantity of fibrin or pus-globules. An inflammatory œdema of the surrounding cellular tissue rapidly takes place. In some rare cases, the exu- dation may contain both fibrin and pus-globules, especially where the inflammation runs high, and in young and vigorous subjects. Post mortem examination reveals ecchymosed spots in the synovial capsule, which is filled with a purulent exudate; even the ends of the bones may be infiltrated by bloody extrava- sations. The heart and large vessels contain much fibrin ; and there are often structural changes in the heart itself, such as peri- carditis, etc. Prédisposition.—Old âge and childhood are less liable to this disease than youth and middle-age ; and those who hâve once been attacked by this disease are more prone to it than those who hâve not had it. Robust persons seem more liable to be attacked by rheumatism than the feeble and debilitated. It prevails in ail latitudes, but more in thetemperatethaninthe hotor polar zones, and oftener in winter and spring than in summerand autumn. Symptoms.—The disease may be preceded by a chill or chilly sensation, or it may come on gradually. Very soon the fever rises, with severe pain and swelling in one or several joints, which become very red. The swelling may be confined to the part first attacked, or it may spread from joint to joint, envelop- ing the spine and symphysis pubis, and sometimes even the joints of the toes and fingers. The pain is so exeruciating as to compel the patient to keep in motion, which often aggravâtes the pain. Fever.—The fever is often very high, the température ranging between 104° and 104.°9, although the température may not run [176] DISEASES OF THE MOTORY APPARATUS. 177 higher than 100°, and the puise may not be over ninety to one hundred beats in a minute. Occasionally, there may be free per- spiration without any réduction of the inflammation. The urine is scanty, and loaded with urates and uric acid. About twenty per cent, of the cases of rheumatism of the purely acute type are complicated with endocarditis, and about fourteen per cent, are complicated with pericarditis. Complication with myo- carditis are not so fréquent, but occasionally it occurs with pleuri- tis, pneumonia, meningitis or even cerebro-spinal meningitis. Its course is not regular, passing off sometimes in from 10 to 12 days, or contining several weeks, and finally terminating m the chronic form. Rheumatism seldom ends in death, unless it be complicated with disease of the heart, lungs, or méninges of the brain. It is liable to return and produce disease of the valves of the heart, which finally proves fatal. Treatment,—This form of inflammation has yielded to aconite, (one drop every hour or two,) and salicylic acid, (from the oil of wintergreen,) or salicylate of sodium, gr. 3 to 5 every three hours dissolved in sweet spirits of nitre. I usually add gr. 40 of salicy- ic acid to 5 1 of sweet spirits of nitre, giving a teaspoonful every three hours. I alternate this mixture with the tinot. of aconite, until the fever falls considerably, and then lessen the quantity of both remédies. If the pain still remains after the fever is sub- dued, and is increased by motion, I order gtt. J to 1 of bryonia every three hours, but if moving the limbs give ease, gtt. 1 of rhus tox. is the indicated remedy. The most speedy relief to acute rheumatism is from an alcholic or camphorated vapor bath, made by evaporated camphor (made in alcohol) on an iron or flat rock, just hot enough to evaporate the spirits of camphor. This bath should be taken by the patient while his body is bare, so that the camphor may come into contact with the skin while the pores are ail freely open. The patient may sit in a chair, well enveloped in blankets, with a plank under him, so as to pre- vent the hot vapor of the camphor from burning. I hâve relieved some very extrême cases in this way, in three sittings. Man- aca—the franciscea uniflora (Pohl), (lately introduced from Bra- zil, by Parke, Davis & Co., of Détroit, Mich.)—has acted well in some cases, given in doses of gtt. 10 to 20, every three hours. Bonzoate of ammonium is also a good remedy where the disease is associated with more or less indigestion. Lithium and its salts are invaluable where there is an acid state of the urine. I hâve eu red rheumatism in the sub-acute form, with phytolacca and tincture of colchicum, given in gtt. 5 doses, ter die. Chronic Rheumatism.—This form rarely occurs, unless it has been preceded by the acute or sub-acute form. Post mortem ex- amination reveals a thickened condition of the synovial capsules 12 178 THE AMERICAN PRACTICE OF MEDICINE. and ligaments, and sometimes the cartilages of the bones are spongy, and the s37novial fluid turbid. Occasionally single joints become very painful from motion and show paroxysms of ag- gravation, chiefly at night or in damp, cold weather. In sub- acute attacks, there is more or less swelling, but not much, if any, gênerai fever. Sometimes the sub-acute or chronic form of rheumatism may be complicated with muscular rheumatism, and also with certain forms of paralytic and neuralgic affec- tions, which are usually called rheumatism, or neuralgic rheu- matism. Muscular rheumatism receives its name according to the lôcality. The principal form is cephalalgia rheumatica, which attacks the frontal, occipital or temporal muscle, perios- teum ot the skull, or the aponeurosis. Torticollis rheumatism, or myalgia cervicularis ("stiff neck" or "crick of the neck,'-' has its seat in the cervical muscles, rendering any movement of the head very diflicult and painful, and frequently drawing the neck to one side. This position may become a permanent one if the muscles should contract. Pleurodynia rheumatica is myalgia of the breast and intercostal space, and principally at- tacks the pectoralis major and intercostal muscles. When it attacks the pectoralis major, it hinders the motions of the arms, and when it attacks the intercostal muscles, it impedes respiration, and simulâtes pleuritis, for which it is oft-times mistaken. Omodynia rheumatica, myalgia scapularis, is rheu- matism of the muscles of the shoulders and back, and causes great pain in moving the back or the trunk in any direction. Lumbago rheumatica, myalgia lumbalis, ("kink in the back"), attacks the lumbar muscles and the lumbo-dorsalis fascia. It frequently strikes the patient down as he attempts to stoop or lift some heavy weight, and is characterized by a lancinating keen, darting, pain in the lumbar régions or hip joint, and sometimes in some of the other muscles about the pelvic ré- gion. Treatment.—For lumbago, berberis vulgaris (tinct.), every three hours, has proven very satisfactory in some cases, as has also gtt. 1 to 2 of the tincture of rhus tox., especially where the pa- tient is compelled to move about to get a little respite from the pain. Where the pain is tearing, and there is irritability of the bladder, I order benzoic acid in doses of gr. 3 or 4, three times a day, alternated with cimicifuga. Should there be anaemia, iron will be required, as well as other remédies. Benzoate of ammo- nium is also a good remedy. In cases recently treated, manaca gave quick relief in doses of gtt. 30 of the plain extract, crcry three hours. If there is constipation, torpid liver, sweat without relief, great soreness of the flesh, lameness and stiffness of the limbs, with a drawing pain in hips, thighs, legs and feet, cheli- DISEASES OF THE MOTORY APPARATUS. 179 donium in doses of gtt. 30 of the fluid extract or saturated tinc- ture, acts admirably. Cimicifuga is very valuable alternated with chelidonum. Where the pain is tearing, worse in the evening and at night, attended with great soreness, numbness, and swelling of the parts, arnica in doses of gtt. 1 to 2, every three hours, will be apt to give more or less relief. If the pains are in the bones, and there is great irritabilty of the bladder, with strong ammoniacal smelling urine, benzoic acid is the indicated remedy, administered in doses of gr. 3 or 4, four times daily. If the small joints, as the fingers and toes, are the parts affected, caulophyllum will do good service, using gtt. 30 to 60 of the saturated tincture. If the dis- ease affects the periosteum and synovial membrane of the joints, especially the small joints and fibrous tissues, and is accompanied with acid sweat and urine, I find colchicum in doses of gtt. 20 three times a day, very useful, alternated with salicylic acid. In some cases, phytolacca has acted remarkably well for me. If the pains are erratic, and much increased in cold, damp weather, and if there be constipation of the bowels, tension or drawing of the tendons, great sensitiveness to wind or open air, and hot head and cold feet, small doses of sulphur will do effective service. Where there are rheumatic pains in the limbs, attended with numbness of the joints, and keen pains when touched, a drawing of the fibrous tissues, joints and sheaths of nerves, with a feeling of formication and lameness, which is worse in bed or at rest, and better when moving about, rhns toxicodendron is the remedy in- dicated, and must be given every four hours in doses of gtt. | to 1. Rhododendron is highly praised by some English writers, especi- ally in chronic rheumatism, and so is sticta pulmoneca, but the latter has not seemed to do any material good in cases where I hâve tried it. Ranunculus is recommended in cases that affect the chest, diaphragm and scapula, and in spasmodic pains in the arms and thighs, especially in women. When produced by mer- cury, or from gonorrhœa checked suddenly, sarsaparilla will aid iodide of potassium in the cure. Where it effects the heart, cer- eus grandiflorous and spigelia are the best remédies, giving gtt. 10 of each, every hour, or alternating them with one another. If the digestion is very feeble, nux vomica, in doses of gtt. 3 to 5, is a valuable remedy three times a day. Goût.—This disease very rarely attacks persons under thirty years of âge, very young children or infants. Old men are subject to it who live on a rich diet, or those who habitually indulge in the use of béer, wine, and other acids, and take but little exer- cise. It seems to be hereditary in families, and this prédisposi- tion to the disease is easily aroused and put into activity by sur- charging the blood with nitrogenized substances. After goût has existed for some time, or become chronic, a chalky deposit is left, 180 THE AMERICAN PRACTICE OF MEDICINE. consisting of the urate of sodium, or sometimes of uric acid with lime, magnésium and ammonium. This deposit either lines the internai surface of the synovial capsule as a soft substance or incrustâtes at the cartilages of the bones as a hard mass, or even fills the joints, and causes, in many cases, anchylosis. At the same time there may be deposits on the external surface of synovial capsules or in the cellular tissues, which gives rise to hard nodosities. In one case that I examined—that of an old inebriate —there was a large deposit under the skin just above the knee- joint, which was as large as an egg. Attacks of goût come on very suddenly, and generally at night time. They commence with a burning, screwing pain in one or both of the big toes or the heel. The parts aflected soon become swollen and red, and the patient has fever, thirst, dry skin, and highly concentrated urine. The disease may abate in violence in the morning, and the patient may pass the day comfortably, but it will return the next night with the same violence. Thus it will be apt to continue for a week or ten days, when the pain, redness and swelling gradually subside, the skin of the aflected part peeling off. If the patient's constitutional proclivity to the disease is not arrested, it will return again and again, involving other joints. It may finally attack the finger-joints, the knee-joints and shoul- der-joint. The disease eventually becomes chronic, and is attended by dérangement of the digestive organs. The swelling also remains longer and longer between the attacks, and in some cases, changes into a hard tophus. Thèse hardened, chalky de- posits within the joints not unfrequently terminate in abscesses, which may break and discharge pus mixed with calcareous substances. The internai organs, as the stomach, brain or heart, are also liable to be attacked. If it attack the stomach, it produces severe cardialgia, vomiting and nausea ; if the brain, apoplexy, headache, vertigo, delirium and sopor ; or, if it attack the heart, it gives rise to dyspnœa, syncope, palpitation, etc. Treatment.—One of the first things to be done, is to regulate the patient's diet, and make him take exercise. In acute attacks, the following remédies are indicated : aconite, in doses of gtt. 1, every two hours, until the fever is subdued, and then gtt, 10 to 20, of colchium, every three hours, should follow. vVhen it becomes a chronic form, the phosphate of ammonium may alter- nate with colocynth in small doses. The phosphate of lime in gr. 2 doses, is also a valuable remedy, and should not be forgotten. In some cases, the iodide of potassium has done great good, and in others, the gum guaiacum, in ammoniated tincture, has proven valuable. Where there are gouty concrétions, benzoic acid, or the benzoate of ammonium, will do good service in gr. 3 doses, three or four times a day. The carbonate, or citrate of lithium, DISEASES OF THE MOTORY APPARATUS. 181 in doses of gr. 3 or 4, three times a day, will meet this last condition, as well as, or better than, the benzoic acid. Lycopo- dium is indicated where there are hardened concrétions about the joints, and may alternate the carb. of lithium. Benzoate of ammonium will be found to do well in many cases. It should be given wherever the blood is surcharged with urates or uric acid. The digestion should also be corrected, so asto cutoff the source of the acid in the blood, for which purpose tonics are required. CHAPTER XVIII. DISEASES OF THE OSSEOUS SYSTEM. Rachitis.—This is due to imperfect ossification and a prépon- dérance of cartilaginous and fibrous growth in the bony structures of the body. In conséquence of this, the bones remain soft, and are easily broken or bent ; the epiphyses of the long bones are easily bent, and the diaphyses are easily broken. Children are often very much deformed by this disease, their legs being crooked, their spines curved, and the breast so deformed as to présent the sharpness of that of a chicken. Rachitis is apt to occur between the first and second dentition. Causes.—The causes of this disease are quite obscure. Some pathologists believe it to originate from a want of proper food, that is, food déficient in hypophosphites. Americans live on the finest flour, containing the starch of the grain, while the better part, which is the darker and coarser, lies next to the bran, and is rejected and fed to cattle. This coarser flour contains the phosphites and other rich cléments of the grain. This affection may sometimes originate from a want of proper assimilation, and, again, may be caused by nutritive disturbances in the cartilages of the epiphyses, and in the periosteum. Signs.—One of the first symptoms is a very obstinate diarrhœa, consisting of a foamy, fermented discharge, with great emacia- tion. Children aflected with this disease lie with their limbs extended, and dread being moved. Very soon the epiphyses become tumefied. The process of teething is very slow, some- times no teeth appearing for the first y ear or more. Rachitis is manifested in the lower limbs first, and then the bones of the pelvis and thorax become involved in the disease. Treatment.—One of the first things to be done is to examine the milk which the child receives, and see whether or not it is of a healthy character. If the food is of a proper kind, and the disease still develops itself, the child should receive proper médical treatment. Small doses of cod-liver oil should be given in an emulsion, made with good Maltine. The carb. of calcium (cala carb.) should also be ordered in small doses. Sometimes this may be alternated with cale, phosphate in small quantifies. Very large, open fontanels, diarrhaea, aud emaciation, are ail indicative of rachitis. I had a case, this past summer, of a little child, with the characteristic diarrhœa, tardy teething, emaciation, curved spine and bowed limbs. I put it upon the cale, carbonate (the [182] DISEASES OF THE OSSEOUS SYSTEM. 183 white, flour-like substance between the inner and outer layers of the oyster shell), and very small doses of bryonia to tone up its liver and stomach Under this treatment it improved rapidly, and is now healthy. It has eut some teeth, and its limbs are about natural in shape. Osteitis ; Exostosis.—Osteitis consists either in inflammation of the periosteum, of the bone itself, of its marrow, of its medul- lary membrane, or of ail thèse together. It is often very tedious in its course. Causes.—It often follows bruises, fractures and other injuries ; or it may resuit from chemical influences. In some cases, it seems to hâve originated from a certain constitutional contamination, such as scrofula, arthritis, scurvy, syphilis, mereurial poisoning, or some suppressed chronic affection of the skin. Symptoms—It generally begins with heavy, burning pain, which finally assumes a tearing character, especially where the perios- teum is also affected, which is often the case, The pain is increased by night air, motion, pressure, or any light jar. The bone feels hot to the patient, and, if it is superficial, the skin and flesh of the limb soon participais in the inflammatory process. The gênerai fever may not be very high. Terminations.—This disease may resuit in caries or necrosis, and a large sequestrum may be thrown off, to be replaced, in favor- able cases, by a new formation. I recently assisted in the removal of a large sequestrum from the ulna. We had, lately, in our surgical clinic, a case where there was a large sequestrum of the fémur, which we succeeded in removing. Such cases often occur, and if thèse irregular pièces of bone are not removed, they become sources of great annoyance to the patient, and may prove fatal. Treatment.—Where there is periostitis and enlargement of the bones, especially the tibia, with violent aggravations at night, daphne mezereum, in small doses, gtt. 1 to 2, three times a day, will be useful. If the disease is from the abuse of mercury, or from a syphilitie taint, gtt. 2 to 3, of nitric acid, three or four times a day, will give good results. After suppuration takes place, small doses of triturated silicea will be proper, say gr. 1 of the lst dec. trituration, every three hours. Staphisagria is a valuable remedy in many cases where osteitis takes place in the phalanges of the fingers. This may alternate with Horsford's Acid Phosphate, in small doses. The phosphite of lime is a valuable remedy where caries or necrosis of the bone has taken place. Where this disease attacks the bones of the nose, face or head, the chloride of gold, in doses of gr. 1-50 three times a day, will do good service. Angostura, as a tonic, is often called for in this affection, especially in caries of the long bones. If this disease occurs in scrofulous constitutions, small doses of tincture 184 THE AMERICAN PRACTICE OF MEDICINE. of asafœtida may be given in alternation with menesperum or aselli jecor. ol. If there are glandular swellings in scrofulous individuals, gtt. 1 to 2 of tinct. of belladona will be required, three times a day. Where there is profuse suppuration and emaciation, small doses of the tinct. of cinchona must be given. White Swelling.—Tuberculosis is a constitutional disease, but may localize itself, as it has often done, in différent structures or organs of the body. When it attacks the joints, it usually ap- pears on the hip, knee, ankle, elbow, or wrist-joint. It is a form of inflammation presenting a peculiar glossy, shilling appear- ance, which has given it the name of " White Swelling.' In the early stage the synovial membrane is highly injected, somewhat opaque, softened, and thickened in patches by fibrous exudation. There is generally an effusion of lymph, of a pale yellow color, and of a pulpy consistency. The articular cartilage présents a grayish, or dull whitish color, and is generally thickened, soft- ened and partially separated from its connection with the bone. The cancellated structure of the bones is abnormally vascular, por- ous, humid, light and generally easily broken. In nflany cases its cells are distended with a yellowish tubercular material, of a semi-solid, osseous character. The ligaments are unusually red, tumefied and softened. The synovial fluid is increased in quan- tity, but not to any very great exent. As the disease advances the lymph gradually increases in quantity, and may be mingled with sero-purulent matter. The synovial membrane finally becomes destroyed to a great extent, and what remains, présents a muddy, opaque and ragged appearance. The cartilage is ulcerated,discolored, perforated, and partially detached from the bone. Large quantifies of pus accumulate, sometimes thick, caseous, ichorous or sero- sanguinous. In some rare cases it may be thin and almost black, from the necrosed condition of the bones. If recovery takes place, the joints are generally left anchylosed, or firmly attached by new material to the surrounding structures. In time, an artificial joint may be formed, and admit of considérable motion, but it is rarely the case that the joints recover mobility. Thèse are the characteristic symptoms of tuberculosis of the joints, ite gênerai pathological changes, etc. Coxalgia.—Coxalgia generally attacks children from the third to the seventh year, but I hâve known it to appear in later periods of their life, Where there is a constitutional diathesis, it may be excited by excesses, injuries, exposure to cold, or by certain wast- ing diseases. It rarely attacks both hips at the same time, but may be complicated with psoas abscess, ophthalmia or pulmonary phthisis. Symptoms.—In incipiency the patient is easily tired, and com- plains of a pain in the knee joint, or its inner side. which is much DISEASES OF THE OSSEOUS SYSTEM. 186 aggravated by motion, causing the child to limp when walking. The pain is also worse at night, and may prevent sleep by spas- modic jerking in fhe affected limb. This pain gradually extends up the limb, and is frequently felt also in the lendo achillis, (over the instep), or it may shift from one place to another, and some- times cease for awhile altogether. After some weeks, or even months, the pain is felt in the hip-joint, and is intense over the articulation, deep-seated, and of a rather dull gnawing character. During the second stage, when the pain has become very violent, the buttock becomes flattened, the gluteo-fémoral crease disappears, the limb appears longer, the muscles waste away, the appetite be- comes precarious, the bowels coustipated, and there is more or less fever, and sometimes copious sweat. The patient now begins to show emanciation and debility, In the third stage suppuration takes place. This may be known by the increase of the pain on the slightest motion, by throbbing and a sensé of tension ; by an increased swelling of the gluteal région ; by œdema of the sub- cutaneous cellular tissue, and a turged condition of the subcutan- eous veins, by violent rigors, high fevers and copious sweats. The pus may work its way to the surface, which is indicated by a circumscribed blush over the pointing part, and by7 the distinct fluctuation of the part, which, when opened, gives vent to large quantifies of pus. Or the pus may make its way internally, by perforating the acetabulum into the rectum, bladder or vagina, or it may collect in a sort of pouch, between the inner surface of the iliac bone and the soft parts of the pelvis bones. The limb is shortened from one, to one and a quarter inches, and the foot points either outwards or inwards. The neck of the femer is wasted away ; sometimes the bone may be so destroyed as to allow the superior extremity to niove about and attach itself in an en- tirely new position. Treatment.—In the first, and even in the second stage, when pressure on the trochanter causes pain in the hip-joint, gtt.l to 2 of the lst dec. dilution (not stronger) of rhus tox. should be given every two hours. As soon as hectic feveç takes place, tincture of phosphorous may be given (2 dec. dilution), gtt. 1 to 2, three times a day. If there is congestion of the head, starting in the sleep, burning, stinging pain in the hip, gtt. 1 to 3 of tincture of belladonna may be administered with marked relief to the patient. In the third stage, where suppuration has commenced, the phos- phite, or the hypophosphite of calcium should be given gr. 1 to 2 three times a day, to restrain the suppuration. Where there is suppuration and rapid caries of the bone going on, with glandu- lar swellings, silicea, in doses of gr. 1 of the lst dec. trituration, may be given three or four times a day. In cases where there is a free discharge of acrid pus, the iodide of arsenic will be of 186 THE AMERICAN PRACTICE OF MEDICINE. material service in doses of 1-20 to 1-30 of a grain. I usually triturate gr. 1 with gr. 9 of sugar of milk, then put gr. 4 to 6 of this into 3 4 of water, and give a teaspoonful four times a day, well diluted with water. Igive, in the first stage, the tincture of menispermium, in doses of S 1, three times a day, and anoint the joint with an oiutment of polymnia uvedalia and oil of cedar. Genu Album.—White swelling of the knee is from the same constitutional taint that gives rise to hip-joint disease, and runs nearly the same course. It is excited by an external injury in many cases, such as a fail, twist, or blow upon the knee-joint. Symptoms.—This disease generally begins with a severe, dull, heavy pain at the inner condyle of the patella or at the inside of the head of the tibia. The pain may be rather intermittent, and extend up and down the limb. Very soon interstitial deposits take place, and the joint begins to swell. The swelling is first confined to the front and sides of the patella, effacing the natural dépressions in that région, and producing soft fluctuating sacs or bags instead of the usual dépressions, Sometimes there is a con- sidérable prominence just above the joint, over the lower part of the fémur, bounded by the inferior portion of the patella, and on each side by the latéral ligaments, its anterior wall being formed by the tendon of the exterior muscle. The popliteal région rarely, if ever, swells. The skin over the swollen part is tense and glossy, and the subeutaneous veins become very much enlarged. The knee joint is stiff and the leg more or less flexed. The thigh soon becomes considerably atrophied. The ligaments weaken, and the deformity of the joint increases, owing principally to the dis- placement of the head of the tibia, which causes the muscles to draw the leg outwards. In some rare cases there is actual en- largement of the diseased bones. As the disease advances ad- ventitious deposits take place upon the synovial membrane, and the synovial fluid is absorbed. The fluctuation, which marked the earlier stage, now disappears and the joint, now swelling largely, becomes tirmer and more resisting, but still possesses some elasticity. In mpst cases, the diseased structure finally be- gins to suppurate, and the pus may be absorbed, or it may escape at différent places about the knee forming numerous fistulous openings, and leading to caries of the bones, or to necrosis of the larger portion of the diseased tissue. The above disease must be distinguished from bursitis house maid's knee, on account of its fréquent occurrence among female servants, from working in a kneeling position. It is distinguished from synovitis by its superficial nature and the regularity of the tuméfaction. It may suppurate, or become chronic—a solid tumor. Tkeatment.—If this affection of the synovial membrane follow a fail or blow, I give arnica, in doses of gr. J to 1, every three DISEASES OF THE OSSEOUS SYSTEM. 187 hours, whiie a diluted tincture is applied to the knee. If there is gênerai fever, or in case the disease follow exposure to cold, the tincture of aconite, in doses of gtt. J, every half hour should be given, until the fever is moderated, then three or four times a day. If the disease follow a twist or sprain, rhus tox., in doses of gtt. | to 1, should be given every two hours. I hâve cured some grave cases with thèse remédies, properly used. In scrofulous constitutions, the pure oyster-shell lime, in small doses, will be found a good remedy. I use the lst dec. trituration, in doses of gr. 1 to 2, three times a day. Where suppuration has taken place, and the discharge is thin and acrid, and the openings are surroUnded with pale spongy edges, which bleed easily, small doses of tincture of iodine will be of material service. After caries takes place, and when there are fistulous openings, and a cachectic condition of the system, silicea will be required. If there be a discharge of fœtid pus, and there is œdema of the limb, emaciation and exhaustion, tincture of arsenic, in doses of gtt, \ to 1, three times a day, will prove a good tonic. CHAPTER XIX. DISEASES OF THE NERVOUS SYSTEM. Neuritis.—ISTeuritis may be of the acute or chronic form. Acute neuritis is usually produced by external injury, or some destruc- tive process in the adjacent parts, such as sloughing, ulcération or cancer. It generally begins with chilliness, or an actual rigor, which is soon followed by fever, headache, pain and sleeplessness. In some cases a red line may be seen in the skin, indicating the course of the inflamed nerve, and the tissue through which it is distributed exhibits a very marked degree of hyperaesthesia, and a sensation of numbness and formication. The chronic form is characterized by paresthesia and more or less pain, with sensory and motor irritation, subséquent paralysis, and a painful swelling of the nerve itself. Treatment.—Aconite in doses of gtt, 1 every hour, should com- mence the treatment, and be continued until the force of the fever is stayed. At the same time the course of the inflamed nerve should be rubbed with an ointment of hypericum perforatum. Hyperaesthesia, which is one of its most common attendants, will require spécial remédies. In many cases, belladonna alternated with aconite, will relieve this complication, or it may require rhus tox., sulphur, arsenic or euphrasia. Neuralgia.—Neuralgia is a pain in the nerves. Ail pain, in one sensé, is neuralgia—pain of a sensitive nerve, but this is not the sensé in which the term " neuralgia " is used. It is an irrita- tion in the course of one or several sensory nerves, which may exist in any part of the nerve, from its origin down to its termination, or over the whole course of the nerve. Not only is it felt where the inflammation exists, but in différent places along the same nerve, and sometimes even throughout its entire length. This nervous irritation or pain, may resuit from a great many»différent things, hence neuralgia may be a symptom of numerous patho- logical conditions. Some structural changes of the nerves them- selves, are occasionally found, especially in paralytical conditions of parts. Neuroma, or tumors of the nerves, may exist without neuralgia ; and neuralgia may exist without a single trace of struc- tural change. It is therefore very diflicult to define the pathology of this affection, as it is often a mère syTmptom of very différent conditions, such as peripheral or central. Peripheral causes are or- ganic changes in the nerves themselves, or such as may occur in neighboring parts of the nerves, as in inflammation, caries, exos- [188] DISEASES OF THE NERVOUS SYSTEM. 189 tosis of the bones, tumors and affections of the utérus, liver, ova- ries, stomach and kidneys, ail thèse may be causes of neuralgia. The gênerai central causes are structural changes in the spinal cord and brain, and their membranes ; such as softening, tumors, scle- rosis, and morbid deposits, metallic poisoning, exposure to cold, miasmatic influences, ail thèse may give rise to neuralgia. Symptoms.—One of the most marked symptoms is pain of a bor- ing, cutting, tearing, exeruciating character. It most commonly cornes on in paroxysms, and is often felt running along the course of the affected nerve, and this pain is increased by touching the surface. There may also be spasmodic motions in those parts in which the sensory branches are distributed. The vaso-motor nerves may also be affected causing paleness of the skin, chilly sensations, fiushes of heat, perspiration, or profuse urination. The spécial forms of neuralgia are, viz. : cephalgia, hemicrania, nervous sick headache, and migreine. Cephalalgia, or headache may originate from many morbid conditions ot the system at large, and some constitutions are predisposed to it, and will hâve it after slight disturbances of the gênerai health. Headache may be produced either by hyperaemia, anaemia, or hysteria. Rheumatism and many other pathological conditions may also be associated with it. The trouble may return pcriodically, that is, may come on in the morning and cease at evening. Sometimes it only attacks one side of the head, and sometimes it passes from one side to the other, or again, it may be confined to the top of the head, or to the occiput or forehead. Sometimes the pain is exeruciating, and is associated with extrême nausea and vomiting of bile and slimy acid. Frequently the pain ceases when vomiting occurs, and sleep usually relieves it. Hysterical, anaemic and chlorotic women are very prone to cephalalgia, and so are literary men of weak consti- tutions. The use of tea, coffee and tobacco, and of ail alcoholic drinks or fermented beverages, leads to this disease. Treatment.—When the spells come on regularly, the tincture of arnea diadema in doses of gtt. 3 or 4, will often overcome them. Other cases yield to belladonna or aethusa cyn. in small doses, and such as are associated with vertigo, dimness of sight, and ringing in the ears, call for argenti nitras. If they are intermittent, and do not come on at any regular hour, quinine in gr. 4 to 5 doses daily, will generally cure it. If there is a throbbing pain of the occiput, I give ignatia amara in doses of gtt. 1 to 2, three times a day. Tic Douloureux.—This form of neuralgia attacks one or another branch of the trigeminus or fifth nerve, enter the supra orbitalis or the infra orbitalis nerve; and hence the names, neuralgia supra orbitalis, neuralgia infra-orbitalis, and neuralgia infra- maxillaris. This form of neuralgia is generally confined to one 190 THE AMERICAN PRACTICE OF MEDICINE. side, but may attack first the right and then the left side. The pain is generally paroxysmal, and very severe, sometimes shooting to the back part of the head and neck and down into-the shoulder and breast. Again, the motor nerves are affected, causing convul- sive action of the muscles of the face and eyes or trembling of the whole body. The vaso-motor nerves are also frequently affected, in which case, we hâve pulsation of the arteries, swelling of the veins, and redness, paleness, and heat of the face. If the ramus ophthalmicus becomes involved, we hâve injection and redness of the conjunctiva, and a free flow of tears. I hâve a patient who has this last complication every time neuralgia cornes on. If the second branch is affected, there will be a watery and slimy dis- charo-e from the nose, and if the second and third branches are in- volved, there will be a free flow of saliva. Treatment.—Where the patient is hot and feverish, or when the cheeks are red, and the pain very severe, gtt. 1, of aconite should be administered every half hour, until the fever is relieved. If the pain is of a tearing, cutting character (shooting from the side of the face up into the temples and ears, and then down into the neck), and is aggravated by motion or touch, and if it is atten- ded by a deep flush of the face and twitching of the muscles of the lace, the tincture of belladonna acts admirably in doses of gtt. 3 to 5, every four hours. If the eyes are puffed out, and there is burning, stinging pain, (worse at midnight) pale, distorted face, with the disease originating from miasma, gtt. 1 to 2, of the tinc- ture of arsenic will be of material service, used three times a day, until the pain is gone. If the pain affects the stomach, gr. 5, of the subnitrate of bismuth, should be ordered and repeated in three hours, if it fail to give relief. If it occur in females about the menstrual flow, and this flow be excessive and the pain severe, I give chamomilla, in doses of gtt. 1 to 2, every half hour. If the pain exist in the infra-orbital and maxillary nerves, gr. 2 of qui- nia, will be required every two hours, alternated with tincture of colocynth. In orbital neuralgia, coming on in paroxysms, gelse- minum, in doses of gtt. 5 to 10, every half hour, has acted tinely with me in many récent cases. Cervico-Occipatal Neuralgia.—This rather uncommon form ol neuralgia has its seat in the first four spinal nerves, and gener- ally on one side, extending over the upper part of the nape of the neck and occiput, over the latéral région of the head, and towards the lower jaw in front. Cervico-tracheal neuralgia, is one form which attacks the whole trachéal plexus, shoulder blade and arm ; intercostal neuralgia is yet another form, and has its seat in the dor- sal nerves, sometimes aftecting both sides of the chest, but most frequently located between the fifth and ninth intercostal spaces on the left side. It produces a sensé of tension in the chest, which DISEASES OF THE NERVOUS SïSlEM. 191 gives rise to shooting pain when the patient attempts to expand that organ. The spinal process, where the dorsal nerves émerge from the spine, is tendcr, and pressure on it, increases the neural- gia. Lambo-abdominal neuralgiahas its seat in the lumbar nerves, causing there, and in the abdomen, pain which is increased by pressure over the lumbar vertebrae. This pain may extend to the inguinal région, to the symphysis pubis, and in females, over the crest ofthe ilium, to the vagina àncl labia majora. Mastodynia, or neuralgia of the mammae in females, lias its seat in the mammary glands, which oftenbecome very painful, although there is no ex- ternal change of appearance. The pain may shoot into the axillae, or into the back and down into the bips. It often occurs with some irregularity of menstruation, as menorrhagia, dysmenorrhœa, etc. It generally exists between the âges of sixteen and thirty years, but may occur later. Neuralgia ischiat(ca,2iûects the nerves supply ing the nates and posterior part of the thigh. Sometimes it runs along the nerves of the bend of *he knee, and along the fibula into the external part of the ankle and heel, and external part of the foot ; occasionally the pain is only felt in the sole of the foot—neuralgia plantalis. Crural neuralgia, generally has its location in the crural nerve, in which case, the pain is felt in the lower and inner région of the thigh, the inner portion of the knee-joint, and the ankle, (on the inner side), possibly passing into the big and second toe. It may be caused by utérine tumors, cancers, inflammation of the hip-joints, crural hernia, or by anything that presses on the nerve. Treatment.—The remédies mentioned in the treatment of the other local, forms of neuralgia, as belladonna, aconite, arsenic, chamomilia and quinia, will be applicable hère, under the same pathological conditions. If the neuralgia be caused by over exertion, arnica, in doses of gtt. 1, ofthe tincture, will give great relief, and may be repeated every two hours. For a throbbing pain in the hip, ignatia amara, in doses of gtt. 2 to 3 will be required. Anœsthesia-—Anaesthesia originates from two pathological conditions : (1) from an inability of the sensory nerves to convey the external impression to the central organs ; (2) Irom an inability of the central organs to perceive the impression. The first is the case where the nerve has been severed ; and the latter may hâve its prime source in some diseased condition of the spinal marrow or brain, and is generally7 associated with paralysis of corresponding parts. The degree of anœsthesia varies greatly in each case ; amounting, in some instances, to mère numbness or torpor, or, again, to complète deadness of the part aflected. It is manifested by torpor of the capillary circulation ; decrease in the heat of the part ; dryness of the skin ; œdema ; livid color of the skin ; 192 THE AMERICAN PRACTICE OF MEDICINE. ecchymosis ; and sometimes blisters filled with bloody sérum appear on the toes and fingers. Trigeminal Anœsthesia.—In this form of the disease the patient does not feel any irritation upon the affected parts ; but when eating he does not taste anything in the affected side, and the saliva drips from his mouth without his knowledge. He does not feel a glass or cup when he .puts it to his lips on the affected side. There may be, also, loss of sight, smell and taste. The reflex movements of the face are lost, the eyelids do not shut when the conjunctiva is touched, nor does irritation of the mucous membrane of the nose cause sneezing. Causes.—The central causes are apoplexy, softening and tumors of the brain ; périphérie inflammation ; and softening, hardening and atrophy of the nerve and of the gasserion ganglion. Severing of this nerve or one of its branches, by a wound or surgical opéra- tion, or by wounding the nerve by severe blows, etc.; pressure upon the nerve by tumors or foreign bodies, and a fraction of the petrous portion of the pariétal bone, may ail give rise to this form of anaesthesia. Thèse causes show the incurability of this affection, unless its cause be removed. Morbid Affections of the Motory Nerves.—We hâve 6een that the sensory7 nerves may be morbidly aflected, either by an increase or by a loss of sensibility. So, also, may the motory nerves be affected by spasm, cramp, paralysis, and excess or deficiency of the nervous tone of the parts in question. Spasms : Convulsions : Cramps.—Spasms may manifest them- selves either as short, slight jerks of certain muscles; as violent, fréquent.y repeated contractions ofthe same or différent muscles; as hasty motions without purpose, repeated mechanically ; as irre- gular, misdirected motions, or incoordinate spasms ; as trembling, tremor or rigidity of muscles. Spasms differ in violence and extent, and not in proportion to the importance ofthe lésions causing them. Sometimes very grave lésions in the central organs may be attended with but slight spasms ; and again, a slight reflex irri- tation may give rise to the most violent convulsions of a very persistent character. Causes.—The causes of convulsions are various. Childhood is predisposed to this morbid affection of the nervous centres ; the younger the child, the greater being its proneness to this disease. Any fébrile or inflammatory attack in young children may be followed by spasms. Two spécial forms of spasms of this early âge are eclampsia and trismus. As the child advances in years to the âge of puberty, the tendency is to différent forms of chorea, stammering, squinting, and likewise to the incipiency of epilepsy. From the âge of puberty to middle âge there is a tendency or liability to hysteria, epilepsy, eclampsia, and tetanus; and in old âge, DISEASES OF THE NERVOUS SYSTEM. 193 tremor and writer's spasm are most common. Females are more prone to spasms than maies, generally speaking, and ceteris pari- bus. Exciting Causes.—Mental émotion, fear and sudden shock upon the nervous system through the mental sphère, will often provoke au attack of spasms. Diseases of the central organs and their membranes, as softening of the brain, encephalitis, myelitis, tumors, tubercles, inflammation of the cérébral and spinal mem- branes, and morbid processes in the bones encasing the central organs, are ail exciting causes. Spasms are also caused by péri- phérie irritation of the nervous system, byT strong, light, tickling, wounds, blows, bruises of some organs (as the testicles or the utérus), irritation over large surfaces (as the mucous membrane of the bowels by worms or indigestible food), conditions of the blood (as stagnation, loss of blood), and by qualitative changes of the blood in fevers, pyaemia, urœmia and cholaemia. Certain poisons, as alcohol, narcotics, stry7chnia, secale, lead and mercury, may also give rise to this trouble where there ie prédisposition to it. Prognosis.—The prognosis dépends very much upon the causes. If spasms are the resuit of grave lésions of the internai organs, as they often are, they are of a grave character, but not so much so as when they arise from périphérie irritation. Spasms from blood-poisoning, as in urœmia, cholaemia, are always unfavorable in prognostication. When they appear in the beginning, or dur- ing the course of exanthematic fevers, it indicates that thèse fevers are of a violent and dangerous type. The prognosis, however, is not quite so unfavorable in children as it is in grown people. Chorea.—Chorea consists in a spasmodic, involuntary agitation of single or several groups of muscles, preventing the regular vol- untary muscular movements. Thèse irregular movements usually abate during sleep, and any effort on the part of the patient to re- strain them, only aggravâtes them. Symptoms.—Thèse motions of the muscles sometimes extend to ail of those which ordinarily obey the will, and again only affect certain groups of muscles, as those of the face, upper half of the body, or one side of the body. It may be that the arm of one side, and the leg of the opposite side, is affected with the disease. This morbid agitation, may first start in a few muscles, and gradually extend over the whole body. This gives rise to constant jerking, twisting, swinging, and sometimes very ludicrous sights. Intercurrent diseases hâve occasionally cured this one, but fever increases it, The reflex motions are not interfered with, for when the patient itches, he can scratch him- self without hinderance, and can cough, sneeze, and evacute the bladder and bowels with usual facility. The involuntary motions 13 194 THE AMERICAN PRACTICE OF MEDICINE, of the body are free in their action, as the respiratory motion, the action of the heart, déglutition and the peristalic action of the bowels. The. sensibility is also natural. The mental faculties may remain intact for a time, but finally, they suffer from the long duration of the disease. The patient, at first, begins to show a loss of niemory, then weakness in other mental faculties and in some cases, marked imbecility of mind takes place, the disposition becoming irritable and peevish. Causes.—Its predisposing cause seems to dwell in the âge be- tween the time of the second dentition and puberty. Mental émotions, fright, fear, and ecstaey, are exciting causes ; and debil- ity, from long continued disease, rapid growth, and the sudden suppression of cutaneous éruptions may also produce it. In some cases, no spécifie cause can be seen. Treatment.—Agaric is indicated in cases that are attended with jerking of the muscles and fréquent nictation of the eyelids. Bel- ladonna should be used in cases that are attended with empros- thotonos and opistJûotonos. Caulophyllum, in small doses, acts well in young girls with irregular menstruation. If chorea occurs with rheumatism, cimicifuga, in small doses, will do good service, alternated with sticta pul. If the muscular motions are ail over the body, and are attended by a melancholy mood, loss of memory and speech, or a disposition to pray, I give stramonium, in doses of gtt. 5, of the tinct. every two hours. Zinc and copper hâve been used successfuUy in some cases. If the spasms are the resuit of exposure to cold, belladonna, in doses of gtt. 4 to 5, every three hours, will generally arrest them readify. If not, I usually let the patient inhale about five drops of the nitrite of amyl, every half hour, until relieved of the spasm. The inhalation of chloro- form has the same effect. If the spasms are caused by diseased bones, they are incurable. If they are excited by fright and ter- ror, hyoscyamus, in doses of gtt. 5, every half hour, may be fol- lowed by relief. If not, ignatia amara, may be given in doses of gtt. 1 to 2, every three hours, alternated with gtt. 4 to 5, of tincture of gelseminum. Sometimes stramonium will give relief, especially where the spasms affeet the eyes and their lids. If from soften- ing of the brain, the phosphide of zinc, is the remedy, in doses of gr. y1^, three times a day, well diluted with water, or it will irri- tate the stomach. If the spasms are provoked byr worms, I would give spigelia, alternated with santonin, 5 1 to i of the first, and the last in doses of gr. I to -|, three times a day in sugar. For writer's or painter's eramp, belladonna will often be sufficient ; but it may fail, nux vomica may then be tried, aud if it fails too, ignatia amara may aceomplish some good. It may be given in doses of gtt. 1 to 2, three times a day. In some cases, sta- phisagria does remarkably well in doses of gtt. 3 to 4, three DISEASES OF THE NERVOUS SYSTEM. 195 times a day. Gelseminum is the remedy wherewith to check the spasm. Hysteria.—This is a protean disease, which seems to affect al- most the whole nervous system, without any apparent anatomical lésion. It would seem to consist of excessive irritability, hallu- cinations, neuralgic pains in the sensoryT nerves, and often convul- sions in the motor sphère ; or the reverse—anœsthesia and paralysis. Hysteria most commonly attacks the female sex, and is frequently connected with diseases of the female génital organs. Nevertheless, it sometimes attacks the maie sex. It generally appears among females between ten and thirty years of âge. After the climateric period, its occurrence is very rare, although it may occur up to fifty. Etiology.—A peculiar physical constitution, which consists in an emotional nature and a want of will power, together with abnor- mal conditions of the female génital organs, menstrual irrégulari- tés, excessive gratification of the sexual appetite, depressing mental émotions, disappointed love, jealousy, wounded pride, a guilty conscience, grief and anxiety, reading trashy fiction that excites the imagination, aud disappointed ambition, may lead to it. Symptoms.—The symptoms are multitudinous, various, variable and very diflicult to deseribe, for hysteria simulâtes a great many other diseases. Patients will often complain of a great many pains and aches that are hard to diagnosc. The patient may hâve photophobia, a dislike to bright colors, or a dislike to bright flashes of light, sparks, and complicated figures. Subjects are liable to phantasms and visionary hallucinations, and some hâve a perverted sensé of hearing, ringing in the ears, and roaring or hearing of voices, etc. There may be a perversion of smell and taste, and the sentinent nerves may be so disordered that the patient complains of headache, tickling cough, pain in the larynx, soreness of the mouth and tongue, pain in the mammary gland or ovaries, in the chest or about the heart, in the stomach, in the ex- ternal génital organs, in the bladder or uretha, in the coccygeal région, or in the back, and occasionally the feet. There may be anaesthesia of the sensé of touch, especially in certain parts of the body. Globus-hystericus in the throat is a very common symptom; also spasmodic breathing, singultus, yawning, crying, laughing or screaming, spasmodic rétention of urine, stricture ot the constric- tor ani, and local spasms about the head. Aponia may exist with hemiplegia and paraplegia. Thèse last symptoms may last for years, in spite of ail treatment, or may be relieved by some moral influence or change of condition. In some cases, there is palpita- tion of the heart, cold extremities, red face, hot head, etc. Again, there may be haemorrhage from the nose, throat, stomach or lungs. Treatment.—As hysteria is a functional disease, one very 196 THE AMERICAN PRACTICE OF MEDICINE. potent agency is the psychical and moral influence of the physician over his patient. If the latter has no confidence in the attendin^ physician, he had best retire and let another take his place, in whom the patient confides. A great many remédies hâve been recommended for this disease, from time to time, but none of them, with a few exceptions, hâve proven very successful. Ignatia amara is valuable in cases attended with a feelino- of suffocation, globus hystericus, and convulsive crying or flatulence of the stomach and bowels. Camphor gives relief from a paroxysm, when used as snuff. Musk is an old remedy, and may be used in small doses ofthe tincture. If the condition is con- nected with utérine disease, cimicifuga, in dDses of gtt. 20 of the tincture will aid other proper remédies. If "there are spasms of the throat, I prescribe tincture of assafœtida, in doses of gtt. 30, every two hours, uutil relief is obtained. Some cases are bene- fited by vervain, alternated with scutellaria, in doses of gtt. 30 each, every two or three hours ; but, in most cases, the valeriauate of zinc is better. If constipation exist, nux vomica, in doses of gtt. 1 to 2 of the tincture may be taken at every meal. Gelsem- inum may be ordered while there are spasms of the face or any part of the body. It should be given in doses of gtt. 25 to 30, alternated with the bromides. Cannabis indica is also a good remedy where there are hallucinations. Trismus: Tetanus.—Trismus and Tetanus are characterized by tonic contractions ofthe vol untary muscles. It may be several days before it fully develops from the injury that gives riseto it. The patient may hâve oeeasional chilly sensations and pains in the injured part ; and thèse symptoms are finally followed by drawing pains of the neck, stiffness of the jaws, and diflicult déglutition. Ail thèseVymptoms gradually intensify, until finally the head becomes immovable and drawn backwards, the lower jaw becomes set, and déglutition still more difficult, or al together impossible. This is called trismus ovlock-jaw. The disease seldom ends at this stage, but very frequently this tonic spasm extends further, over al] the dorsal muscles, down the sacrum, and over the muscles ofthe chest and abdomen, rendering the whole body as rigid as a stick. The muscles of the extremities, are not quite so badly affected, nor are the muscles of the face, but the eye-balls are often rigidly drawn towards the inner canthus, the eyes stare, the lips are drawn asunder and show the teeth, and the tongue is thrust out between the teeth, and often severely bitten. There is very frequently risus sardonicus, that is in tetanus. This tonic contraction of muscles has intermissions, the rigidity yielding occasionally to a relaxed state. Thèse spells of intermission how- ever, soon give place to sudden and violent convulsive attacks of very great rigidity, and in this way the disease progresses with DISEASES OF THE NERVOUS SYSTEM. 197 alternate rigidity, and partial relaxation. So great are the con- tractions in some cases, that bundles of muscular fibres are severed, blood-vessels broken, and the blood extravasated in the parts thus violently affected. The following forms of tonic spasms hâve been recognized, viz. : opisthotonos, bending the body backwards ; emprosthotonos, bending the body forward ; pleurothotonos, bending the body side-ways ; and orthotosnos, straightening the body. The most fréquent form is bending the the body backwards, opistho- tonos, caused by predominating effect upon the dorsal muscles. The other forms are exceptional. The will has no control over thèse spasms, and any effort to control them only increases the rigidity ofthe muscles. Occasionally the slightesttouch ormove- ment of the patient's bed, or a draught of air, will cause most vio- lent convulsive concussions. The respiratory action is greatly dis- turbed, the breathing is carried on mostly by the diaphragm, and this function frequently becomes more and more diflicult, until it finally ceases. There is always pain in the convulsed parts, and also in the pit of the stomach. The circulation is but little affected, and the puise may be normal, or rather quicker than natural. The urine and faeces may be retained, and singultus and vomiting be présent. The brain is rarely affected, hence the patient suffers ail the tortures of this painful disease, and this torture is ail the worse from the fact that there is full consciousness of his situation. Sleep is generally impossible in tetanus. Trismus Neonatorum.—Tetanus of new-born infants, présents the same features as the form of tetanus above described. It com- mences with stiffness of the jaws, and such difficulty in dégluti- tion, that the child becomes incapable of taking the nipple in its mouth, the rigidity gradually extending over the whole body. Trismus, like tetanus, may terminate fatally in twenty-four hours, or it may last several weeks. If recovery takes place,it does so very gradually. The majority of cases prove fatal from suffocation, or from exhaustion and starvation. Causes.—Wounding of the périphérie nerves of the skin and extremities, or of the face, head and genitals ; and abortion and parturition, may ail produce tetanus, in impressionable persons. Lésions of inner organs may also cause tetanus. Central irrita- tions, from concussion of the spine and brain, hyperaemia of the cord or of its membranes,extravasation of blood within the spinal canal and the skull may give rise to this disease. Small punc- tured wounds made by nails, penknives, needles, splinters, or any small substance, are much more liable to produce tetanus than large cuts. Strychnia and brucia in large doses, produce tetanus. Treatment.—If the circulation is much disturbed, gelseminum and aconite are excellent remédies, the former in doses of gtt. 25 to 50, the later in doses of gtt. 1 every hour, until the gelseminum 198 THE AMERICAN PRACTICE OF MEDICINE. affects the muscular system. Belladonna is required in most cases where there is restlessness, twitching of the muscles of the face and limbs, inability to swallow, (in which case, atropia may be used by the hypodermic method), convulsions, spasmodic respirations, open staring eyes, and involuntary discharges of urine and faeces, Cicuta is a valuable remedy where there is stiffness of the whole body, in doses of gtt. 1 to 2 every half hour until its effects are manifested, after that the intervais between the doses ma}7 be pro- longea. Nux vomica in very small doses, is an important agent where the respiration is greatly disturbed, and may be given every hour, in doses of gtt. \. The tincture of calabar bean has been highly extolled by some late writers, and will doubtless prove a useful remedy. The tincture of phyostigma may be used in doses of gtt. 5 or 6, and if it fail to relax the muscles, I repeat in an hour. Esserine is also very7 good in very minute doses of gr. 1-6, or the extract in doses of gr. \. Dr. Fraser recommends the sub- cutaneous injection of this drug, repeating it until the muscular system is decidedly under its influence, and then maintaining the effect by administering the remedy monthly until the patient is out of danger. No rules can be laid down for the dose. It will vary in each case, from gr. \ to \ of the extraet, Catalepsy.—Catalepsy is a sudden loss of voluntary motor power. The patient fails suddenly, and ail the muscles remain in precisely the same position as they were in when attack came on, making the patient appear like a statue. At first the muscles are rigid, but they very gradually grow pliant,so that they remain in any position, in which they are placed. The patient usually loses ail sensibility and consciousness ; and recollects and perceives nothing. Occasionally some sensibility still remains, and in some cases, both sensibility and consciousness are undisturbed. The patient sees, hears, feels, and knows everything transpiring around him, but has no power to move a muscle in his body. This dis- ease, in the simple form, may end as suddenly as it began. The patient first takes a full inspiration, then sighs, yawns, and cornes to, as if awakening out of a deep sleep. He often résumes his usual work without knowing what has befallen him. Thèse at- tacks may follow one another in quick succession, and last but a few minutes. Graver attacks, however, last for hours aud days. I saw one man who had thèse fits whenever very highly excited by religious revivais, and they lasted for several hours. I saw another case, that of a colored girl, which had been caused by re- ligious excitement, and which lasted several days. Skoda men- tions one instance where itlasted several months. Catalepsy may be eombined with hysteria. It is often connected with ecstacy, St. Vitus dance, somnambulism and other nervous dérangements. Causes.—It is frequently caused by mental agitation, anger, DISEASES of THE NERVOUS SYSTEM. 199 fright, sudden joy, grief, disappointment, vexation, ecstacy, and religions excitement when carried to excess. Treatment.—When it results from anger, or vexation, chamomilla, in doses of gtt. 1 to 2, alternated with gtt. 1 to 2 of bryonia, will frequently be sufficient to check the attack. If it is cansed by fright, let belladonna be alternated with St. Ignatius' beau, and thèse followed by gelse- minum, in doses of gtt. 20 every three or four hours in the day. If caused by joy or grief, I give phosphoric acid, alternated with St. Ignatius' beau, in doses of gtt. 5, three or four times daily, until there is complète relief. If catalepsy results from disap- pointed love, gtt. 4 or 5 of tincture of hyoscyamus is an excellent remedy, given every three hours. If sexual erethism be the cause, stramonium will be the proper remedy, gtt. 5 every hour. If caused by ecstacy or religious excitement, I use stramonium, al- ternated with the tincture of sulphur,gtt. 5 each, three or four times a day, until it brings relief. If caused by obstruction to the catamenial flow, gtt. 5 or 6 of pulsatilla acts well alternated with senecio, 5 è, every three hours. When the cause is unknown, the tincture of cannabis indica, in doses of gtt. 4 to 5, three times a day, may cure the disease, and so artemisa vulgaris. Scutellaria is a good remedy, in doses 5 | of the tincture. Epilepsy.—This disease consists of chronic fits, which occur re- peatedly, but in many cases, without exact typical regularity. They are characterized by a want of sensibility and consciousness, and are attended by clonic spasms. At first, thèse fits do not af- fect the mind in the intervais, but finally, the brain is attacked. Symptoms.—The disease is often preceded by severe headache, vertigo, dizziness, sparks floating before the eyes, roariug in the ears, trembling, nausea, a désire to empty the bowels and the blad- der, sometimes ehilliness, palpitation of the heart, dyspnœa and soreness over the stomach and abdomen. The aura—which is a sensation as if cool air was passing quickly up the limbs towards the head—cornes over the patient just before the attack. The fit generally commences with a shrill, piercing shriek, and then the person fails violently to the ground unconscious. In many cases, convulsions, tonic or partially clonie in character, alternate each other in quick succession. Thèse spasms are occasionally very violent, so much so, indeed, as sometimes to cause luxations of the joints or fractures. The tongue is often badly bitten, and some- times the teeth are broken by the contractions. In some cases, extravasation of the blood upon the brain and its membranes takes place. The respiratory muscles are disturbed, and respiration is imperfectly performed, hence asphyxia and cyanosis may resuit, and the face and eyes may become much swollen. The saliva fiows from the mouth, causing foam in the lips, which is often 200 THE AMERICAN PRACTICE OF MEDICINE. mingled with blood. The urine and fœces may pass off involun- tarily, and in some cases there are érections of the pénis. The convulsions last two or three minutes or longer, and then relaxa- tion gradually takes place. The patient rouses with, perhaps, a deep sigh, having no knowledge of his past condition. In a short time he fails into a deep sleep, which may last several hours, and after awaking from it, he résumes his former occupation. Fre- quently, however, delirium, agitation, or wild excitement follow the fits. This condition lasts but a short time, and then con- sciousness returns. The following may be put down as the char- acteristics of epilepsy, viz : falling to the ground suddenly, shrieks, and tonic contraction of the muscles—spasms, lasting from one fourth to one minute. The intensity of the paroxysms greatly varies. In some cases, it is very light, consisting merely of an epileptic vertigo. If this be the case, the patient does not fail nor hâve clonic spasms, but is unconscious for a moment, staggers, and trembles. If it attack the patient by night, while he is asleep, it passes off unnoticed by him. Thèse fits occur quite fre- quently with some, and with others, only once in a great while. Sometimes attacks come on during the day, and sometimes by night. Symptoms.—Just before an attack, the patient becomes low spirited and morose, or grows excited and angry. Occasionally, patients are forgetful, stupid, lewd, and unmanageable. Causes.—In some cases it is doubtless inherited, and in other instances is the resuit of improper marriages, as is the case with neuroses. The emotional, ecstatic, state of mind, produced by peculiarly morbid impressibility the resuit of reading fiction con- stantly, doubtless leads to this, as well as to other nervous diseases. Morbid changes within the brain and its membranes may de- velop epilepsy, and so may repeated irritations of the périphérie extremities of the sensory nerves. Differential Diagnosis.—Impostors sometimes endeavor to deceive physicians by trying to simulate epilepsy, but by opening their eyes, and examining their pupils the truth will be at once known. If they are dilated by the disease, strong light will not contract them, but if the patient is feigning epilipsy, the pupils will then quickly contract when the light fails upon them. Prognosis.—When the attacks come on very frequently, and are very severe, with asphyxia, one sided convulsions, paralytic symptoms, long continued coma, delirium, mania, or great stu- pidity after awakingfrom the paroxysms, the disease is very apt to terminate fatally. Short attacks, which are light, and hâve very long intervais between each other and do not injure the health, in- dicate a more favorable condition, and when the attacks become less fréquent and milder, then it is more favorable still. When the disease is inherited, the outlook is unfavorable. DISEASES OF THE NERVOUS SYSTEM. 201 Treatment.—To ward off an attack let the nitrite of amyl be inhaled, gtt. 5 at a time, from the palm of the hand. Nitro-glyce- rine is slower in its action, but more enduring than nitrite of amyl. It may be taken in doses of gtt. 10 of the lst cent, dilu- tion, or gtt. 1 ot the lst dec. dilution, and repeated, if it fail. Ar- temisia vulgaris is indicated when the fits follow each other in rapid succession. Verbena hastata (vervain) has made some cures in doses of gtt. 60 of the fluid extract. Cocculus indicus has also proved itself efficient in many cases. Belladonna is valuable for old or long-standing cases, and may be administered in doses of gtt. 3 or 4, three or four times in the twenty-four hours. For ré- cent epilepsy in children, ignatia is a good remedy, in doses of gtt. 1 to 2 according to the âge. The oxide of copper is useful in small doses, of gr. 1-30, three times a day. If the spells come on in females about the menstrual period, I order caulophyllum, in doses of gtt, 30 of the tincture three times a day, in the interval between the attacks. If epilepsy is attended by painful menstru- ation, cocculus indicus, in doses of gtt. 4 or 5, three times a day7, will generally give relief. Viscum alb. is an old remedy that is worthy of more gênerai use. The bromides, especially bromide of lithium and bromide of sodium, or ammonium, hâve often given relief from the attacks, for months. and sometimes made permanent cures. I usually give the bromide of lithium in doses of gr. 10 three times a day, gradually increasing itto gr. 20. Acute Eclampsia: Puerpéral Convulsions.—This disease is very rare during pregnancy, and occurs before the sixth or seventh month, in the proportion of only one case in five hun- dred pregnancies, or even less frequently. It occurs more fre- quently during the act of parturition, but seldom during the lying- in period. Primaparœ are the most subject to it, and it usually commences during the dilatation of the os uteri, just at the expul- sion of the fœtus, or immediately after the expulsion. If it set in during the lying-in period, it is at the commencement of labor- pain. The convulsions in this disease resemble very much those occuring in epilepsy. If they occur during the prégnant state they are apt to cause abortion, and when at the commencement of labor, they are apt to retard and prolong it. If, however, they occur towards the end of labor, they generally hasten it. In many cases, after the expulsion of the child, the contractions of the womb cease, and haemorrhage results. Rétention of the plac- enta, and inflammation of the womb may also resuit from it. The convulsions seldom continue long after the birth of the child, but may in some rare cases ; I know a case where they continued for life. Where the mother has puerpéral convulsions about one-half of the children die. The later the convulsions, the greater the 202 THE AMERICAN PRACTICE OF MEDICINE. chance for the child. The prognosis is doubtful in any case al- though many live. Treatment.—Inhalation of chloform often suspends the spasms; and its influence must be kept up until the child is born. Where there are rapidly occurring spasms, with redness of the face, céré- bral congestion, dilated pupils, and cold hands and feet, belladona, in doses of gtt. 3 to 5, every three hours, will aid the chloro- form. Aconite may alternate with belladonna, in doses of gtt. 1. Large doses of veratrum viride hâve been recommended for nau- sea and vomiting. When from reflex excitability, chloral hy- drate will often ward off convulsions, if given in doses of gr. 15 or 20, just as the first indications of the spasms appear. The in- halation of gtt, 5 of nitrite of amyl, every half hour, will also ward them off, and often suspend them. If the spasms occur in labor, with a rigid os uteri, gtt. 25 of gelseminum should be adminis- tered and repeated every three (or two hours, if the spasms are severe), until the muscles are ail relaxed, and the spasms relieved. The convulsions of children—"Eclampsia Infantum"—which of- ten occur during the period of dentition, and from worms, may be cured by the removal of the cause, and by giving belladonna, gtt, | to 1, every three hours, alternated with gtt. J to \, of chamomilla. Gtt. 10 to 30 of the tincture of cypripedium and scutellaria, or half the quantity of the fluid extract, will give relief in most cases. Gelseminum may be required in some instances. Paralysis Agitans—This is tremor to a great extent, but dif- fers from it in its increasing intensity, and in its tendency to ter- minate in paralysis and finally in death. The attack may com- mence with a feeling of weakness, with trembling motions of the limbs and head. Thèse feelings may be mastered at first by the power of will, but finally increase in intensity, until the patient has no control over them, not even in sleep. The disease becomes so serious in some cases as to deprive the patient of the power of locomotion, and sometimes ends in complète paralysis and finally, in death, from exhaustion. Causes.—The causes are rather obscure. It is supposed to hâve its origin in a morbid affection of the brain near the corpora quad- rigemina and adjacent parts, or it may be caused by mental ex- citement, Treatment.—Rhus tox. is one of our most trustworthy remé- dies, in doses of gtt. \ to 1, three times a day. If the attack is attended by any affection of the mind, as hallucination, or re- ligious frenzy, I order gtt, 5, of the tincture of stramonium, three times a day. Small doses of the tincture of arsenic will often do food service. Phosphoric acid, (Horsford's Acid Phosphate) may e administered with benefit in many cases. The phosphide of DISEASES OF THE NERVOUS SYSTEM. 203 zinc where there is softening of the brain, in doses of gr. 1-10 or 1-15, three times a day; will often prove invaluable. Paralysis.—Paralysis is the loss of the faeulty of exciting the natural function of the motor nervous system and muscles. Causes.—It may arise from destruction of, or functional inca- pacity of those parts of the cerebrum, or ganglia at the base ofthe brain, or of the cerebellum, in which volitional impulses are con- verted into motor excitations, It may also arise from loss or diminution of conductive power of the motor nerves, or it may originate from a want of excitability and contractibility of the muscles themselves. Wounds, occurring in the peripheral nerves, or in the brain and spine may also give rise to paralysis. Dis- ease in the neighborhood of the nerves, such as exostosis, caries, aneurisms, enlarged glands, herniae and tumors, are liable to pro- duce it, and so too are neuritis myelitis, encephalitis, cérébral and spinal apoplexies, softening, scléroses, and tumors of the brain and spine. Poisoning of the blood with vegetable alkaloids, such as nicotine, ergotine, woorare, saponine, hydrocyanic acid, camphor and also some metalic préparations* such as lead, cop- per and zinc, are productive of paralysis. Typhoid fever, ery- sipelas, choiera, dysentery, acute articular rheumatism, diphtheria, syphilHs and scrofulosis, may ail be followed by it. Paralysis may atfect a single muscle, or group of muscles. It may attack one-half the body, (hemiplegia), from a lésion in the brain on the opposite side, or from a spinal lésion. It sometimes affects both halves of the body symmetrically, usually commencing in the lower extremities and spreading from thence to the truuk and upper ex- tremities (paraplegia). If the lésion exists in both hémisphères of the brain, there is generally paralysis of both sides of the body. Or with the most severe lésions it may be confined to the opposite side. Treatment.—If there is a degenerative change in the brain and spinal cord, the tincture of phosphorus will do good service ; given in small doses. If there is congestiou of the brain and spine, gtt 1 to 2, of belladonna should be administered every four hours until this symptom disappears. If paralysis is the resuit of softening of the cord, I use the phosphide of zinc in doses of gr. 1-5, alternated with gtt. 2 to 3 of tinct. of nux vomica, If thé attack is connected with rheumatism, rhus tox. is a most valuable agent in doses of gtt. 1, three or four times a day. This drug is also the remedy for paralysis of the eyelids. It is one of our most powerful anti-paralytics. Cocculus indicus is also an efficient remedy for most cases of hemiplegia, paraplegia and gênerai paralysis, but some cases are incurable by any treatment. *Mercury may produce the affection. 204 THE AMERICAN PRACTICE OF MEDICINE. Hydrophobia.—Hydrophobia, when it occnrs in the human faniily, is an acute infectious disease, produced by a spécifie virus, almost always inoculated by the bite of a rabid dog, wolf, fox, cat, skunk, or horse ; most freqneutly by that of a rabid dog. The latter has beeu known to produce this disease during the stage of incubation. Not everyone, however, that is bitten by a rabid dog will hâve hydrophobia. When the teeth go through the clothes, they may intercept the virus, and thus prevent the otherwise ill effects of the bite. It is estimated that only 8 or 10 per cent, of those who are bitten by rabid dogs, take hydrophobia and die of it. It does not require a severe wound to inoculate the poison, but a slight abrasion of the skin may readily absorb the virus. In fact, it is considered that very large wounds, which bleed freely, are the least apt to be followed by the disease. Wounds of the face are considered most fatal, and next, those about the hands. The wounds generally heal during the period of incuba- tion, about two weeks, but may last from three to six months, and, in very rare cases, two years. Premonitory Symptoms.—The wound generally becomes in- flamed, and assumes a reddish or bluish color. Severe, tearing pains are sometimes felt in the bitten part, or there may be a burning, prickling or boring sensation in the wound. Small blis- ters may appear under the tongue, The appetite fails, the head is apt to ache, the patient becomes very gloomy, and sometimes ill-natured, apprehensive, excitable, anxious and deeply concerned about his situation. He grows more and more restless, and sleep- less, and dreads light and fluids. In the second stage, the patient bas spasms of a paroxysmal character, which are easily provoked by an attempt to drink water, or by any sudden agitation or fright. Thèse convulsions may be light or veryT severe, and of a clonic character. They are often associated with maniacal raging and strange hallucinations, causing the patient to snap at ail who come near him. The spasms last from one half to three quarters of an hour. The patient can generally drink warm soups more easily than cold water, and better when he closes his eyes than when he has them open. There are intervais when the spasms cease for a time, and the patient is himself; but occasionally even thèse iutervals are omitted, and he has, at best, a perverted imag- ination. In the third stage, or the stage of paralysis, the patient becomes very weak ; the convulsions grow feeble, and finally entiaely cease; the muscles twitch; the pupils are contracted; the eyes are fixed ; the saliva is not ejected, but runs from the patient's mouth : the voice becomes very harsh and weak ; the breathing short and rattling ; the puise small, irregular and rapid, and the skin is covered with clammy perspiration. Death may take place in from two to eighteen hours after the DISEASES OF THE NERVOUS SYSTEM. 205 third stage sets in, and is the direct resuit of a convulsion, or asphyxia. Pathology.—One marked change, after death, is hyperaemia of the brain and its membranes, of the cord and its membranes, and of the lungs and kidneys. The sinuses and peripheral veins are generally much distended with dark, coagulated blood. Diagnosis.—It may be distinguished from traumatic tetanus by the intervais between the spasms. In the former disease, the spasms are continued. there is an increased reflex excitability, conscioucsness remains clear until death, and the organs of déglu- tition are unaffected ; but in rabies, consciousness is often suspen- ded, and the organs concerned in déglutition are very much affec- ted. Prognosis is very grave in any case. Treatment.—One of the most successful measures is cauteriza- tion ofthe wound at once, which stays the disease in 33 per cent. of those bitten by mad animais. The wound should first be well syringed out with salycilic acid, permanganate of potassium (saturated solution) or a saturated solution of boracic acid, and then dried with a sponge. It should then be cauterized with caustic potassium, and suppuration maintained for several weeks by dressings of resin cerate, and the occasional application of a solution of potassium to the wound. Anagallis arvenis and con- vallaria majalis hâve been highly recommended, and so has scutellaria. As soon as the brain becomes involved, belladonna is one of our best remédies, in doses of gtt. 5, every three or four hours. Dr. Gryzmala says that he lias found the xanthium spinosum to be a positive remedy in rabies, in doses of gtt. 10 to 20. It éliminâtes the poison through the skin and kidneys. He says he has cured one hundred cases with this drug. It can be alternated with belladonna or the anagallis arvensis. It may be commenced in doses of gtt. 10 to 15, every three hours. It is worthy of a trial, as our remédies are scarce. CHAPTER XX. DISEASES OF THE SKIN. Acné.—Acné, or stone-pock, is an inflammation of the sebaceous glands, caused by the rétention of sébum. It is characterized by the formation of papules, tubercles and pustules. It may make its appearance upon any part of the body, except the palms ofthe hands and soles of the feet, but most generally appears on the face or nose. Acné may be complicated with other follicular diseases of the face, nose, or body. The disease consists of élévations about the size of a pin-head, or a pea, situated around the glandular ori- fices, attended by more or less inflammation. If this inflamma- tion is superficial, the disease is apt to run a mild course, preseut- ing only slightly reddened élévations, with, or without a central yellow suppurating point; this form is called acné vulgaris. When, on the other hand, the inflammation involves the glandular structures themselves, considérable disturbance may be occasioned, which may end in small abscesses and then cicatrices. This form is called acné indurata. A form of acné may prevail with anaemia or chlorosis. The acute form may run its course in a few days or weeks, but the chronic form may run on for years. It is mostly found in persons of light complexions, and usually commences about puberty, being believed to be associated with functional disorders of the sexual system. The severe forms may be produced by dérangement of the digestive functions, and very frequently, it results from masturbation. The excessive use of iodide of potas- sium, will sometimes give rise to acné. The local use of far may also produce this affection ; and persons who handle tar are liable to an artificial acné on the hands. Treatment.—The diet should be restricted ; ail stimulating, and highly seasoned articles of food and drink, being entirely pro- hibited. If there are comedones in the skin, they must be pressed out with a watch-key or extractor. Where there is inflammation, soothing applications should be employed, such as the ointment of the iodide of sulphur ; adding 40 parts of rose water to 1 part of the iodide of sulphur. Large and painful pustules may be laneed, and indolent tubercules may be touched with the nitrate of silver or the ehlorite of gold. Sometimes a solution of biniodide of mercury, 1 part, and emulsion of almonds, 50 parts, is valuable applied two or three times a day. Rumex crispus, strong tincture, may also be applied. The sulphide of potassium, 1 part, to the emulsion of almonds, 30 parts, is an efficient application. Lotions [206] DISEASES OF THE SKIN. 207 of the sulphide of potassium, and the biniodide of mercury, are adapted to the indurated forms, the parts being well cleaned and softened with soap suds before applying thèse drugs. The Juniper tar soap is, also, well suited to this disease, and sait baths render good service in some cases. Where there is a tendeucy to pustu- ktion, small doses of ant. fart, may be administered, or the bro- mide of potassium, in gr. 1 doses. Where it follows onanism, and there are red pimples on the face, gr. 1-100 of chloride of gold, will act well, ordered three times daily. In the indurated form, with red, burning, gnawing pimples, surrounded with red areolee, and leaving brown spots, berberis vulgaris, is useful, in small doses. In young, full-blooded persons, belladonna will often do great good, given in small doses of gtt. 2 to 3. Sulphide of cal- cium is applicable in cases where large, firm pimples appear on the neck. If pimples and pustules appear in groups of three or four on the face, I give chelidonium majus, m doses of gtt. 3 to 5, three times a day. If it occur in old scrofulous subjects, iodine is the remedy. Juglans einerqa is also efficient in small doses. Alopecia.—Baldness is the absence of hair, either partial or gênerai, aud may exist as an accompaniment of a variety of affec- tions. Alopecia areata is a parasitic disease, which is characterized by the sudden appearance of white bald patches, of various sizes, either upon the scalp or in the heard. At times it affects the en- tire body. Occasionally it is unilatéral, and it occurs mostly in young people. It may appear in patches not larger than a nickel, and then spread rapidly. Other spots soon appear elsewhere, and in a short time the whole side of the head may be devoid of hair, which cornes out by the roots, leaving a smooth surface. Small downy hairs appear on the affected part in some cases, but they generally fail off. It is now demonstrated to be a parasitic disease, the spores, which are highly refractive bodies, being found among the epidermal scales. Treatment.—Acetie acid 1 part, and glycérine 2 parts, may be applied thrice a day, or rumex crispus steeped in acetie acid, and then applied with equal parts of tincture of cantharides, will re- lieve this disease. As internai remédies I employ moderate doses of phosphorous and muriatic acid. Icthyosis.—This disease is a congénital, chronic disease of the skin. It is characterized by a dry, harsh, dirty looking skin, generally covered with a species of furtùraceous scales. When nilly developed, the papillœ become enlarged, the diseoloration of the skin becomes more distinct, and the epidermal scales are loz- enge-shaped, and separated by numerous lines and fissures. In more grave cases, the scales form hard, dry, brittle pUtes of a yel- lowish or grayish color, separated by white intervening lines, 208 THE AMERICAN PRACTICE OF MEDICINE. which mark the furrows of the skin. Occasionally, thèse scales become heaped up into black papillaiw, horny projections. The disease affects the whole surface of the body, especially the front of the knees, the flexures of the elbows, knees, and face generally escaping. The skin is very dry in icthyosis, and in wiiiter it is apt to chap the face and hands. Diagnosis.—As pityriasis is the only disease that resembles ic- thyosis, they are easily distinguished, the skin being more or less hyperœmic in pityriasis, but not so in icthyosis. Moreover, the scales in pityriasis are branny, and readily fail off, while those of icthyosis resembles fish scales, and are firmly adhèrent to the skin. Treatment—The treatment of icthyosis should be of a tonic character, as cod-liver oil, or chaulmoogra oil, internally and locally. The application of the sapo viridis, is also of much value in the local treatment. Internally, I find the iodide of arsenic to be one of the principle remédies. I use the lst dec. trituration as follows : arsenicum iodatus lst dec. trituration gr. 2 ; aqua pura 3 4, dose gtt. 60, three times a day. If there should be much itch- ing, the above may be alternated with clematis erecta, in doses of gtt. 2 to 5 thrice daily. If the skin has a brown or dingy color, gtt. 3 to 5, of comp. tincture of iodine should be given three times a day, instead of the arsenic iodide. If the skin is dry and rough, like a hog's skin, the iodide of potassium may be ordered in small doses alternated with the hypophosphites of lime, sodium and magnésium in doses ofgr. 2 of each, three times a day. If the skin looks dirty, gray and cadaverous, I order the tincture of thuja oc, in doses of gtt. 1 to 2, three times a day. Washing the skin in an infusion of the bark of the quillaya saponaria also does much good. A generous diet should be allowed the patient, and the digestive organs should be kept in good condition; the kidneys being kept active. The skin should be daily washed in a warm alkaline solution, as the bicarbonate of sodium or the borate of sodium (S 2, to a quart of warm water.) Dermatitis Contusiformis.—This is an acute affection of the skin, which is characterized by oval or round purplish nodules, vary- ing from the size of a hickory nut to that ofthe fist. The attack is usually ushered in by fébrile disturbances ; loss of appetite ; malaise and erratic pains like those of rheumatism. The nodules are developed suddenly, and appear in erops. They feel firm and hard to the touch, and tender upon pressure, and are of a reddish or purplish color when first formed, becoming darker and softer in a few days. They generally appear upon the anterior surface of the leg, with their long diameters ruuning length wise with the limb. In some cases, they appear upon the face and arms, and are marked upon a dark red periphery. Thèse nodules never DISEASES OF THE SKIN. 209 suppurate, but disappear by absorption, fading away in color like bruises of the flesh. It generally attacks young persons, es- pecially females ; and is often associated with rheumatism and chorea, The trouble seldom lasts longer than two or three weeks, and tends to spontaneous recovery, although it may relapse in a short time. Dermatitis contusiformis is supposed to be due to embolism in the cutaneous vessels, and is somewhat allied to pur- pura. It is often followed by desquamation, and in young chil- dren appear3 between the folds of the skin around the neck and thighs. Treatment.—A solution of the tincture of arnica (one-tenth per cent.) may be applied locally, upon compresses of lint, alternated with au infusion of hamamelis, applied the some way. If the disease is attended with a burning stinging pain, rhus toxicoden- dron, in doses of gtt. 1 to 2, every two hours, will relieve the severity of the inflammation. If there is œdematous swelling of the parts, and an inflamed erysipelatous appearance of the nodules, attended by stinging, burning pain, rgtt. 2 to 5, of the tincture of apis mel., may be given every three hours until the pain and swellino- subside. If the nodules assume a purple color, ptelea trifoliata (the tincture) may be used in doses of gtt. 20 to 30, every three hours. When it occurs on the thighs of infants, it is called intertrigo, and is often attended by diarrhœa. It should in this case, be treated with small doses of borax, and boracic acid should be applied (in the form of a saturated solution) to the parts affected. If the discharges from the bowels are of a greenish color, o-tt. 1 to 2, ofthe tincture of chamomilla may be adminis- tered every three hours. If it appear behind the ears of infants, graphites (black lead) may be given, in doses of gr. \, three times a day. In strumous subjects, sulpher should first be tried for several days. If there is a tendency to acidity of the stomach, sulphuric acid, in gtt. 2 to 3 doses, will be found useful. Herpès.__There are différent forms of this disease but they are ail characterized by an exudation, usually of a watery sub- stance beneath the epidermis. This forms globular vesicles which are arranged in clusters upon an inflamed patch of skin and terminate frequently in the formation of a thin incrustation, without leaving marks or scars. Herpès Facialis—Th'm form of herpès appears on the face ; when on the cheeks and upon the eyelids, it is called herpès phlyctœnoides ; and when it occurs upon the lips it is called herpès labialis or hydroa febrilis—lever blisters.^ This latter form fre- quently attends croupous pneumonia and intermittent and other fever, but it rarely ever occurs in the course of typhus. Treatment.—The milder forms of herpès may be met by the 'local application to the parts of camphor cerate, calendula jelly, or 14 210 THE AMERICAN PRACTICE OF MEDICINE. cologne water. Where there is much fever, gtt. 1, of the tincture of aconite, may be administered every two hours until the fever is subsided or lessened. In chronic herpès, the syrup, tincture, or the fluid extract of alnus rubra,may be given in doses suitable to the âge of the patient. If there is a red herpetic coloring of the skin around the mouth, with a burning sensation, the tincture of arsenic may be administered in doses of gtt. 1 to 2, every four hours until there is decided improvement. For herpès zoster the local application of the tincture of hypericum, is sufficient. Urticaria.—This affection is characterized by prominent, smooth patches upon the skin, the color of which is either redder or whiter than the natural color of the surrounding skin. They are elevated either in the form of round nodes, or long welks. Thèse wheals are attended by an intense itching, stinging, and burning sensation. They vary in size, but are usually about the the size of the finger nail, and are generally surrounded by an areola, They may be many in number, and most commonly are round oroval in shape. They are sometimes sore and sometimes hard tothe touch, and when uncomplicated disappear without leaving any scar or mark upon the skin. This disease is called unettle rash," from the burning, stinging, itching and tingling sensation, which islikened to the sting ofthe nettle. Thèse wheals come and go suddenly, and are often excited by simply rubbing the skin. They are very liable to change of base. Urticaria may occur at any period in life, and may appear upon any part of the skin or the mucous membrane. It is mostly of an acute type, excited by some dietetic error, and generally lasts about five or seven days. Oc- casionally, however, urticaria appears in a chronic form. Some- times an œdematous swelling précèdes and accompanies this éruption. Again, an effusion of blood may take place into the wheals. An acute attack is generally ushered in with more or less fever, and more or less gastric dérangement. The éruption appears suddenly, accompanied by severe itching, and may spread over the entire body. After the exciting cause is removed, the sy7mptoms subside, and soon disappear. Causes.—It may be caused by utérine diseases in females, and by intestinal irritation in children. Overloading the stomach, or the use of wine or highly seasoned food, will give rise to it in some constitutions. Oysters, lobsters, crab, mushrooms, sau- sage, eggs and strawberries may provoke this disease. Large doses of copaiba, cubebs, turpentine or valerian. will produce it in some habits. Urticaria is easily distinguished from any other skin disease It bears some resemblance to dermatitis contusifor- mis, but lacks the livid color of that affection. The intense itch- ing of urticaria will at once distinguish it from dermatitis contusi-, formis. DISEASES OF THE SKIN. 211 Treatment.—If excited by an overloaded stomach, an emetic of ipecacuanha should at once be given. If from improper food, the diet must be properly selected to suit the patient's digestive powers. Warm vinegar and water lotions may be applied to al- lay the itching. A mixture of chloroform and cream, (3 2 of chloroform to o 4 of cream) applied on fine cloths, will also ease the itching. Gtt. 1 to 3 of rhus tox. administered internally, often cure this disease in one or two day's time. Gr. 5 or 6 of benzoic acid to 5 3 or 4 of rose water are often of material service, and a solution of S 1 of the tincture, or fluid extract of grindelia to 5 5 or 6 of water, will often readily assuage the itch- ing and stinging sensations. Sometimes gr. 2 of carbolic acid in 5 i of glycérine (this to be eombined with 5 2| of water, aud applied to the diseased surface), will be of material bene- fit. The Turkish bath may be employed, if the above applica tions fail. Should the disease be confined to the thighs, the tincture of allium cepa. in doses of gtt. 5 to 6 every hour, will aid the cure. Anacardium is recommended by some wri- ters. If the eyelids look puffy, the tincture of apis mel. should be given in doses of gtt. 3 to 5 every two hours until it af- fords relief. If the wheals are on the face, and of a scarlet color, with burning and stinging pain, I use the tincture of arsenic in doses of gtt. every three hours until it gives relief to the pain. If there are dirty, yellow blotches scattered over the legs, and attended with burning sensations, very small doses of the chloride of gold and sodium may be given three times a day. If there is a bright scarlet redness of the wheals gtt. 3 of belladonna every four hours, will give relief in a few hours. Eczéma.—Eczéma is a catarrhal inflammation of the skin, running through the stages of erythema, papulation, vesicula- tion, postulation, incrustation, and squamation, and is charac- terized by the présence of a discharge of the consistency of stiffening linen. It may commence abruptly or come on very gradually, and may run its course in a few weeks, or it may become chronic and last for years. Sometimes it consists in a diffuse, superficial dermatitis, which causes numerous little vesi- cles upon an inflamed, irregular surface, and in some cases there may be pustules intermingled with the vesicles (impétigo.) A^ain the exudation may not be abundant enough to raise the epider- mis into vesicles, but only sufficient to slightly loosen it, so that dies off and forms a scaly surface. Perhaps the epidermis is actually thrown off, leaving a raw, moist surface behind (inter- trigo), which occasionally becomes covered with a thin scurf, with a thick crust. Causes.—Eczéma may be caused by direct irritation of the 212 THE AMERICAN PRACTICE OF MEDICINE. skin, by heat, or wet bandages, or it may arise from stasis of the venous'capillaries. As this disease occurs most frequently on the lower extremities, so consécutive eczéma takes place in the form of salt-rheum. In many cases, however, we cannot trace the disease to any particular cause. When it attacks the scalp, it is called tinea furfuracea ; and if it peels off in the form of thin asbestos- like iayers upon the inflamed surface, it is called dandruft. The disease may also form thick crusts, and thereby mat the hair to- gether, in which case it is called tinea cavitis, or "scald head." In children, it is apt to pass rapidly through the erythematous and vesicular stage to the pustular stage, in which greenish-yellow crusts are formed, covering a red and cracked surface beneath. When it appears on the face of children it is called crusta lactea. If it attacks the ears, it is attended with considérable inflamma- tion and swelling, and sometimes abscesses. If it appears in the axilla, enlargement of the axillary glands is apt to follow, and it may resuit in abscesses. If upon the nipple, it is liable to be ac- companied by severe pruritus, and a copious discharge of yellow- ish sérum. If it exist upon the génital organs, there is generally considérable heat, redness and moisture. If upon the arms, legs, thighs or feet, it proves very obstinate, and is always attended with intolérable itching. If in the flexures of the joints and the clefts of the nates, it is apt to be of a severe and protracted type. When upon the hands and feet, it frequently assumes the fissured form, with but slight exudation and crustation. Chronic Eczéma.—This disease may start in a chronic form, or may.be preceded by acu te or subacute symptoms. If the chronic form attack the head, it is apt to cause dropping of the hair Scrofulous or lymphatic persons, or women at the ménopause, are very apt to be troubled with chronic eczéma. Sometimes it at- tacks the ears and eyebrows, and may then produce a thick- ening of the skin. If it appears on the chin, cheeks and upper-lip, it is very intractable ; and the parts will probably become infiltrated, and are often covered with bran-like, ex- foliate scales ail the time. This disease constitutes about thirty to forty per cent, of skin diseases in many localities, trav- eling from head to foot, as âge advances. It is most likely to at- tack the head of infants, the trunk of youths, the genitals of adults, and the lower extremities of very old people. The excessive use of mercury, croton oils, cantharides, mustard, rhus toxicodendron, and rhus venetta, and analine dies and strong soaps of potassium will also provoke this disease. It is due to want of tone in the nerves, by which cell prolifération and capillary congestion, with their conséquences, are produced. Eczéma is developed as follows; an exudation of sérum takes place from the congested vessels which floats the over-supply of DISEASES OF THE SKIN. 213 new cells, and the two push on to the rete from the papillary layer, sépara te the cell éléments of the stratum Malphighii and stratum lucidum, and uplift the cuticle so as to form first papu- les, and then the vesicles. Diaunosis.—In the erythematous stage eczéma may be con- founded with erythema, but the subséquent course of the disease soon disperses ail doubt. In the papular stage, it somewhat resem- bles litchen. This disease affects the outside of the limbs, and is de- cidedly a plastic inflammation, while eczéma is of a serious char- acter. In the vesicular stage, eczéma resembles herpès zoster, and scabies, but the vesicles in herpès are larger than those of ec- zéma, and appear mostly upon the face and genitals. Eczéma is never attended by the characteristic neuralgic pain of zoster nor does the éruption follow the course of the nerves. Eczéma is not attended by the mighty itching, so common with scabies, nor is it accompanied by acari, which are readily destroyed by parasi- tical treatment. It may be mistaken for impétigo in the stage of incrustation, but the crusts of impétigo contagiosa, are superficial and appear as if stuck on, while those of eczéma are greenish yel- low, and adhère firmly. In the squamous stage, it may be con- founded with psoriasis, seborrhœa, dermatitis exfoliativa, and the foliaceous variety of pemphigus ; were it not that psoriasis has no discharge, and its scales are silvery white. The scales of seborrhœa, also, look oily and are larger than those of eczéma, and dermatits has large, thin, and easily détachable scales in flakes, which when loosened, leaves a dry, reddish glazed sur- face. Foliaceous pemphigus starts from bullœ, and the scales ap- pear; thick and parchment-like. Thèse peculiar appearances must be noticed in the diagnosis. Treatment.—The diet should be well regulated, pork, pastry, and ail stimulating drinks, being strictly forbidden. As local remédies, bran washes and poppy fomentations, or emollient poultices of marshmallow, boiled starch or linseed meal, may be used at the outset to allay irritation and inflammation in the parts. In cases where there is but slight inflammation, the parts may be dusted over with the oxide or carbonate of zinc and starch in equal parts. Glycerole of tannin sometimes also answers well. If there should be severe itching, I use of carbolic acid gr. 5 ; glycé- rine S \ ; water, % 4J ; applied three times a day on lint. I find grindelia robusta (tincture) very useful with glycérine, && 5 4 and bran water, 5 16, mixed, and applied as often as required to keep the parts moist. Pyroligneous oil of Juniper, % 2 ; olive oil, S 4, mixed atfd applied three or four times a day, is an excellent remedy. I sometimes use borax, gr. 20 ; lime water, % 4, mixed and applied as above, three or four times a day. Ail thèse are applicable in chronic cases, or after the infiammation subsides. If 214 THE AMERICAN PRACTICE OF MEDICINE. there is great dryness of the skin, the oleates are the best remé- dies we hâve, as the benzoated oxide of zinc ointment. It only protects the parts from irritation. Chrysophanic acid, in the form of a cerate, is a useful application in the squamous stage. An ointment of dulcamara, is also valuable in some cases, The oilof cade, and the oil of Juniper, are the most useful drugs in the chronic form of eczéma. The pyroligneous oil of Juniper, or oil of cade, may be mixed with equal parts of olive oil. If there is is much infiltration, the oleate of tannin, is very successful, made by triturating and boiling S 1 of tannin, in 5 6 of oleic acid, to be applied twice a day after cleaning the parts well. One part of sapo viridis, and two parts of alcohol, is often of material benefit as an application. The oleate of litharge, applied on linen cloths, also gives excellent results. The internai remédies are the follow- ing, according to the respective indications. Aconite, in the sim- ple forms of acute eczéma, where there is more or less fever, and small doses of aluminium, where there are hard crusts on the arms and scalp. If the disease is in the bends of the limbs, with ex- coriations between the legs and about the anus and gentials, car- bonate of ammonium may be ordered in doses of gr. 2 to 3. If the disease attacks the face, head legs, and gentials, which itch very much at night, the tincture of arsenic acts well in doses of gtt. 1 to 2, three times a day. The carbonate of barium is also a valuable remedy in cases attended with moist crusts on the scalp, swelling, and induration of the glands, and in fat or lymphatic children. In the inflammatory stage, if there is a deep scarlet redness of the face, small doses of belladonna are invaluable. Sul- phide of calcium is often a useful adjuvant. Clematis erecta is is very useful in moist eczéma, when it occurs about the neck and on the head. Dulcamara is very applicable where there are thick brown, or reddish brown crusts on the forehead and chin. Where there is a tendency of the skin to crack open, and the cracks look ragged, graphites, in small doses (not more than gr. 1-10) will aid in the cure, especially if the disease be located about the ears. Hy- drastis canadensis, in doses of gtt. 10 to 20, of the tincture, is a valuable remedy where the digestion is feeble. In some ca es of eczéma of the face, iris versicolor, in doses of gtt. 3 to 5, of the tincture, does good service. If there is a dry, grayish white crust, or an offensive éruption on the head ofc hildren, syrup of arctium lappa (burdock) is a valuable remedy, and often cures this form of eczéma. The iodide of arsenic, where there is a syphilitie taint, is often absolutely required. It may be given safely as follows: iodide of arsenic, gr. 2 : sugar of milk, gr. 18. triturate'and add 3 4, of water. A teaspoonful of this mixture may be given three times a day. Where there is buruing and itching of the vesicles upon the cracked surfaces, with a greenish discharge, stiffening DISEASES OF THE SKIN. 215 the clothes, the tinct. or fluid extract of juglans cin., in doses of gtt. 3 to 10, according to âge, has proven a valuable remedy. Moist eczéma of the gentials, or where the hands and feet are cracked and rough, calls for the local application of petroleum. Piper methysticum is a valuable remedy where the skin is dry, scaly, cracked and ulcerated, especially on the feet and hands. In the acute stage, with small, yellow vesicles, red areolœ, and itch- ing at night, rhus toxicodendron, in doses of gtt. 1 to 2, every three hours, has proven a valuable remedy in my hands. Sepia has seemed to be efficient in some cases. Staphisagria is a valu- able remedy where there is an offensive discharge oozing from under the crusts. Small doses of sulphur prove most potent in some old chronic cases, especially where the éruption is dry7 and scaly. The dose is gtt. 5. In some cases the viola tricolor is a good remedy. Impétigo Contagiosa.—This is an acute inflammatory affec- tion of a contagious character, occuriug mostly in children. It is characterized by one, two, or more discrète vesicles or vesico-pus- tules, which are generally umbilicated, vary in size from that of a split pea to a hazel nut, and are followed by fiât, large, straw- colored, fungoid crusts. It may be ushered in with more or less fever, and in that case the éruption quickly follows. It appears in crops of small vesicles, which gradually develop into vesico pus- tules. Thèse vesicles which are small at first, grow rapidly, until they attain the size of a hazel nut. They are generally umbili- cated and contain a lymph-like fluid with granular, and subse- quently, pus cells. They are usually surrounded to a greater or less extent, by red areolœ. The fluid contents of thèse vesicles begin to dry up in about four or five days, and finally form fiât shaped, straw colored scabs about the size of a split pea or hazel nut, which look as if they had been stuck on. The most common seat of the éruption is upon the forehead and cheeks, but occasion- ally it extends to the arms and head, and may implicate the mu- cous membrane ofthe eyes, mouth and nasal fossœ. This disease was first described by Tilbury Fox, in the year 1864. It occurs most- ly in children of the poorer classes, but the better-to-do and the rich are also liable to it. It may be épidémie, but most commonly occurs sporadically. It is also contagious. It tends to run a defi- nite course and usually lasts for one or two weeks. In some lo- calities, it constitutes about one per cent, of ail skin diseases. Vac- cination will sometimes produce this disease. It is not consid- ered a parasitic disease, in as much as no fungus, similar to that observed in vaccine crusts, has, as yet, been found in the fluid of this affection, or in the vesico-pustules of the disease. Diagnosis.-—In the first place, we must bear in mind that this disease occurs mostly in children, and that it is preceded by more 216 THE AMERICAN PRACTICE OF MEDICINE. or less fever, and consists of isolated vesicles, which are usually umbilicated, and about the size of a split-pea, or larger. They are mostly situated upon the face, and generally follow in the wake of vaccination, presenting scales that appear to be stuck on. We need not mistake it for any other disease. It is most liable to be confounded with eczéma and'varicella. It may be distin- guished from eczéma by the fact that the children attacked are usually healthy, while those with eczéma are not healthy ; more- over the scabs look as if stuck on, and are of a light yellow color and lie fiât on the skin. The scabs of eczéma, on the contrary, are of a greenish, yellow color and adhèrent. Impétigo is con- fined to the face and upper extremities, while eczéma attacks any part of the body. It may be distinguished from varicella by the smaller (vesicles and différent crusts of varicella, and by its con- stitutional disturbance. Treatment.—Crude antimony is one of the first remédies in this disease, gr. 1 of the first dec. trituration (of the homœopathic pharmacy), three times a day, Euphorbia is indicated where the skin is irritable, dose gtt. 1 to 2, of the tincture every three hours. Bichromate of potassium in doses of gr. X to \, three times a day, is next in value to crude antimony. When the disease is quite pustular, small doses of tartar emetic will be found to do good service. When eczéma follows vaccination, thuja oc. in doses of gtt. 3 to 5, every three hours, will be of material service. The nitrate of potassium may be called for, where there is much fever at the beginning. In vigorous subjects, where the fever is considé- rable at the outset, gtt. 1 of tincture of aconite may be given three or four times a day, until the fever subsides. If the skin is very irritable, it may be anointed with 5 parts of olive oil and 1 part of oil of cade, after washing well with soap suds. Ecthyma.—This disease consists of large, isolated, painful pustules, situated upon hard and inflamed bases, and followed by brown crusts. Thèse pustules are oval or roundish, flattened, of a yellow or yellowish color, and are surrounded by a red areola. The disease is generally preceded by a slight fever. After a few days thèse pustules dry up and form flat, dark brown crusts, which, when removed, leave extensive excoriations, which finally develop into temporary pigmented scars. This disease may occur at any stage of life ; and usually attacks those who are badly nourished. It most frequently appears on the neck, shoulders and back. It is a superficial lésion, and rarely extends beyond the papillary layer. It may be confounded with eczéma and impétigo contagiosa, but is more apt to be mistaken for the large, flat, pustular syphilide. Ecthyma, however, develops more rapidly, gives rise to more heat and pain, and présents slight ulcération and brownish crusts; while the syphilide shows an ulcer more or DISEASES OF THE SKIN. 217 less deep, with abrupt edges, and blackish, instead of brown crust. The disease may become chronic, and may then be protracted for an indefinite time by successive crops of pustules. Treatment.—The treatment of ecthyma must be inaugurated by local applications. The affected parts may be anointed with a white precipitate ointment, say gr. 3 to § 1 of simple cerate. After the pustules burst, if the ulcers show but little tendency to heal, a weak solution of carbolic acid may be applied ; gr. 2 to g 3 or 4 of water will generally be sufficient to heal them. One of the best internai remédies is the triturated crude antimony (lst dec, trituration, in doses of gr. |, every three hours), especially whére the scabs are of a dark brown color. If the pustules are red or white, with an intense burning sensation, with thick crusts, arsenic is indicated, aud may be given in doses of gtt. 2 or 3, of the tincture, three or four times a day, until the patient is decidedly better, when it must be discontinued. If the pustules are ail over the body, and resemble those of small pox, the bichro- mate of potassium is the remedy, and may be given, in doses of gr. \, every two or three hours, dissolved in a wineglassful of water. If the pustules are on a very red base, and itch and sting, gtt. 1 to 2 of rhus toxicodendron should be given every three hours. If the pustules are large, tartar emetic, in doses of gr. 1-8, may be given every two hours. Pemphigus-—This disease is characterized by large, isolated bullœ or blisters upon a red, inflamed, but not infiltrated surface. The blisters are quite large, and are filled with clear sérum, greatly resembling those caused by a scald or burn. Thèse blis- ters vary in size from that of a pea to that of a hickory-nut, and even that of a walnut. This disease is almost always in a chronic form. There are two varieties of it, viz.: pemphigus foliaceus and pemphigus vulgaris. Pemphigus vulgaris generally appears on the limbs, especially on the ankles. Occasionally it attacks the mucous membranes and other parts of the body, but this is rare. The blisters or bullœ are rounded or oval, and rise abruptly from the skin (sometimes to the height of a centimeter or more), and may be attended by slight itching. The contents of thèse swellings are at first colorless, but later they become cloudy or milky. They usually appear in successive crops, each bulla run- ning its regular course in four or five days. Acute pemphigus is most commonly found among children, rarely in adults. It runs its course in from three to six weeks, but its subject is very prone to relapses. Pemphigus foliaceus generally attacks the body, and, though an uncommon disease, frequently proves fatal when it does occur. This form usually commences with the appearance of a single flaccid bulla on the sternum, which spreads over the whole surface of the body. The bullœ differ from those of pemphigus vul- 218 THE AMERICAN PRACTICE OF MEDICINE. garis, in that they do not become tense, but remain flaccid, and when they dry up, form yellow, parchment-like flakes, which vary in size from one to four centimeters. Treatment.—The patient should take exercise in the open air, and hâve a libéral animal diet, as beef, fowl, fish, eggs, etc. As local remédies, bran, starch or gélatine baths, are of material aid in the cure. As an internai medicine, rhus toxicodendron is one of our best remédies for acute pemphigus, and in the chronic form of the disease, arsenic is a most valuable remedy. I prêter the simple tincture, in doses of gtt. 2 to 3, three times a day. In the foliaceous variety, thuja oc. is oftener indicated than any other drug, the saturated tincture being given in doses of gtt. 3 to 5, every three or four hours. If the blisters itch very much, the muriate of ammonium should be ordered, in doses of gr. 1 to 2, three times a day. Where there are watery vesticles on the palms of the hands, which are very painful, I find gtt. 3 or 4 of tincture of belladonna very useful, given every four hours. Phosphoric acid (Horsford's Acid Phosphate) may be administered in small doses, as a tonic, ter die. Rupia.—Rupia consists of bullœ, containing a purulent reddish matter, which gradually dry and form a thick, dark crust. Under- neath this thick crust, matter continues to form, which again dries, and consequently raises the centre of the crust, while on the peri- phery it becomes encircled by a vesicated bDrder, which also dries up into a crust. This accumulated matter, when dried up, re- sembles an oyster-shell, and, on removing the crust, a deep, foui, excoriating ulcer will be seen. Rupia is a late and malignant manifestation of syphilis. Treatment.—The biniodide of mercury is one of the most trust- worthy remédies, united with the iodide of potassium as follows : biniodide mercury, gr. 2, iodide of potassium 5 2 ; mix well, and add to aqua 5 8—dose, a teaspoonful thrice daily. This is an active préparation of iodine, and the mereurial will not remain in the system, as other préparations of that métal are known to do, to the great injury of the patient's future health. This prépara- tion does its work, and is then eliminated with the iodide of po- tassium. As a vegetable alterative, the fluid extraet of berberis aquifolium (prepared by Parke, Davis & Co., Détroit, Mich.,) is a valuable addition to the compound iodide given above, and may be given in doses of gtt. 30, every four hours. The iodide of ar- senic is also a valuable remedy, provided the above fail to improve the condition of the patient in ten or fifteen days. It may be used in doses of gr. 1-50, three times a day. Faruncle.—Faruncle, or boil, is a eircumscribed inflammation of the skin and conneetive tissue, which varies iu size from that of a pea to that of a hickory nut. It always has an indurated and DISEASES OF THE SKIN. 219 inflamed base, and commonly terminâtes in suppuration and the formation of a "core." A boil commences as a small, round, in- flamed spot, painful to the touch, and surrounded by a bright red areola, which changes to a purple color as the disease advances. It gradually increases in size, and becomes more and more sensi- tive to the touch, the pain increasing in intensity and becoming throbbing. In about five or seven days the swelling suppurâtes and throws out a central slough called a "core." In rare cases, however, no core forms, and it is then called a blind boil. As soon as the discharge of pus takes place, the pain is reduced and the inflammation quickly subsides. Occasionally one boil follows another in quick succession until a number hâve come and gone. Faruncles may attack any part of the body, but generally appear on the face, back, neck, knees and gluteal région. They are doubtless owing to disordered states of the blood. I hâve seen the free use of the common blaekberry produce boils in a large family. They are more apt to attack children and young persons than old persons, although the aged are not entirely exempt, for I hâve seen them appear on old people, and become a great source of suffering to them. Treatment.—The usual treatment is to lance the boil, but this is not a good plan if done too soon, for the early use ofthe lancet always increases the inflammation, and very much retards the healing process. The first thing that I do, is to try to abort the boil by painting it with Lugol's sol utiou, or the tincture of iodine. I hâve often thus aborted them. If I fail, I apply a lotion of arnica, aconite and hamamelis in equal parts. If the gatherings are of a dark red color, and very painful, gtt. 3 or 4 of the tincture of bella- donna should be ordered every three or four hours, and a poultice of honey and flour applied to promote suppuration. Where there is prédisposition to boils, the patient should take sulphide of calcium, carb. of calcium or sulphur. Phytolacca is also an efficient remedy, in small doses. Carbuncle.—Carbuncle is a phlegmonous inflammation of the skin, characterized by necrosis of the cellular tissue, suppuration, and finally, discharge of the necrosed masses, (usually called cores), with pus, through sieve-like openings upon the top of the carbun- cle. Symptoms.—A carbuncle usually commences with severe burn- ing pain in the affected part, and more or less gênerai fever. As the disease advances, if not aborted, the part swells, and assumes a purplish color. The gathering is sometimes as large as a saucer, and again not larger than a fifty cent pièce. At first, small open- ings are seen, and then the whole mass gradually sloughs away, leaving an ulcer with inverted edges which granulates very slowly, and when liealed, leaves a permanent cicatrix. It appears on the 220 THE AMERICAN PRACTICE OF MEDICINE. neck, shoulders, back, forehead or buttocks, and is sometimes mild, sometimes very severe, and finally, fatal. Treatment.—At. the beginning, the carbuncle should be painted with the tincture of iodine three times a day, aud this may abort it. If it goes on however to sloughing, the ulcer should be dressed with carbolic acid and glycérine, equal parts, or if too painful, 1 part of carb. acid to 2 parts of glycérine. Arsenic is useful internally, in doses of gtt. 1. If very painful, belladonna may be given ; dose gtt. 2, ter die. Malignant Pustule.—This affection is sometimes. called car- bunculus contagiosus. It is characterized by a severe pustule, asso- ciated with a gangrenous destruction of the surrounding parts, which pustule owes its origin to a direct inoculation of the poison from an animal affected with the disease called anthrax, milzbrand or carbon. It may7 be caused by transmission of the poison by Aies, by inoculation of the poison from man to man, or it may or- iginate from eating the flesh of diseased animais. It is oftener found among persons who bave the care of diseased animais, or among those who work in manufacturing establishments, where the bides, wool or hair of animais are prepared for use. The in- fection usually takes place on the most exposed parts of the body. Eating the flesh of such diseased animais first causes gênerai indis- position, and more or less intestinal troubles, and in eight or ten days, anthrax carbuncles appear, generally about the arms and head. In a few hours, or even in a few days, itching .will be felt where the poison first took hold, as if some insect had bitten the part, and a little red speck, with a black point in its centre, will be seen. This little speck soon changes into an itching papule, capped with a small red or blue vesiclc, which gradually enlarges. It very soon bursts its dark red base, which becomes covered with a crust, and very often secondary vesicles spring up around it, con- taining a yellow, red, or black fluid. The surrounding parts now swell and extend over a considérable space, the cellular tissue un- derneath becoming infiltrated, and in some cases discolored lines marking the course of the veins, or red stripes showing the course of the lymphatic vessels in the œdematous région. The corres- ponding lymphatic glands also swell up. The symptoms dépend upon the severity of the local disease. There is generally fever, great weakness,delirium, excitement, confusion, sweating,diarrhœa, pain in the lips, and in fatal cases, collapse. Where the outlook is favorable, after the dead masses hâve sloughed off, the wound gradually heals by healthy granulation springing up. Treatment.—Arsenic is one of the best remédies in this affec- tion, and may be given in doses of gtt. 1 to 3 of the tincture, or gtt. 3 to 4 of Fowler's solution, thrice daily. The iodide of arse- nic is préférable, in many cases, to the arsenic itself, and may be DISEASES of the skin. 221 administered in small doses, say gr. 1-40. Bartholow says gr. 1-20, but that would irritate the stomach. Moreover, I hâve found it to act well in very small doses. I usually give the lst décimal trituration of the homœopathic préparation in doses of from gr. J to j three times a day, well diluted with water to pre- vent irritation of the stomach. Epithelioma.—This form of cancer may first begin as a wart, or a flat infiltration. The first sign is often a simple crack, or a small, hard, pale, dusky lump, which sooner or later fissures, and is either moist, or becomes covered with a brown or yellow crust. This growth increases, it may be slowly, until finally it breaks into superficial ulcers. The typical ulcer is round, and usually about the size of a split bean or larger, bas hard, sharply defined edges, and secrètes a scanty, yellow, viscid fluid. This form may continue for years as a mère local disease without undermining the patient's gênerai health in any way. This disease often attacks the lower lips also, especially those of smokers. If it attacks the scrotum it is called chimney sweeperis cancer, and when it appears on the face, it constitutes what English writers call rodent ulcer. Occasionally it first shows itself in the form of papules, which at first are movable, but which later tend to coalesce, and form red- dish or purplish colored aggregations about the size of a walnut or smaller. Thèse finally break up and form ulcers, which are attended with sharp, lancinating pains, increasing in degree as the ulcers increase in size. The ulcers are usually round, hâve hard, everted, indurated edges, secrète an offensive, pale yellow, viscid fluid, a^d bleed easily. Tissue after tissue gives way under this destructive ulcération, until finally the lymphatic glands become enlarged and suppurate, the patient ultimately succumbing from exhaustion. This form of epithelioma usually attacks the mucous membrane and cheeks, but may appear upon any part of the body. It may progress slowly or rapidly, and when left to itself usually proves fatal in from one to five years, although, in a few rare cases, it may extend over eight or ten years. The affection may develop as a wart-like growth, or cauliflower excrescence, that varies in size from that of a split pea to that of a hazel nut. This ulti- mately breaks up and fbrms irregularly shaped, granulating exca- vations, which bleed easily and slowly run the course of other epitheliomatous ulcers. Epithelioma is believed to originate from the endothelium of the lymphatic vessels. Diagnosis.—It is liable to be mistaken for lupus vulgaris, or may be confounded with syphilitie affections. Syphilitie forma- tions, however, are always more rapidly developed than epithe- lioma, and the ulcers of syphilis are generally multiple, hâve a pro- fuse sécrétion, and are devoid of pain, while the ulcer of epithe- lioma is single, with scanty sécrétion, and attended by severe pain. 222 THE AMERICAN PRACTICE OF MEDICINE. Again, lupus vulgaris is most commonly a disease of childhood while epithelioma is one of middle life ; its discharge, too, is very offensive. Treatment.—This disease may be cured in many cases, if taken very early. It is possible to remove the cancer by the knife, the galvano-caustic, or, by what is préférable, Marsden's arsenical mucilage, which is a mixture of arsenic, gr. 40, and mucilage of gum acacia, gr. 20, applied to the ulcers in a plaster J of an inch thick. The chloride of chromium, applied with just enough gum acacia to form a plaster, will slowly enuculate the diseased mass, and it may then be dressed with powdered hydrastis. I hâve used a paste of chromic acid and balsam of fir, with good effect, and also one of chloride of zinc. Some recommend the tincture of thuja oc. internally, but I hâve found, recently, that Parke, Davis & Co.'s fluid ex. of berberis aquifolium, in doses of gtt. 30 to 20, three or four times a day, acts better. I usually alternate this drug with gtt. 2 to 3 of tincture of arnica. Occasionally, I hâve found the chloride of gold and sodium to act very well, ap- plied locally and taken internally. For internai use, gr. 1-50 is the proper dose. In advanced cases, I hâve had marked success by simply washing the ulcer with gr. 5 to 10 of sulphate of zinc to the ounce of water, and then powdering it with the pulverized hydrastis. I now hâve two cases under this treatment, which are mending very rapidly. If there is debility associated with epithelioma, arsenic, or the iodide of arsenic, is the best remedy. Paronychia.—This is an inflammation situated around and beneath the nail, and which terminâtes in suppuration. It gene- rally attacks the thumbs and fingers, seldom the toes, and first ap- pears as a dusky red. and extremely painful border, either com- pletely or partially surrounding the nail. The pain is throbbing in character, and suppuration soon takes place. There is a form of this affection that attacks the big toe, which is usually caused by ingrowing of the nail. Paronychia differs from whitlow or félon, in that the latter involves ail or nearly ail the structures of the fingers, and appears most commonly on the palmar surfaces of the hand. Treatment.—As a local application, the pith of the common bulrush has been successfuUy used. If suppuration is tardy, the the sulphide of calcium is very useful in doses of gr. 1 to 2, three times a day. The sulphate of sodium, in doses of gr. 1 to 2, may be taken thrice daily, with excellent effect. If the gathering proves very severe, and will not readily heal, graphites, (a homœo- pathic trituration of say the lst. dec.) black lead, may be used, in doses of gr. 1-5 to 1-10, three times during the day. Sometimes there is a tendency to the formation of proud-flesh, and in such cases, a little chloride of bromium may be occasionally applied to diseases of the skin. 223 the spongy granulations until they are removed, and then the part washed in boracic acid, and powdered with iodoform. Félon.—This is an affection of the various structures of the fin- gers, and is frequently followed by the destruction of the first, and sometimes the second phlanges. It is attended with ^ very great pain, which often forbids sleep for several days and nights. The pain is throbbingand tensive, often extending as high as the elbow, and even the shoulder, and is aggravated by a depending position of the hand. The pain never ceases until the pus is evacuated, or until the diseased parts die. The swelling is some- times enormous, involving the fingers, wrist and arm, the skin of which is red, œdematous, and puffy, resemblingthe skin of erysipe- las. Very frequently the limb is stiff. The inflammatory pro- cess often commences in the deep seated tissues, pus forming near the bone, in the Connecting cellular substance, within the sheaths of the tendons, or beneath the periosteum. If this pus is not booii discharged, the disease will spread in ail directions, bur- rowing along the finger and hand, and causing extensive destruc- tion. Gangrené may even set in, followed by considérable slough- ingof the tendons, and exfoliation ofthe phalanges, This grave form is always attended with constitutional disturbances ; there will be fever, loss of appetite and sleep, pain in the head etc. Treatment.—Cases that I hâve seen at an early period, before pus has formed, I hâve usually cured by wrapping the finger firmly and evenly, so as to compress the superficial circulation, [f this is done promptly and properly7, it seldom fails to cure the disease, but it it be neglected until the pus forms, an incision down to the bone is the only step that will cure this affection. When thus completely split open, (not merely lanced), and an incision made with a scapel right down to the bone, it.heals as a wound. Where persons however would not submit to this treatment and absolutely rcfused to hâve the félon opened thus with the knife, I hâve resorted to médical treatment. The carb. of ammonium in small doses, will sometimes lessen the pain, and enable the patient to sleep, and the sulphide of calcium accélérâtes the sup- puration. [ hâve shortened the course of thèse painful whitlows on the fingers, by applying tape, as mentioned above, keeping it moistened with iodine (tinct.) 5 2 ; aconite 5 1 ; keeping the tape wet with the solution ail the time. This lotion lessens the pain a good deal, and doubtless aids the bandage in maturing the dis- ease, and drawing the pus to the surface. I hâve no confi- dence in internai treatment, for I hâve never seen it render any essential service towards a cure. Psoriasis-—This is a non-contagious disease of the skin, but one that seems to be constitutional. Symptoms.—Psoriasis is characterized by reddish, thickened 224 THE AMERICAN PRACTICE OF MEDICINE. patches, covered with white or yellow-white scales, resem- bling mother-of-pearl in color. Thèse patches are of various sizes, and usually appear as small, reddish spots, hardly at ail raised above the skin, but always covered with white scales. They generally develop rapidly, and in a few days are as large as a nickel, and look like drops of mortar on the skin. As they in- crease in size, they hâve a tendency to run together, and lose the circular outline that first characterized them. In some cases, the centers of the patches become clear, giving the disease the ap- pearance of rings. Some writers speak of thèse différent stages as distinct varieties of disease, as psoriasis punctata, psoriasis murn- mularis, psoriasis gyrata, etc. Thèse are not distinct varieties of cutaneous disease, but simply différent stages of the same disease. The scales of psoriasis are of a characteristic silvery whiteness, and are situated upon a red and inflamed base. The most com- mon seats of this affection are the elbows, ankles or knees, but it may appear upon any part ofthe body. It is supposed to be due to a perversion of the cell life of the rete. It generally attacks families predisposed to goût, and thèse in winter. Causes.—Its etiology is quite obscure. By some writers it is claimed to be of malarial, and by others, of trumatic origin. Next to eczéma and psoriasis, it is one of the most common disea- ses of this country and of Europe. Diagnosis.—Its characteristics are the silvery whiteness of its scales (which look as if they were heaped up) ; its situation on an inflamed base of the cutis (which is much inclined to bleed in pin-point drops on the removal of thèse scales); and its location (the elbows and knees being its usual situation). Treatment.—The diet should be rieh and of a healthy charac- ter, such as beef,. fish, and fowl. Maltine and cod-liver oil are also of much benefit. I order bran baths to remove the scales, and then anoint the parts with the chaulmoogra oil, or the chrysophanic cerate. I do not use the latter too strong, gr. 1 to 30 of lard is strong enough to begin with. The oil of cade, either in full strength or diluted with olive oil, may also be used in many cases with good effect. A mixture of tar and alcohol (1 part of tar to 5 parts of alcohol) often answers well. The bin- iodide of mercury ointment (gr. 1 of the bin-iodide to gr. 50 of lard) has proven itself to be of much value ; and a wash of the solution of calcium sulphide (not too strong), is of material ser- vice in obstinate cases. A wash every day with green soap is very good in indolent cases, where the scales are thickened and infiltrated. The internai treatment should commence with the tincture of sulphur, or with gr. 1 or 2 of the sublimed sulphur, three times a day. This routine should be continuée for three weeks, and then changed for some of the remédies named below. diseases of the skin. 225 When the scales are continually exfoliating, the carbonate of ammonium, in small doses, may be ordered three times a day. If the skin be dry and scaly, arsenic, in the form of a saturated tincture, may be taken with a prospect of good effect. The dose should not be large, not more than gtt. 1 to 2, three times a day, lest it produce its toxical effects. Iris versicolor is also a valuable remedy. Phytolacca is also efficient, after arsenic. Berberis aquifolium, in doses of gtt. 30, thrice daily, acts well in most cases. Lichen Planus and Lichen Simplex.—This is a chronic dis- ease of the skin, commencing with dull red, flat-topped, angular- based, glazed papules, about the size of a pin-head, which are attended by more or less pruritus. It is not very common in the United States, and when it does occur hère it is generally associ- ated with a debilitated state of health. The éruption resembles millet seed, and at first has a shiny look, but after awhile becomes covered with thin, micacious scales. Thèse papules start abruptly from the skin, are irregularly shaped, are flattened on the top, and frequently présent an umbilicated dépression in the center, which is really the opening of the hair follicle. They are usually discrète, but may b'3 in patches, andj as a gênerai rule develop slowly and occur symmetrically. Sometimes stains are left, and occasionally small pits remain after the disease has gone. This trouble may occur at any âge, but it attacks women more than men. It sélects as its seats the front of the forearms, the wrists, the thighs, the abdomen and the legs below the knees. It is thought to originate from a disturbance of the trophic nerves of the hair papillae. Hyperaemia results from this disturbance of the trophic nerves of the hair papillœ, and so does the formation of new tissue in the parts. ^ Prognosis.—The prognosis is usually favorable, except in the diffused form of the disease, the lichen rubra of Hebra, which is generally associated with marasmus, and may, unless successfuUy treated, terminate fatally. Treatment.—The diet should be libéral. To relieve irritation and itching, local treatment may be necessary. A wash of a solution ofthe tincture of grindelia robusta may be used say, | 1 of it to 3 3 of water, applied three times a day, or carbolic acid l \ to i 7 of water. The pyroligneous oil of Juniper will be found effective in cases of long standing. The best internai remedy is crude antimony, in very small doses. Arsenic, too, is invaluable in chronic cases, in doses of gtt. 1 to 2, thrice daily. Iodine pro- duces good results in cases where the papules are small and red, and so does *;he iodide of sulphur, when the disease attacks the chin and nose. Bichromate of potassium, in small doses, also acts admirably, and so does the tincture of juglans in small doses. 15 226 THE AMERICAN PRACTICE OF MEDICINE. Prurigo: Pruritus.—This disease is characterized by the development of small papules, which are about the natural color of the skin, and which are accompanied with intense itching. It commences with the graduai formation of small, sub-epidermic élévations, which feel like shot, and are sometimes perforated by small hairs. The papules are the resuit of chronic inflammatory changes in the papillary layer. Intense itching, with a sensation like ants stinging, is one of the earliest symptoms, and continues with more or less intensity throughout the whole course of the disease. As the affection advances the skin becomes more or less thickened, rough and harsh, and feels rather dry to the touch. Pruritus may appear upon the exterior surfaces of the lower extremities, but is most frequently found upon the forearms, the trunk, and elsewhere about the body. It is apt to commence before puberty, and to grow worse during the winter, not unfre- quently annoying the patient through life. The trouble is not ver}7 common in the United States. Diagnosis.—It is apt to be confounded with phtheiriasis, but is not accompanied with pediculi, as phtheiriasis always is. Treatment.—The patient should be put upon a nutritious diet, and hâve a sulphur bath at least once or twice a week. To allay the intense itching and formication, a carbolic acid lotion should be ordered, g | to 3 4, water, and a lotion of the tincture or fluid ex. of dioscorea villosa, or mezereum, may alternate with it. Sulphur should be given internally at the outset in doses of gtt. 5 to 6, of a saturated tincture, three times a day. After the affection has become chronic, arsenic (saturated tincture), in doses of gtt. 1 to 2, is the best remedy, and it may alternate diosco- rea vil., in doses of gtt. 10 to 15. Pruritus simplex—simple itching, without any éruption, occurs frequently, and must not be confounded with pruritus, with papules. This simple itching is merely a perverted sensibility of the skin, and is a very common accompaniment of a variety of skin diseases. It aceompanies leucorrhœa in females, piles in either sex, and is often sympto- matic of some nerve disturbance, as indicatingbile, or some other foreign élément in the blood, and must be treated as such. Itch.—This is a contagious disease, caused by the burrowing of an animal parasite called the acarus srabiei, in the skin. It is known by the early formation of cuniculi, attended with intense itching, especially at night. There may be also, in cases of long standing, vesicles, pustules and crusts. The first symptoms are itch- ing and the formation of minute inflamed points or vesicles, which generally appear first, in the space between the fingers, and from thence, if not well treated, spread over the hands, and finally, the body. Under the microscope the itch insect may be seen as a whitish-yellow speck, headed by a dark curved line. This insect DISEASES OF THE SKIN. 227 is often found on the abdomen and on the inner surface of the thighs. Itch is frequently conveyed from one person to another by hand-shaking, and very often by taking books, clothes, gar- ni ents and other articles from the hands of those affected with the disease. . . Diagnosis.—It is known by its cuniculi, with the acari inside. Primarily its seat is generally in the interdigits and the wrist, but later in the flexures of the body, the buttocks, and the abdo- men and pénis. The itching is always worse at night. Treatment.—Sulphur, internally and externally is a spécifie for this disease. As an internai remedy, gr. 3 to 5, may be ordered every three hours in the day, or as an external application gr. 8 or 10, may be incorporated with 51, of lard and be well rubbed in thrice daily, after the patient has been washed well with soap suds. An ointment of liquid borax not too strong makes a good parasiticide. The balsam of Peru 5 2 ; oil of lavender, gtt. 5 ; lard 3 1 ; makes a good local application. It is best to apply thèse ointments at night and wash them off next morning, pursuing this plan for three or four days, and then changing the clothing and allowing the patient to rest a few days from the ointments, and take the sulphur internally to see what has been accomplished by external treatment. AU the clothing should be boiled in strong soap suds before the patient puts them on again. If the above remédies fail, sulphurous acid may be tried (diluted), the sulphites, or an ointment of carbolic acid, or oil of cajuput. An application of the sulphide of potassium, 5 \- and lard g 1, will often cure this affection. Prairie Itch.—This is an acute inflammation of the skin, gene- rally appearing in new districts, where it may be endémie for a time. It may be preceded by premonitory symptoms, such as headache, slight fever and gênerai malaise; or its attack may be first marked by the appearance of erythematous spots. Thèse spots are covered with small, transparent vesicles, of various sizes, from that of a pin's head to a mustard seed, and are situated on the neck, shoulders, back and outer surface of the limbs. The éruption is also accompanied by an intolérable itching, which in- creases at night. Where the patient scratches himself, and rup- tures the vesicles, there exudes an exceedingly acrid, irritating fluid, which prolongs the disease, unless it is washed off, aud the parts covered with a layer of wood ashes. Sometimes large black crusts are found covering suppurating ulcers, and not unfrequently boils are complicated with this troublesome disease, especially if neglected. Treatment.—The syrup of rumex crispus is one of the best remédies we hâve, in doses of 51 to 2, ter die, and a wash of a strong infusion is a good addition to it. CHAPTER XXI. DISEASES OF THE SCALP. There are five layers in the skin of the head, viz. : (1) the derm, or outer skin, thickly covered with hair, and containing countless sebaceous and sudoriparous glands (the sebaceous glands secrète an oily, fatty substance, and the sudoriparous glands are the organs of perspiration); (2) the epiderm; (3) the subcutaneous cellular tissue, containing the net-work of the larger blood vessels, in which the nerves are im- bedded, and which join the epiderm to the aponeurosis. This skin is spread tightly over the cranium. (4) Just under this is found the second cellular tissue, consisting of loose meshes which connect the aponeurosis loosely with the pericranium ; (5) the im- médiate covering of the bones of the cranium, which transmits the vessels. Ail, or a single one of thèse tissues may be involved in disease. The scalp is liable to a peculiar form of rheumatism, in which the entire integument becomes very sore and painful. It is very common in rheumatic habits, and occurs in cold, wet weather. Treatment.—I hâve found cimicifuga, in doses of gtt, 15 to 20, of the tincture of fresh root, a very positive remedy for this affection. Dropsy of the Scalp.—This most commonly consists of a col- lection of sérum in the cellular tissue of the scalp, or there may be a collection of sérum between the aponeurosis and the pericranium. When sérum collects in the cellular structure, it is very apt to spreaddown to the face ; and may be known, like dropsy elsewhere, by its pittirg, upon pressure of the finger. If, however, it forms underneath the aponeurosis or the galea capitis, the swelling is tight, elastic, fluctuating, and neither pits by pressure, nor spreads over the face. Thèse forms may occur with a gênerai tendency to dropsy, or they may be provoked by erysipelas, etc. Treatment.—Sometimes the timely administration of a good dose of compound powder of jalap and cream of tartar, followed by a few doses of the acétate of potassium will overcome this form of dropsy ; and if there be anaemia, the nitrite of iron should be given for a few weeks. In obstinate cases, I hâve succeeded with apochynum canna binum in doses of gtt. 15 to 25, every three hours. Erysipelas of the Scalp and Face.—This is an acute inflam- mation of the skin of a peculiar kind. In some cases the adjacent [228] J DISEASES OF THE SCALP. 229 lymphatic glands are enlarged. The disease is undoubtedly con tagious and inoculable; but often appears spontaneously under some peculiar conditions not well known, and when it occurs in this way, it is called idiopathic erysipelas. So contagious is it sometimes, that it may be carried in clothing, or even in instru- ments which hâve been used in connection with patients afflicted with the disease. When it thus originates from clothing or in- struments,^ is called traumatic. A very slight abrasion or eut may absorb the virus, or the disease may be communicated by the nurse and the attending physician. I once saw the disease pro- duced on a young mother's arm from contact with the scalp of her babe that had erysipelas of the head. It often arises, however, as mentioned above, without any infection, seeming to be the resuit of some peculiar atmospheric condition. It is no less a constitu- tional disease than measles, scarlatina, and roseola. Prof. Da Costa has conclusively shown that erysipelas is almost always attended by albuminuria, although, in the traumatic variety, this is either absent, or appears in a very mild form. Erysipelas, like phleg- monous inflammation, affects ail the tissues of the skin, and also the subeutaneous cellular tissue. The various layers of the scalp with the subeutaneous cellular tissue, are œdematous, swollen, and penetrated by white blood corpuscles. One very decided tendency of this disease, is to.spread very uninterruptedly and gradually over the surface it attacks. It seldom, howœver, extends from the head to the neck. Symptoms.—Chilliness, feverishness, or gênerai indisposition may précède, by one or two days, the outbreak of this disease. The part attacked begins to feel hot and tense, and the skin be- comes very red, swollen and sensitive to the touch. The neigh- boring lymphatics may also become swollen. The skin of the af- fected part bas a smooth shiny appearance, and the color is darker and duller on the scalp than elsewhere on the body. The inflam- mation is apt to creep over the entire scalp, and then down to the face, and^ sometimes even to the neck and shoulders. The swel- ling attains its height in about three or four days, and very often during this stage the epidermis becomes raised and filled with hmpid, yellowish fluid, like blisters in shape. This form is called erysipelas bullosum. The blisters may either dry up, or burst and form scabs or crusts. During the acme of the fever, there may be evening aggravations, and the patient may be delirious, or, if not, his sleep is disturbed by frightful dreams. About the fourth day, in favorable cases, the swelling and redness of the skin begin to subside on the parts first attacked, but the parts which were last attacked still remain inflamed. Eventually the entire diseased surface becomes paler and wrinkled, the crusts fail off, the epidermis peels off in large flakes, and the disease terminâtes 230 THE AMERICAN PRACTICE OF MEDICINE. in from twelve to fifteen days. In some cases it may also attack the mucous membranes of the nasal and pharyngeal cavities, caus- ing an œdema of the glottis, and affecting the larynx, the bron- chial tubes, and sometimes the lungs. In this case it produces pneumonia, pleuro-pericarditis or carditis, and proves fatal. Again, erysipelatous inflammation may be transferrcd to the mén- inges of the brain or to the brain itself, and so terminate fatally. The tongue is covered with a creamy coat, which gradually dries, and becomes of a dirty, yellow color ; or if the disease continues long, the tongue becomes crusty, and of a black or dark brown color. Nausea and vomiting are not uncommon. Occasionally, a violent diarrhœa sets in about this stage, or a profuse haemor- rhage from the bowels, (caused by ulcération of the duodénum), which is very apt to prove fatal. In idiopathic erysipelas, there is generally more or less albuminuria. The température in this disease runs very high, from 104° to 105° F., and in some cases as high as 106° or 107° F. Sometimes there are marked intervais of dépression of température, and then sudden risings. Where the scalp is highly inflamed, the hair may fail out, but will quick- ly grow again. In severe cases, the skin on the scrotum, eyelids, vulva, prépuce and other places where it is tender, may undergo fangrenous destruction, and the disease may thus be protracted 'he first attack of the disease, instead of destroying the patient's suseejittibility, leaves him or her more liable to it again. I hâve frequently treated persons who were subject to periodical returns of erysipelas up>on the face and limbs. Prognosis.—The prognosis is generally favorable unless the dis- ease attack the internai organs and brain, or prevails in an unusu- ally maligant form, when it proves very fatal under any treatment. Treatmemt.—If the disease appears in the'phlegmonousform, I find aconite very useful, in doses of gtt. | to 1, every two hours, alternated with gtt. 2 to 3 of belladonna. I find belladonna to be especially serviceable in cases where there is intense dermatitis, high fever, redness of the skin, headache or delirium. If the disease invades the inner tissues, let apis mel.* (tincture of the honey bee) be taken in doses of gtt. 3 to 5, alternated with rhus toxicodendron, in doses of gtt. \ to 1, every two hours. The rhus tox. is especially indicated where there is simple vesicular œdema, and a purplish color of the skin. Apis mel. is indicated by smooth, acute œdema of the eyelids, and skin of the scalp and face. Where the disease commences in a maglignant form, or as- sumes that type, any time during the course of its attack, I give small doses of arsenic (tincture) in doses of gtt. 1 to 2, every three *See Author's New Medicines. DISEASES OF THE SCALP. 231 hours, well diluted with water. A tendency to gangrené, or a typhoid prostration, also calls for arsenic, and cannot be met as well by any other remedy. The local application of tincture of veratrum viride, diluted with one or two parts water, is of much utility. If there is wild, raving delirium, tincture of strammo- nium, in doses of gtt. 5 to 6, will relieve this symptom. If there is anaemia, the muriate of iron is invaluable in doses of gtt. 10 to 15. Eczéma ofthe Scalp.—In eczéma of the head, the inflammation extends to the hair follicles, and passes rapidly into the_ pustular stage. It is a non-contagious affection of the skin, and is charac- terized by an éruption of minute vesicles, which are frequently confluent. So dense are the vesicles in some cases, that they ap- pear like a large blister. Thèse vesicles form thin scales as they dry up or break and discharge a milky fluid of varied consistency, which finally concrètes into crusts. This form of the disease, like eczéma of the body and limbs, spoken of elsewhere, is acute or chronic. It has received various names, as ecthyma, porrigo, tinea capitis, and chronic psoriasis. To distinguish it, we must look for the following characteristic, viz: vesicular éruption, which is often confluent, and discharges a limpid, turbid, aud milky fluid, which forms thick or thin crusts. Pustular eczéma is called impétigo, and differs from the vesicular form, simply in having pustules, instead of vesicles. A vesicle is a very small blister, and a pustule is a pimple. Impétigo is pyo-genetic (pus- forraing) and forms pus instead of the milky, limpid fluid, that is found in eczéma. Both thèse affections may be found together upon the head, covering large patches on the cranium, and may be distinguished from each other, by the thin scabs of eczéma, and the thick and tense ones of impétigo, which are of a greenish- yellow or brown color, and appear as crusts, because they hâve been formed from real pus. Treatment.—In simple eczéma, the tincture of rhus toxicoden- dron has been very successful. It should be given short of its toxical effects upon the skin, say, gtt. | to 1, three times a day. After the vesicles form crusts, and the disease becomes chronic, I find the tincture of arsenic, in dose3 of gtt. 2 to 5, to be one of our most reliable remédies. It may be alternated with the viola tri- color, in doses of gtt. 5 to 10, given three or four times in the course of the day. The head should first be washed with green or tar soap, and then with sulphuretted potassium or the sulphide of calcium. I find that a wash of a saturated solution of boracic acid is good. Clematis erecta, is a valuable remedy, and may be used in doses of gtt. 5 to 6, three or four times daily. The carb. of barium is also a good remedy, in small doses of gr. £ to £, three times a day. I hâve found a local application of the acetated tinc- 232 THE AMERICAN PRACTICE OF MEDICINE. ture of the rumex crispus to the diseased parts, to hâve very posi- tive curative effects. I had eczéma very severely, in a chronic form, when I was about fifteen years ot âge, and recovered from the attack through the use of rumex crispus. I am at présent treating one of the worst cases of this disease that I ever saw, and hâve given the woman the tincture of arsenic, alternated with dul camara (bitter-sweet) ; the arsenic in doses of gtt. 2 to 3 of the tincture, and the dulcamara in doses of gtt. 5 to 10 of the fluid extract, three times a day. I follow this with the application of a strong solution of boracic acid to the scalp. I hâve also used carbolic acid iu glycérine and water with success, say gr. 2 to 5 of the acid to about § 4 of glycérine and water, applied with a soft cloth or sponge, ter die. A wash of sulphuretted potassium aids in the cure of chronic eczéma, and so does one of equal parts of pure glycérine and tincture of grindelia robusta. An ointment of croton tiglium (5 1 to S 4 aqua rosœ) is also a good application. Dandruff.—Dandruff is an eczéma, in which the exudation is so scanty that it does not produce vesicles, but merely loosens the epidermis, which dries and peels off in scales. The skin under thèse scales remains congested and hence new scales are produced. The disease may be confined to a small surface, or it may extend to the whiskers and eyebrows. It is generally of a chronic char- acter. Treatment.—The tincture of the rumex crispus, in vinegar, ap- plied locally, and sulphur given internally in doses of gtt. 5 to 8 of the tincture, will hâve an excellent effect. If the disease does not yield to thèse remédies, I give small doses of tincture of ar- senic, and wash the scalp with carbolic soap, or anoint it three times a day with carbolic acid and glycérine. An ointment of salicylic acid, or a solution of it in sweet spirits of nitre, gr. 20 of the salicylic acid to S 2, of the nitre, also acts admirably. I hâve used the saturated solution of boracic acid with equally good effect, and I hâve not found anything better as a local remedy. It may be used three or four times a day, as it is not painful unless there is great irritability of the parts. Seborrhœa Capillii and Vernix Caseosa.—This disease aflects principal ly the scalp, but may appear elsewhere upon the body. It has no regard for âge, but attacks females oftener than maies. It is very common in new boni children, and iu them is more a physiological than a pathological condition (vernix caseosa). It generally occurs in the form of an oily coating on the skin, or in the form of dirty white scales, which are flat and more or less greasy. When it attacks the scalp, it may eventually cause bald- ness, and is often confounded with eczéma. It must always be remembered, however, that seborrhœa is a dry, oily disease, while eczéma is not oily, but gives rise to a lymph-like fluid, and dries DISEASES OF THE SCALP. 233 into scales seated upon a reddened, infiltrated surface. The scales of seborrhœa are seated upon a pale, bluish-colored skin, and are abuudant, while the scales of eczéma are scanty. If thèse differen- tial points are considered, the diagnosis is easy. Treatment.—The oily scales should be saturated with olive oil or glycérine, and softened, and then, after some twelve hours, they can be removed with a soft sponge, dipped into soap suds. After removing the scales, the glycerole of tannin may be applied. When the disease appears on the face, a powder composed of gr. 6 of tannic acid to gr. 40 of rice powder, will hâve a good effect. The most effective internai remédies are arsenic, muriaoe of am- monium, bryonia, iodine, phosphorous, bromide of potassium, sul- phur and thuja oc. Where the skin is of a smutty brown color, or yellow aud mottled, gtt. 1 to 2, of tincture of arsenic should be given, three times a day. If the hair is falling off, and there are large bran-like scales constantly accumulating, the muriate of am- monium, in doses of gr. 1 to 2, three times a day, will give excel- lent results. In chronic cases, that hâve lasted long bryonia, in doses of gtt. 2 to 3, may be given every three hours. If the scales adhère firmly to the skin, the compound tincture of iodine (Lugol's solution) should be administered in doses of gtt. 5, thrice daily. If there is a copious formation of the scales, which fail off iu clouds, tincture of phosphorous, may be used in doses of gtt. 1 to 2, well diluted writh water. If the disease be on the face, bromide of po- tassium is the remedy indicated, dose gr. 2 to 5, three times a day. Favus.—This is sometimes called tinea favosa or tinea maligna, and is a contagious disease, characterized by the appearance of one or more différent sized cup-shaped scabs, of a yellow, sulphur color, which are pierced by a hair. This disease is one of filth and dirt, and, hence, is found among the poor and lazy classes of the people, appearing mostly upon the head, but sometimes attack- ing the trunk and occasionally the limbs. It is supposed to origi- nate from a vegetable parasite, which leaves a slight redness that is accompanied by itching whenever it touches the skin. Very soon scales form on this reddened surface, and assume the form of crusts the size of pin-heads, which continue to increase. The dis- ease thus spreads, so that at the end of two weeks, the collected mass présents the umbilicated form of the fully developed favus cup. Thèse cups may remain separated, or they may coalesce and form yellow-colored aggregations, resembling honey comb. Thèse cup-shaped scabs bave their concavity directed upward, and vary in size from that of a half buck-shot to that of a dime. They are straw or sulphur colored, and hâve the odor of straw, mice, cat's urine, etc. When they are removed, the skin appears more or less reddened, and hollowed out, corresponding to the under sur- face of the scabs. It is not uncommon for the hair to be loosened 234 THE AMERICAN PRACTICE OF MEDICINE. from its follicles by the fungus, and for it to come out as the scab is detached. Where the ravages of this parasite are very exten- sive, and the disease severe, the hair follicles may be altogether destroyed, and the scalp left red, smooth, and shining. It is very common among the negroes in the United States, but not of fré- quent occurence among the whites. It is very contagious, seldom, if ever, originating spontaneously, but it may be communicated from beast to man. Favus may hâve its seat in the hair follicles, or upon the skin, but is always caused by the vegetable parasite called the achorion Schonleinii, named after its discoverer Schon- lein. The affection was discovered microscopically in the year 1839, and is known by its straw-colored, cup-shaped scabs, and its contagiousness. It may be distinguished from eczéma by its hav- ing yellow scabs, while eczéma has green ones, which are cup- shaped like those of favus. Treatment.—The first thing to be done is to kill the parasite upon which the disease dépends, and with this object in view the local application of parasiticides should not be neglected. In order that local remédies may be effective, the crusts must ail be removed, and the diseased hairs ail pulled out. The application of almond oil, or of a marsh-mallow or turnip poultice, will so soften the crusts as to allow of their being very easily detached, after which the hairs may be removed by forceps. The hypo- phosphite of sodium gr. 5 to 5 1 of glycérine and water, may then be applied. Sulphurous acid in full strength, if it is not too pain- ful, or diluted, if it is too painful, will be found a very potent medicine. It should be applied, and then the part kept covered with oiled silk or a rubber cap. Chrysophanic acid, in the form of a cerate, may be applied, if there is much itching. If this should fail, a cerate of grindelia robusta will be of good service, or pyroligneous oil of Juniper may be occasionally used with good results. Lotions of carbolic acid, whieh are not too strong, are very efficient in allaying the itching. The iodide of arsenic is one of the most reliable internai remédies, and may be alternated with sulphur. Ringworm.—This is caused by the tricophyton, a microscopic ungus, which sélects for pits seat the roots of the hair, or the body, and there produces the disease known as the "ring-worm." Sometimes it attacks the beard of adult maies, and causes the disease called " barber's itch." One of its first indications is trythematous redness and itching, which is soon followed by a crop of evanescent vesicles, and thèse in turn by a copious, scaly formation. When it appears upon the scalp, the hairs covering the diseased part, gradually become very brittle and break off, or become loosened aud fail out. The skin where the hairs fail out, or break off, becomes wrinkled, and looks like goose-skiu. diseases of the scalp. 235 When it attacks the body it spreads in the ring, until it attains the size of a silver half-dollar or dollar. As the skin becomes accustomed to the fungus, which now had assumed a cellular form in the oldest part of the patch, the redness in the center gradually fades away, while the disease continues to spread to- wards the periphery, where the sprouting mycelia are the most active. This disease occasionally attacks the nails. Tinea kerion [from the Greek *r)piov a honey comb], is the name given to a form of tinea, which is the]Yesult of a more violent action ofthe tricophyton. In this form the hair follicles become very much in- flamed and exude a viscid mucus, somewhat resembling the juice of the ripe mistletoe-berry. The tricophyton, (from Opi; a hair, and furôv a plant) was discovered by Gruby in the year 1843 and in 1854, Bazin of Paris, France, more fully described it. It is composed mostly ol spores and mycelia, and has but few granules in its composition. The spores look much like minute fish roe, being very uniform in size, and the mycelia are more or less com- posed of granules and are jointed. Thèse spores are more abun- dant on the head and in the beard thau on the portions of the body which are without hair, while the mycelia are most abun- dant on the portions w7ithout hair, as the cheeks, neck, etc. Diagnosis.—Tins disease may be mistaken for seborrhœa, ec- zéma, psoriasis, favus, sycosis and acné. It may be distinguished: (1) from seborrhœa by the acute nature of the disorder, and by the absence of enlarged follicles and a greasy surface : (2) from the squamous stage of eczéma, by the abrupt marginal form of the éruption, loosening of the hair and a more rapid «ourse: (3) from psoriasis, after examination under the microscope : (4) from favus, by the absence of the characteristic crusts of the latter, and also by the différence in the character of the fungus: (5) from sy- cosis, by the loosened hairs, the peculiar characteristic tubercles and the présence of fungus: (6) from acné by its appearing gener- ally on the hairy parts, while acné almost always appears on the face and cheeks. Ringworm, to be sure, does occasionally appear on the face, but most often attacks the scalp and beard. If chloro- form be applied to the diseased part, when fungus is présent, the part turns whitish-yellow, as if there were sulphur on it. Treatment.—The first step in the treatment is to kill the parasite. This may be done by epilation, and then by the use of proper parasiticides. A solution of corrosive mercury, o-r. 1 to 2 to 5 2 of water, will kill the parasite. Sulphurous aciof will kill it and so will iodine and chrysophanic acid. Vascular Naevus.—This is a dilation of a portion of the net-work of capillary vessels of the derma and cellular tissue. This disease may also be pigmentary, as well as vascular. The pigmentary form is dark colored, and generally slightly elevated above the 236 THE AMERICAN PRACTICE OF MEDICINE. skin. It varies from the size of a pin-head to that of a silver half-dollar, and is sometimes covered with hair—called "mouse marks." Vascular nœvi are the most common variety, and are of a reddish, or rather brown color, in some cases being nearly black. They appear anywhere on the body, and may increase in size or remain stationary. Treatment.—The pigmentary nœvi may be gradually removed by apply ing a paint of collodion ; say collodion 5 1, and corrosive sub. gr. 5, repeated as often as required, at least once or twice a week. I hâve j ust removed several from the face and neck of a patient by touching each one with nitric acid once a week. Two or three applications hâve removed them nicely, and without much pain. If the nœvi are of the vascular variety, the fluid ex- tract of thuja oc. will often be sufficient to remove them. Baldness.—Simple alopecia consists in the loss of the hair in certain portions of the scalp, or over the larger portion of the head. It is frequently a symptom of some other disease, espe- cially that of disease of the head and appears in the form of va- riously sized, white bald patches. It usually sets in first on the scalp, but sometimes in the beard. In rare cases it affects the whole body but this does not happen often. It usually attacks young people, and mostly on one side of the scalp first. Alopecia commences with nickel-sized, round areas devoid of hair. Thèse spots spread more or less rapidly, and other spots soon appear elsewhere, very frequently spreading over one side of the head. The hairs do not break off as in tinea tricophytina, but generally fail outby the roots, and leave a smooth, polished surface. Very fine down frequently appears on the denuded part, but generally soon vanishes. This disease may run on thus for years. It is now believed to be of a parasitic variety, originating from reg- ular spores, formed in either complète or incomplète rings. Treatment.—As the disease is a parasitical one, the treatment, must be commenced by the use of such remédies as will destroy the insect. At the same time epilation may be resorted to (with broad lipped forceps), upon the margin hairs. Locally, acetie acid, tincture of cantharides, or tincture of iodine may be applied. If thèse remédies do not seem to arrest the disease in two or three weeks, equal parts of glycérine and tincture of capsicum may be applied to the diseased part ; and if thèse should fail, a weak lotion of tincture of phosphorus may be tried. The oleate of mercury has strong, curative powers, say iodide of mercury gr. 16, simple cerate g l. I apply it lightly over the diseased sur- face, once or twice a week, for there is no danger in using this préparation, especially if about 5 2 of iodide of potassium be added. One of the best internai remédies we hâve is phosphorus in doses of gtt. 10, three times a day. The sulphide of calcium is DISEASES OF THE SCALP. 237 also a very efficient medicine in doses of gr. 1, three times a day. The testa prœparata (the white substance just beneath the inner layer of oyster shells), in doses of gr. 2 to 3 three times a day, is also worthy of at least a trial. CHAPTER XXII. DISEASES OF THE HEAD AND BRAIN. Anaemia.—Anaemia of the brain, upon inspection, shows the grayish substance of the brain paler, or nearly white, and the white substance of the brain, milk white and glistening. When the brain is eut open, fewer clots of blood are found, than exist in the normal, healthy brain. The blood vessels of the membranes are found empty, and sometimes, an increased quantity of sérum has been found between the subarachnoidal spaces within theskull. Causes.—Thèse are, ail hœmorrhages, loss of vital fluids by diar- rhœa, summer eomplaint of children, long spells of fevers, hepati- zation of the lungs, starvation, and anything that exhausts the vital fluid. Congestion of the blood in other organs gives rise to it by withdrawing the blood from the brain, and compression of the carotid or vertébral arteries, either by ligation, tumors, or emboli, prevents the flow of blood to the brain. Spasmodic con- traction of thèse vessels, from émotions of the mind or otherwise, may also cause anœmia ; and so may dépressions of the skull, ex- travasations, exudations, tumors, etc. Heart and lung diseases may prevent the normal oxygénation of the blood in the lungs. Symptoms.—The symptoms of this condition of the brain differ somewhat in accordance with the cause. If it be from violent depletion, there will be suddeu paleness of the face, cold perspira- tion of the forehead, gaping, slow respiration, dimness and flick- ering before the eyes, nausea and vomiting, faintness, and in some cases epileptiform convulsions. Where anœmia is gradually developed, the symptoms differ in each individual case, although ail are attended by paleness of the face. There is apt to be either mental torpor, drowsiness, delirium, coma, sleeplessness, restless- ness, or nervousness. Occasionally there is only vertigo and head- ache. Ringing in the ears commonly exists, and specks float be- fore the eyes, accompanied with dimness of sight. Great weak- ness of the entire muscular system prevails in most cases, and some- times, temporary paralysis, or epileptiform convulsions. Anaemia, conséquent upon summer eomplaint, was called "hydrocephaloid" by Marshall Hall,on account of the similarity of the two conditions. Anœmia may assume either the irritable, or the torpid form. If it assume the former, the child will be restless, start and cry out suddenly in his sleep, and grate his teeth. The face, too, becomes red, the puise fréquent, the skin hot, and spasms may occur ; hence, the resemblance to acute hydrocephalus. In the second [238] DISEASES OF THE HEAD AND BRAIN. 239 stage, collapse takes place, and the child becomes apathetic, and does not look at objects. The eyelids, are also closed, (the pupils failing to react against the light), the respiration becomes very ir- regular, the puise grows fréquent and small, the body gradually grows cold, and, in fatal cases, the patient may die with the symptoms of coma. Treatment.—As a stimulating tonic to the brain and spinal sheath, there is no remedy superior to nux vomica or strychnia. Nux vomica (tincture), may be taken in doses of gtt. 5, every three hours, in alternation with moderate doses ot Horsford's Acid Phosphate. If there is dizziness and vertigo, which is worse in the evening, the carb. of barium may be ordered in doses of gr. 1 of the 3d trituration, thrice daily. If the disease is from the loss of vital fluids, I give the tincture, or fluid extract of cinchona bark, in doses of gtt. 25 to 30, three times a day, and alternate it with phosphate of iron. Staphisagria may bé taken in the form of a tincture, in doses of gtt. 1 to 2, three times a day, with good effect. If there is delirium, after great loss of blood, arsenic acts well, in doses of gtt. 1 to 2 of the saturated tincture, every three or four hours. 1 use it alternated with the tincture of ignatia amara, in doses of gtt. 5, every three hours. If there are convul- sions, conséquent upon the loss of blood, I order belladonna, in doses of gtt. 4 to 5, every four hours, alternated with the tincture of pulsatilla, in doses of gtt. 3 to 5. If this mixture does not give relief in twelve hours, I try ignatia amara, in doses of gtt. 5, al- ternated with conium, in doses of gtt. 1 to 2, every three hours. If there is gênerai anaemia connected with this state ofthe brain, the patient should hâve a diet rich in blood producing qualifies, such as wine, mutton chops and beef essence in small quantity. Ile should be kept quiet, and must stayjin a reclining position until out of danger. Hyperaemia.—This disease consists in an over supply of blood to the brain. It may resuit from active congestion, from rush of blood to the brain, or from stagnation of blood in the cérébral substance, owing to passive hyperaemia of the brain. In post- mortem examinations a large quantity of blood is usually found in the vessels and sinuses, especially in the lower part of the cranium, The gray substance of the brain appears swollen and darker than usual, and the white substance generally présents a reddish color. The subarachuoidal meshes contain no fluid. In chronic cases the blood vessels are generally dilated, the substance of the brain it- self is often found atrophied, and the subarachnoidal spaces are filled with fluid, especially in cases of old topers. In some cases however, the above conditions of the brain do not prevail ; the vessels being found empty of blood, although during life there were symptoms of hyperœmia. This fact is quite diflicult to ac- 240 THE AMERICAN PRACTICE OF MEDICINE. count for, and proves conclusively that the dead body does not al- ways reveal clearly what was going on in the living organs. When the brain is atrophied, there is in addition to hyperaemia an in- crease of cerebro-spinal fluid. Congestion.—This condition may take place in conséquence of an undue activity of the serous membranes, which, berna* around the brain, act (upon the principle of suction) within the cranium. This is doubtless the state of affairs that gives rise to what is called " a rush of blood to the head." Congestion may be the re- suit of a déficient flow of blood to other portions of the body, in which case there is an increased flow towards the brain and its membranes. It is also caused by compression of the common aorta abdominalis by tumors, effusions or enlarged abdominal viseera, by contraction of the capillaries of the skin during a chill, by suppres- sion of menses and by severe hœmorrhoidal discharges. Cono-es- tion may also arise from dilitation of the capillaries within the brain, either from the excessive use of opium and alcoholic drinks, from too free use of other narcotics, exposure to the sun, continued irritation of the brain by severe mental émotion, or from lono- con- tinued mental labor. The trouble may also resuit from paralysis of the vaso-moto nerves, whereby the normal tone of the walls of the capillary vessels is altered, and they dilate and give vent to an abuormal amount of blood. This is often the cause of thèse Budden deaths that follow violent mental émotions, fright, grief, ecstatic joy, etc. Stagnation or hyperaemia by stasis may arise from compression of the jugular veins, by pressure, goitre, gland- ular tumors on the neck, or by an aneurism of the aorta pressing upon the vena cava. Deep and rapid inspirations with forced ex- pirations, such as take place in severe fits of coughing, straining and blowing wind instruments, may give rise to this affection where there is prédisposition. Disease of the heart (especially tri- cuspid insufficiency), stenosis of the venous orifice, and insufficiency of the heart's valves may also bring about congestion. Croup, œdema of the glottis, emphysema, extensive pneumonia, pleuritic exudations and cirrhosis may ail be followed by this disease with more or less frequency. Symptoms.—Excitability, dépression, headache, sensitiveness to light, noise or touch, flickering before the eyes, ringing in the ears, formication or tenderness of the flesh, great restlessness, grat- ing of the teeth, convulsions, dizziness, hallucinations, vivid or frightful dreams, and morbid vigilance, ail indicate this disease. From dépression there may be insensibility to light and noise, numbness of the limbs, dilated pupils, rapid puise, slow respiration and nausea. Some of thèse symptoms may be wanting, and there may be others which I hâve not named. Treatment.—If there isa rush of blood to the brain, or delirium, DISEASES OF THE HEAD AND BRAIN. 241 aconite acts well in doses of gtt. 1 every hour, alternated with gtt. 2 or 3 of tincture of belladonna. If, however, the patient craves death and complains of heat, noise in the head, and sparks before the eyes, gr. 1-50 of chloride of gold should be taken every three hours. If it occur in children during dentition, gtt. 3 to 5 of gel- seminum may be given every three or four hours. If there be loss of sight or hearing, convulsive movements of the muscles of the head and face, wild, stupid expression, with delirium and sleep- lessness, gtt. 4to 5 of the tincture of stramonium should be admin- istered every three hours until thèse symptoms subside. In some cases that I hâve had in females, where there were hystéries and where it occurred about the menstrual period, the inhalation of gtt. 5 or 6 of nitrite of amyl has given very ready relief to the hyperaemia. If this affection be caused by mental émotions, igna- tia amara should be ordered in doses of gtt. 3 to 5, every four hours. If hyperaemia is easily provoked by exercise, tincture of phosphorous may be given in doses of gtt. 1 to 2, well diluted in water, every two or three hours. If it occurs in females from sup- pression of the menses, small doses of iron act admirably, alterna- ted with gtt. 5 or 6 of pulsatilla (tinct.), every two hours. If it resuit from hypertrophy of the left side of the heart, I hâve found the tincture of cereus grandiflorus to give immédiate relief in doses of gtt. 15. Collinsonia, in doses of gtt. 20, should alternate the above. Vertigo.—This may originate in its milder forms from indi- gestion, or from nervous exhaustion, but if it appears in a more aggravated type, it points to disease of the brain, kidneys, liver, or heart. It is often associated with structural lésions of the brain, and often exists with hyperœmia or anœmia of this organ. It may be of rather an epileptic or psychical character, and oc- curs under varied conditions: while quiet, or during motion, on rising or upon stooping, on suddenly turning [the head, during sleep, while reclining, from bright and dazzling light, from swift motion, as in riding in the cars, from witnessing a surgical opéra- tion, or from seeing blood flowing. It may also arise from look- ing up or down great heights. It is generally prévalent among adults. Treatment.—If vertigo occurs from dilatation of the right ven- tricle, from emphysema, or during pregnancy, and is accompanied with pale, puffed lips and face, gtt. 3 or 4 ofthe tincture of arsenic will aid in relieving it ; and if there is also headache, I order gtt. 5 of tincture of belladonna every four hours. If indigestion is the cause, gtt. 5 of nux vomica gives good results, used three times a day, and alternated with gtt. 2 of nitrate of iron. Insomnia.—If insomnia is attended with vertigo, fever, dry skin, restlessness, and pain in the head or teeth, aconite should be 16 242 THE AMERICAN PRACTICE OF MEDICINE. given, in doses of gtt. \ to 1, (according to the âge of the patient), every hour, until thèse symptoms pass off, and the patient becomes quiet. If he or she be drowsy, and yet unable to sleep, and the pupils are dilated, gtt. 1 to 2 of tincture of belladonna should be taken, and repeated in three hours, if it fails to give relief. If there is a wild expression of the face and eyes, sleeplessness and wild, raving delirium, I prescribe gtt. 2 to 3 of the tinct. of stra- monium. or hyoscyamus, repeated every three or four hours, until thèse sy7mptoms disappear. If this condition follow loss of blood, the fluid extract of Peruvian bark is invaluable, given (in doses to suit the âge of the patient), as a tonic to the appropriative organs, three times a day, alternated with the nitrate of iron. If insomnia occurs in adults, from mental strain, or from the use of tobacco, opium or liquor, gtt. 5 or 6 ofthe tincture of nux vomica, three times a day, is the proper remedy, alternated with the phosphate of iron. Tubercular Meningitis.—This disease generally occurs in scrofulous children, but persons of ail âges are subject to it. The chief morbid indication consists in the déposition of tubercular material between the membranes of the brain. It often occurs ni families, a member or members of which hâve died with scrofula or consumption. Symptoms.—When meningitis appears in children there will be more or less fever, with quick and irregular puise, vomiting, con- stipation of the bowels, clay colored stools, red tongue, and con- tinuous heat of the whole body. There is always great irritahility, disturbed sleep, grinding of the teeth, pain in the head with in- tolérance of light and noise. Severe vertigo, when the patient stands erect, and great debility soon set in. Delirium is very often attendant upon this disease, and if is not présent the patient is greatly distressed, very often cries out suddenly, and sometimes is so drowsy, that it is difficult to keep him or her awake long at a time. The disease most generally has its seat in the pia mater, the milary granulations being found in the immédiate neighbor- hood of the vessels of the brain, either in the convexity or the base ofthatorgan. In post-mortem examinations, yellow, cloudy, patches hâve very frequently been seen along the vessels; the ventricles also being dilated and containing hydrocéphalie effusion, The quantity of fluid varies greatly in each case, and in soine in- deed, there may be none at ail. Occasionally white softening ol a portion of the fornix and the corpus callosum has been seen, and again in other cases, there is no softening of any part. Miliary tubercles are often found in almost ail parts of the body. This disease doubtless dépends upon a scrofulous constitution, which has a tendency to bring on inflammatory exudations, which lead to cheesy degeneration. DISEASES OF THE HEAD AND BRAIN. 243 In adults there may be mère indisposition at first, short napa full of dreams, starting in the sleep, loss of appetite, constipation of the bowels, fever towards evening, and headache and vertigo. Then follows meningitis, with facial paralysis, vomiting and de- lirium. In some cases, however, the symptoms come on more oradually, and instead of delirium, there will be headache, vertigo, great sensitiveness to noise aud light, vomiting (especially when moved about), and either constipation or diarrhœa. There may be either gênerai or partial convulsions at this stage of the disease. Paralysis of the face, eyelids, or muscles ofthe bail may set in, and the pupilmay be dilated. The patient cries out suddenly in some cases, and convulsive movements take place, which often distort the face and eyes. There may also be squinting or winking of the eyelids, and chewing or grinding of the teeth. One or another ofthe extremities may become paralyzed, and convulsions of the oppo- site one. may appear. The muscles of the tongue and those of déglutition may become paralyzed, and very often the puise fails down to about 60 per minute, and the température to about 100° F. Diagnosis.—It is quite diflicult to distinguish this affection from simple meningitis. If the patient has any tendency to tuber- culosis, we may then conclude that his disease is tubercular meningitis. The prognosis is always bad. Treatment.—Where there is fever, and a quick, small puise, gtt. | to 1 or 2 of aconite (according to âge), may be given every one or two hours, as the fever may be more or less severe. If the pupils are dilated, and there is headache, vertigo or delirium, bel- ladonna should be taken, in doses of gtt. 1 to 5, according to the âge of the patient, until thèse brain symptoms disappear. If there is merely drowsiness and stupor, hyoscyamus, in doses of gtt. 3 to 5, may be prescribed every two or three hours, until relief is given. If there is évidence of effusion upon the brain, gtt. 3 or 4 of bryonia alba may be taken every three hours, alternated with small doses of tincture of helleborus niger, in doses of gtt. 10, four times a day. Should the above not act well on the kidneys, apocynum canuabinum should be tried, in doses of gtt. 15 to 20, every three hours, with gtt. 10 to 12 of digitalis to each dose. I hâve always found thèse last to act well in hydrocephalus. After the effusion is removed, to complète the cure, if such be possible, I give arsenic, in doses of gtt. 2 to 3 of the saturated tincture, three times a day7. Iron may alternate with the arsenic, if there be anaemia. Acute Meningitis.—This disease is considered to be an inflam- matory affection of the pia mater. Upon post-mortem examina- tion, this membrane is generally unchanged, although in some cases it has been found to be anœmic, and in others to contain the usual amount of blood. Usually, the cortex and white substance 244 THE AMERICAN PRACTICE OF MEDICINE. of the brain are more or less compressed, and appear dry and firm the ventricles, perhaps, being dilated, on account of the effusion but the surrounding brain tissue not being so extensively softened as in tubercular meningitis. The choroid plexus shows greater hyperaemia than the superficial portions ofthe pia mater, but there is seldom any exudation at the base ofthe brain. The hyperœmic or inflammatory nature of this disease cannot be accurately deter- mined by the anatomical évidences as presented upon post-mortem examination. Causes.—The exciting causes are dentition, eruptive fevers, acute pulmonary affections, and concussion of the brain from wounds. It affects children from one to five or six years of ace, but rarely later than that. Symptoms.—The symptoms are so nearly like those of tuber- cular meningitis that it is hard to distinguish one from the other. If, however, there is an hereditary tendency to scrofula, we may conclude that it is tubercular meningitis, and not simple acute hydrocephalus. In many cases, there are certain proclromic symptoms, such as an inability to swallow, very dry skin while the head is moist, and frequently paralysis of the face and extremi- ties, although this last symptom is not as common in this form as in tubercular meningitis. Besides this form of meningitis, there may be also simple meningitis of the base ofthe brain. In this last form, there is often a formation of quite dense, hard strips of con- neetive tissue, and in the more active forms of inflammation, there may be fibro-purulent infiltration into the tissue ofthe pia mater at the base of the brain. Where hydrocephalus is associated with this form of the disease, it is apt to be very profuse and hard to remove. Hydrocephalus generally prevails between the âges of sixteen and thirty years, and may last from thirty to sixty, or even seventy days. Symptoms.—This form of meningitis usually commences with a chill, which is followed by more or less fever, thirst, sweat, loss of appetite, and severe headache. The fever may be rather paroxysmal, that is the température may run up as high as 104° F., in the evening, and fail, in the morning, to the normal state. In many cases, however, the fever continues high ail the time, while in others, the température, at times, fails very low. There is much irregularity, also, in the condition of the mental facul- ties. There may be periods of entire consciousness, and then again attacks of wild delirium. There may be paralysis, contractions and spasms, alternating one another. Thèse motor disturbances, however, are entirely wanting in some cases, and death may take place during coma. Thèse indications distinguish this form of meningitis from ail others. Again, hydrocephalus occurs in con- stitutions where there is no hereditary tendency to scrofula or DISEASES OF THE HEAD AND BRAIN. 245 tuberculosis ; and it will also be remarked, that paralysis occurs much later than in tubercular meningitis. It may be distinguished from typhoid fever by the absence of enlargement of the spleen, which occurs in typhoid fever. It differs from cerebro-spinal meningitis, in not having the épidémie character of that disease. The prognosis is generally not favorable. Treatment.—If the children are emaciated, and hâve large fontanels, and green or slimy stools, the phosphate of the hypo- phosphite of potassium may be ordered, in doses of gr. £ to 1, three times a day. In the first stage of fébrile excitement, aconite should be given, in doses of gtt. £ to \ (according to âge), every two or three hours, until the fever subsides. The effusion should be removed by the diuretic effects of apis mel. and apocynum cannab., in doses to suit the âge of the patient. If there is wild delirium, hyoscyamus, or stramonium may be taken, ter die, in doses of gtt. 1 to 2. Sometimes when other diuretics hâve failed to act well, I hâve had signal success with small doses of tincture of digitalis (say gtt. 2 to 10, according to âge), given in an infusion of pipsissewa. At other times, I hâve found digitalis to act well upon the kidneys, alternated with the tincture of apocynum can- nabinum. I hâve had some cases, that after the inflammatory symptoms were subdued, needed small doses of iodine to prevent a return of the effusion. The tincture of sponge also acts well under similiar circumstances. Bryonia alternated with belladonna niger, sometimes has a good effect, especially where the liver is torpid, and the bowels constipated. If there is coldness of the extremities, while the head is hot, twitching of the muscles of the limbs, a bluish appearance of the tongue and mucous membrane of the mouth, and convulsive movements of the tongue, I use the acétate of copper, in small doses. If, after the active symptoms hâve subsided, there is still pain in the head, vomiting, etc., small doses of phosphide of zinc should be taken, say gr. 1-20, thrice daily. Cerebro-Spinal Meningitis.—This consists of an acute inflammation, of the pia mater of the brain, and spinal cord, giving rise to an exudation of purulent matter. It generally occurs about the base of the cerebrum, the pons, the optic nerves, the medulla oblongata, the spinal cord, and especially about the dorsal and lumbar vertebrae. Fot only is it not uncommon to find the substance of the brain congested with punctiform hœmorrhage and small spots of soften- ing, but in some cases, where the disease has existed long, the substance of the brain is found juicy and œdematous, presenting a watery appearance on section. "In some rare cases," says von Ziemssen, " the substance of the brain is found to be tough in consistency." This disease has been described under différent 246 THE AMERICAN PRACTICE OF MEDICINE. heads, such as brain fever, pernicious fever, malignant typhus, exanthematic typhus, spotted fever, etc. It has prevailed in France, Italy, Spain, Ireland, Germany, and in various parts of the United States and North America. I hâve passed through two épidémies of it in Georgia. The young are more liable to it than the old, and maies more so than females. The first invasion of it that I remember to bave read of was that which prevailed in Geneva, in the year 1805. It is now believed to be an infec- tious disease, but writers that I hâve consulted seem to be igno- rant of the nature of the germ. It most commonly appears either in winter or spring, and more frequently when there hâve been great rain-falls and sudden changes in the atmosphère. It is be- lieved to attack most fiercely families who are poorly fed and who are living in damp and badly ventilated bouses, built upon the ground. It may prevail in the most healthy régions, however, as an épidémie. Symptoms.—Meningitis of this type almost always sets in sud- denly, commencing with a severe and generally protracted chill, which is followed by a high fever, violent vomiting, headache and prostration. The pain may be in the front or back part of the head. The température is not always the same, varying from 100° F. to 104° F., and sometimes, indeed, there may be intervais of normal température. The puise may be rapid and small, or it may not even correspond to the height of the température, vary- ing thirty beats in a few hours. In severe cases there may be coma or delirium, but generally there is only somnolence. Some- times there are convulsions, stiffness of the neck, and finally tonic contractions of the extensor muscles of the spinal column. Or- thotonos is quite common ; episthotonos not quite as usual, and pleurothonos is rarer still. In some few instances the neck is not affected, but there is itching, aching of the limbs and spine, and such sensitiveness of the skin that motion and touch cause pain. Occasionally there may be erythema, roseola, urticaria and pete- chiœ. In most cases, there are apt to be ecchymosed spots on the limbs and breast, which occur about the second day. They differ in size from that of a pin's head to that of a silver dollar. About the third or fourth day, the tongue becomes dry, and cracked in places, or still remains moist and heavily coated. The bowels are either constipated or too loose. In severe cases there may be such profound coma or delirium that the fœees and urine pass off involuntarily. Convulsions frequently take place, deep coma and death closing the scène. If the case is about to terminate favor- ably, the headache and pains in the limbs and spine gradually lessen, and convalescence takes place about the second week. The disease does not last long in severe cases, sometimes termina- ting fatally in from twelve to twenty-four hours. DISEASES OF THE HEAD AND BRAIN. 247 Sequel^.—Injury of sight and hearing, chronic hydrocephalus, chronic meningitis, imbecility of mind, and paralysis, may ail, under certain conditions, follow this disease. Diagnosis.—Meningitis is somewhat diflicult to diagnose, es- pecially when it occurs with pneumonia. It differs from tuber- culous meningitis in the suddenuess of the attack, the irregularity of the puise and the température. It is distinguished from typhoid fever by the différence in the éruptions. Treatment.—The Jever in this disease demands aconite, which should commence the treatment, in doses of gtt. 1 to 2, given every hour until the circulation is regulated. After this is effected,it should be continued in drop doses, every two hours. The headache calls for belladonna, which may be taken in doses of gtt. 5, once in three or four hours, until the pain in the head is relieved. If the pain in the spine is also relieved by it, it may be discontinued for a time, until the symptoms return or until delirium occurs. If there is severe pain in the back part of the head, with vertigo, paralysis of the lower extremities, convulsions, emprosthotonos, stupor, and feeble and irregular puise, gtt. 3 to 5 of cannabis indica. may be given every two hours. If this drug fails to give relief to the paralysis, gtt. 5 of tincture, or fluid ex. of gelsemi- num may be given every three or four hours, until it subdues thèse symptoms. At the same time, I hâve always found strong counter-irritation (produced by turpentine), ail along the spine, a good auxiliary Sunstroke.—Prof. H. C. Wood, of Philadelphia, says this disease is the resuit of paralysis of the vaso-motor nerves, or of some controlling centre of the brain, which influences the produc- tion of heat in the body. Some writers believe that it is from an imperfect decarbonization of the blood, while others think that it arises from hyperaemia of the pia mater, and other portions of the brain. Arnt says it is a diffuse encephalitis, but there are others who déclare that it is caused by venous hyperaemia, due to a di- minished activity of the heart's action. Thèse are ail conjectures, however. Causes.—Ail writers agrée, however, that this affection is caused by the influence of intense heat, and not from mère expo- sure to the sun's rays, as first alleged. Patuology.—Post-mortem investigations hâve not thrown much light upon the real pathology of sunstroke. Prof. H. C. Wood, in his paper on " Thermie Fever," written in 1872, states that " the right heart and pulmonary arteries, with their branches, are engorged with dark fluid blood. There is also venous con- gestion of the luugs and entire body. The heart, especially the left ventricle, is rigidly contracted in every case, a condition caused by coagulation of the myosin." It is uncertain however, 248 THE AMERICAN PRACTICE OF MEDICINE. whether the above conditions are really post-mortem, or ante mor- tem phenomena. Sunstroke seems to attack the unacclimated in préférence to the old résidents of a locality. The want of pure water also seems to give rise to the disease, and so does the use of spirituous liquors, fatigue, debility, bad ventilation and dépres- sion. Symptoms.—One of the first premonitory indications of the approach of " sunstroke," is an inelasticity of the muscles, gênerai indisposition, debility, thirst and loss of appetite. There may also be dizziness or headache, and the chest may feel oppressed, breathing be fréquent and strong, the throat be dry, and swallow- ing be painful. The voice too is apt to be more or less changed, becoming hoarse and weak. Much anxiety and restlessness of mind exists, the extremities grow numb, the patient becomes drowsy and restless, and there is often vertigo or bleeding from the nose, paleness of the face with redness of the conjunctiva, and very often notable weakness in the knees. Sometimes there is nausea, vomiting, cold perspiration, and sudden diarrhœa. The mind also becomes clouded and confused. After thèse symptoms appear, if nothing is done to ward off the attack, the " stroke " will speedily follow. The patient fails down, as if from a blow upon the head, with entire loss of sensibility and consciousness. Subsultus tendium, partial spasms, violent convulsions, or paraly- sis of the spinal cord now set in, so that the limbs lie motionless. The face may at first be pale, but it soon becomes flushed, suffused and sometimes cyanosed, finally assuming a dull leaden color. The respiration may be oppressed, slow, sighing, rapid, deep, rather diflicult, and very often stertorous. The puise soon be- comes feeble and very quick, finally becoming irregular, intermit- tent, small and thready. The premonitory symptoms, and the intense heat of the season distinguish this disease from apoplexy. The latter may occur in hot weather, but it does not show the above well marked prodrome. Sunstroke is not necessarily fatal, but often leaves very unpleasant effects, Treatment. —If the patient can hâve attention when he feels the above depressed symptoms, the disease may generally be averted, by the use of moderate doses of gelseminum. This drug should be administered in doses of gtt. 20 to 25 (of the saturated tincture of the green bark, or the root), every two hours, until the patient is relieved, which may be with the first or the second dose. Gtt. 10 may then be taken every7 two hours, to prevent a re- turn of the morbid symptoms. If the patient has already fallen, and has lost consciousness,* glonoine (nitro glycérine) acts well, in doses of gtt. 1 to | of the first cent, dilution in water, repeated *See Author's New Remédies. DISEASES OF THE HEAD AND BRAIN. 249 every two or thrae hours, if the first dose fails to relieve the symptoms. If there is still consciousness, but dizziness, redness of the face, and dilated pupils, gtt. 2 to 3 of belladonna may be taken every three hours, until the patient is decidedly better. ^ If noue of the above remédies seem to relieve the head, the patient should inhale gtt. 5 of nitrite of amyl, every half hour, until he is well relaxed, and then belladonna will relieve. Apoplexy.—This disease is characterized by a sudden loss of consciousness due to intra-cerebral haemorrhage and the pressure of clots of blood upon the brain. Thèse clots of extravasated blood are sometimes as large as an apple, and sometimes not larger than a marble. They may be round or spread out in layers, and there may be one or several of them. Varieties.—An overloaded condition ofthe vessels ofthe brain gives rise to that variety of apoplexy which is appropriately called congestive apoplexy. Hœmorrhagic or sanguineous apoplexy, however, is the most fréquent iu occurrence. This form consists in the rupture of a vessel, from which the blood becomes extrava- sated upon the brain or in its substance, pressing upon the nervous masses. It comes without warning in most cases. The patient is generally suddenly struck down, devoid of ail consciousness or voluntary motion. This is called primary apoplexy. Sometimes there may be prémonitions, such as headache, giddiness, fulness and throbbing of the arteries of the head, bleeding from the nose, dimness of sight, contraction or dilatation of the pupil, noises in the ear or dealhess, flashes, mist, etc., before the eyes, vomiting, numbness or tingling of feet or hands, unsteady movements of the limbs, and partial paralysis in the muscles of the face, or of the limbs. The patient fails into a comatose state in some instances, and in others only becomes drowsy, and finally coma- tose. This is called ingravesncet apoplexy, because the symptoms gradually grow worse. It is a far more serious type than the primary form, because we hère bave évidence that the cause of the symptoms are still in opération, and that the case is hœmorr- hagic in its origin. Moreover, the brain has undergone organic and permanent pathological changes. A primary case may be of the congestive variety, which may be finally relieved without leaving any injury, Symptoms.—Some of the first indications of approaching apo- plexy are headache, giddiness, faintness, sickness at the stomach, oppressed puise, with reaction following. In the early stage of an ingravescent case, before the patient becomes comatose, there is generally very great dépression in the circulation from the shock to the nervous system. The surface also is cold, pale, and clammy, and the puise fréquent, small and weak. As coma comes on, the puise grows full, slow and labored, and the surface becomes 250 THE AMERICAN PRACTICE OF MEDICINE. warm, (beiug sometimes warmer than normal,) and rather moist ; the countenanee has a peculiar, bloated appearance, and is often rather congested ; the pupils are insensible to light, and in many eases, largely dilated, (or one dilated and the other contracted) ; the respiration is labored and often stertorous from paralysis of the soft palate ; the bladder becomes inactive ; the urine is retained; and the bowels are sluggish, and apt to be constipated. Several of the above symptoms may occur as the resuit of dyspepsia or indigestion. Vomiting and headache are more important, as indi- cations, when they comédon suddenly without any obvious cause, and not on first rising in the morning. The vomiting may be continued beyond empty ing of the stomach ; and if thèse symp- toms are associated with degeneration of the arteries, and albu- minuria, we may reasonably infer that there is a clôt of blood, large or small, in the brain. Prédisposition.—Men or women who hâve very large heads, large, broad necks, very broad shoulders, a well developed muscu- lar system, (with which is associated very large cérébral arteries,) great heart power, and, of course, a vigorous circulation, (which drives the blood with force to every part of the system, but especially to the brain,) are very liable to apoplexy. Now, if the lungs become impaired or feeble in their functional activity, so that the blood is imperfeetly oxygenated, congestion may resuit, and a tendency of the vessels of the brain âto rupture. A little intempérance, either in eating or drinking, uncontrolled passions, excessive sexual indulgence, close mental labor, or anything that favors cérébral congestion, will develop apoplexy. Diseases of the heart or kidneys also favor the development of this disease. Apoplexy occurs most commonly after the fortieth year; rarely in early life. Cérébral haemorrhage sometimes proves fatal, but it does not always kill instantly. Ihave seen some men live seve- ral years with this disease, and others die in the first attack. Causes.—The direct cause of apoplexy is disease of the coats of the blood vessels, hence, the increasing tendency to the disease iu advanced years. As old âge comes on there is a graduai tendency to degeneration or ossification of the arteries and atténuation of the veins. This degeneration of the arteries, or their ossification renders them inelastic, and as the blood is forced through them by a strong heart, they give w7ay, and apoplexy is the natural re- suit. It is true that an aneurism, involving an artery of the brain, may rupture and produce apoplexy in those who are not constitutionally predisposed to the disease. Unsouudness of the body generally may be a predisposing cause of apoplexy. Grarui lar disease of the kidneys and hypertrophy of the left ventricle of the heai t may also prédispose to this disease. Diagnosis.—Apoplexy is distinguished from epilepsy by the DISEASES OF THE HEAD AND BRAIN. 251 latter's beginning with a scream, and being always attended with convulsions, and frothing at the mouth which symptoms do not occur in apoplexy. To distinguish it from poisoning with opium and alcohol, the history of the patient's previous habits must be known. The odor of the breath will détermine whether or not he has been imbibing alchoholic liquors The pupils should be exarained to see if they are contracted as in opium poisoning. Treatment.—Where there is a full, strong and quick puise, dry, hot skin, aconite is indicated, aud should be given in small doses, until a decided impression is made upon the circulation. I give of aconite, gtt. 20 ; aqua para, S 4 ; dose, a teaspoonful every hour. This remedy is far better than venesection and is not attended by danger. If the face is red and swollen, and there is strong throbbing' of the carotids, convulsive movements of the muscles of the face or limbs, dilatation of the pupil loss of speech, suppresion or involuntary discharge of urine, gtt. 3 to 5 of belladonna, every three hours, should be given until thèse symptoms are relieved. If there is a tendency to a calcareous degeneration of the coats of the arteries, phosphorus is needed. It may be given in doses of gtt. 2 to 3, largely diluted with water, or 5 1 may be added to l 4 of water; dose, 5 1, ter die. Thrombosis : Embolism.—Thrombosis may be produced by the formation of a clôt of blood at the spot where occlusion exists, but embolism is caused by a clôt or mass, which is formed in the heart and carried along by the stream of blood until the artery become so small that it cannot proceed any further. Emboli may consist of clots of blood, masses of fibriu, conneetive tissue growths, or chalky formations, which originate from endocarditis, aneurisms of the aorta, &c. Thrombosis owes its origin to some structural changes in the vascular walls themselves, such as in- flammation, fatty degeneration, and ossification or calcification of the arteries, by which the speedof thecurrent may beso slackened that the blood is finally blocked up. The left carotid artery is much oftener obstructed than the right. Sometimes several ar- teries are blocked up at the same time. Whenever the embolus is lodged in a terminal artery of the basai brain system, or is car- ried beyond the circleof Willis, it first causes red softening of ad- jacent, brain tissue. Finally the red color fades into yellow, i. e., yellow softening of the brain, and if the patient should live a few months, this affected tissue is converted into a semi-ffuid milky mass, which is called white softening, and which may be absorbed, leaving a cyst filled with a thin fluid. Predisposing Causes.—Rheumatism is one of the prime causes of embolism, but thrombosis has its predisposing cause in a mor- bid condition of the vascular system, and is mostly met with in the aged. 252 THE AMERICAN PRACTICE OF MEDICINE. Symptoms.—Embolism resembles an apoplectic attack, without prémonition. lu some cases there is no coma or loss of conscious- ness, but there may be delirium, aphasia, paralysis and vomiting, ail of which may soon pass off. Thrombosis may come ou slowly, with dizziness, headache and a gênerai confusion of mind, loss of memory, numbness, coldness, and a creeping sensation in one side, or ail over the body. Sometimes there are convulsive movements in some part of the body. There may be symptoms resembling an apoplectic fit. Occasionally there is no loss of consciousness. This condition may terminate in death, or the patient may recover. Diagnosis.—It is quite diflicult to diagnose between embolism and hœmorrhage, unless we notice the predisposing causes, such as valvular disease of the heart, and diseases of the lungs. It is im- possible to distinguish between thrombosis" and hœmorrhage of the brain, except that thrombosis is not so fréquent. Treatment.—Whenever this condition shows inflammation, belladonna, in small doses, will always do good service. If it be due to an atheromatous condition of the arteries, phosphorus or phosphoric acid (llorsford's Acid Phosphate,) may be given, in small doses. If there is hemiplegia, nux vomica, in doses of gtt. 1 to 2, every three hours, will be useful ; but large doses do more harm than good, by increasing the force of the cérébral circulation. If there is vertigo, iodine may be used with good effect. If there be sleeplessness, moderate doses of tincture of hyoscyamus, say gtt. 10 to 15, every three or four hours, will produce refreshing sleep. Cocculus indicus, in small doses, say gtt. 3 to 5, may also be given with good effect. If there are convulsions, belladonna, in doses of gtt. 5, may be given every three hours, alternated with gtt. 15 to 20 of gelseminum. Aphasia.—Under this head fail a variety of deficiencies of speech. When the patient understands what is said to him, and can express himself in writing, but is unable to make himself in telligible by means of words, (the organs of speech being in perfect order), his disease is called ataxic aphasia. This consists in an in- terruption between the idea and the organs of speech. Sometimes the aphasia does not amount to entire speechlessness, and the patient may be able to utter some words of one syllable, or it may be that he can only utter a few senseless syllables and words. Ataxic aphasia is occasionally complicated with agraphia—an in- ability to join either a letter or a combination of letters into intelli- gible words, although the hands may be able to perform other mechanical movements. Amnésie aphasia is an incapaeity for re- cpllecting words, although the idea is présent and the patient can artieulate. This form is due to an interruption between the idea and the word, the verbal expression being wanting. Treatment.—Loss of memory for words and the power of ar- DISEASES OF THE HEAD AND BRAIN. 253 ticulation bave been cured with gtt. 1 to 2 of the lst cent, dilution of *glonoine (nitro-glycerine) taken every two or three hours, un- til it gives relief. Bromide of potassium in very small doses, is also valuable in some cases of congestion, and stramonium has often proven very successful in cases where there is a want of co- ordination of the organs of speech. Where there is difficulty in in understanding what the patient is reading, small doses of cro- nium will do good service. Where there is simply a difficulty in talking, I give thuja, in doses of gtt. 1 to 2, three or four times a day, aud find it serviceable in most cases. When this affection consists merely in making constant mistakes in writing, ignatia amara may give relief in doses of gtt. 3 to 5, thrice daily. When the troublé is only absent-mindedness, cocculus indicus,in doses of gtt. 5, every three hours, is indicated, and may be alternated with Horsford's Acid Phosphate. If the patient is forgetful, aud has headache, carbonate of ammonium is indicated. Thrombosis of the Cérébral Sinuses — The free passage of the blood through the vessels may be interrupted by various causes. Although the sinuses are of a rigid nature and incapable of collap- sins:, coagulation of the blood may readily take place in them. The propelling power of the heart may also be weakened, or in- flammation of the coats of the sinuses may cause coagulation of the blood. Marasmus may lead to it wThen it appears among chil- dren, who hâve been much reduced by long attacks of diarrhœa and teething ; also among adults who are feeble, and whose propel- ling power ot the heart is impaired by various causes, such as ex- haustion by long continued suppuration, cancer, and senile maras- mus. This form of thrombosis is usually found in the longitudi- nal and tran-^verse sinuses. The phlebitic form of thrombosis most generally originates from the disease of the bones of the cra- nium, but occasionally it accompanies otitis média from disease of the petrous portion of the temporal bones. In this case, it is located in the adjacent sitiuses, that is, the transverse and petrous. This form of thrombosis may also arise from disease of other cranial bones. Symptoms.—When thrombosis is accompanied by marasmus in children, the symptoms much resemble those of hydrocephalus, as both conditions give rise to cérébral anœmia and collapse, followed in both by coma, and somnolence. If diarrhœa (in very young children) occur, and is followed by cérébral disorders of an active, motor kind, such as rigidity of the muscles of the back and limbs, there is a strong probability that thrombosis exists in the superior longitudinal sinus. This affection has not such definite symptoms in the adult, sometimes showing nothing but apathy and gênerai * See the Author's Materia Medica and also his New Remédies. 254 THE AMERICAN PRACTICE OF MEDICINE. dépression, such as headache, delirium, loss of consciousness, and more or less disturbance of the motor functions, either in the form of spasms or paralysis. In some rare cases, the veins outside of the cranium, which communicate with the diseased sinus within swœll up, and epistaxis, cyanosis of the face, and fulness of the vessels takes place, when the affection is located in the longitudi- nal sinus. Œdema, of a limited space behind the ears may take place in thrombosis of the transverse sinus ; or the internai jugular vein may hâve less blood in it on the side of the lésion than on the opposite side. If the sinus cavernosus is the seat of the throm- bosis, there is apt to be hyperœmia of the fundus oeuli, œdema of the eyelids and conjunctiva, and, in some cases, prominent eyeballs. There may also be neuralgia or paralysis of the motor nerves, from pressure, etc. Prognosis.—This is very unfavorable. Treatment.—The carbonate of, and aqua ammonium both hâve a tendency to liquify the blood, and to thereby dissolve the throm- bosis. Especially is this the case after free hœmorrhage, when the circulation is languid from want of cardiac force. Bar- tholow7 even advises the intervenous injection of aqua ammonium, 5 1 to 5 2 of water. I strongly advise this treatment in cases where large venous trunks, as the pulmonary artery, are blocked up by thrombosis. Again, he advocates this drug in sudden paralysis of the heart from chlorform, or from the bite of serpents or spiders. Drs. Brunton and Fayrer hâve shown that intraven- ous injection is without value. Ammonium is the most trust- worthy remedy we hâve. Dementia Paralytica.—This is a diffuse disease of the brain, in which the spine is also often implicated. It is characterized by a combination of physical changes with certain motor distur- bances in the muscles of various parts ofthe body. Thèse changes generally run a chronic course, and end in death, if not relieved. Pathology.—In chronic cases, post-mortem é*xamination shows atrophy of the brain. The dura mater lies in folds over the frontal lobes ; the pia mater is generally more or less œdematous ; the ventricles are often enlarged ; the dura mater often adhères to the skull and may be thickened ; and there are also extravasations of blood upon its surface, which give it either a red, yellow or livid color. The brain tissue itself shows intersitial encephalitis, which in time leads to the destruction of the ganglionic cells, and to atrophy of the brain itself. The spinal cord generally présents gray degeneration of its posterior columns,or granular-cell myelitis. Causes.—Dementia paralytica may be hereditary, or abuses of alcoholic hquors or excessive mental labor may produce it. Ex- cessive venery is one of the most fruitful sources of this disease, and syphilis and the morbid influences of acute fébrile diseases DISEASES OF THE HEAD AND BRAIN. 255 also give rise to it. It rarely ever occurs under the âge of twenty years. and is most common between the âges of thirty and forty. Symptoms.—There may be premonitory symptoms preceding the final attack of this disease, such as dizziness, headache and rheu- matic pains in the legs, which come and go suddenly, and are worse at night. Irritability, poor memory of récent events, while past ones are distinct in the mind, are indications ; and frequently the muscles of the face and mouth may tremble, etc. The speech, perhaps, becomes lisping, as if the patient were intoxicated, and the voice is changed. Occasionally the trouble begins with an apoplectic attack. As it progresses, the patient is inclined to hâve exaggerated ideas of himself and of his possessions, and loses his natural affection for his family, squandering his money, if not prevented. In some cases the patient shows great anger, and even violent rage, rendering him dangerous to his friends or family. There may be a melancholic mood, or he may be in a hypochon- driacal frame of mind, which again may change to excitement. Kleptomania is also of fréquent occurence, and the patient some- times pockets whatever he or she may fancy, believing that they are only taking what belongs to them, and it is impossible to con- vince them ofthe contrary. The motor disturbances, when there is gray degeneration of the posterior column, consists of want of co-ordination, such as staggering upon shutting the eyes, a jerking, unsteady gait, difficulty in turning round, and trembling upon attempting to write. If eranular-cell myelitis is présent, there will be an awkward, shuffling, helpless gait, and unsteadi- ness in attempting to turn about quickly. In many cases there is more or less unilatéral facial paralysis, and apoplectic attacks may frequently occur leaving behind hemiplegia, and although this' may disappear, the mind still continues to degenerate. The at- tack may also be eombined with unilatéral or gênerai epilepti- form spasms, which occasionally end in the death of the patient. Senile Dementia.—Senile dementia has symptoms correspond- it^ to those of gênerai paralysis, with the exception of a peculiar weakness of memory. Chronic alcoholism also resembles senile dementia. Senile dementia, as occuring in advanced âge, mav be known by a lack of motor co-ordination, or by the existence of marked hemiplegia, and the absence of extravagant delirium. It is almost always of a childish character, and is free from epileptic attacks. The apoplectic attacks of the aged are associated with serious permanent paralysis, providedthey do not end in death. The dementia of old âge is more regular, and not subject to remissions or intermissions. Treatment.—The carb. of ammonium is one of our most suc- cessful remédies, taken in médium doses, three times a day. Phos- phorus in moderate doses may alternate it, and the hypophosphite 256 THE AMERICAN PRACTICE OF MEDICINE. of lime, in doses of gtt. 2 to 3, three times a day, will doubtless prove valuable, Especially where the memory is injured will the carbonate of ammonium do good. If this disease is caused by sexual abuses, nux vomica, in doses of gtt. 5, three or four times a day, will hâve a good effect. Delirium Tremens.—Delirium tremens is chronic alcoholism, and occurs in conséquence of excessive use of alcoholic drinks. It often follows the sudden withdrawal of stimulants from an habituai drunkard. It is a very strange disease, and is marked by varied symptoms, such as hallucinations of vision, the patient seeing démons, ghosts, rats, Aies, birds, snakes, and horrid sights, such as great beasts, persecuting officers, etc. Those imaginations are always of a very frightful character. I hâve known some persons to imagine that a familiar friend or relative was pursuing them with the purpose of killing them. I saw two cases some time since where the patients fancied that their brothers were thus pursuing them to murder them, and they both eut their own throats to prevent this from being done. When I was attending my first course in the University of Georgia, at Augusta, there was there an unfortunate old inebriate, who was suffering from this disease, who would run and hide iu some corner of the hos- pital, because he fancied that the students were an army pursuing him to put him to death. The victims hâve a wild expression, but seldom lose consciousness. They are rarely able to rest, unless they force sleep with soporifics. They are generally harm- less, but in some rare cases they become violent, maniacal, and even destructive and dangerous to others, as well as to themselves. Tremor is very common with this condition, and tétanie and eclamptiform convulsions take place quite frequently. Différent tempéraments exhibit différent signs of this morbid impress upon the brain. The disease is always worse after night, and the attacks last from a few days to two or three weeks. Post-mortem exami- nations of old topers show various lésions of the brain, such as anœmia and dryness of the org;an. The stomach, too, shows many lésions, such as a thickened mucous membrane, and there is fatty degeneration of the liver, and often hyperaemia of the kidneys. There are, of course, many other nervous effects of this disease not mentioned in the above catalogue of symptoms. Treatment.—Actœa racemosa is a valuable remedy where there is sleeplessness, convulsions or tremors, headache and melancholia. Where there are hallucinations (especially at night) soreness about the stomach, or nausea, gtt. 1 to 2 of tincture of arsenic is required. In young subjects, where there is congestion of the head and great excitability of the sensorium, want of memory, indistinct speech, cramps in the limbs and trembling of the hands, belladonna will do great good, in doses of gtt. 3 to 5, DISEASES OF THE HEAD AND BRAIN. 257 every three hours, but if ordered in larger doses it will do more harm than çood. Where there are illusions of sightand hearing, cannabis indica often allays thèse, in doses of gtt. 5 to 6, every three hours. G; t. 5 is' the safest dose, although some few7 will require gtt. 10. If there is palpitation of the heart, vertigo, nausea, thirst and headache, I use gtt. 5 to 6 of digitalis (tinc- ture), every three hours, or gtt. 3 to 5 of convallaria majalis, every two hours, until the heart is quieted. If there be persistent wakefulness, gelseminum sometimes produces sleep where morphia has failed. Occasionally the chloral hydrate has served me better than anything else, producing sound sleep, from which the patient awakes very much improvecl in mind. Where there are epilepi- form convulsions, ignatia amara, in doses of gtt, 3 to 5, will give relief in a short time, and may be repeated every three hours. Dipsomnia.—The long-continued use of alcoholic liquors, although the victims may not ever become intoxicated, shatters their whole system to its foundation. They soon lose their man- liness, and every émotion of enlightened humanity ; their constant craving for strong drink overpowœring their very best intentions and strongest will-power. They hâve to struggle continuously with this mighty temptation, and too often are found yielding in their unequaîconflict with a created appetite. Their better judgment dictâtes a cessation of the ruinous habit, but the strong cravings of an insatiable thirst call for more and more, and are never satisfied. If the subject of dipsomnia cease îrom indulgence for a time, he fails into a deep, melancholic niood, which shows a suicidai ten- dency, and to which or.ly a resort to their accustomed stimulant brings ready relief.. Hence, the poor victim plunges again into the profound depths of hisiniquitious débauchery, and continues in it until he either dies with a ruined constitution, or becomes a habituai drunkard, and in this state terminâtes a misérable life of sinful excess. If there is any class of sufferers that the physician should pity more than another, it is the misérable drunkards, descending from a life of promise and hope to an untimely grave, and worse still, to the poor inebriates' hell. It is a noteworthy fact that many of our most talented men at the bar, in the field of science, in the halls of Congress, and leading physicians and mechanics, fail victims to this most destructive vice. The higher the individual stands in the scale of intellectual or moral being, the lower he fails down into the depths of human dégradation. Physical Degeneration.—Alcoholic drink produces varied effects upon the mind and body of différent individuals. In some it gives rise to varied forms of insanity, and in others, to exhalta- tion and absurd delusions. Again, we sometimes find forms of melancholy with religious mania, delusions of maltreatment by friends and relatives, and a kind of tranquil dementia, or imbe- 17 258 THE AMERICAN PRACTICE OF MEDICINE. cility. Apoplectic and epileptic attacks are very often the resuit of long continued use of alcoholic drinks. Among the many physical disorders produced by chronic alcoholism or dipsomania may be mentioned various degrees of amblyopia and amaurosis with atrophy of the optic nerve. Chronic inflammation of the stomach may arise from it, rendering digestion very diflicult, and interfering very much with nutrition. The liver, too, is almost always badly diseased, and this condition often ends in cirrhosis. The kidneys frequently suffer with Bright's disease, and some die with anœmia. At first, the sexual appetite is greatly stimulated, and this finally ends in impotency. Children begotten in drunk- enness are not only very nervous, but often epileptics or imbéciles from birth. Post mortem examination reveals meningitis haemor- rhagica, atrophy ot the cortical substance, fatty degeneration of the ganglionic cells, thickeniug of the coats of the veins, thicken- ing of the mucous membrane of the stomach, and occasionally flat érosions of the mucous coat of the stomach. Treatment.—Nothing but moral suasion can reelaim the habi- tuai drinker of alcoholic or fermented liquors. Of medicines, nux vomica may be tried, in doses of gtt. 5, ter die. Hyd. chloral quiets the patient. Opium and Morphia Poisoning.—So prévalent has the hab- ituai use of opium and morphia become,that I hâve beenfor years very cautious about prescribing itfor any length of time. I am utterly amazed at the reckless and indiseriminate prescribing of opium by physicians, while they seethecriminal effects of their carelessness, It is now the custom of most practitioners to prescribe either by the mouth or by hypodermic injection, laudanum, Dover's powders, or morphia, for every little pain and aehe that their patients may complain of. The destructive habit of opium eating has increased alarmingly in the last ten years. It is now entailing untold misery and dégradation upon thousands and thousands of unfortunate victims. It is diflicult to détail the symptoms which may be found in works upon toxicology, to which the reader is referred. It is neccessary, however, to mention hère some of the chronic effects of this evil habit, viz. : gênerai emaciation, pale, shrivelled dry skin, (looking like fish scales), flabby muscles, loss of appetite, feeble digestion, constipation, irritability of temper, giddiness, headache, sleeplessness, neuralgia, loss of memory, energy, and will power, and sometimes paralysis and diseases of the bladder. Thèse effects are the results of opiates upon the substance of the nerves. The brain is in a state of hyperœmia, and very frequently fluid is found in the subarachnoidal spaces aud in the ventricles. Sometimes there are sanguineous effusions into the brain. There may be other anatomical conditions in certain cases after death. Treatment.—We may first, with propriety, give the remédies DISEASES OF THE HEAD AND BRAIN. 259 for acute poisoning by opium. To remove the opium from the stomach, the stomach pump is used, but as that apparatus is not at the command of every country practitioner, he may hâve to resort to emetics. It requires active emetics, as there is great insensibility of the gastric nerves, caused by the obtunding effects of the opium. The sulphate of zinc is used.by some, ipecac and lo- belia by others. I hâve succeeded well with the tinctures of thèse last articles (made from fresh materials), or saturated tinctures, in doses of 5 5 each, given every ten minutes, until thorough emesis takes place. Gr. 1-16 of apomorphia, given hypodermi- cally by injection, will produce speedy emesis, or gr. £, given by the mouth, will give the same resuit. After the stomach has been entirely emptied, it should be thoroughly washed out with green coffee tea, or with green tea. This forms the tannate of morphia, which lessens the poisonous effect very much, and I think to a great extent neutralizes the opium. In addition to the tea of green coffee, freely taken, I always give tincture of belladonna, in doses of gtt. 5 to 10 at once, and repeat it in two hours if the first dose does not counteract the effects of the opiate. The patient should be kept moving ail the time, to prevent com- plète narcosis. By thèse means I hâve just saved the life of a lady hère, and that of several patients before her. I also saved in this way the life of a little girl of 8 or 10 years of âge, who had eaten a large quantity of the blooms of stramonium. As an antidote to the opium habit, gtt. 15 of the tincture or fresh root of ipecacuanha, given three times a day, has proved valuable il other remédies fail. The patient's resolution is the best remedy in the world. Tumors of the Brain and its Membranes—The conneetive and epithelial tissues of the blood vessels and their sheaths are liable to become altered by the modification of newly formed éléments, and by changes in their relations to their conneetive tissue and vascular distribution over the brain. Causes.—Hereditary prédisposition, the habituai use of alcoholic spirits, syphilis, blows or bruises of the skull, and tuberculosis may ail