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        A MANUAL

             OP THE


PRACTICE of MEDICINE.

       DESIGNED FOR THE USE OF

 STUDENTS AXD THE GENERAL PRACTITIONER.

              BY
     HEE"ET O. MOIR  M.D.
FOUR1H EDITION.
    NEW YORK :
J. H. VAIL & COMPANY. 
VsJB
    Entered, according to Act of Congress, in the year 1881,
                 By HENRY C. MOIR, M.D.,
in the office of the Librarian of Congress, at Washington, D. C. 
AS THE CONDITION OF THIS VOLUME
WOULD NOT PERMIT SEWING, IT WAS
TREATED WITH A STRONG, DURABLE
ADHESIVE ESPECIALLY APPLIED TO
ASSURE HARD WEAR AND USE. 
 
s*
       AMBROSE LOOMIS RANXEY,  A.M., M.D.,





ADJUNCT PROFESSOR OF ANATOMY IN THE MEDICAL DEPARTMENT OF THE UNIVER-



                     SITY OF NEW YORK,







This -work is respectfully dedicated, as a  mark of  esteem and




      gratitude for his many acts of kindness, by his




                 friend and late student, 
 
PREFACE TO THE THIRD EDITION.
  In presenting this edition to the profession, I have endeavored
to keep pace with the standard literature of the day.
  To this work I have added (on page 34) the causes of Hepatic
Abscess, and (on page 399) a chapter on Chorea.
                                            H. C. M.
Union Hill, New Jersey. 
PREFACE TO THE SECOND  EDITION.
  The success with which my exertions have been crowned in
this little work, has far exceeded any reasonable expectations, and
it has thereby encouraged me to bring out my second edition.
  During the revision of this edition, I have endeavored to follow,
as far as possible, all suggestions offered by many friends, thereby
enabling me to make this work as nearly complete as possible,
thus enhancing its value, both to the student and the busy prac-
titioner.
  I have especially to thank the editors of the  various medical
journals, for the favorable manner in which the work has been
received by them, and for many valuable hints thrown out during
their remarks.
  The work has been enlarged ; several of the diseases have been
entirely re-written, and all errors, wherever detected, carefully-
expunged. 
PREFACE.
   In a small work like the present manual, nothing can possibly
 be given which will  supply the place of exhaustive treatises.  It
 must, of necessity, either presuppose some erudition on the part
 of the reader,  or be elementary in character to have any special
 value.
   This volume has been designed chiefly to aid the medical  prac-
 titioner  and student in refreshing  their  remembrance of the
 pathology, etiology,  symptomatology, differential diagnosis, and
 treatment of the more important diseases.
   By grouping the various causes of the more prominent diagnos-
 tic symptoms which are encountered by the physician, an  effort
 has been made to Impress upon the reader that no diagnosis should
 ever be final without a careful study of each individual symptom ;
 and that, to be accurate and rapid in diagnosis, the causes of each
 and every prominent symptom of disease should be particularly
 memorized and constantly reviewed.
  This volume, as it  now appears, comprises the substance of a
 course given by a well-known  instructor to his  private students
 as a preparation  chiefly for  competitive examination, and em-
 braces also a careful resume  of such standard works as those of
 Niemeyer, Roberts, Loomis, Da Costa, Bristowe, Hartshorne, and
others.
  To be a skillful diagnostician, as it seems to the author, one should
first know every disease which can affect any tissue or organ; he 
VI                       PREFACE.
should, furthermore, have at his command the causes in full of
each and every prominent symptom which the  patient  may
present; and, finally, be able, by a thorougli familiarity with the
symptoms of each disease, to  exclude, from  the list of causes of
each symptom, such as are not sustained by other points in the
history of the patient.
  By such a process of deductive reasoning,  diagnosis becomes
more nearly a positive science than by relying upon " keenness of
perception," or "inborn intuition," which, although valuable as
aids, are often worthless when the exigencies of the case demand
a positiveness of diagnosis.
  The  arrangement of this volume is  intended, as far as possible,
to assist the reader to master in succession (1) the general basis on
which the symptoms of disease are divided; (2) all the diseases
which may be met with in each of the various organs or tissues;
(3) the more important symptoms of disease  and their etiology;
and (4) the special points pertaining to the diagnosis and prognosis
of individual forms  of disease.  This general plan of arrange-
ment will be found carried out in the successive chapters of this
volume, with an approach to completeness.
  The author has appended to this volume a number of reliable
and valuable prescriptions which have been obtained from pro-
minent medical instructors  and members  of the profession who
have fully proven their value, so as to afford the reader a pocket-
memorandum of treatment of all the more important diseases;
while the full details of the treatment of each disease have  been
incorporated throughout the text.  Many points of value  as to
the pathology, etiology, and the diagnostic symptoms have been
selected from the valuable lectures of the more prominent pro-
fessors of the United  States, while no work pf prominence has
been slighted in the preparation of this book. 
                         PREFACE.                         vii
  The prescriptions, at the close of the manual, are arranged
according to their therapeutical uses, in alphabetical order, so as
to enable the practitioner to turn at once to the disease for which
he seeks a recipe.
  The use of  italics, throughout the volume, has been adopted
to make prominent such symptoms as are  of  special value in
diagnosis.
  The scope of  the work will be found to  be  quite  extensive,
notwithstanding its small compass, since condensation has been
the aim of the  author in every page, where  brevity did not
demand any important omission. 
 
TABLE  OF  CONTENTS.
                         PART I.
                                                      PAGE.
General Introduction...............................     1-6
    Explanatory of the Diagnostic Value of Rational and
    Physical Symptoms.
                         PART II.
An Enumeration of the Diseased Conditions of Vari-
    ous Parts of the  Body (Classified to Aid Memory),    7-16

                        PART III.
Prominent Symptoms of Disease Possessing a Special
    Diagnostic Value, and their Causes.............    17-34
    Varieties of Pulse.—Causes of Epigastric Pulsation.—
    Causes of Displaced Apex-beat of the Heart.—Causes
    of Abdominal Pain.—Causes of Pain in the Thorax.—
    Causes of Vomiting.—Causes of Headache.—Causes
    of Chill.—Causes of Dyspnoea.—Causes of Jaundice.
    —Causes of  Coma.—Causes of Ascites.—Causes of
    Hemorrhage from  the Digestive  Tract.—Causes of
    Haemoptysis.—Causes of Aphonia.—Causes of Hemi-
    plegia.—Causes of Paraplegia.—Causes of Suppression
    of Urine.—Causes of Retention of Urine.—Causes of
    Blood in the Urine.—Causes of Pus in the Urine.—
    Causes of Instantaneous Death.—Types of Expector-
    ation.—Types of Diarrhoea. —Causes of Albuminous
    and Chylous Urine.
                        PART IV.
Diseases of the  Respiratory Organs................   35-100
    Diseases of the Larynx.—Diseases of the Bronchi.—
    Diseases of the Lungs.—Diseases of the Pleura, 
X
CONTENTS.
                         PART V.
                                                        PAGE.
Diseases of the Circulatory System................ 101-149
    Diseases of the Heart.—Diseases of the Pericardium.

                         PART VI.
Diseases of the Digestive Tract.................... 150-224
    Diseases of  the Mouth.—Diseases of the Pharynx.—
    Diseases of the CEsophagus.—Diseases of the Stomach.
    —Diseases of the Intestines.—Diseases of the Liver.

                        PART VII.
Diseases of the Brain and Nervous System.........  225-260
    Diseases of  the  Meninges of the Brain.—Diseases of
    the Brain-substance.—Diseases of the Vessels of the
    Brain.—Diseases of the Meninges of the Spinal Cord.
    —Diseases of the Spinal Marrow.—Sun Stroke.

                        PART VIII.
Diseases of the Blood.............................. 261-358
    Fevers. — Infarction.—Septicaemia.—Pyaemia.—Ery-
    sipelas.—Rheumatism (its various forms).—Diabetes.
    —Purpura. —Scurvy. —Gout. —Diphtheria.

                         PART IX.
Diseases of the Kidneys..........................350-397
    Renal Congestion.—Renal Hemorrhage.—Uraemia.—
    Bright's Disease  (its  various  forms). — Pyelitis.—
    Hydro-nephrosis.—Renal Calculi.—Renal Cancer.—
    Addison's Disease.—Surgical Kidney.

                         PART X.
Prescriptions ; Disinfectants ; Poisons and Antidotes. 398-446
    Arranged Alphabetically, as to  their Therapeutical
    Uses, to Assist Reference.
Index.
447 
GENEKAL  IOTROBUCTIOST. 
 
GENERAL  INTRODUCTION.
  Symptoms  or  Signs  of  disease comprise '' any past or present
circumstances afforded by the examination of  a  patient,  or of
matters concerning him,  whence a conclusion may be drawn re-
garding the nature and seat of existing disease."
  Symptoms are usually classed under one of two heads,  Rational
or Physical.
  A Rational Sign of disease  implies, by its derivation, one
which is  perceived by the intelligence only.   It is, however,
generally used in  a more liberal sense, and may be said to com-
prise all forms of manifestations of disease of which the patient is
self-conscious, or which is capable of  being perceived by the pa-
tient, in case it has escaped attention.
  A Physical Sign, on the contrary, is one which, according to
its derivation, must be perceived by the senses, in contra-distinc-
iion to the reasoning faculties.   It is therefore, as a rule, unper-
ceived by the patient or friends, and requires a special  cultivation
of touch, sight, or hearing before it can be accurately determined.
             RATIONAL SIGNS OF DISEASE.
  The rational symptoms of disease form the chief means of diag-
nosis, except in  conditions of the respiratory organs, the heart,
and the blood-vessels.
  Percussion may,  however, be of value in other conditions,  since
it assists in mapping out the situation of organs, or the outline of
tumors; but  the rational  symptoms are, as a rule, the great and
often the only guides in diagnosis, excepting in case of the organs
above mentioned.
  Among  the more prominent of  the  innumerable forms of
rational symptoms of disease may be enumerated (1) variations in
the pulse and temperature, (2) pain, in all its forms and situations,
<3) cough  and expectoration,  in all  its varieties, (4) nausea and
vomiting,  (5) chill, (6) dyspnoea, (7) diarrhoea,  (8) jaundice, (9)
coma, (10) ascites, (11) hemorrhage from the different organs, (12) 
4
general introduction.
aphonia, (13) constipation, (14) paralysis in all its forms, (15) ab-
normal conditions of urine, and (16) abnormal attitudes and phy-
siognomy.
              PHYSICAL SIGNS  OF  DISEASE.
  Physical symptoms are of value in determining, during life, the
anatomical changes taking place in tissues and organs.  In order
to dectect them, the following methods are employed: (1) inspec-
tion, (2)palpation, (3) percussion, (4) auscultation, (5) mensuration,
and (6) succussion.
  Inspection reveals the following  points of diagnostic value:
Condition of the surface; abnormalities of outline and contour (if
present); deformities; abnormal growths, their character and situa-
tion; abnormal or deficient movement of parts, especially in the
chest and abdomen; abnormal points of  pulsation; abnormal con-
ditions of vessels;  abnormal physiognomy or  attitude of some
special region of the body.
  Palpation (sense of touch) reveals the following points of diag-
nostic  value: Condition of  the surface; condition of the  deeper
tissues; outline and character of new growths;  abnormality of
movement of parts, as of chest and abdomen, of tumors, the heart
impulse, etc.; abnormality of transmitted impulses, as in vocal
fremitus, cough impulse of hernia, etc.
  Percussion, by the note produced, determines the relative solid-
ity of parts.  Its note varies between that obtained over cavities
filled with air and having thin, tense walls, called the tympanitic
percussion note;  and that obtained over fluid or solid tumors,
where all air is excluded, called flat percussion.  The percussion
note is sometimes  also modified by the force of  the percussion
stroke, since the  flat note of solid  structures is often masked by
the presence of confined air between the solid body and the sur-
face.  This seldom occurs, however, in the case of fluids.
  Percussion may be performed in one of two ways: directly upon
the part, called " immediate," and indirectly through some inter-
vening substance, as the finger, etc., called "mediate.'1'' In the
percussion note, as in all forms of sound, the variations are con-
fined to one of the four elements of sound, viz., its intensity,
pitch, duration, and quality. 
general introduction.
5
  The pitch modifies both the intensity and duration of all sounds
 as  follows:  High pitch is  accompanied by short duration and
 great  intensity.   Low pitch is accompanied by long duration and
 diminished intensity.  This fact is evidenced in every-day life by
 the intolerance felt towards shrill piercing notes, and the absence
 of such feeling when the pitch is low.
  The intensity may be also increased, irrespective of the pitch,
 by the force of the blow.
  The pitch is modified in disease by the solidity of the underly-
 ing structures; being high or flat when no air is present,  and pro-
 portionately lower as the tissues approach the density of air.
  The quality is modified in health by the character of the tissues
 over which percussion is made, and it varies also in certain local-
 ities with the diseased conditions of the  parts.  The following
 names have been given to percussion sounds as  expressive o}
 qualities peculiar to certain states of the body.  (1) Dullness, i\
 over partial consolidation; (2) flatness, if over complete consolida-
 tion or fluid; (3) amphoric, if over air in a small cavity with tense
 walls (this sound may be imitated  by blowing into a bottle); (4)
 tympanitic if over air in a large cavity with tense walls; (5) vesi-
 culotympanitic, as in emphysema; (6) vesicular, the normal per-
 cussion note of lung-tissue; (7) wooden, where a peculiar ring or
 wooden character is present; (8) cracked-pot,  (which requires a
 large superficial cavity with thin tense walls, communicating with
 a bronchus).  Firm percussion should be employed to produce this
 variety of percussion-note, and the patient's mouth should be kept
open;  (9)  auscultatory, where a stethoscope is  used  simultane-
ously with percussion.
  Auscultation (sense of hearing) admits of the detection of ab-
normal sounds, which are often of great diagnostic value.  These
sounds vary with different diseases, and are of special value in
diseases of the lungs, heart,  and blood-vessels.
  The prominent auscultatory signs of disease may be thus enum-
 erated:
                  Varieties of  Respiration.
  Normal or " Vesicular"—is a breezy sound, like the rustling of
wind through the trees. 
6
GENERAL INTRODUCTION.
   Rude or "Broncho-vesicular"—is due to partial consolidation
 of lung—is an admixture of tubular and vesicular breathing.
   Tubular or "Bronchial"—is due to complete consolidation of
 lung.
   Exaggerated or " Puerile "—so called since it is normal in child-
 hood—is produced when the lung is doing double duty.
   Amphoric—occurs in cavities with tense walls, opening into a
 bronchus, and near the surf wze.
   Cavernous—occurs in cav^ies with flaccid walls, opening into a
 bronchus and near the surface.
   Emphysematous—where the expiratory sound is prolonged and
 of low pitch.
   Phthisical—where the expiratory sound  is prolonged and  of
 high pitch.
   Cog-ivheel—where the inspiratory sound is jerking and inter-
 rupted.
                    Varieties of Rales.
 Dry Rales.—
    Sonorous—due to partial occlusion of a large bronchial tube by
        tumefaction of the mucous membrane, spasm of the mus-
        cular fibre,  or mucus.
    Sibilant—due to a  similar condition of a small bronchial tube.
 Moist Rales.—
    Crepitant—due to the agglutination of the walls of an air-cell,
        which are subsequently separated by the entrance of air.
    Mucous—due to the flapping of mucus in the bronchial tubes,
        or the passage of air  through mucus, pus, serum, or blood.
    Sub-crepitant—due to fluid or mucus in the ultimate capillary
        bronchi.
    Gurgles—due to bubbling of air through fluid in a cavity in
        the lung, where the  bronchus is below level of fluid (has
        a peculiar metallic, hollow sound).
    Mucous-click—due to sudden and forcible passage of air through
        a small bronchus, whose sides are brought together by ex-
        ternal pressure or agglutination of their walls.
  Of these rales, all but one  are heard with both inspiration and
expiration, this one exception being the crepitant rale which is
 heard only at the end of inspiration. 
AN EOTJMEEATIOH" OF THE YAEI-
  OUS  DISEASED  CONDITIONS
    OF THE DIFFEEENT PAETS
         OF THE BODY. 
 
DISEASED  CONDITIONS  OP THE  BODY.
         DISEASES  OF  THE NERVOUS  SYSTEM.
            Diseases within the Cranial Cavity.
Inflammatory Conditions.
    Acute  meningitis.—Subacute meningitis.—Chronic  menin-
    gitis.—Acute tubercular meningitis. — Chronic  tubercular
    meningitis.—Cerebro-spinal meningitis, epidemic and sporadic.
    —Pachymeningitis, externa and interna.
Tumors.
    Carcinoma.—Cholesteatoma.—Cysts.—Glioma (exists in nerve-
    tissue). —Gummata. —Hydatids. —Lipoma. —Myxoma.—Psam-
    moma.—Sarcoma.—Tubercle.
Conditions of Brain Substance.
    Abscess. —Atrophy.—Cerebral concussion.—Hypertrophy.—
    Sclerosis.—Red  softening.—"White softening.—Yellow soften-
    ing.—Tumors, as above (except glioma).
Conditions of Vessels.
    Anaemia. — Apoplexy, cerebral.  — Apoplexy,  meningeal.—
    Atheroma. — Embolism.—Fatty  degeneration.—Hyperaemia,
    active.—Hyperaemia,  passive.—Miliary  aneurism.—Throm-
    bosis.
             Diseases within the  Spinal Cord.
Inflammatory Conditions.
    Cerebro-spinal meningitis.—Diffuse idiopathic spinal  menin-
    gitis.— Localized  idiopathic  spinal  meningitis.—Traumatic
    spinal meningitis.
Tumors of the Spinal Meninges.
    Carcinoma.—Cysts. — Enchondroma.—Gummata.—Hydatids.
    —Lipoma.—Myxoma.—Sarcoma.—Spina bifida. —Tubercle.
Conditions  of the Spinal Marrow.
    Abscess. — Concussion. — Locomotor ataxia. — Sclerosis. — 
10  AN ENUMERATION OF THE VARIOUS DISEASED CONDITIONS

    White  softening.—Red  softening or  myelitis.—Tumors (as
    above, excepting Spina bifida).
Conditions of Vessels.
    Active hyperaemia.—Passive  hyperaemia or "congestion."—
    Anaemia.—Apoplexy, meningeal or  spinal.—Atheroma.—
    Embolism.- Fatty degeneration.—Thrombosis.
                 ORGANS  OF  DIGESTION.
              Diseases of  the  Buccal Cavity.
Inflammatory Conditions.
    Simple or catarrhal stomatitis.—Mercurial stomatitis.—Croup
    ous stomatitis.—Aphthous sore mouth.—Diphtheritic stom
    atitis. — Cancrum   oris.—Exudative   stomatitis.—Thrusl
    or  " sprue." — Gangrenous  stomatitis. — Noma or  "wate»
    canker."
Mucous patches (syphilitic).
Ulcers (non-specific).
Parotitis or " mumps."
Glossitis.
Scorbutic condition.
Lead affections.
Gummata of tongue.
Surgical Diseases.
    Epithelioma.—Tumors of bone.—Necrosis.—Caries.—Epulis.
    —Parulis.—Ranula.—Cleft-palate.—Hare-lip.
Eruptions of the different fevers.
Angina Ludovici.
                  Diseases  of the Pharynx.
Inflammatory Conditions.
    Catarrhal pharyngitis. — Croupous  pharyngitis.—Follicular
    pharyngitis.  —  Diphtheritic  pharyngitis. — Phlegmonous
    pharyngitis. —Retro-pharyngeal abscess. —Gangrene.—Angina
    Ludovici.—Ulcers.
Syphilitic Conditions.
    Specific catarrh.—Specific ulcers.—Mucous papules.__Condy-
    lomata.—Gummata.—Cicatrices.—Constrictions  and distor-
    tions of pharynx, from adhesions or cicatrizations. 
OF DIFFERENT PARTS OF THE BODY.
11
 Cancer of the pharynx.
 Polypi of the pharynx.
                 Diseases of the (Esophagus.
 Inflammatory Conditions.
     Catarrhal oesophagitis.—Croupous oesophagitis.—Diphtheritic
     oesophagitis. — Pustulae  (small-pox).—Ulcers,  as  in  chronic
     catarrh.—Ulcers  from  corrosive substances.—Ulcers from
     foreign bodies.
 Stricture as a result of
     Cicatrices.—Compression  (from outside sources). — Hyper-
     trophy of its walls.—New growths in the oesophagus.
 Dilatation of the (Esophagus.
     Partial dilatation, if circumscribed.—Total dilatation if affect-
     ing the entire length.
 New Growths.
     Carcinoma.—Fibroid  tumors.—Gummata  (rare). — Tubercle
     (rare).
 Perforation or Rupture.
     From abscess of bronchial glands.—From  aneurism.—From
     cancer.—From caries of  the  vertebrae.—From corrosion.—
     From ulcers.
 Nervous Conditions.
     Globus hystericus (spasm).—Hyperaesthesia.—Paralysis.
                  Diseases  of the Stomach.
 Inflammatory Conditions.
    Acute catarrhal gastritis.—Chronic catarrhal gastritis.—Sub-
    acute catarrhal gastritis.—Croupous gastritis.—Diphtheritic
    gastritis.—Phlegmonous  gastritis.—Toxic  gastritis.—Ulcers,
    acute or perforating, and chronic.—Cancer, scirrhus, medul-
    lary, and colloid.
Nervous Conditions.
    Dyspepsia.—Spasm or " gastralgia."
 Unclassified Conditions.
    Dilatation of the stomach.—Rupture of the stomach.—Stric-
    ture of the stomach.
Hemorrhage dependent upon
    Ulcer,—Cancer.—Thrombosis of portal vein.—Cirrhosis of the 
12  AN enumeration of the various diseased' conditions

    liver.—Acute  yellow atrophy of the liver.—Enlargement of
    gall-ducts.—Pulmonary obstruction.—Tricuspid regurgitation.
    —Hemorrhagic diathesis.—Rupture of aneurism and varices.
    —Traumatism. —Improper living (as abstinence from meat or
    vegetables).
Blood Conditions.
    Yellow fever. —Malaria. —Scurvy.—Purpura.
Ulcers.
    Acute or perforating.—Chronic  catarrhal.—Phlegmonous.—
    Scrofulous. — Syphilitic. — Diphtheritic.—Cancerous.—Vario-
    lous.—Corrosive (due to poisons).—Typhus.—Typhoid.—Fol-
    licular.
             Diseases of the  Intestinal Canal,
Inflammatory Conditions.
    Acute  and  chronic catarrhal enteritis.—Gastro-duodenitis
    (cholera morbus).—Perforating duodenal ulcers (as occur in
    burns).—Peri-typhlitis. —Proctitis and peri-proctitis.—Typhoid
    conditions. — Dysentery,  sporadic and  epidemic.— Cholera
    morbus.—Asiatic cholera.
Tumors.
    Vascular.—Carcinoma—Tubercle.—Fatty tumors  (lipoma).—
    Scrofulous enlargements of  the mesenteric glands.
Conditions Dependent upon the Vessels.
    Intestinal hemorrhage.—Vascular dilatations.
Conditions impairing the free action of the Bowels.
    Contractures, by adhesions  or  bands of  lymph.—Rupture or
    perforation.—Foreign bodies —Volvulus.—Gall-stones.—Intus-
    susception. —Peritoneal bands. —Hernia. —Worms.—Strangu-
    lation.—Pressure of tumors  and cancer.—Impaction of faeces.
Unclassified Conditions.
    Worms.—Tympanites or wind colic—Intestinal colic—Lead
    colic.
                   Diseases of the Liver.
Inflammatory Conditions.
    Affecting the capsule of the organ (peri-hepatitis).—Affecting
    the parenchyma of the liver (diffuse hepatitis).—Affecting the
    connective tissue (cirrhosis).—Circumscribed suppurative in-
    flammation (abscess). —Ascites. —Jaundice. 
OF different parts of the body.
13
Degenerations.
    Amyloid or waxy liver.—Fatty liver.—Acute yellow atrophy.
    —Chronic atrophy from pressure.
Abnormal Conditions of the Vessels.
    Active hyperaemia.—Passive  hyperaemia  (nutmeg  liver).—
    Hepatic apoplexy.—Hepatic infarction.—Portal thrombosis.
    —Suppurative portal  phlebitis.—Embolism  of hepatic artery.
Hepatic Tumors.
    Cancerous  tumor.—Tubercle.—Cysts, simple and hydatid.—
    Carcinoma.—Gummata.—Enlarged gall-bladder.
Conditions of Bile Ducts.
    Gall-stones.—Catarrhal  obstruction.—Croupous obstruction.
    —Foreign bodies in the duct.—Tubercle.—Cancer.

                ORGANS OF  RESPIRATION.
                  Diseases of the Larynx.
Inflammatory Conditions.
    Acute  catarrhal laryngitis.—Chronic  catarrhal laryngitis.—
    Croupous catarrhal  laryngitis. — Diphtheritic laryngitis. —
    Tuberculous  laryngitis. —  Syphilitic laryngitis.—Laryngeal
    peri-chondritis.—CEdema glottidis.
 Ulcers.
    Catarrhal.—Typhus.—Variolus.—Syphilitic—Tubercular.
New Growths.
    Papillary or warty.—Mucous polypi.—Fibrous  tumors.—Car-
    cinoma.—Cystic tumors.
Nervous Conditions.
    Laryngeal spasm (false croup).—Paralysis of muscles of larynx.
                  Diseases of the Bronchi.
Inflammatory Conditions.
    Acute catarrhal bronchitis.—Chronic catarrhal bronchitis-
    Capillary catarrhal bronchitis.—Croupous bronchitis.—Diph-
    theritic bronchitis.—Bronchial dilatation.
 Nervous Conditions.
    Asthma.—Whooping cough.
 Surgical Conditions.
    Foreign bodies.—Occlusion by pressure, or from tumors. 
14   AN ENUMERATION OF THE VARIOUS DISEASED CONDITIONS
                   Diseases of the Lungs.
Inflammatory Conditions.
    Croupous  or lobar pneumonia.—Catarrhal or lobular pneu-
    monia.—Chronic, or interstitial pneumonia.—Pulmonary ab-
    scess.—* Pulmonary gangrene.—* Pulmonary oedema.
Conditions dependent upon the vessels of the Lung.
    Pulmonary apoplexy.—Pulmonary infarction.—Pulmonary
    oedema.—Pulmonary gangrene.—Active hyperaemia.—Passive
    hyperaemia.—Compensatory hyperaemia.—Brown induration.
    —Splenization.—Hypostatic congestion.
Conditions dependent upon an altered state of the Air-cells.
    Collapse (atelectasis).—Emphysema, vesicular.—Emphysema,
    interlobular.—Phthisis, catarrhal.—Phthisis,  tubercular.—
    Phthisis, fibrous.—Compression of the  lung.
Cancer of the lung.
                  Diseases of the Pleura.
Inflammatory Conditions.
    Acute pleurisy.—Subacute pleurisy.—Chronic pleurisy (empy-
    ema).—Traumatic pleurisy.
Pneumo-thorax.
Hydro-thorax (non-inflammatory).
Haemo-thorax.
Hydro-pneumo-thorax.
Cancer of the pleura.
Tubercle of the pleura.
Adhesions of the pleura (usually secondary to an inflammatory
  process).
          Diseases  of the Heart and Pericardium.
Inflammatory Conditions.
    Acute endocarditis.—Chronic endocarditis. — Ulcerative endo-
    carditis.—Myocarditis.—Pericarditis, with  serous  effusion.—
    Pericarditis, with pus exudation.—Pericardial adhesion.
Abnormal Valvular Conditions.
    Aortic  obstruction. — Aortic   insufficiency. — Pulmonary
  * Pulmonary oedema and gangrene are  not always of  inflammatory origin-
hence enumerated under two headings. 
OF DIFFERENT PARTS OF THE BODY.
15
    obstruction  and insufficiency. — Mitral obstruction and in-
    sufficiency.  — Tricuspid  obstruction  and  insufficiency. —
    Vegetations on the valves.—Rupture of chordae tendineae.—
    Hypertrophy, 3 varieties, simple,  eccentric, and concentric.—
    Rupture of the heart.
 Unclassified Conditions of the Heart.
    Fatty degeneration of the heart.—Amyloid degeneration of
    the heart.—Angina pectoris.—Cardiac neuralgia.—Heart clot,
    or cardiac thrombosis.—Cardiac polypus.—Cardiac dilatation,
    3 varieties, simple,  hypertrophous, and atrophic.
Conditions of the Pericardium.
    Basedow's disease. — Pneumo-pericardium. — Haemo-pericar-
    dium.—Cancer of pericardium.—Aneurism in pericardial sac.
    —Tubercle of pericardium.
                 THE URINARY ORGANS.
                  Diseases of the  Kidney.
Inflammatory Conditions.
    Catarrhal or desquamative nephritis.—Croupous nephritis.—
    Chronic parenchymatous nephritis.—Acute interstitial nephri-
    tis.—Chronic interstitial nephritis.—Peri-nephritis.—Amyloid
    degeneration.—Abscess in kidney. — Fatty  degeneration.—
    Pyelitis.—Surgical kidney.
Renal Tumors.
    Carcinoma.—Tuberculosis.—Parasites.—Cysts, due to oblitera-
    tion of kidney tubules.
Abnormal Conditions of Vessels.
    Active  hyperaemia  or congestion.—Passive hyperaemia.—In-
    farction. —Thrombosis.—Embolism.
In the Cavity of the Kidney.
    Hydro-nep'hrosis or dropsy of kidney.—Calculus in the pelvis
    of the kidney.
Affecting Supra-renal Capsule.
    Addison's disease.
                 Diseases of the Bladder.
Inflammatory Conditions.
    Acute catarrhal cystitis.—Chronic catarrhal cystitis.—Ulcer- 
16  AN  ENUMERATION OF THE VARIOUS DISEASED CONDITIONS.

    ation. — * Paralysis. — Croupous  cystitis.— Diphtheritic cys-
    titis.
Tumors.
    Cancer.—Tuberculous.—Vegetations.
Nervous Conditions.
    Atony.—Spasm.—Paralysis.—Neuralgia.
Conditions affecting the cavity of the Organ.
    Dilatation.—Rupture.—Retention.—Incontinence.—Overflow.
    —Calculus in the bladder.—Hemorrhage.
A CLASSIFICATION OF THE  ABNORMAL STATES OF THE
                          BLOOD.
Changes in its Corpuscular Elements.
    Increase of red globules (plethora}. —Increase of white globules
    (leucocythemia).—Decrease  of red globules  (anaemia).—De-
    crease of red and white globules (chlorosis).—Disorganization
    of globules (fevers).
Changes in its Inorganic Elements.
    Increase  in chloride salts.—Increase  in alkaline salts (some
    nervous diseases).—Decrease in chloride salts.—Decrease  in
    alkaline salts (scurvy).
Changes in its Organic Elements.
    Incresase in  fibrin (starvation,  inflammation).—Increase  in
    albumen (inflammation).—Decrease in fibrin (all the fevers). —
    Decrease in albumen (all the fevers).—Increase in fat  (chylae-
    mia).—Decrease in fat (tuberculosis) (?).
Changes Dependent upon Mal-assimilation.
    Excess of lactic  acid  (rheumatism).—Excess of  uric  acid
    (gout).—Excess of oxalic acid (oxaluria).—Excess of sugar
    (diabetes).
Changes due to Poisons Developed within the Body.
    Uraemia.—Ammonaemia. — Cholestraemia.—Cyanosis.—Intes-
    tinal secretion (fetid  odor to breath).
Changes due to Poisons Developed outside the Body.
    Glanders.—Anthrax.—Hydrophobia.—Snake-bite. — Syphilis.
    — All  the fevers. — Dysentery. — Cholera. — Cerebro-spinal
    meningitis (?). - -Pyaemia. —Septacemia. —Fevers.
* May also be dependent on many other causes. 
PEOMINENT  SYMPTOMS  OF  DIS-
 EASE,  POSSESSING- A SPECIAL
   DIAGNOSTIC  IMPORTANCE,
      AND  THEIE VALUE. 
 
PEOMINENT  SYMPTOMS OF  DISEASE, POSSESS-
      ING  A SPECIAL DIAGNOSTIC  VALUE.
                  VARIETIES  OF  PULSE.
Modifications in Volume.
    Full pulse.—Small pulse.—Thready pulse.—Gaseous pulse.
Modifications in Rhythm.
    Regular, where the rhythm is perfect.—Irregular, where the
    number of beats per minute or fraction of a minute is not uni-
    form.—Intermitting, where the beats  cannot be perceived at
    intervals.—Delayed, where the radial  pulse and the apex beat
    are not synchronous with each other.
Modifications in Force.
    Weak pulse. — Strong  pulse. — Suppressed pulse. — Jerking
    pulse.—Compressible pulse.— Incompressible  pulse. — Wiry
    pulse.—Shot pulse (in aortic regurgitation).
Modifications shoicn by the Sphygmograph.
    Dicrotic, where the aortic wave is prominent and the aortic
    notch approximates toward the  respiratory line.—Fully Di-
    crotic,  where  the aortic wave is prominent and the aortic
    notch on a level with  the respiratory line.—Hyper-dicrotic,
    where the aortic notch falls below the respiratory line.
  The depth of the aortic notch shows the tension or emptiness of
the vessels.  The less the  depth the greater the tension.  The
greater the depth the greater the emptiness of the vessels.*

         CAUSES OF EPIGASTRIC PULSATION.
Aneurism of caeliac axis.
Aneurism of abdominal aorta.
  * A state of great tension after scarlet fever is indicative of a developing kid-
ney complication. 
20
PROMINENT SYMPTOMS OF DISEASE
Tumors lying upon the abdominal aorta.
Displacement of the heart toward the right side.
Pulsation in the hepatic veins and  inferior vena cava (due to tri-
    cuspid regurgitation).
Transmission of the heart impulse through the left lobe of the
    liver.
A relaxed condition of the abdominal aorta, or its loose  attach-
    ment to the vertebrae.
Hypertrophy of right auricle (as in emphysema, tricuspid regurgi-
    tation, etc.).
CAUSES OF DISPLACEMENT OF APEX BEAT OF HEART.
Downward.
    Emphysema.—Mediastinal tumors.—Cancer of lung or upper
    part of  pericardium.—Cardiac  dilatation.—Hypertrophy  of
    right and left ventricles of heart.
Upward.
    Dilatation of right ventricle of heart (?).—Distended stomach.
    Enlarged left lobe of liver.—Enlarged spleen.—Tympanites.—
    Abdominal tumors (if very large).—Ascites (if extensive).
Laterally.
    Fluid in pleural cavities.—Pleuritic adhesions.—Pleurisy.—
    Emphysema. — Mediastinal tumors. — Abdominal tumors (if
    the development is most extensive on the right side).
            CAUSES  OF ABDOMINAL  PAIN.
Conditions of Stomach.
    Gastritis (all varieties).—Ulcers  of stomach.— Cancer of stom-
    ach.-Distention of stomach.—Rupture of stomach.— Gastro-
    dynia.
Conditions of Intestines.
    Enteritis (all varieties).—Dysentery (all varieties).—Impaction
    of faeces.—Stoppage of bowel, and its causes.—Tympanites.—
    Wind colic—Lead colic—Typhoid conditions.-Tuberculous
    ulcers. — Perforation.—Typhlitis.—Peri-typhlitis. - Periproc-
    titis.—Cancer.
Conditions of Liver.
    Hepatic colic (gall-stones).—Cirrhosis.— Hepatitis.— Peri-hepa- 
POSSESSING A SPECIAL DIAGNOSTIC VALUE.
21
    titis.—Abscess of liver.—Cancer of liver.—Hydatids of liver.
    —Tumors of liver.—Pylo-phlebitis.
Conditions of Kidney.
    Renal colic  (gravel).—Renal abscess.—Pyelitis.—Pyonephro-
    sis.—Hydatids. r-Cancer.—Peri-nephritic abscess.—Addison's
    disease.
Conditions of Spleen.
    Malarial enlargement.—Leucocythemia (by pressure on other
    organs).
Conditions of Peritoneum.
    Localized peritonitis.—Tuberculous peritonitis.—Acute peri-
    tonitis.—Cancer of omentum.
Conditions of Ovary.
    Ovarian tumors.—Prostitutes' colic (ovaritis).
Conditions of Uterus.
    Metritis. — Endo-metritis.— Cancer. — Rupture.—Polypus.—
    Tubal pregnancy.—Flexions.
Conditions of Bladder.
    Cystitis (all forms).—Retention of urine.—Rupture of bladder.
    —Spasm of bladder.—Cancer of bladder.—Ulceration of blad-
    der.—Calculus.
Conditions of Vessels.
    Aneurism.—Haematocele.

          CAUSES  OF  PAIN  IN  THE  THORAX.
               Affecting Respiratory Organs.
In the Lung.
    Bronchitis (acute).—Pneumonia.—Cancer.—Abscess.—Infarc-
    tion.—Phthisis.—Foreign bodies in bronchi.
In the Pleura.
    Pleurisy  (all varieties).—Pneumo-thorax.—Haemo-thorax. —
    Cancer.
Located in Mediastinal.
    Mediastinal tumors.—Diaphragmatic hernia.
              Affecting Heart and Coverings.
In the Heart and Pericardium.
    Pericarditis  (all varieties). — Pneumopericardium.—Haemc- 
22
PROMINENT SYMPTOMS OF DISEASE
    pericardium.—Cancer of pericardium.—Myocarditis.—Ulcer-
    ative endocarditis. —Angina pectoris. - Cardiac neuralgia.
                Affecting Walls of Thorax.
Surgical Conditions.
    Contusions.—Traumatisms.—Fracture of ribs.—Fracture  of
    vertebrae (dorsal).—Dislocation of vertebrae (dorsal).
Diseased Conditions.
    Intercostal neuralgia. — Muscular rheumatism.—Abscess  in
    soft tissues over the thorax.—Cancer of soft tissues.—Cancer
    of thoracic walls.—Tumors of thoracic  walls.—Stricture  of
    oesophagus.
Abdominal Causes.
    Dyspepsia.—Abdominal pressure upward.

                  CAUSES  OF   VOMITING.
                            Local.
Gastritis (all varieties).—Gastric cancer.—Gastric ulcer.—Dyspep-
    sia.—Stricture  of stomach.—Cirrhosis of liver (from passive
    hyperaemia of the stomach).—Cholera (from desquamation  of
    the epithelium).—Cholera  morbus.—Impaction of  faeces.—
    Peritonitis.—Strangulated  hernia.—Volvulus. — Intussuscep-
    tion.—Worms in stomach or intestines.—Mechanical irritants
    (as mustard, emetics, poisons,  etc.).
                           Reflex.
Diseases of  uterus.—Diseases of ovaries.—Diseases of kidney.—
    Diseases of spleen.—Diseases of liver.—Diseases of bladder.—
    Diseases  of testicle.—Diseases of brain.—Diseases of spinal
    cord.—Pregnancy.—Irritation  of  palate or fauces.—Irritation
    of olfactory nerve (by odors).—Severe pain (from any cause).
                            Blood.
Poisons of a Medicinal Nature.
    Emetics.—Narcotics.—Cardiac sedatives.—Anaesthetics.
Poisons from the Body.
    Uraemia.— Cholaemia.—Ammonaemia.—Uric  acid. — Choles-
    traemia.
Malarial poisoning. 
           POSSESSING A SPECIAL DIAGNOSTIC VALUE.         23

All the fevers.
Hemorrhage (if profuse).
Anaemia.
Chlorosis.
                CAUSES OF  HEADACHE.
                      Cranial Causes.
Anaemia of cerebral capillaries.—Congestion of cerebral capillaries.
    —Thrombosis  of  cerebral capillaries.—Embolus of cerebral
    capillaries.—Cerebral apoplexy.
Inflammatory Diseases.
    Meningitis  (9 varieties—see  page 9). — Cerebritis. — Cerebral
    abscess.—Caries and necrosis.
Tumors of meninges and of brain substance (see page 9).
Cerebral concussion.
                       Reflex  Causes.
Abnormal states of stomach.—Abnormal states of uterus.—Preg-
    nancy. —Constipat;on.—Excessive venery.
                       Blood Causes.
Poisons.
    All  the fevers.—Malaria.—Diphtheria.—Syphilis.—Uraemia.
    —Cholaemia.—Cholestraemia.—Pyaemia.—Septicaemia.—Medi-
    cinal agents.—Alcohol.
Anaemia.
Chlorosis.
Scurvy.
Purpura.
                   CAUSES OF  CHILL.
                      General Axiom.
  Any disease in which a marked and sudden rise in temperature
occurs, may be ushered in with or accompanied by a chill.
1.  All inflammatory diseases  of any of the various  organs or
    structures of the body, if severe, may begin with a chill.
2.  Blood Poisons.
    Pyaemia.—Septicaemia.—Puerperal fever.—Malaria.—All the
    fevers.—Erysipelas.—Surgical fever.
3.  Nervous Causes.
    Sudden shock.—Nervous exhaustion.—Mental emotion. 
24
prominent symptoms of disease
                 CAUSES  OF DYSPNOEA.
  Is  due to some mechanical interference to the free entrance of
air to the lung.
Causes abor the Larynx.
   May result  from pressure  on facial  nerve.--May result from
   obstruction in nares.—Suppurative tonsillitis.—Retro-pharyn-
   geal abscess. — Cancer of mouth or  pharynx.—Tumors  of
   mouth or pharynx.—Foreign bodies in pharynx.
Causes in the Larynx.
   Laryngitis (5 forms—see page 13).—(Edema glottidis.—Laryn-
   gismus stridulus.—Laryngeal tumors.—Laryngeal paralysis.—
   Pressure upon the larynx.—Foreign bodies in larynx.
Causes in Bronchi.
   Bronchitis (its various forms).—Asthma.—Foreign  bodies in
   the bronchi.—Hemorrhage  from a bronchus.—Pressure on a
   bronchus. —Bronchial dilatation.
Conditions of the Lungs.
   Emphysema. — Pneumonia. — Phthisis. — CEdema.— Conges-
   tion. — Infarction. — Apoplexy.—Abscess.— Cancer. — Gan-
   grene.—Atelectasis.—Compression of the lung.
Conditions of the Pleura.
   Pleurisy, acute. — Pleurisy, subacute. — Pleurisy, chronic
   (empyema).—Pleuritic adhesions.—Hydro-thorax.—Pneumo-
   thorax.—Hydro-pneumo-thorax.—Haemo-thorax.—Cancer.
Conditions of the Heart.
   Pressure on the heart.—Enfeebled heart's action.—Mitral dis-
   ease.—Rupture of valves.—Angina pectoris.—Cardiac dilata-
   tions.—Fatty heart.—Myocarditis.—Endocarditis  (ulcerative
   form chiefly).—Greatly accelerated heart's action.
Conditions of the Pericardium.
   Pericarditis with effusions.—Pericardial adhesions.—Pneumo-
   pericardium. — Hydro-pericardium.  — Haemo-pericardium.—
   Cancer of pericardium.—Pus in pericardium.
Conditions of the large Vessels.
   Aneurism of arch (by pressure  on lung).—Aneurysm at peri-
   cardial sac (by pressing on heart).—Air in veins. 
           possessing a special diagnostic value.         23

Conditions of Air Respired.
    Deficiency of oxygen.—Too high altitudes.—Deleterious sub-
    stances and impurities in the air.
Conditions of Blood.
    Anaemia.—Chlorosis.—Poisons.
Conditions of the Nervous System.
    Diseases of the brain.—Diseases of upper part of the spinal cord.
    —Injury to or pressure upon the following nerves: Pneumo-
    gastric, Phrenic, Spinal Accessory, Laryngeal, Cardiac.—Ex-
    haustion.—Tetanus.—Hydrophobia.
Conditions affecting Parietes or Muscles of Chest.
    Spasm of chest muscles.—All painfid  affections of structures
    external to chest.—Paralysis of respiratory muscles.—Wounds
    or  contusions of soft tissues.—Ossified cartilages.—Fracture
    of ribs.—Dislocation or fracture of spine (in dorsal region).
Conditions affecting the movements of the Diaphragm.
    Enlarged organs,  including pregnancy.—Tympanites.—Asci-
    tes.—Peritonitis (from the pain).—Tumors.
                  CAUSES  OF JAUNDICE.
                Hepatogenous (Obstructive).
Affecting the common Bile-duct.
    Congenital defect of the valve in the duct.—Extension of catar-
    rhal inflammation from the intestines.—Plugging of duct by
    calculus.—Plugging of duct by hydatids.—Plugging of duct by
    mucus.—Plugging of duct by foreign bodies.—Plugging  of
    duct by worms.—Stricture of the duct.—Pressure on duct by
    abdominal tumors.—Pressure on duct by enlarged lympha-
    tics.
Affecting the Radicals of the Bile-ducts.
    Cancer  of the  liver.—Hydatid of  the liver.—Abscess of the
    liver.—Cirrhosis of  the liver.—Gummata.—Tuberculosis.—
    Hyperaemia.—Hyperplastic inflammation of the capsule of
    Glisson. in the transverse fissure of the liver.
              Hematogenous  (Non-obstructtve).
Blood Poisons.
    Malaria. —Antimony. —Phosphorous. —Snake bites.—Pyaemia.
    —Septacemia. —Anaesthetics .—Fevers. 
26
prominent symptoms of disease
Emptiness of blood-vessels of the liver (favoring osmosis).
Hypersecretion of bile.
Acute yellow atrophy.
Fevers.
Pneumonia.
Mental emotions.
Secondary to the hepatogenous variety.
                    CAUSES OF  COMA.
                      Cranial Causes.
By producing Pressure or Injury.
    Bony tumors.—Suppuration, from caries or necrosis.—Depres-
    sed  fracture. — Meningitis (9 varieties — see page 9) due  to
    pressure from the  exudation. — Meningeal hemorrhage. —■
    Meningeal tumors  (see page 9).—Abscess of brain.—Sclerosis
    of brain.—Apoplexy.—Tumors of the brain (see page 9).
Affecting the Generative Power of Nerve Centres.
    Cerebral softenings,  red, white, and yellow.—Cerebral  con-
    cussion. —Cerebral anaemia.—Thrombosis. —Embolism.
Nervous Causes.
    Epilepsy. — Hysteria.—Catalepsy. — Syncope  (through  the
    sympathetic).—Reflex coma (especially in children).
Blood Poisons.
    All  the fevers.—Malaria. — Diphtheria.—Uraemia.—Pyaemia.
    —Septicaemia.—Alcoholism. — Cholestraemia.—Ammonaemia.
    —Narcotics, such as chloral, opium, etc—Cholaemia.—Anaes-
    thetics.
                  CAUSES  OF  ASCITES.
In the Liver.                    m
    Pressure on portal vein from abdominal tumors.—Atrophy of
    liver.— Cirrhosis of liver (from pressure on portal vein).—Can-
    cer.—Waxy liver.—Enlarged lymphatic glands in transverse
    fissure of the liver.—Hydatids.—Abscess.—Tubercle.—Gum-
    mata.—Portal thrombosis.
 In the Heart.
    Triscupid regurgitation (by causing imperfect venous return
    to the right auricle). 
POSSESSING A SPECIAL DIAGNOSTIC VALUE.         2?
 In the Lungs.
    Emphysema.—Cancer.—Fluid  in  pleural  sacs.—Mediastinal
    tumors (by causing insufficiency of tricuspid valve).
 In the Kidneys.
    Chronic Bright's (by producing a general hydraemia).
 Peritoneal Causes.
    Cancer of peritoneum.—Tubercular disease of peritoneum.^
    Chronic inflammation of peritoneum.
 Blood Causes.
    Anaemia.—Hydraemia.—Chlorosis.—Purpura.—Scurvy.

  CAUSES  OF HEMORRHAGE   FROM  THE  DIGESTIVE
                           TRACT.
              From the  Stomach  (Hematemesis).
 Dependent on Stomach.
    Acute  catarrhal gastritis. — Toxic  gastritis.—Phlegmonous
    gastritis.—Gastric ulcer.—Gastric cancer.
 Dependent on Hepatic Changes.
    Cirrhosis of liver (by obstructing portal circulation).—Acute
    yellow atrophy.—Portal thrombosis.—Pressure on portal vein.
Dependent on the Vessels.
    Traumatism.—Hemorrhagic  diathesis (usually due to an ab-
    normality of the coats of the blood-vessels).—Pulmonary ob-
    struction (by producing tricuspid regurgitation).
Dependent on the Blood.
    Malaria. —Scurvy. —Purpura. —Yellow fever.
 Vicarious Causes.
    Hemorrhoids. —Menstruation.
                  Intestinal Hemorrhage.
Dysentery.—Typhoid fever.—Yellow fever.—Malarial  poisoning.
    —Tuberculous ulceration. — Cancer.—Scurvy. — Purpura._■
    Traumatism.—Obstruction of portal vein.

                CAUSES  OF  HAEMOPTYSIS.
Those Situated above the Lung.
    Diseases of larynx.—Diseases of trachea.—Diseases of bronchi.
   (Such as Congestion, Inflammation, Ulceration, Cancer, etc.) 
28            prominent symptoms of disease
In the Lung.                                           ,    .
    Mechanical hyperaemia (from too high altitudes, and the  in-
    halation of irritants).-Traumatism.-Pulmonary congestion.
    —Pneumonia, acute.—Pneumonia, chronic—Abscess.—Gan-
    grene -Apoplexy.- Phthisis.-Cancer.-Weak capillanes.-
    Aneurism of pulmonary  capillaries.-Pleuritic  adhesions
    (causing interference with the lung tissue).
Mediastinal Causes.
    Tumors, pressing on the pulmonary vessels.
Circulatory Causes.
    Aneurism of arch of aorta (breaking into a bronchus).—Mitral
    diseases.—Hypertrophy of right ventricle.—Dilatation of left
    ventricle.—Diseases of pulmonary vessels  (as aneurism of pul-
    monary artery).—Aneurism of  the arteria innominata,  the
    carotid, or subclavian arteries opening into the air-passages.
Nervous Causes.
    Vicarious menstruation.
Blood Causes.
    Hemorrhagic diathesis.—Scurvy.— Purpura.

                 CAUSES  OF  APHONIA.
Inflammatory.
    Catarrhal laryngitis (acute and chronic).—Tuberculous laryn-
    gitis.—Syphilitic laryngitis.—Croupous  laryngitis. — Diph-
    theritic laryngitis.
New Growths.
    Cancer. —Polypi.—Vegetations.
Mechanical Causes.
    Hemorrhage of vocal cords.—Paralysis of muscles of the larynx.
    —Thickening of cords.—Spasm of cords.—Rupture  of  cords.
    OMeina of the larynx.—Foreign bodies in the larynx.—Exter-
    nal pressure  upon the larynx.
Nervous Causes.
    Injury to the brain in the region of origin of  spinal accessory
    nerve.—Injury to the trunks of  the pneumo-gastric or spinal
    accessory nerves.—Hysteria. —Mental excitement (from fright,
    anger,  etc.).—Diphtheria.—Shock. 
possessing a special diagnostic value.
39
                 CAUSES  OF  HEMIPLEGIA.
                           Cranial.
 Affecting the Bones.
    Depressed fracture.—Necrosis.—Caries.—Exostosis.—Cancer.
 Affecting the Meninges.
    Meningitis (9 varieties [see page 9]).—Tumors (Cancer, Tuber-
    cle, Cholesteatoma, Gummata, Myxoma, Lipoma, Psammoma,
    Hydatids, Cysts).—Meningeal hemorrhage.—Abscess (between
    dura mater and the bone).
 Affecting the Brain Substance.
    Cerebral softenings (red, white and yellow).—Cerebral tumors
    (see above and add " Glioma ").—Sclerosis.—Abscess.
 Affecting the Vessels.
    Thrombosis.—Embolism.—Apoplexy.
                           Spinal.
         (Involving only the lateral half of spinal cord.)
 Affecting the Bones.
    Same as those among  the  cranial causes, with dislocation
    added.
 Affecting the Meninges.
    Spinal meningitis.—Cerebro-spinal  meningitis.—Meningeal
    hemorrhage.—Tumors (same as those under  cranial causes).
 Affecting the Substance of Spinal Cord.
    White softening. —Red  softening or myelitis.—Tumors (same
    as those under cranial  causes).—Sclerosis of the cord.—Ab-
    scess of the cord.—Congestion of the cord.—Apoplexy.
                        Functional.
 Diphtheria. —Epilepsy. —Hysteria —Chorea.—Poisons.

               CAUSES OF PARAPLEGIA.
                           Spinal.
 Same as spinal causes of hemiplegia (provided both lateral halves
    of the cord are involved).
                        Functional.
Anaemia.—Rheumatism.—Syphilis.—Hysteria.—Diphtheria. 
30
prominent symptoms of disease
                          REFLEX.
Phymosis.—Diseases of bladder.—Diseases of uterus.—Diseases
    of intestinal canal.—Diseases of ovary.—Diseases of clitoris.
    —Diseases of kidney.
         CAUSES OF SUPPRESSION OF URINE.
Acute active congestion of kidney.
Blood-poison of yellow fever.
Blood-poison of scarlet fever.
Blood-poison of small-pox.
Suppurative interstitial nephritis (following injury to  or  opera-
    tions on the urinary tract).
Any inflammatory diseases may cause it.

           CAUSES OF RETENTION OF URINE.
Dependent on the Urethra.
    Organic urethral  stricture.—Hypertrophy of prostate.—Sup-
    puration  of prostate. — Pressure on urethra from perineal
    abscess.—Pressure on urethra from perineal tumors.—Pressure
    on urethra from  fracture of  pelvic  bones. — Rupture  of
    urethra.—Calculus in urethra.—Spasm of urethral muscular
    fibres.—Congestion of urethral mucous membrane.—Fracture
    of penis.—Cancer of penis.—Polypus of the urethra.
Dependent on the Bladder.
    Paralysis of  the  bladder. — Atony  from  over-distention  or
    shock.—Cancer at neck of the bladder.—Vegetations at neck
    of the bladder.—Stone in  cavity of the bladder.—Rupture of
    the bladder.—Pressure from tumors.

             CAUSES OF BLOOD IN  URINE.
                           Local.
Dependent on the Kidney.
    Hyperaemia.—Cancer.—Pyelitis.—Infarction.—Stone in pel-
    vis. —Abscess.—Traumatism. —Parasites.
Dependent on the Ureter.
    Cancer. — Traumatism. — Stricture.—Ulceration.—Impaction
    of calculus. 
POSSESSING A SPECIAL DIAGNOSTIC VALUE.
3l
 Dependent on the Bladder.
    Cystitis.—Over-distention.—Cancer.—Stone  in bladder.—
    Vegetations.—Rupture.—Ulceration.—Traumatism.
 Dependent on the Urethra.
    Gonorrhoea.—Chordee.—Chancre or chancroid.—Cancer.—Im-
    paction of a calculus.—Rupture of urethra.—Rupture of a
    prostatic abscess.—Fracture of penis.—Traumatism.
                        Blood-Causes.
 All of the Fevers and Malarial Conditions.
 Poisons.
    Turpentine.— Copaiba.—Cantharides.—Cubebs.—Alcohol.
 Scurvy.
 Purpura.
                      Vicarious Causes.
 In connection with amenorrhoea.
 In connection with hemorrhoids.

             CAUSES OF  PUS IN THE  URINE.
 Dependent on the Kidney.
    Pyelitis.—Cancer of kidney.—Metastatic abcess of kidney.—
    Stone in the pelvis of kidney.—Perforation of peri-nephritic ab-
    scess.
 Dependent on the Bladder.
    Cystitis in all its  forms.—Stone in the bladder.—Cancer of
    the bladder.
 Dependent on the Urethra.
    Cancer of the penis.—Prostatic abscess.—Ulceration.—Gonor-
    rhoea. —Urethritis.
 Dependent on the Adjacent  Viscera.
    Escape of pus from other organs into the genito-urinary tract

          CAUSES  OF INSTANTANEOUS DEATH.
In the Heart.
    Aortic regurgitation.—Heart-clot.—Rupture  of  the heart.—
    Angina pectoris.—Rupture of aneurism into the pericardial
    sac.—Fatty heart. 
32
prominent symptoms of disease
Dependent on Blood-vessels.
    Apoplexy.—Air in veins.
Unclassified Conditions.
    Concussion of solar plexus.—Perforation of some abdominal
    viscera (from shock [?] ).—Sudden injury to brain or medulla
    oblongata (as occurs in apoplexy).

              TYPES  OF  EXPECTORATION.
Muco-purulent.
    Occurs in phthisis—and is present in all forms of bronchitis,
    except croupous.—Appears after attacks of asthma.—Accom-
    panies emphysema,  as a rule, since it is usually complicated
    by bronchitis.
Pearls of Tenacious Mucus.
    Are frequently detected in emphysema.
Pneumonic Sputa.
    Very tenacious at all times; at first, scanty and whitish; later
    on, pink or brick-dust in color; in bad cases,  resembles " prune
    juice."
Profuse- Watery.
    Occurs in pulmonary oedema (prominently).
Gangrenous Sputa.
    Characterized by a putrid odor, and the presence of gangrenous
    shreds of lung-tissue (present in  gangrene of the  lung and
    in phthisis).
Currant Juice.
    Occurs in cancer of the lung.
Purulent.
    May occur in abscess of lung; or in empyema, when the pleu-
    ral cavity communicates with a bronchus.—Occurs also  in
    abscess of liver, by perforation of diaphragm and  pleura.
Fibrinous Casts.
    Present, in  shreds or patches, in true membranous croup.
    Present  in croupous bronchitis (when they resemble a tree in
    form).
Sputa, with Small Blood-Clots.
    Is usually characteristic of pulmonary infarction. 
possessing a special diagnostic VALUE.          33
 Sputa, Streaked with Blood.
     Present, as a rule, in tuberculous phthisis during the stage of
     deposit.—May exist also in a severe type of bronchitis and in-
     flammatory sore throat.
 Blood.
     Occurs in  aneurism; pulmonary apoplexy; bronchial hemor-
     rhage.
                  TYPES  OF DIARRHOEA.
 Symptomatic.
     Typhoid fever.—Dysentery.—Cholera.—Exhaustion. — Mala-
     rial conditions.—Fatty diarrhoea.—Typhus (in later  stages).—
     Tuberculosis (in  later stages).
 Irritative.
     From indigested food, or any irritant (as cathartics,  etc.).
 Sympathetic.
     In connection with worms.—In connection with dentition.—
     In connection with menstruation.—In connection with nerv-
     ous shock.—In connection with fright.—In connection with
     mental exercise.
 Eliminative.
     An evidence of nature's attempt to eliminate, through the in-
     testinal tract, some accumulated poison, or an excess of some
     salt absorbed, as in the case of saline cathartics.

             CAUSES OF ALBUMINOUS URINE.
  Mollifies Ossium.—Excessive use of albuminous food.—Irrita-
 tion of the renal nerves.—Irritation of the floor of the fourth ven-
 tricle.—Inhalation of  irritants (as  arsenuretted hydrogen  and
 carbonic acid).—Dyspepsia.—Acute or Chronic Bright's Disease of
 the Kidneys (due to  structural changes in those organs).—Preg-
 nancy  and the puerperal state (due to obstruction of  the renal
 veins from pressure or an excess of excrementitious substances in
 the blood to be  eliminated by the kidney).—The various fevers, as
 typhoid fever,  scarlet fever,  measles, yellow fever, small pox,
 cholera, ague, diphtheria, (due to pyrexia and  the operation of a
specific poison indicating serious structural changes  in the kid- 
84
PROMINENT SYMPTOMS OF DISEASE
neys).—Certain inflammatory diseases, such as articular rheuma-
tism, peritonitis, pneumonia, traumatic fever, etc :—Obstruction
to the circulation of the blood, as occurs in emphysema, valvular
heart lesions, abdominal tumors, cirrhosis of the liver, atheroma,
etc :—An hydraemic and disordered state of the blood and atony
of the tissues, as in purpura, scurvy, pyaemia, hospital gangerene,
also haematinuria ; and finally saturnine intoxication.

              CAUSES  OF  CHYLOUS URINE.
  Long residence in tropical climates.—A fail or shock to the ner-
vous  system.—Excessive mental or bodily work.—Cessation of
lactation.—Tuberculosis of the lungs.—Fatty stage of parenchy-
matous nephritis.—Some derangement of the process of assimila-
tion causing  an elimination of food elements by the kidneys.—
Some imperfectly understood derangements of the  submucous
tissues of the urinary passages  or bladder.—Hypertrophy of the
lymphatic or lacteal vessels, or the inguinal glands (which become
enlarged and tumified and ultimately discharge their contents in-
to the urinary  passages.—It may possibly be caused by minute
parasites which infest the urinary passages (?).
  Characteristic of Chylous Urine :
  (1st.), a whitish or milk color.—(2), more or less perfect sponta-
neous solidification of the  urine on standing, which in marked
cases may allow the urine to be turned out like a jelly from one
receptacle to another.—(3), a strongly albuminous reaction to heat
and nitric acid, and (4), the presence of fat globules in a condition
resembling that of chyle when examined bv the microscope.
             CAUSES  OF  HEPATIC ABSCESS.
  Varieties.—Acute, chronic, metastatic or pyaemic,  and inflam-
matory.  Wounds and  contusions;  impaction in the gall-ducts
of angular substances; ulcerations or gangrenous affections of
the abdominal organs; embolus of the branches of the portal vein
or some injurious irritating matter,  carried to the liver through
the portal vein, or some other vein as the  hemorrhoidal; inflam-
mation of the parenchyma (Glisson's capsule) from injuries, sup-
puration, thromboses and inflammation of the veins ; inflamma-
tion and suppuration of the' gall-bladder or gall-ducts; exposure to
vicissitudes of temperature (especially in  hot countries); malar-
ious poisons; cold; nervous depressions; pregnancy; drunkenness. 
DISEASES  OF THE  RESPIRATORY
            ORGANS. 
 
DISEASES  OF THE   LARYNX.
  These may he primary, when the larynx is first affected, sJ d of
 a purely local  type; or secondary, when the disease occurs *is a
 complication.
                        VARIETIES.
 Catarrhal laryngitis, acute and chronic
 QMema glottidis, or inflammation of the submucous tissue oi the
    larynx.
 Croupous laryngitis, or " membranous croup."
 Ulcers—which may be catarrhal, typhus, variolus, tuberculw, or
    syphilitic
 Nervous affections—spasm and paralysis.
 New formations—polypi, cancer,  tubercle, ossification of carti*
    lages, etc.

        ACUTE  CATARRHAL  LARYNGITIS.
                       DEFINITION.
  Is an inflammation of the mucous membrane of the  larynx, of
either a partial or  general character, resulting in catarrhal pro-
ducts.
                   MORBID ANATOMY.
  The mucous membrane of the larynx will be found  to be red,
swollen, and softened, and its surf ace covered with mucus, contain-
ing epithelial or pus cells. When the deeper tissues are affected, a
tumefaction of the parts may take place, from accumulation of the
inflammatory products beneath the mucous membrane ; which
may be attended with great danger. Erosions or ulcers may occur,
accompanied by ecchymosis of the membrane, and  escape  of
blood into the secretions (due to rupture of the capillary v^sels).
                        ETIOLOGY.
                   Predisposing Causes.
Badly nourished, cachectic subjects.—Constitutional vice. 
38          DISEASES of the respiratory organs.
                      Exciting Causes.
Chilling of the surface  (by exposure).—Mechanical violence.—In.
    halation of irritant gases, etc.—Exanthematous fevers (chiefly
    typhus).  Blood poisons (diphtheria,  syphilis, etc.).—Tonsil-
    litis.—Erysipelas:—An accompanying influenza or bronchitis.

                        SYMPTOMS.
                         Rational.
The approach is insidious.
Sore throat and constriction exist.
Cough—is at first harsh and stridulous, becoming metallic as the
    disease increases.
Tenderness on pressure over the larynx.
Tickling sensation in the throat.
Dyspnoea.
Dysphagia.
Prolonged and wheezing inspiration and expiration, if the inflam-
    mation is severe. The patient is often unable to lie down on
    this account.
Expectoration—(if any) is tenacious at first, and, later on, is thick,
    purulent, and abundant.
Face—flushed at  onset (the skin is usually hot and dry).
Countenance—pale and anxious as the disease increases.
Temperature—elevated—105°.
Pulse—hard and  frequent.
Drowsiness, suffocation and cyanosis—from imperfect aeration of
    the blood.
Delirium—in severe cases.
Coma—in severe  cases.
Death—in severe cases.
                         Physical.
Inspection—respiration  at  first  is  labored, but, later on, may
    become of a gurgling and gasping type.
Auscultation—a feeble vesicular murmur is heard over the lungs
    —which may be entirely absent.
On Laryngeal Examination.
    The mucous membrane is found to be bright-red. If severe, 
ACUTE CATARRHAL LARYNGITIS.
39
     there may be  oedema ; the parts are red, swollen, and semi-
     transparent, and the oedema is usually on the ventricular folds.
     These changes may extend to the trachea,  or remain in the
     mucous membrane of the larynx or of the epiglottis.

                DIFFERENTIAL DIAGNOSIS.
   Croupous "laryngitis,  diphtheria,  oedema  laryngis,  spasmodic
 asthma, hysteria,  laryngeal spasm, thoracic aneurism,  may be
 mistaken for this disease.  In very young children, it must be dis-
 tinguished from croupous laryngitis, which is seen by the laryngo-
 scope  as a  false  membrane; but  the history, constitutional
 symptoms, and physical examination will  stamp either of the
 other diseases.
                         PROGNOSIS.
 In adults, it depends upon the amount of oedema present.
 In infancy, if it is  severe, the disease is always fatal.

                    CAUSE OF DEATH.
   Death may occur in a few hours from oedema glottidis, if the
 attack be severe ; but if mild, five to eight days usually elapse be-
 fore death occurs.   It is caused from closure of the rima glottidis,
 from swelling of the mucous and submucous  tissues, and it may
 also occur from pulmonary or cerebral congestion.

                        TREATMENT.
   Venesection—only if the patient is robust, and there is a likeli-
 hood of syncope.   A warm, moist, uniform temperature is essen-
 tial.  The temperature of the room should never be  below 76 ° F.
 Absolute rest to the larynx is all-important.  Vapor inhalations
 should be resorted to early in the disease and persevered with.
 Quinine should be  given in large doses and cinchonism produced;
 for a child three years of age, gr. xx. may be administered during
 the first twenty-four hours, if it is suffering from a severe attack.
 If there is oedema,  the parts should  be scarified, or  tracheotomy
 performed, if you are unable to  scarify; but tracheotomy may
 cause the inflammation  to extend to  the trachea, and result in
pneumonia and bronchitis. 
40
DISEASES OF THE RESPIRATORY ORGANS.
       CHRONIC  CATARRHAL  LARYNGITIS.
                         SYNONYM.
  " Clergyman's sore throat."—Laryngeal Phthisis.

                       DEFINITION.
  Is a chronic inflammation of the lining membrane of the larynx
(which may be general, or partial, or manifest a tendency to remain
stationary), and in which the vessels of the areolar tissue slightly
participate.
                   MORBID  ANATOMY.
  When fully developed,  the  mucous surface is usually coated
with mucus or pus, and is of a dark or grayish-red or blue  color,
due to ecchymosis, and may  be softer or firmer  than normal.
The glands are enlarged and prominent;  and there may also be
erosions,  fissures, ulcers,  polypi, etc.  Sub-mucous thickening
and oedema may also occur, producing considerable narrowing of
the glottis.  The epiglottis may often be eroded.
                        ETIOLOGY.
                   Predisposing  Causes.
Pharyngeal  inflammations (from alcoholism  or  tobacco in ex-
    cess).—Chronic bronchitis of old age.—It may be a primary
    disease, or a sequela of acute laryngitis.
                     Exciting Causes.
Irritating inhalations.—Morbid growths (laryngeal).—Pulmonary
    phthisis, syphilis, etc.—An extension of a laryngeal,  catar-
    rhal, or follicular faucitis (when the racemose glands of the
    larynx are principally affected).

                       SYMPTOMS.
                         Rational.
Voice.
    Chronic hoarseness, or a husky whisper, or an ultimate loss of
    voice. 
chronic catarrhal laryngitis.
41
Cough.
    Hoarse or stridulous.
Expectoration.
    Muco-purulent or purulent (possibly streaked with blood).
QSdema—as shown by the laryngoscope.
Pain and tenderness on pressure over the larynx.
                          Physical.
Auscultation.
    Moist rales over the larynx may be detected.
Laryngoscopic examination.
    Shows general or partial hyperaemia of the lining membrane,
    and dilatation, or contraction of the larynx ; a muco-purulent
    secretion on the mucous membrane ; or, the membrane may
    be dry and shining in appearance.—The orifices of the glands
    may be seen  as  pale specks on the congested membrane, or
    as red circles.  In syphilitic or phthisical patients, in addition
    to the  above symptoms, there may be thickenings, ulcera-
    tions, or  papillary excrescences.—Chronic oedema, of one or
    both of the  aryteno-epiglottidean folds, is often  observed in
    the chronic laryngitis of phthisis.

                DIFFERENTIAL  DIAGNOSIS.
  From laryngeal growths; nervous affections; pulmonary phthi-
sis (when examination of the lungs  decides); and syphilis (where
the history decides).
                        PROGNOSIS.
  Depends upon the pathological associations.
  Recovery is rare,  if it occur in  connection  with pulmonary
phthisis; the chances of recovery are better if it depend on syphilis,
but the voice is permanently affected, as a rule.
  Is usually  good, unless  complications exist.  The disease is
rarely fatal in itself.
                        TREATMENT.
  Local internal applications should be frequently applied to  the
diseased tissues.   A solution of nitrate of silver (gr.  Ix. to 1 i. of
water), or chloride of zinc (gr. xxx. to  § i. of glycerin), is often
ased with benefit. 
42          diseases of the respiratory organs.

  Inhalations with  either of the following prescriptions may be
applied for five minutes at a time, three times a day : R. 01. pini,
 3ij.: Mag. carb., gr. ij.; Aquae, § ij.; Sig. one drachm in a pint
of hot water (at 150° F.).—R Creasoti,  3 iij. ;  Glycerinae,  3 iij-,
Aquae, 3 iij.; or R 01. juniperis, ni 1.;  Mag. carb., gr. x.; Aquae,
 |ij.; or R Acid, carbol.,  3ss.; Glycerinae, 3ij-5 Aquae, |ij.
  Nebulized liquids, or spray of either of the following drugs,
should, like the inhalations, only be continued for five minutes at
a time : alum, perchloride of iron, tannin, or sulphate of  zinc,
from gr. i.-xx. to the ounce of water.
  Rest of voice is imperative, and the  patient should be removed
to a warm dry climate.   If the disease is due to syphilis, potassium
iodide should be administered in large doses, and the  p itient put
under proper hygienic treatment ; or, if due to phthisis, the
general treatment of phthisis is indicated.

                 03DEMA  GLOTTIDIS.
                        DEFINITION.
  Is a dropsical effusion, usually of inflammatory origin, in the
areolar tissue above the vocal bands; or. in other words, an oedema
of the upper portion of the larynx.

                    MORBID  ANATOMY.
  The changes that  occur in this disease are principally observed
during life; as,  after death,  owing  to the disappearance of the
greater part of the effusion, the  mucous membrane is found to be
wrinkled, and probably a very small quantity or  only a trace of
the effusion can be found.
  On examination, during life, a tumor, about an inch or so in dia-
meter, may be observed projecting,  on one or both sides, into the
cavity of the larynx  and often into the pharynx, which may com-
pletely close the laryngeal opening.  The mucous membrane  may
be either red or pale. The serous effusion commences in the loose
cellular tissue beneath  the mucous  membrane, principally in the
aryteno-epiglottidean folds,  at the base of the epiglottis. When
the tumor  is pricked,  a  clear,  turbid, or purulent fluid escapes. 
03DEMA GLOTTIDIS.
43
 Collapse of the tumor and wrinkling of the mucous membrane
 then take place.

                         ETIOLOGY.
   The predisposing causes are: constitutional disturbance; any in-
 flammation of adjacent tissue, or local irritation (as acute laryn-
 gitis); erysipelas; deep-seated cervical abscesses; acute tonsillitis;
 laryngeal ulceration; due to typhus, typhoid, scarlatina,  and
 small-pox ; Brighfs disease;  venous obstructions in cardiac dis-
 eases; and thoracic aneurism.

                         SYMPTOMS.
                         Rational.
 Dyspnoea on inspiration, (often alarming).
 No fever or constitutional disturbance.
 Suffocative breathing (often the first indication).
 Paroxysm of strangulation.
 Cyanosis.
 Veins prominent (due to obstructed venous return).
 Drowsiness (due to  approaching cyanosis).
 Cold extremities.
 IncUnation to  rid the upper part of the throat of some supposed
    secretion.
                          Physical.
 The laryngoscope  reveals two small tumors, about one-half an
    inch to one inch in length, which are at  first smooth  and
    round and possibly oval, situated at the ventricular folds, thus
    causing difficulty in laryngeal respiration.

                DIFFERENTIAL DIAGNOSIS.  .
  Is easy, on account of the  circumstances under which it is de-
veloped, together with the sudden  occurrence, and the peculiar
character of the respiration  ; the absence of febrile symptoms,
and the aid of the laryngoscope confirm the diagnosis.

                        PROGNOSIS
Is fatal, if not  properly attended to. 
44
diseases of the respiratory organs.
                       TREATMENT.
  Prompt surgical interference, as laryngotomy, tracheotomy, or
scarification are the only means of relief.  Medications are of no
avail.

         ACUTE  CROUPOUS LARYNGITIS.
                       DEFINITION.
  A fibrous inflammatory exudation of the larynx, which usually
commences on  th** tonsils and often extends to the trachea and
bronchi.
                   MORBID  ANATOMY.
  There exists on the mucous membrane a  whitish or yellowish-
white fibrinous layer, often covered with dots or lines.  This mem-
branous exudation may be in patches, or form a cylinder, extend-
ing into the trachea or bronchi.  It may be firm in consistence,
and adhere with great tenacity to the subjacent membrane, or it
may be.soft and easily separated.  The surface is smooth,  and
adheres with great firmness to the vocal cords and upper part of
the epiglottis (whi^h possesses pavement epithelium).  The mem-
brane may be cast  off in the form of a cylinder, or shreds, in
consequence of the damming up of the secretion of the  follicles,
as well as by the serous exudation from the previously inflamed
membranes.   It may be expectorated, or undergo granular, fatty,
or mucous degeneration, thus resembling a mucous fluid ; there-
fore, in the latter case, no membranous exudation is observed.
Under the microscope it will be seen that there are generally pus
and rarely epithelial cells.  It is  questionable  whether these are
changed epithelial cells  or white globules.  The mucous mem-
brane,  likt* all inflamed tissues,  contains a varying  amount of
these celK  As  the exudation is cast off, the surface  epithelium
is quickly repaired,  and the laryngeal membrane  returns to its
normal condition.
       STAGES AND  DANGERS  OF THE  DISEASE.
Is* Stage:—Precursory or catarrhal.  There is danger of the form-
    ation of a membrane in the trachea and larynx, if the inflam-
    "nation continue downward. 
                 ACUTE CROUPOUS LARYNGITIS.              45

 2d Stage—Development.  There is danger of inflammation con-
     tinuing to the minute bronchi.
 3d Stage—Suffocation or collapse.  There is danger to the patient
     from exhaustion and carbonic acid poisoning.

                         ETIOLOGY.
   Occurs between dentition and puberty.  Rarely in very young
 infants or adults.
                    Predisposing Causes.
   Occurs in delicate, weakly, ill-fed children.
                       Exciting  Causes.
 From exposure to cold and moisture.—From sudden alteration in
    temperature.—From irritation of  hot  water, etc., applied to
    the larynx.—Follows eczematous eruptions on the head and
    face, and frequently measles, scarlatina, and small-pox.
                        SYMPTOMS.
              Precursory or Catarrhal Stage.
 Rational.
    Catarrh—mucous membrane red and tumefied.
    Slight hoarseness.
    Cough—noisy, high-pitched, stridulous.
    Crowing noise after the cough.
    Dysphagia—(puts the hand to the throat).
    Pulse—accelerated, full, and hard.
    Temperature of axilla—102° to 105°.
    Fever—intermittent.
    Redness of the face.
    Dyspnoea—most severe at night.
Physical.
    Inspection—difficult respiration.
                  Stage of Development.
Rational.
    Aphonia—speaks or cries in a whisper.
    Cough—suppressed and more stridulous.
    No expectoration.
    Head thrown back (an evidence of dyspnceaX 
46          diseases of the respiratory organs.
 Physical.
    Inspection—difficult respiration; during inspiration there is a
        contraction of the lower part of the chest and sinking
        above the clavicles.   Epigastrium is depressed, and there
        is arrested expansion of ribs.
    Auscultation—feeble vesicular murmur.
             Stage of Suffocation or Collapse.
 Rational.
    Nostrils—dilated.
    Great restlessness.
    Countenance—pale and livid (expression of fear often present).
    Pulse—rapid and feeble.
    Temperature—falls below normal.
    Cold extremities.
    Drowsiness.
    Gasping.
    Cyanosis.
    Paroxysmal dyspnoea.
    Coma
    Death.
                DIFFERENTIAL DIAGNOSIS.
 From simple catarrh of the larynx ; (spasmodic or pseudo croup) in
    nervous subjects; purely spasmodic affections of the larynx
    (in each of which the spasm gives rise to croupy symptoms);
    diphtheria involving the larynx.

                        PROGNOSIS.
In childhood, this is the most fatal of all the diseases (especially if
    membranous exudation occurs on the tonsils and epiglottis).
Favorable signs—if the paroxysms of dyspnoea are diminished in
    frequency and severity; if the breathing is not so distressed;
    if there is a gradual return of voice, and a moist sound with
    the cough.
A fatal result is indicated if the dyspnoea become more frequent
    and violent; the cough less powerful and stridulous; and when
    there is marked cyanosis and drowsiness.
The recovery is slow.  It may be weeks before the patient regains 
                           bronchitis.                      47

      the use of the voice, and violent  dyspnoea may occur during
      the whole period of recovery.

                         TREATMENT.
   In the very early stage give turpeth-mineral, Hyd. sulph. flavce,
  gr.ij., or (as it is better known) "German croup powder.*'  Pa-
  tient should  be  placed  in  a large,  well-ventilated room, with a
  temperature  about 75 to 803; and the air should be moistened by
  steam, etc, as in other laryngeal affections. Administer Quinine,
  gr.  xxx., in  gr. v. doses to  a child  to arrest inflammation.  A
  moist, nutritious diet should be given from the onset of the dis-
  ease, together with stimulants if a failure of  the vital power be-
  come apparent.
   Tracheotomy (?) is  only a temporary relief, and must be done
  early in the disease or not at all.

                       BRONCHITIS.
                         DEFINITION.
   Is an inflammation of the mucous membrane of the trachea and
 bronchi, which may vary in extent, intensity and duration.

                         VARIETIES.
   Acute catarrhal.—This form may be simple or capillary; and
 localized or general.  It occurs in infancy and old age, from acute
 catarrhal inflammation,  typhus, and measles; first  affecting  the
 large tubes, and by passing downward to the smallest tubes, often
 becomes capillary in  form.  In middle life, it affects the larger
 bronchi.
  Chronic catarrhal.—This is a secondary affection.  Is a low
 grade of inflammation of the bronchial mucous membrane, and a
 disease of adult life, having a tendency to recur, with increased
 vigor, till it becomes permanent.
  Croupous or plastic.—This may be acute or chronic  This is a
 very rare form of the disease. Is met with in the young adult, prin-
cipally in the female, and those of feeble or delicate constitutions.
 In acute fatal cases, it only lasts from three to ten days; but, in 
48          DISEASES of the respiratory organs.

those likely to recover, its duration is about fourteen days.  Com-
plete recovery is, however, exceedingly rare-


        ACUTE  CATARRHAL  BRONCHITIS.

                    MORBID ANATOMY.
  This disease is the continuation of an inflammation which
usually commences in the nasal, pharyngeal, or laryngeal mucous
membrane; or the inflammation may commence in the alveoli and
extend to the smaller tubes. The mucous membrane is found to be
swollen and red, softer and more moist than normal, and occasion-
ally ecchymotic  A clear transparent mucus is at first contained in
the bronchi, which, as the disease progresses, becomes opaque,
whitish, yellowish,  greenish, or muco-purulent; this change is
owing to an  increased number of cells contained in  the  fluid
(which are pus cells), and also to the presence of epithelium (of t<m
of the ciliated variety).
  On a post-mortem examination, the presence of mucus or muco-
pus in the tubes may be the only evidence of bronchitis; these
same changes may exist whether  the large or small tubes are
affected.  Yellow spots may be found on the surface of the lung,
occurring in young, feeble children, from gravitation of mucus or
muco-pus from the larger into the smaller tubes.  The accumula-
tion of this mucus or muco-pus may produce a temporary obstruc-
tion, and distention of the alveoli, which may be mistaken for vesi-
cular emphysema.
                        ETIOLOGY.
                    Predisposing Causes.
Infancy and old age.—Indulgence in enervating habits.—Debility,
    from any cause.—Constitutional disease (as  gout, syphilis,
    etc).—Chronic pulmonary affections (phthisis, emphysema,
    etc.).—Bad air.
                     Exciting Causes.
Chilling of  the surface of the body.—Secondary result of blood
    poisoning. — Irritation, produced by  substances  inhaled. —
    Atmospheric conditions.—Heart lesions (as mitral stenosis or 
ACUTE  CATARRHAL BRONCHITIS.
4i>
    insufficiency, or tricuspid  regurgitation). — Pressure  on the
    aorta below the bronchial  arteries, or from fluid in the peri-
    toneal cavity, or gas in the intestines pressing the blood back
    in the abdominal aorta, thus  causing congestion of the lungs
    and the bronchial tubes.
                         SYMPTOMS.
                          Rational.
 Stage of Invasion.
 Coryza. — Uneasy  sensation in  the frontal sinuses, extending
    down the nasal passage to  the larynx and trachea.—Aching
    in the back and limbs; convulsions may occur in children.
 Pain and discomfort behind the sternum.
 Sense of soreness on coughing.
 Sense of constriction in the chest.
 Cough.
    In the early stages is dry or hacking.—In the later is loose in
    character.
 Expectoration.
    Frothy mucous, muco-purulent, or purulent.
                          Physicial.
 Inspection and palpation are negative.
 Auscultation—Sibilant and sonorous rales  (in the dry stages); or
    large  and small mucous rales after the disease is fully de-
    veloped (which change their position on coughing).
                DIFFERENTIAL DIAGNOSIS.
  From pneumonia and pleurisy; but  the symptoms of the stage
 of invasion and the physical signs are sufficient to distinguish it
 from either.
                        PROGNOSIS.
  Never destroys life directly, unless it occur in very young chil-
dren; as it usually terminates  in resolution, or becomes chronic.
The inflammation may, however,  sometimes extend to the smaller
tubes, resulting in capillary bronchitis or lobar pneumonia.
                        TREATMENT.
  In the stage of invasion, a Dover's powder, and  a warm bath at 
50
DISEASES OF THE RESPIRATORY ORGANS.
night, followed in the morning by a  brisk saline cathartic (for
children a full dose of castor oil), may be all that will be required
to avert the  attack.   The patient must be kept in a warm room
of equal temperature for a few days.
  In the early stage, great benefit is derived from inhalations of
the vapor of molasses and water; or from mustard  poultices ap-
plied to the upper part of the chest.
  Quinine gr. viij-x.  should be given daily if the disease is likely
to pass into the chronic stage, or to extend to the smaller bronchi.
Oleum morrhuce, with lime-water, should also be given;  but if it
occur with gout or rheumatism, give colchicum with  alkalies.


        ACUTE  CAPILLARY  BRONCHITIS.
                        DEFINITION.
  It is an extension  of  acute  catarrhal inflammation into  the
small-sized bronchial tubes, and may be localized or diffused.
  Localized—it the inflammation is limited to the smaller tubes.
  Diffused—when the inflammation attacks the lining membrane
of all the bronchial tubes.
                   MORBID  ANATOMY.
  Is the same as in acute catarrhal bronchitis.
                        ETIOLOGY.
  The same as in acute catarrhal bronchitis.
                        SYMPTOMS.
                         Rational.
Dyspnoea—marked (patient unable to lie down).
Recurring chills.
Febrile symptoms often well  marked.   Temperature 100° to 103°.
Pulse 100 to 130, and  feeble.
Respiration—labored  and frequent; 60 to 70 per minute.
Cough—violent at first; is usually hacking in character.
Expectoration—at first, of a thick tenacious mucus; later on, It
    becomes more abundant, less tenacious, thin, and frothy
Exhaustion—marked. 
                 ACUTE CAPILLARY BRONCHITIS.               51

 Countenance—anxious and flushed; in later stages, livid.
 Great restlessness—(later on in the disease).
 Pulse—becomes small and thready as death approaches; is always
     raised in frequency.
 Body—is covered with a cold, clammy sweat as death approaches.
 Delirium—muttering.
 Coma—partial.
 Death—from apnoea (from imperfect oxygenation of the blood).
                           Physical.
 Percussion—is exaggerated in the infra-clavicular regions (unless
     oedema exist).
 Ausadtation — diminished  respiratory murmur. — High-pitched
     sibilant rales.—Subcrepitant ralee, as the disease advances.

                DIFFERENTIAL DIAGNOSIS.
  From pneumonia;  pulmonary  oedema;  acute  and  chronic
 phthisis.
                         PROGNOSIS.
  When general capillary bronchitis occurs in infancy or old age,
 or follows phthisis, Brighfs, heart disease, or any acute blood dis-
 ease, it is always attended with great danger.
  If there is difficulty of expectoration, signs of accumulation in
 the bronchial tubes,  shallow breathing, cessation of cough, dys-
 pnoea, apnoea, or failure of  heart's power, the  prognosis is un-
 favorable.
                        TREATMENT.
  The patient must be kept in bed the surface of the body covered
 with flannel, the temperature of the room be about 70%  and the
 air moistened with steam.  The  diet should be of a concentrated
 nutritious nature as milk, eggs, etc.  Dry cups must be applied
to the chest  which should afterwards be covered with an oil-skin
jacket.  Steam inhalations should be used freely, as it increases
the secretion and facilitates expectoration.
  Give muriate of ammonia and chlorate of potassium gr.  v.-x.,
.every two hours to an adult (gr. ij. to a child two years of age).
  If expectoration is entirely absent, give stimulating emetics. 
52          DISEASES OF THE RESPIRATORY ORGANS.

  Should the pulse become small and thready, give quinine and
brandy.  Stimulants require to be administered judiciously early
in the disease and continued.
  If there is spasm of the bronchial tubes, full doses of hydro-
cyanic acid may markedly relieve, but never give opium.

      CHRONIC  CATARRHAL  BRONCHITIS.
                        DEFINITION.
  Is a low grade of inflammation of the broncnial mucous mem-
brane, having a tendency to recur with increased severity and
duration, till it becomes permanent
  It may be  primary or secondary. Primary, when it results from
external  causes; and secondary, when it results from some pre-
viously existing or constitutional dyscrasia.
                    MORBID ANATOMY.
  The inflammation may be limited to the large  bronchi, or it
may extend into the capillary  tubes.   The bronchial mucous
membrane has a gray or reddish-blue color, and, in chronic cases,
is often hypertrophied.  Its glands are enlarged and prominent, and
their ducts  so increased in  size that their mouths  are readily
visible.  In the early stage, the other coats of the bronchial tubes
may be weak or yielding; and later on, there may be thickening
and induration.  The results of  chronic bronchitis are dilatation
and stenosis of the bronchial tubes; an accumulation  of secretion
in a state of cheesy degeneration (obstructing their calibre); and
pulmonary emphysema and induration of the adjacent  lung-tissue.
                        ETIOLOGY.
                    Predisposing Causes.
Exposure to cold or wet.
Bad air.
Constitutional diseases (gout, etc.).
                      Exciting Causes.
Irritation by substances inhaled.
Mitral stenosis.
Chronic alcoholismus. 
CHRONIC catarrhal bronchitis.
53
                         SYMPTOMS.
                          Rational.
 In Early Stage, or simplest form.
     Cough—at first, may be slight.
     Expectoration—muco-purulent, which comes on in the winter
        and disappears in the summer, and ultimately becomes
        permanent.
 Later on in the Disease.
     Cough—is violent, (especially in the morning).
     Expectoration — tenacious and scanty, or thin,  semi-trans-
        parent, and abundant, sometimes streaked with blood and
        difficult to expectorate ; varies from an ashy  yellow to a
        dark-green color, and sinks in water.
     Emaciation—(may occur).
     Fever—(may occur).
     Night sweats—(may occur).
     Dyspnoea.
     Pulse—is normal.
     Temperature—is normal (except where there is a foetid breath).
     Soreness behind the sternum (increased by coughing).
                          Physical.
 Inspection—respiration is accelerated and labored.
 Palpation—vocal  fremitus may be normal, exaggerated,  dimin-
     ished, or absent.
 Percussion—normal, or temporary dullness.
 Auscultation—vesicular murmur is more or less deficient, and the
    respiratory sound is coarse, loud, and harsh, with prolonged
    expiration.  There may be large or small mucous rales which
    are  altered in character  and position by coughing, and by a
    full inspiration. Vocal resonance is normal, diminished,  or
    slightly exaggerated.

                DIFFERENTIAL DIAGNOSIS.
  From  pleuritic effusions; pneumonic consolidation; and pulmo-
nary phthisis. 
 54          diseases of the respiratory organs.

                         PROGNOSIS.
   This disease rarely destroys life directly;  but, if associated with
 any pulmonary affection, the condition of  the patient is serious,
 on account of the liability to  obstruction from the accumulation
 of the secretion in the bronchial tubes.   When it  occurs in  per-
 sons past middle life, recovery is rare.

                        TREATMENT.
   Remove the patient from every source of bronchial irritation,
 and guard against exposure to changes of temperature.  Flannel
 should be worn next to the chest.  Keep the patient in the house
 in bad weather.  See that the apartments are well ventilated and
 at a temperature of about 65° to 70° F.   The patient must not be
 allowed to expose himself to the night-air or cold winds, and, if
 possible, should be sent to a warm, dry climate.   If there is severe
 emaciation, a long sea voyage is advisable.  The diet  should al-
 ways be nutritious,  and  a moderate amount of stimulants will be
 necessary.
  If a rheumatic or gouty diathesis exist,  then give colchicum and
 alkalies.  Iodide of potassium should be administered internally
 if the disease be associated with pulmonary emphysema.
  If there be anaemia, iron is indicated and a general tonic treat-
 ment, when quinine, mineral acids, bitter vegetable infusions may
 be combined with iron.   If the bronchial secretions are excessive,
 steam inhalations of tar, creasote, and naphtha are of great ser-
 vice.  When the expectoration is deficient, stimulating expector-
 ants, such as senega, serpentaria,  camphor, tincture of benzoin,
 combined with carbonate of potash, soda, etc., are indicated.
  If the  bronchial  mucous  membrane is irritable, the secretion
scanty,  and the  cough  paroxysmal,  opium, hydrocyanic acid,
hyoscyamus, belladonna, or conium should be  administered in
full doses.
  If the bronchial secretion accumulate in the larger bronchi and
cannot be expectorated, emetics may be employed. 
croupous bronchitis.
55
               CROUPOUS  BRONCHITIS.
                         SYNONYM.
   " Plastic bronchitis."

                    MORBID  ANATOMY.
   It differs from  catarrhal bronchitis,  since plastic material is
 poured out into the tubes in the form of casts, which are either
 solid or hollow, according as the large or small tubes are affected,
 and are of a whitish color, sometimes dotted over with blood spots.
   In  the  chronic form, the membranous exudation occurs only
 over a circumscribed portion of the bronchial membrane ; in the
 acute, it is distributed over a greater portion of the bronchi.  The
 membrane may be firmly adherent,  or loosely attached to the
 mucous surface.   The casts under the microscope consist of fib-
 rillated fibrin, abundant granular matter, exudation corpuscles,
 and ovoid cells.
                         ETIOLOGY.
  It is most frequently met with in the young adult, especially in
 females, and in those of a feeble and delicate constitution.  It is
 said to be due to some diathetic state.
  It may be acute or chronic, but both forms are rare; the acute is
 the most infrequent.
                         SYMPTOMS.
                          Rational.
 Fever.
 Cough—which is hoarse and ringing in character.
 Dyspnoea—(often severe).
 Haemoptysis.
 Expectoration—consists of casts of the bronchial tubes (often re-
    sembles trees with short branches).
 Death—may result from asphyxia.
                          Physical.
Percussion—may be normal, extra  resonant, or dull. 
56
DISEASES OF THE RESPIRATORY ORGANS.
Auscultation—Respiratory murmur is feeble ;  or absent, if the
    bronchial tubes are obstructed.  Dry or moist rales are usually
    present.
               DIFFERENTIAL DIAGNOSIS.
  From acute catarrhal bronchitis ;  pneumonia ; or pleurisy.

                        PROGNOSIS.
  In the acute form (which lasts  from three  to ten days) more
than half die.  In the chronic form, which lasts from ten to four-
teen days, if it is not complicated, the prognosis is good as regards
life, but having once occurred is apt to return. Complete recovery
is rare.  It  is very likely to lead to pneumonia and phthisis.

                       TREATMENT.
  In the acute form,  the treatment  is the  same as in croupous
laiyngitis.  In the chronic form, alkaline steam inhalations should
be used during the paroxysm, and the patient kept in a warm
equable temperature.  During  the interval, iodide of potassium,
quinine, iron,  and cod-liver oil have been recommended.  If the
paroxysms  return, the patient should be sent to a warm climate,
or on a long sea voyage.


                        ASTHMA.
                        Definition.
  Is a condition produced by spasm of the involuntary muscular
fibre of the bronchial tubes.

                   MORBID  ANATOMY.
  This disease is  looked  upon  as a  spasmodic affection of the
bronchi causing dyspnoea.  These bronchial contractions are due
to a reflex nervous action ; and the disease may be regarded as a
neurosis, dependent upon the existence of a peculiar diathesis.
Catarrhal symptoms may be wanting, and, when present, may
precede the paroxysm.  These attacks may occur in those suffer-
ing from organic  diseases of the  heart, or lungs, but true asthma
is spasmodic. 
asthma.
57
                         ETIOLOGY.
   Hereditary predisposition ; irritation of the mucous membrane
 of the bronchi by certain atmospheric changes ; reflex irritation,
 from abnormal conditions of the nervous  system, or of organs ;
 or as a complication of some other disease.

                         SYMPTOMS.
                          Rational.
 Premonitory symptoms (peculiar to the individual) are present in
     some cases, as drowsiness, wakefulness, headache; etc
 Dyspnoea—intense and of sudden onset.
 Respiration—wheezing.
 Posture—sitting (arms briiced, mouth open).
 Face—red, or livid, and anxious.
 Extremities—blue and shrunken in prolonged cases.
 Cough and expectoration (after the attack) which may consist of
     mucous or be profuse and watery.
 Sense of extreme exhaustion—after the attack has subsided.
                          Physical.
 Percussion—exaggerated.
 Auscultation—high-pitched, sibilant, and sonorous rales.
 Respiratory murmur—is jerking or exaggerated and usually short.

                DIFFERENTIAL DIAGNOSIS.
   From acute  capillary bronchitis;  pulmonary oedema; pulmo-
 nary congestion ; hydro-thorax ;  angina pectoris ; and laryngeal
 obstruction.
                         PROGNOSIS.
  Is seldom, if ever, directly a cause of  death.  This class of
 patients are  generally long-lived, as they  have to attend most
 rigidly to all the principles of hygiene.

                        TREATMENT.
  It should  be borne in mind that  you must first  relieve the
paroxysms, and then prevent their occurrence. In order to accom-
plish this end, it will be  your duty first to ascertain the cause, 
58          DISEASES OF THE RESPIRATORY ORGANS.

and then, by overcoming the cause, you may relieve the paroxysm
at once.  If .you are unable to remove the cause, or the paroxysm
is not relieved, place the patient in the easiest position possible.
The best remedies to use in this disease are  stramonium, in the
form of cigarettes ; chloroform; hyoscyamus; ergot; ether; canna-
bis indica, opium or atropine; and the fumes of burning nitre
paper.
  Loomis advises opium, in full doses  (£ gr. morph. sulph. hypo-
dermically); but very good results have been obtained with the
prescriptions which will be found at the end  of this volume, and
should be tried, especially hyoscyamus and ergot for the first two or
three days; if they have not the effect of relieving it for some con-
siderable time, the other remedies might be resorted to.  Should
there be anaemia, or the patient be poorly nourished, ol. morrhuai
and iron should be  administered at intervals.   Quinine, gr.  v.-x,
daily, often prevents the  paroxysms,  and  it must be continued
regularly,  or else the paroxysms will return.


                  WHOOPING  COUGH.
                         SYNONYM.
  Pertussis.
                       DEFINITION.
  It is an infectious and portable disease, dependent upon a specific
poison ; characterized by  a  paroxysmal cough, consisting  of  a
series of short, spasmodic, forcible expirations, followed by a deep,
prolonged inspiration,  attended with  a peculiar sonorous sound
called  the "whoop" or "kink," the paroxysms terminating in
expectoration or vomiting.

                   MORBID ANATOMY.
  The  principal changes are those of  catarrhal bronchitis.   It  is
considered by many prominent physicians to be of nervous origin;
and that either an inflammation of the pneumogastric nerve or
congestion of the  medulla oblongata  exists.  The complications
are lobular collapse, lobular emphysema, bronchial  dilatation, and
catarrhal pneumonia. 
WHOOPING COUGH.
59
                          STAGES.
  It has three stages, catarrhal, spasmodic, and decline.

                        SYMPTOMS.
                          Rational.
 In the Catarrhal Stage.
    Marked naso-pharyngeal and bronchial catarrh.
    Coryza.
    Cough—paroxysmal in character.
    Expectoration—abundant,  (tenacious,  viscid,   transparent
        mucus).
 In the Spasmodic Stage.
    Cough—severe and distressing, there is at first a long, clear,
        piping, inspiratory sound ; followed  by convulsive and
        forcible expiratory puffs and succeeded by a whoop.
    Face—becomes red or purplish during the paroxysm.
    Eyes—protrude during paroxysm.
    Vomiting may follow paroxysm.
   'Bleeding from nose, mouth, and ear may occur.
In the Stage of Decline.
    Paroxysms gradually diminish in frequency and severity.
    Expectoration is less difficult (becomes more purulent, and,
       after a while, ceases altogether).
                          Physical.
Auscultation—during  the paroxysm, the respiratory murmur is
    feeble or absent.  Sibilant and  sonorous rales (which during
    the interval are mucous in character).

                DIFFERENTIAL DIAGNOSIS.
  In the early stages, its diagnosis is uncertain ; but if there is a
violent spasmodic cough, the fever excessive and prolonged, and
the disease is prevalent, its existence may be suspected. Its pecu-
liar cough distinguishes it from aU other diseases.

                        PROGNOSIS.
  Is always a serious disease, although rarely directly fatal ; but 
60          diseases of the respiratory organs.

it frequently  causes death  indirectly.  Fatal results are due to
complications.
                        TREATMENT.
  In order to relieve the paroxysms of coughing, the most effec-
tive remedies are belladonna, hyoscyamus, cannabis indica, chloro-
form, and musk,  which should be administered in small doses.
The patient should guard against undue exposure  ; his clothing
should be warm.   During fine, warm weather, the patient should
be in the open air as much as possible ; but damp,  cold weather,
and exposure to  draughts must be strictly avoided.  The diet
should be simple,  and the bowels carefully attended  to.   In
obstinate cases and in convalescence, a change of air, if only for a
short distance, often  proves very beneficial.  If possible, moun-
tain, or sea air, or pure country air, should be chosen, as it acts
favorably by removing irritation of the nervous system, and com-
pleting restoration to health.


                      EMPHYSEMA.
                        DEFINITION.
  Is an abnormal accumulation of  air within the air-cells ; or  an
infiltration of air into the sub-pleural cavity, or interstitial con-
nective-tissue, due to rupture of the air vesicles.

                         VARIETIES.
Vesiculai—where the air-cells alone  are over-distended and con-
    tain an excess of air.
Interlobular or interstitial—where the air has escaped between the
    lobules of the lung (through rupture of  the air-cells).

                   MORBID  ANATOMY.
  Before opening the body you will  notice the  "barrel-shaped"
chest, emaciation, and the emphysematous countenance.
  On  opening the chest,  the  lungs fail to collapse, and, in bad
cases, protrude from the chest; they frequently  bear the impres-
sion of the ribs, and have blebs on the surface  (due to an inter-
stitial emphysema). 
EMPHYSEMA.
61
  The specific gravity of the lung is greatly diminished ; they are
paler in color than normal, and crepitate less than normal.  The
bronchi are partially filled with sticky mucus, and spaces may be
seen, by the eye (when a section is made), in the lung substance,
due to breaking down of the air-cells, thus allowing of a communi-
cation with each other.  The heart will be found displaced, and
the right heart is usually hypertrophied.   Tricuspid regurgitation
is not infrequent.  There is often found the "■nutmeg'''' liver, and
the other organs may be in a state of fatty degeneration.
  When one of the lungs is removed, inflated, injected through
the pulmonary  and bronchial  vessels, and dried, a section will
show (1st) abnormal spaces due to rupture of the air vesicles ; (2d)
obliteration of the blood-vessels in the septa between the air-cells;
(3d) destruction of  the septa between the air-cells, due to fatty
degeneration, from poor nutrition, on  account of destruction of
the blood-vessels.
                         ETIOLOGY.
Primary Causes.
    Forced inspiratory and expiratory  efforts.—Severe coughing
    or straining.—Hereditary,  or acquired  impairment  of the
    elasticity of the lung tissue.—Abnormal growth of the chest-
    walls.
Secondary or Compensatory Causes.
    Emphysema of the immediate lung tissue, around small por-
    tions of the lung, rendered inexpansible from disease.
Vicarious Emphysema.
    Emphysema, of the healthy lung, may be produced  where
    large portions of the lung tissue are consolidated, or impaired
    by disease, as in atelectasis, from obstruction of a small bron-
    chus, a lobar pneumonia, or pulmonary infarction.
  Interlobular emphysema may follow the  vesicular form (by
rupture), or  perforation  of the  lung tissue  (from traumatism,
foreign bodies, etc.).
                         SYMPTOMS.
                          Rational.
Dyspnoea.
    Increased by exercise.—Increased by attacks of bronchitis.—
    Increased by attacks of asthma.—Increased by cold climate. 
62
DISEASES OF THE RESPIRATORY ORGANS.
Expectoration.
    Of a  pearly, tenacious mucous (due  to  an accompanying
    bronchitis).
Countenance.
    Dusky—Puffy, even where the body is emaciated.—The nos-
    trils are distended, and vascular, and expand with inspiration.
    —Angles of  mouth are drawn down.—Jugular veins are dis-
    tended.
General Condition.
    Feeble voice.—Emaciation.—Stooping attitude in walking.—
    Gradual loss of strength.—Low temperature.—Feeble pulse.—
    Vertigo, after coughing.—CEdema of feet  and ankles (in late
    stage) due to tricuspid regurgitation.—Exhausting cough.
                         PHYSIdAL.
Inspection Reveals
    Prominence  of  the sternum.—Widening  of  the intercostal
    spaces. —Round or  "barrel shaped"  chest.—No actual ex-
    pansion, but a rising and falling  movement of the sternum
    during respiration.—Displacement of  the  apex-beat.—Abdo-
    minal breathing.—Muscles of the neck very prominent.
Palpation.
    Variable—vocal fremitus is usually diminished, except in the
    senile form,  when it is increased.
Percussion.
    Vesiculotympanitic (due to too much air).
Asucultatvon.
    Inspiratory sound, is feeble, or suppressed.—Prolonged, low-
    pitched, expiratory sound (due to loss of elasticity of the lung-
    tissue).—Crackling sound like the crumpling of parchment.

                DIFFERENTIAL  DIAGNOSIS.
  From pneumo-thorax only.
                     COMPLICATIONS.
Heart disease,   (chiefly of the right  heart);  bronchitis (acute
    attacks).
Fatty degeneration of the organs throughout the body, and dis- 
PULMONARY OCDEMA.
63
     ease of the kidney, or liver (due to the interference of the
     general circulation).
                         PROGNOSIS.
   It is an incurable disease ; is modified  by the extent of the dis-
 ease, and by its complications;  the most frequent being bronchitis,
 which is always an extremely grave affection, when the smaller
 tubes are attacked.
                        TREATMENT.
   Iron should be given daily with the meals for a long period, in
 the form of the ethereal tincture of the acetate; and, also sulphate
 of quinine in  small  doses  with the  iron.  If  there  should  be
 dyspeptic symptoms,  bitter vegetable infusions should be given ;
 and oleum morrhuce for the emaciation  that is present.  Stimu-
 lants axe often  of great benefit when taken  in small quantities
 during, or shortly after meals. The diet should be most nutri-
 tious ; principally animal food.  The stomach should not be over-
 laden.  The food should not be bulky or  watery in character, but
 as digestible as possible.  Small  quantity of liquids  should be
 used at a time.   The patient should live in the open air, but not
 expose himself to cold ; and all violent exercise should be avoided.
 The complications should be treated  as they arise ; but the most
 persistent is bronchitis, and, when this occurs, iodide of potassium
 should be administered, in gr. v.-xx., three times a day, and con-
 tinued for a long period. The other  complications will be treated
 under their respective headings.


                PULMONARY  OEDEMA.
                        DEFINITION.
  Is a serous transudation from the  pulmonary blood-vessels, de-
pendent either upon some local cause, or an altered state of the
blood.
                    MORBID ANATOMY.
  Serum will be found in the cavity of the alveoli, and the inter-
stitial-tissue of the lungs.  If the oedema be associated with con-
gestion, the serum will be blood-stained;  otherwise it will be of a 
64
DISEASES OF THE RESPIRATORY ORGANS.
clear color.  On opening the thorax, the lungs do not collapse.
That part of the lung where the oedema is  present will be paler
than normal, unless congestion be present. In the  oedematous
portion of the lung, if it pit  on pressure, it proves that the elas-
ticity of the lung has been diminished.   On section, serum exudes;
which is usually frothy, unless the air-cells are  filled with serum.
GMema may occur in any portion of the lung, but it is usually in
the most dependent part.
  In order to determine whether the oedema has occurred before
or after death, it will be necessary to know what the physical
signs and symptoms were before death took place.

                        ETIOLOGY.
General hydraemia (as  in purpura, Bright's disease, scurvy, etc.).
Pulmonary congestion (dependent upon obstructed return circula-
    tion through the heart).
Enfeebled heart's action (chiefly in the aged).
Long confinement to one position^as in fevers, debility, etc.), be-
    cause the blood  always goes to the most dependent part of the
    body.
Inflammatory  conditions of the lung tissue (as in  pneumonia,
    tuberculosis, capillary bronchitis), due to passive hyperaemia
    or stasis.
                        SYMPTOMS.
                          Rational.
Dyspnoea—is often sudden and severe.
Respiration—is increased in frequency.
Cough.
Expectoration—watery, and slightly blood-stained (if pulmonary
    congestion exist).
Temperature—normal.
Pulse—if increased in frequency, is feeble.
Cyanotic Condition (if oedema is excessive) as shown by
    Blueness of the  face.—Blueness of the extremities.—Coldness
    of the limbs.—Delirium.—Drowsiness.—Coma.
                          Physical.
Percussion—there is dullness over the seat of the oedema which is 
pulmonary csdema.
65
    usually at the most dependent portion of the lung.  This dull-
    ness never reaches the condition of flatness, nor changes posi-
    tion.
 Auscultation—bubbling rales  over the seat of the oedema,  heard
    with inspiration and the commencement of expiration.  These
    rales have a liquid character, and are thus to be distinguished
    from the  crepitant rale.  Respiratory murmur is feeble,  or
    absent, or harsh.

                DIFFERENTIAL DIAGNOSIS.
   From  pneumonia (1st  stage) — hydro-thorax — capillary  bron-
 chitis—and pulmonary congestion.

                        PROGNOSIS.
 Is bad, if it depend upon the general dropsy of  renal or cardiac
    diseases.
 Is bad, if complicating an extensive pneumonia.
 Is bad. if extreme cyanotic symptoms appear.
 Is bad, if dependent on exhaustive diseases.

                        TREATMENT.
  If it occur in connection with Bright's disease, increase the ex-
 cretory functions of the  kidneys, bowels, and skin with hydra-
 gogue cathartics, diuretics, and diaphoretics,  and crowd them to
 the fullest extent.
  Apply dry cups to the  thorax. Stimulants should be given, if
 it occur in connection with typhoid and typus fever.  Any means
 which will relieve or arrest the congestion are of benefit.
  If the  oedema be due to the  patient remaining too long in one
 position, then  move him  constantly to prevent the gravitation  of
 the fluid to the same dependent part; and endeavor to have the
lungs emptied as frequently and fully as possible.

            PULMONARY  CONGESTION.
                        DEFINITION.
 Is an excess of blood in the circulation of the lung. 
66
diseases of the respiratory organs.
                          Varieties.
Active Hyperemia.
    Active—associated' with dilated capillaries, increased  flow of
    blood to the part, and an increased rapidity of the current.
Passive Hyperemia.
    Passive, or "congestion"—associated with dilated capillaries,
    increased flow of blood to the part, and a slow current.
Hypostatic congestion—is that  form  of  pulmonary congestion
    which is due to gravitation, and associated with intra-cellular
    oedema.
Compensatory or collateral congestion—is that form of pulmonary
    congestion which is due to obstruction  in some other part of
    the lung.
Splenization of the lung—is that form of pulmonary congestion,
    which may  be superficial  or central;  is  associated with
    interstitial oedema, with red or yellow spots throughout the
    lung; and which resembles the spleen in appearance.
Brown induration of the lung—is that  form of pulmonary conges-
    tion which is  characterized by pigmentation;  as a result of
    chronic passive hyperaemia,  from mitral obstruction of regur-
    gitation.

                    MORBID ANATOMY.
  When the condition constitutes hyperaemia, the lungs are dis-
tended, of a dark-red color, slightly crepitating, and heavier and
less elastic than normal.  On section, dark blood flows freely from
the cut surface; but the lung-tissue is  still of a dark color, due to
blood remaining in the capillary vessels.
  Pulmonary hyperozmia may be active  or passive, it is  simply
an increased quantity of blood in the capillaries, and may be due
to increased heart's action, or obstruction to t:»e return of blood to
the heart, or local  interference with the  pulmonary circulation.
The various conditions which the lung mayassume  are as follows:
  Splenization.—In this condition the lunar  is of a dark reddish-
blue, brown, or black color, airless, firme** than normal, and cre-
pitates imperfectly.  On section, a dark fluid  oozes from its sur-
face, but not so freely as in hyperaemia. 
pulmonary congestion.
67
   Hypostatic congestion. —This occurs in  persons suffering from
 diseases which confine them to their bed for a long time.   This
 form closely resembles splenization, but has neither the doughy
 feel, nor the whitish or reddish points.
   Compensatory Congestion.—This is due to obstructed pulmonary
 circulation, (as in pneumonia) and occurs also in collapsed  lung-
 tissue.
   Brown induration.—This is epecially  connected with mitral
 obstruction, or regurgitation.  The lung will be found to be dis-
 tended,  firm, heavy, slightly moist, and dotted over with yellow-
 ish or brownish spots; these spots are due to old blood extravasa-
 tions which have undergone  granular pigmentary degeneration.
 The capillaries are enlarged.   Under the microscope, the air-cells
 are found to contain large cells which have undergone more or
 less pigmentation.
                         ETIOLOGY.
 ■Caiises of Active Hyperatmia.
     Violent hearfs action.—Accelerated  heart's action.—Exces-
     sive exercise, especially in those whose chest  is small.—In-
     halation of too stimulating air.—Too rarefied air.
 Causes of Passive Hyperemia.
     Feeble heart's action (due to obstruction to the return circu-
     lation of the lungs).—Mitral disease.—Pressure on the pulmon-
     ary  veins.—Fluid in the  pleura, aneurism, cancer, tumors,
     collapsed lung (by  impeding the  venous return from the
    lungs).
Hypostatic Congestion.
    Is dependent on gravitation, and occurs in those who have
    been long confined to one position.—Is associated with intra-
    cellular oedema of the lung.
 Compensatory Congestion.
    Is the result of obstruction  in the circulation in some other
    part of the  lung.  Occurs in connection with pneumonia,
    mediastinal tumors, and collapsed lung.
Splenization.
    Lung resembles  spleen-tissue.—Is due to hyperaemia,  with
    interstitial oedema superadded.—Occurs chiefly in connection
    with typhoid and typhus fever.  Is of slow development. 
68
diseases of the respiratory organs.
Brown Induration.
    Is  a pigmented condition of the lung, due to obstruction or
    regurgitation at the mitral valve.

                        SYMPTOMS.
                         RATIONAL.
Dyspnoea, (very marked if pulmonary oedema exist;.
Cough.
Expectoration (blood-stained and watery).
Symptoms of impaired function of lung-tissue.
                         Physical.
Palpation.—Increased vocal fremitus.
Percussion.—Dull over the seat of the disease (on  occount of
    oedema).
Auscultation.— Respiration feeble, or harsh; liquid rales, if oedema
    exist.
                DIFFERENTIAL  DIAGNOSIS.
  From pulmonary oedema;  spasmodic  asthma;, first stage of
pneumonia; and capillary bronchitis.

                        PROGNOSIS.
In active hypercemia—of a rapid  type; terminates either in re-
    covery, pneumonia, or pulmonary hemorrhage.
In passive  hyperaemia—depends upon the complications ^ espe-
    cially heart-diseases.
In brown induration—the prognosis is uncertain.
In splenization—the results are unfavorable.

                       TREATMENT.
  When  the congestion  is active and comes on suddenly, the
quantity of  blood in the vessels must be lessened.   Wet or dry
cups should then be applied over the entire chest, or, by opening
of the vein  in  the arm, the general system may be depleted.
In passive  congestion, the pulmonary circulation must be regu-
lated.  If the heart's action be weak, stimulants must be resorted 
pulmonary apoplexy.                  69
 to, but should the heart's action be too forcible, give aconite in
 full doses.  If it be associated with pulmonary oedema, administer
 catliarties.

              PULMONARY  APOPLEXY.
                         VARIETIES.
 Circumscribed, or "pulmonary infarction," when the lung tissue
     is not lacerated.
 Diffused, or  " pulmonary apoplexy," when the  parenchyma of
     the lung is lacerated.
                    MORBID  ANATOMY.
  In the  circumscribed variety, the lungs contain hemorrhagic
 nodular infarctions, which may be of a dark-red, or black color,
 containing no air.  These infarctions may be hard or soft, according
 to their age, and are recognized by their firmness when pressure is
 made. They may be from one to four inches only, but are usually
 about  one ineh in diameter.  They are found most frequently in
 the posterior portion of the lower lobe of the lung.  These nodules
 are, as a Tule, formed by the escape of blood from the capillaries
 of the air-cells into the cavity of the alveoli, and minute bronchi,
 some of which is retained in these cavities as the blood coagulates;
 the  capillaries  around  the alveoli are found to be filled with
 blood,  but there is no rupture of the lung-tissue.  Resolution is
 the  most frequent change that occurs; the infarction becoming
 either absorbed or expectorated.
  As a second  result,  these infarctions may remain as  dark
 pigmented, cicatricial spots, impermeable to air; they may excite
 inflammation of a pneumonic character, which may terminate in
 gangrene; or the nodules may become gangrenous.
  If the infarctions occur in connection with  pyaemia, they may
 terminate in gangrene, or in the formation of abscess.
  If the  infarctions  be near the surface,  the pleura may  be
 lacerated.  In case the diffuse variety exists, the cavity made m
 the lung tissue  by the extravasation is  of considerable size, and
the coagulated blood resembles a blood-clot.  These extravasations
are diffused and are much larger than the circumscribed variety. 
 70          DISEASES OF THE RESPIRATORY ORGANS.

 They may prove fatal at once, if the pleura be perforated.  If the
 patient survive the shock, recovery  usually takes place ; either
 by adhesion of the torn  surfaces, or a connective-tissue capsule
 being formed around the  clot, which  undergoes a cheesy, chalky,
 or pigmented degeneration, and remains  imbedded in the lung
 tissue.
                         ETIOLOGY.
 Causes of the Circumscribed Form.
    Embolism (due to vegetation of the valve of the right heart).
    —Coagula from  the  right heart or some superficial vein.—
    Pyaemia (metastatic).—Phthisis.—Cholera.—Scurvy.
 Causes of the Diffuse Form.
    Aneurism.—Degeneration of the arterial coats.—Traumatism.

                        SYMPTOMS.
                         Rational.
 Dyspnoea—if the apoplexy be extensive.
 Sense of constriction in the chest.
 Pain—if the pleura be affected.
 Expectoration—of small blood-coagula.
 If pyaimic in origin, the attack  is  accompanied by a chill  and a
    marked rise in temperature.
                         Physical.
 Percussion—local dullness over the seat of the disease.
 Auscultation—respiratory murmur may be absent, if the air-cells
    are extensively involved.
 Bronchial breathing is often detected over the seat of the disease.

               DIFFERENTIAL DIAGNOSIS.
  From pulmonary congestion; pulmonary oedema; and bronchial
hemorrhage.
                        PROGNOSIS.
  Is good, in the  case of infarction, if not too extensive, and not
dependent upon pyaemia or in connection with thrombosis.
  Is  bad,  in the diffused form, unless slight in  amount and oi
traumatic origin. 
bronchial hemorrhage.
71
                         TREATMENT.
   The patient must be kept in bed, and perfectly quiet.  Stimulat-
 ing applications, such as mustard sinapisms, must be applied to
 the extremities, and dry cupping to  the chest-surface.   Should it
 result from heart disease, regulate the heart's action, and increase
 its force by moderate use of stimulants and full doses of digitalis.
 If it occur with  pyaemia, support your patient to the utmost, by
 giving stimulants, quinine, and iron, and apply dry cups over
 the chest-surface frequently.  The diffuse variety is not amenable
 to treatment.
              BRONCHIAL  HEMORRHAGE.
                        DEFINITION
   Is a hemorrhage of the brcn hial mucous membrane, and not of
 the parenchyma of the lung,
                    MORBID  ANATOMY.
   The bronchial mucous membrane,  at the seat  of hemorrhage,
 will be found to be swollen, relaxed, and bleeds on slight pres^
 sure.  It is uniformly dark-red in  color, with  spots of ecchy-
 mosis, provided the examination  be made soon  after, or at the
 time of a hemorrhage.  But should th? examination be made some
 time after the bleeding, the  bronchial mucous membrane will be
 pale, and bloodless in appearance,  or, the seat of the hemorrhage
 will not be able to be discovered.   If any of the small bronchi are
 occluded by blood-clots, the lung-tissue beyond  the seat  of the
 plugs will remain inflated after the thoracic cavity is opened.
                         ETIOLOGY.
                    Predisposing Causes.
 Previously weak pulmonary  capillaries are often  a predisposing
  cause, as occurs:
    In delicate persons  of  phthisical parentage.—In developed
    phthisis or a  phthisical  diathesis. — In  chronic bronchial
    catarrh, which tends to weaken the vessels.
                      Exciting Causes.
Excessive exertion.—Atmospheric conditions.—Inhalation of irri-
    tant gases, etc—Excessive rarefaction of air. 
72
diseases of the respiratory organs.
                         SYMPTOMS.
                          Rational.
 Expectoration—is of bright arterial blood, with a frothy appear.
    ance.
 Previous sense of constriction in the chest.
 Cough and frequent return of hemorrhage.
 Pallor and anxiety of face.
 Tremulousness.
 Syncope—is possible.
 Nausea and vomiting—may folio' r the hemorrhage, but never pre-
    cede it.
 Symptoms of a subsequent pneumo  ia or phthisis may develop.
                          Physic iL.
 Auscultation—large and small bronchial rales, over the seat of
    hemorrhage, may be detected.

                DIFFERENTIAL DIAGNOSIS.
  From gastric hemorrhage, thoracic aneurism, epistaxis, and
 pulmonary apoplexy.

                        PROGNOSIS.
  Is seldom fatal, even in severe attacks, unless associated with
 some other disease. It is either the precursor of phthisical de-
 velopment, or a sign that phthisis exists.

                         TREATMENT.
  The patient should be placed  in bed, and  kept absolutely quiet;
 not even being allowed to sit up, or  move, or speak above a
 whisper.  The room should be cool.  Opium should be given in
 full doses, if the cough be  constant and produce hemorrhage.  In
 order to quiet the anxiety of the patient or friends, ergot, spirits
 of turpentine, persulphate of iron, or chloride of sodium may be
 given.  Ice bags may be applied, but great care should be used in
 applying them, as broncho-pneumonia is apt to follow such attacks
 of hemorrhage.   Ice should be eaten, and cold iced-water drank
 freely.  The nutrition of the patient should be improved by iron,
and a very nutritious but not stimulating diet.  Avoid all mental 
PULMONARY GANGRENE.
73
and physical exercise, but the patient should spend some hours
daily in the fresh air.

              PULMONARY  GANGRENE.
                       DEFINITION.
  A death of lung-tissue in  mass—as contrasted with molecular
death.
                        VARIETIES.
Circumscribed—where only small localized spots are affected.
Diffused—where extensive portions of the lung-tissue are involved.

                   MORBID ANATOMY.
  In the circumscribed form, it usually occurs in the lower lobes
or on the surface of the lungs.  Small portions of the lung become
converted into sloughs, which may be  discharged through a
bronchus and leave a ragged cavity surrounded by inflamed lung-
tissue.
  An opening is sometimes  found  in the  pleural cavity, causing
acute pleurisy, or hydro-pneumo^horax.
  In the diffused form, an entire lobe may be involved or even the
entire lung; the gangrenous processes are not limited, but may
become cedematous, or hepatized lung-tissue may be found.  It
may become converted into a putrid mass, and as the gangrenous
process reaches the pleura, that membrane becomes destroyed, and
the patient dies of pyaemia or septicaemia.

                        ETIOLOGY.
  It may occur from:
Local Causes.
    Pneumonia. —Hydatids. —Infarction (hemorrhagic).—Cancer.
    —Bronchial dilatations.—Embolism of an artery.
Nervous Diseases.
    Dementia.—Cerebral softening.—Epilepsy.—Chronic alcohol-
    ism.
Blood-Poisoning.
    Pyaemia.—Septicaemia.—Glanders.—Fevers. 
74
DISEASES OF THE RESPIRATORY ORGANS.
                        SYMPTOMS.
                         Rational.
Marked fetor to the breath.
Expectoration—of a gangrenous material, or black lumps of lung-
    tissue.
Hemorrhage—in some cases.
Great physical prostration —(if septic poisoning occur).
                         Physical.
These are often obscure, and comprise those of consolidation, and,
    possibly, the existence of a cavity, viz.:
Percussion—localized dullness.
Auscultation — bronchial respiration; amphoric or cavernous
    breathing; and, possibly, gurgling.

               DIFFERENTIAL  DIAGNOSIS.
  From abscess of the lung; phthisis; and foetid bronchitis.

                        TREATMENT.
  Sustain the patient with stimulants, tonics, and a most nutri-
tious diet.  Give opium to relieve pain, allay the cough, and ^er-
come constitutional irritation.


             CANCER  OF   THE  LUNGS.
                        VARIETIES.
  Medullary (as the rule); and melanotic, in rare cases.  This dis-
ease may also be unilateral; or diffused, as nodules, throughout
both lungs.
                    MORBID ANATOMY.
  The medullary cancer is the only one met with in this disease,
as  a rule.  Primary cancer only  affects  one lung,  while the
secondary form usually  affects both.  Jt occurs in  the form of
nodules scattered through the lung-substance.  The nodules may
blend and involve the entire lung.  The cancerous matter may
undergo fatty degeneration, and softenhg; it may  also involve
the pulmonary vessels and bronchi, or cause obliteration of them 
                    CANCER of the lungs.                 75,

 through pressure.   There are usually extensive pleuritic thicken-
 ings and adhesions present.

                         ETIOLOGY.
 Predisposing Causes.
    Hereditary tendency.—Is most common in the male sex, and
    occurs between 40 and 60 years of age.
 Exciting Causes.
    Cancer in the breast in females.—Injury.—Previous disease.

                         SYMPTOMS.
                         Rational.
 Pain—in the chest.
 Cough.
 Expectoration—often like "currant jelly."
 Dyspnoea—most marked when the mediastina are affected.
 Emaciation and oedema of the face.
 Temperature—elevated.
 Night-sweats and exhaustion.
 Hemorrhage—severe in some cases.
 Cyanosis.
 Vertigo.
 Swollen jugulars.
 Cachexia.—(may exist in some cases).
                         Physical.
 Inspection—enlargement of the  affected side, if the disease be ex-
    tensively developed.  Diminished respiratory movements.
 Palpation—diminution, or absence of vocal fremitus.
Percussion—marked dullness over the seat of  the disease  with
    spots of resonance.
Auscultation — feeble or  absent respiratory sounds.  Bronchial
    breathing  (if the cancer and a large bronchus be intimately
    connected).

                DIFFERENTIAL  DIAGNOSIS.
  From  pleurisy with  serous effusion;  gangrene  of the lung;
aneurism of the aorta; phthisis;  or fibrous pneumonia. 
76         diseases of the respiratory organs.

                       PROGNOSIS.
  Always fatal.  Death may occur from exhaustion; hemorrhage;
pulmonary oedema; asphyxia ;  or pressure on the  oesophagus,
trachea, or thoracic duct.

                       TREATMENT.
  Is  altogether palliative.  The  symptoms must be  relieved as
they arise.

                      PNEUMONIA.
                       DEFINITION.
  Is  an inflammation of the air-cells and intercellular passages—
or, of the parenchyma of the lung.

                       VARIETIES.
Croupous or "lobar"—where a distinct lobe is affected.
Catarrhal or'' lobular "or " broncho-pneumonia "—where a lobule
    is affected in different parts  of the lung.
Fibrous or "interstitial" or  " pulmonary cirrhosis"—where new
    connective-tissue development  is the  principal  pathological
    change.


         CROUPOUS  PNEUMONIA  (Lobar).
                          STAGES.
   First, engorgement; second, red hepatization; third, gray hepa-
tization.
                   MORBID ANATOMY.
   In the first stage—the lung in the affected part is redder, and
crepitates less than normal.  The specific gravity is increased.
The lung is firmer on pressure than normal.  On section, you will
perceive a reddish fluid, partly  serous and partly blood, to exude
from the cut surface.   The microscope will show a congestion of
the capillaries of the walls of the air-cells.
   In the second stage—the affected lobe will be solid to the touch,
and all crepitation absent,  It pits  on  pressure  and becomes 
croupous pneumonia.
77
 friable, and is of a dark-brown or reddish color; is heavier than
 normal, and sinks in water.  On section, it will be granular (due
 to filling up of the cells with pneumonic material), giving it an
 appearance similiar to liver-tissue.  About twelve hours after
 death, you get the post-mortem  fluid, which, under  the  micro-
 scope, will be  found to consist of fibrillated fibrin, blood-globules,
 lymphoid cells and large nucleated cells.  The lung-substance will
 have lost the outline of the air-cells, if viewed microscopically.
  In  the third stage—the lung will be found mottled with dark
 spots, becoming uniformly gray (due to decoloration of melanine).
 On squeezing, it will now begin to crepitate, and has lost its solid-
 ity.  The specific gravity is  nearly normal, and the lung will
 sometimes float in water.  On section and squeezing the lung, a
 milky or purulent fluid will be obtained.
  Microscope.— The outline of the cell wall will be seen (from loos-
 ening and separation of the inflammatory material);  and a granu-
 lar substance  in the centre of  the cell will be perceived (which is
 a degeneration of the fibrin and the other inflammatory products).
 The  blood-vessels  will appear normal, and the epithelial  lining
 will probably  be intact.

                         ETIOLOGY
Predisposing Causes.
    Age (most common between  20 and 40).—Sudden change in
    temperature.—Poverty. —Intemperance.—Previous attacks.
Exciting Causes.
    Exposure  to cold  or  wet  (as chilling of the feet or body).—
    Special diseases (as exanthematous fevers, uraemia, pyaemia,.
   septicaemia, alcoholism, etc ). —Traumatism.

                         SYMPTOMS.
                          Rational.
Chill—usually severe, prolonged, and distinct.
Headache, or vomiting, or bronchial hemorrhage.
Convulsions—(in children).
Coma—(in the aged).
Pain—(in the affected side for  about three days). 
78
diseases of the respiratory organs.
Cough—(a constant symptom).
Expectoration—scanty, pinkish, and  viscid (at onset); (later on),
    brick-dust, and tenacious; (severe case) resembling prune juice.
Temperature—elevated (highest on the third day, 102°-105).
Respiration—increased (80 per minute), panting in character.
Pulse—elevated (90 to 120)—is intermittent, in old age.
Countenance—anxious; flushed spot on the cheek; mahogany
    color (in severe cases).
Delirium—(in alcoholismus).
Urine—scanty, high-colored, high  specific gravity, and  albumin-
    ous.
                          Physical.
Stage of Engorgement.
    Inspection—slight impairment of motion on the affected side.
    Palpation—slight increase of vocal fremitus.
    Percussion—slight dullness.
    Auscultation—crepitant rale, (at the end of inspiration).
In Red Hepatization.
    Inspection—marked  impairment  of  motion on  the affected
        side, and increased motion on the healthy side.
    Palpation—marked increas" of vocal fremitus.
    Percussion—marked dullness.
    Auscultation—bronchial respiration; bronchophony; increased
        intensity of vocal sounds.
In Gray Hepatization.
    Inspection—partial return of motion on the affected side.
    Palpation—slight increase  of vocal fremitus and resonance
        over normal standard.
    Percussion—decrease in dullness.
    Auscultation—rude respiration or "broncho-vesicular;" rale
        redux, or modified subcrepitant, and crepitant.

                DIFFERENTIAL DIAGNOSIS.
  From cerebral disease, and cerebro-spinal meningitis (in  chil-
dren); from pleurisy in all its forms; phthisis (second stage); from
capillary bronchitis : pulmonary oedema, and abscess of the liver. 
CROUPOUS pneumonia.
79
                         PROGNOSIS.
   Is bad in infancy; old age; chronic alcoholism; in complications
(as Bright's,  heart, pregnancy);  when very  high temperature
exists; if the pulse be over 150: in case of delirium after first week;
if pulmonary oedema be present or double pneumonia, also when
jaundice and prune-juice expectoration exist.

                    CAUSES OF  DEATH.
   Heart's failure and  heart-clot; pulmonary oedema; asphyxia;
and exhaustion.

                        TREATMENT.
   Bear  in  mind the constitutional condition of the patient and
trust Nature to help you.  Blood-letting is only to be resorted to if
the heart is  engorged, and  pulmonary congestion and oedema
seem likely to take place.  Digitalis  or  nux vomica should be
given as a heart-tonic   Keep the patient in bed in a large, well-
ventilated  room, with  a temperature about 68° to 70% and give
good nourishment (as milk, eggs, etc.).
  Inject morphine hypodermically, if  there is pain.  Give opium
or chloral,  in small doses, should there be vomiting.
  The dangers of  this disease, in delicate subjects, are high tem-
perature and feeble  heart-power; it will therefore be advisable to
reduce  the temperature by giving  sulphate of quinine, gr. xx.-
xxx. per diem, and sustain the heart-power with alcoholic stimu-
lants (judiciously applied—that is, just sufficient to tide the heart
over the crisis).
  If the pulse be rapid and feeble (120 to  130 per minute), stimu-
lants should be given in small  doses, not exceeding six to eight
ounces  in  the twenty-four hours.  Belladonna may be adminis-
tered if  the pupils are contracted.
  Give chloral, in small doses, if  the patient be restless and cannot
sleep.   Use champagne as a heart-stimulant.  In convalescence,
give iron, oleum morrhuce, and a good nutritious diet. 
80          DISEASES OF THE RESPIRATORY  ORGANS.
   CATARRHAL  PNEUMONIA  (LOBULAR)  OR
                BRONCHO-PNEUMONIA.

                       DEFINITION.
  The form  which affects the scattered lobules and not a lobe of
lung.  Is most extensively developed in the anterior and posterior
portion of each lung.

                   MORBID ANATOMY.
  When the lung is inflated, there are small yellow or red spots
which  do  not inflate, and which are not granular on section.  If
these spots  be near the surface of the lung, they will be found to
be rounded  masses, and may be mistaken for tubercles.  If the
nodules are large, a reddish or grayish fluid exudes when cut; the
nodules break down easily, and sink when thrown into water.
  In the second stage or " stage of red hepatization," the exuda-
tion is made up of granular fibrin, blood-globules, lymphoid cells.
and large nucleated cells.
  In the third stage or "stage of gray hepatization," the nodules
have a tendency to terminate either in resolution, purulent infil-
tration, or cheesy degeneration.  The small bronchi are filled with
tenacious  mucus or muco-pus; their walls are  thickened; and
their calibre is enlarged.
  If resolution or purulent infiltration occur, the  inflammatory
products undergo changes similar to those which take place in
croupous pneumonia.   If the products in  the alveoli or bronchi
become cheesy, a hyperplasia of the connective-tissue takes place,
producing more or less induration (thus corresponding to catarrhal
phthisis).

                         STAGES.
  The same  three as in croupous pneumonia, viz.:  engorgement;
red hepatization; and gray hepatization. 
         CATARRHAL PNEUMONIA OR BRONCHO-PNEUMONIA.      81

                          ETIOLOGY.
 Predisposing Causes.
     Most frequent in children, and follows pulmonary collapse;
     measles; diphtheria; whooping cough; bronchitis; prolonged
     recumbent position; or debility.
 Exciting Causes.
     Inhalation of an impure or irritating atmosphere.

                         SYMPTOMS.
                          Rational.
 Previous symptoms of a bronchitis.
 Temperature—rising to 104° or even higher.
 Pulse and respiration—accelerated.
 Respiration—becomes panting aud rapid.
 Face—flushed and anxious.
 Cough—dry, hacking, and painful.
 Expectoration—scanty ; often absent; seldom brick-dust in color.
 In Acute Cases.
     Lividity.—Extreme dyspnoea.—Convulsions.—Speedy death.
 In Subacute Form.—(principally in strumous children).
     Cough—severe  and metallic.—Emaciation marked.—Marked
     pallor of face.—Night-sweats.—Gradual exhaustion.—Absces-
     ses often form on nates and back.
                          Physical.
 Percussion—slight dullness, in front and behind, (if pneumonic
     nodules are  large).
 Palpation—vocal fremitus slightly increased.
 Auscultation—respiratory  sounds  feeble (when tne tubes are ob-
     structed); and bronchial in character, within the spots of con.
     solidation.  Crackling rales, of a  fine and metallic quality,
     may often be detected after violent  coughing, at the end of
    inspiration.
                DIFFERENTIAL DIAGNOSIS.
  From capillary bronchitis; collapse of the lung; croupous pneu-
monia; and acute tuberculosis. 
82          diseases of the respiratory organs.

                       PROGNOSIS.
Is bad, if secondary to scarlet fever, kidney disease, or infarction.
Also bad, if developed in the weak; or if the temperature exceed
105°; or if due to pyaemia, or bad hygienic surroundings.

                       TREATMENT.
  The patient should be kept in bed, in a large, well-ventilated
room with a temperature about 65° to 70% and the chest protected
with flannel.  Avoid all antiphlogistic measures or depressing
remedies.   Stimulants should be given from the onset,  and con-
tinued to the end of the disease.  Dry cupping should be the only
counter-irritant used.  Quinine should be administered  (from gr.
x. -xx. may be given daily to a child of three years  of  age).  In
convalescence, give iron,  oleum morrhuaz, and good nutritious
food.  Avoid fatigue and exposure, and insist upon change of air.


               FIBROUS PNEUMONIA.
                        SYNONYMS.
  Interstitial, or " pulmonary cirrhosis."

                       DEFINITION.
  Is that  form of  pneumonia associated with  connective-tissue
growth, and its subsequent organization and  contraction.  Is
commonly called " chronic pneumonia."

                   MORBID ANATOMY.
  There is, at first, a hyperaemia and swelling of the intercellular
and interlobular tissue; followed by  a rapid hyperplasia of the
connective-tissue, which contracts, and therefore diminishes the
size of the lungs.  The chest-walls contract, in consequence of the
diminution in the size of the lung; and the bronchi become dilated,
owing to weakness and loss of their elastic power.

                        ETIOLOGY.
  The predisposing causes are: encapsulated infarction; encapsu- 
                      FIBROUS PNEUMONIA.                   83

  lated abscess; acute pneumonia; and splenization.  It may occur
  as a result of phthisis.

                          SYMPTOMS.
                           Rational.
  Retraction of the chest-wall over the affected lung.
  Pain—in the affected side.
  Cough.
  Expectoration—profuse—if the bronchi are dilated—is often foetid
     and contains cheesy matter,,
  Dyspnoea—not severe, although constant.
  Emaciation.
  Night-sweats.
  Anaemia.
                           Physical.
 Inspection—retraction of  the chest-wall and loss of expansive
     motion.
 Palpation.—the hoart is often displaced toward the affected side.
     and signs of hypertrophy of the right side exist, due  to ob-
     struction of the pulmonary circulation.
 Percussion—wooden; "cracked-pot resonance," over the dilated
     bronchi may be present.
 Auscultation  — feeble and bronchial breathing.  Respiration—
     amphoric; or cavernous, if bronchi are dilated.  Mucous rales
     —possibly gurgling in character.

                DIFFERENTIAL DIAGNOSIS.
   From pleurisy with effusion; pleurisy with retraction; and can-
cer of the lung.

                        PROGNOSIS.
   Is good, as to duration of life; but bad, if complicated with diar-
rhoea, hemorrhage, or general dropsy, from either heart or kidney
lesions.
                       TREATMENT.
  This disease, when fully developed, is incurable.  If it be due to
a bronchitis, it is advisable to guard against its recurrence.  In 
84
diseases of the respiratory organs.
order to get rid of the accumulated secretion, and prevent a foetid
accumulation, inhalation of benzoin or oil of turpentine has been
recommended.

                       PLEURISY.
                       DEFINITION.
  Is a partial or general inflammatory exudation into one or both
pleural cavities.
                        VARIETIES.
Acute pleurisy—is well defined;  runs a  rapid course; and has a
   fibrinous exudation.
Subacute pleurisy—is mild; of slow development; and has a, serous
    exudation.
Chronic pleurisy, or "empyema"—is of slow development; has a
    sero-purident exudation; and occurs  in persons of debilitated
    constitutions.
Hydro-pneumo-thorax—is a modification of the chronic  form,
    with perforation of the lung, admitting air into the pleural
    cavity (in which fluid also develops, later on).


                  ACUTE PLEURISY.
                   MORBID ANATOMY.
  There will be a  reddening of the pleural surface, extending to
the lungs or costal tissues; and, possibly, ecchymosis.  New con-
nective-tissue is formed; with new vessels which have thin walls.
The pleura will have  a thick, swollen, rough, and shaggy appear-
ance, and have lost its lustre.  Its surface may be agglutinated by
coagulable lymph  (fibrin),  causing connective-tissue adhesions.
These adhesions are covered by a layer of pavement epithelium,
within which run long  slender blood-vessels.   These adhesions
may be permanent; or contract, and then undergo fatty degenera-
tion  and absorption,  thus producing  a simple thickening of  the
pleura. 
acute pleurisy.
85
                          ETIOLOGY.
   It may occur as a primary or secondary disease, and at any age.
 Primary form may follow
     Exposure to cold or dampness.—Injury.
 Secondary form may be due to
     The different fevers.— Rheumatism.—Bright's disease.—Pyae-
     mia.—Septicaemia.—Alcoholism. —Pneumonia.—Cancer of the
     lung.—Phthisis.
                         SYMPTOMS.
                          Rational.
 Localized pain—in the side, usually near the nipple.
 Increase of pain on inspiration ; respiration " catching."
 Bending of the trunk t< >ward the affected side.
 Countenance—pale and anxious ; may become flushed as the dis-
    ease advances.
 Pulse—increased (90 to 120);, flrri, small and tense,
 Temperature—is seldem ibove ^00°—ma; reach 104°.
 Cough—hacking ;  usually no expectoration is present.
 Thirst.
 Tongue—usually coated.
 Nausea and Vomiting—occasionally present  in the early stages.
 Dyspnoea—sudden (if the pleural cavity be over-distended).
 Chills—and, possibly,  expectoration of pus (if  empyema  is de-
    veloped).
                          Physical.
 Inspection—restricted movement of the affected side.
 Palpation—vocal fremitus absent, below the level of the fluid.
 Percussion—dullness, till the  fluid accumulates.  Flatness below
    the line of the fluid (the line of which changes  with  the atti-
    tude of the patient).
 Auscultation — friction sounds  are  heard (before the  fluid is
    formed).   Vocal sounds are absent, below  the level of the
    fluid (after it is exuded).  Bronchial breathing, below the level
    of  the fluid (in exceptional cases).  Return of friction and
    voice sounds (as the fluid is absorbed).
Retraction of the chest-wall often follows this disease. 
86          DISEASES OF THE RESPIRATORY ORGANS.

               DIFFERENTIAL DIAGNOSIS.
  From intercostal  neuralgia; pneumonia; pulmonary  oedema;
phthisical consolidation; thoracic aneurism.

                        PROGNOSIS.
  Is good, if of the  primary form; grave, if following any severe
form of disease, or if absorption be too long delayed; also if em-
pyema be developed; or if phthisis be a complication.

                       TREATMENT.
  Inject opium, hypodermically, to relieve pain.  Patient must be
kept quiet in bed, in a large, well-ventilated room, at a tempera-
ture about 65° to 70°, and have good nourishing diet  without
stimulants.
  Give syr. ferri iodidi,  3 i- three or four times daily, if there is
anaemia.

               SUBACUTE PLEURISY.
                        SYNONYM.
   ' Sero-fibrous *' pleurisy.

                    MORBID ANATOMY.
  There is more extensive connective-tissue formation than in the
acute form;  the pleura is more thickened and there is more effu-
sion (serous).  The serous fluid in the pleural cavity does not de-
generate  into pus; but an abundant cell-formation takes place.
The intercostal spaces are* distended; the diaphragm is pushed
down;  the viscera are displaced; and the lung is pushed upward
and inward  against  the spinal column (if there is much effusion),
or compressed'(becoming of  a pale-red or green color, tough and
leathery, and containing no air).  As the fluid disappears, adhe-
sions form;  the pleura becomes thickened; the  chest-walls  re-
tracted; the lungs  inexpansible; and  the liver may rise higher
than normal.
                        ETIOLOGY.
  The  same as in the acute form; it is also secondary to Bright's, 
SUBACUTE PLEURISY.
87
phthisis, etc, and occurs in the week and feeble.  It is often the
first stage in the development of phthisis.

                         SYMPTOMS.
                          Rational.
Pain—is rare (but there is, often, a sense of uneasiness after exer-
    cise).
Emaciation.
Dyspnoea—on exertion.
Cough.
Expectoration—muco-purulent, or mucus.
Pulse—small and feeble (110 to 120).
Dryness of the skin—(especially at night).
Temperature—about 101°.
Countenance—pale and anxious.
Breathing—short and catching (patient can only lie on the affected
    side).
In the active form.
    The symptoms are active. They will increase for a time; then
    cease; and  subsequently return with greater severity.   There
    is a rapid  increase of fluid, causing intense dyspnoea and
    cyanosis, and oedema of the  other  side (from the pressure
    created).  Patient is frequently unable to lie down.
                          Physical.
If the cavity be partly or completely filled.
Inspection—the affected side is  enlarged in all directions.   Bulg-
    ing of the intercostal spaces may be detected.  Respiratory
    movements on the affected side are upward and downward,
    and are increased laterally on the other side.  There may be
    entire absence of respiratory movements on the affected side.
    The heart is displaced; a fullness, below the ribs, in the abdo-
    men may exist (from the liver being pushed down below the
    free border of the ribs).
Mensuration—the affected side is larger than normal after expi-
    ration, (one or two inches).
Palpation—complete absence of vocal fremitus. 
88          DISEASES OF THE RESPIRATORY ORGANS.

Percussion—flatness  of  the affected  side (below the level of the
    fluid).
Auscultation—entire absence of  the respiratory and vocal sounds
    (below the level of  the  fluid).  Bronchial respiration and
    bronchophony above the fluid (if the lung be sufficiently com-
    pressed).
As absorption takes place, the vocal sounds return to normal, and
    a creaking, rubbing, friction sound is  produced as the two
    surfaces play on each other.  The surfaces of the pleura are
    thickened (due  to new connective-tissue  formations).  The
    vocal fremitus is diminished;  the  respiration is feeble; and
    there is dullness on percussion, with a tendency to return to a
    vesicular quality, as the lung expands.
               DIFFERENTIAL  DIAGNOSIS.
  From pneumonia;  consolidation of the lung; enlarged  spleen
and liver; cancer of the lung and pleura; and aneurism.
From pneumonic and phthisical consolidation of the lung.
    There is  the history to aid in the discrimination.
    The  expectoration  of pneumonia  is  pink,  brick-dust,  or
        " prune-juice."
    The expectoration of phthisis is streaked with blood.
    Percussion— there is dullness, but not a flatness which changes
        with the position of the patient (as in pleurisy).
    Auscultation—vocal fremitus is intensified and increased; the
        respiration is feeble; bronchial and moist rales exist.
    The symptoms of pulmonary consolidation begin from above;
        extend downward; and are often bilateral.
From the spleen (when enlarged).
    The enlargement extends upward and downward; is confined
        to the abdominal cavity;  and there is continuous dullness.
From cancer of the lung.
    Aspiration with  the hypodermic needle, and the microscope
        will settle the question; and the physical signs may assist
        in the diagnosis.
                        PROGNOSIS.
  Is good, if there is no complication; but if there is over-disten-
tion from fluid and marked dyspnoea, the prognosis is bad. 
CHRONIC PLEURISY.
89
                        TREATMENT.
  Syrup of the iodide  of iron (3 i.), three or four times daily
should be given; also a large amount of good nutritious food.
The patient may be given a bottle of wine daily, and the nutritive
process should be raised to the highest possible degree; as, by keep-
ing up the vital powers  to their utmost, you thus aid Nature to
get rid of the  fluid in any serous cavity.  Cathartics, diuretics,
diaphoretics, or blood-letting should never be resorted to, as there
is too great an increase of fibrin, and they have no power to re-
move it.
  Aspiration (see hydro-pneumo-thorax) should be resorted to
early if the effusion is very great, until all the fluid,  necessary to
relieve extreme pressure,  is removed;  but great care should be
used, as pulmonary emphysema or phthisis  may ensue if carried
too far.  In the young, a systematic course of gymnastics may be
resorted to in  order to overcome the adhesions (should they
occur).

                 CHRONIC PLEURISY.
                         SYNONYM.
  Empyema.
                       DEFINITION.
  There is pus, or a purulent exudation, in the cavity  of the
pleura; due to an  inflammation,  which may be primary  or
secondary, and  which comes on gradually (in the  majority of
cases).
                    MORBID ANATOMY.
  A pouring out  of plastic material, which  undergoes trans-
formation into pus, occurs (especially in pyaemia and septicaemia);
and a migration of white blood-corpuscles through the walls of
the blood-vessels into the connective-tissue of the pleura, from
which they are  washed by the serous effusion, and held in suspen-
sion, may also take place in other conditions.  The exudation is at
first clear;  but,  later on, consists  of yellow, greenish-yellow pus
(primary empyema); this exudation goes on increasing, causing the 
90          DISEASES OF THE RESPIRATORY ORGANS.

pleura to become a "pyogenic membrane " (produced by excessive
irritation).   If the irritation is mild, the cell-production may be
circumscribed and not general.  The accumulations may escape
by spontaneous openings, such as perforation of the chest-walls by
ulceration; perforation of the lung, and its escape by the bronchi;
perforation through  the diaphragm,  entering the  abdominal
cavity, producing fatal peritonitis and death ; or into the intesti-
nal canal,  through adhesions between  the  intestines  and the
diaphragm, when pus will  appear in the discharges from the
bowels.   If recovery takes place, there  is a general contraction,
by cicatrization,  of all the viscera, to fill up the gap and stop the
purulent discharge.
                         ETIOLOGY.
                      Exciting Causes.
  Traumatism; broken  down  subjects; phthisis; protracted  ex-
haustive diseases (as  advanced phthisis,  suppuration of bones,
chronic syphilis,  chronic alcoholismus, cancer, or special vice).

                        SYMPTOMS.
                         Rational.
Pain—is rare.
Uneasiness and weight on the affected side.
Countenance—pale and anxious.
Hectic chill, fever and sweating (at intervals).
Cough.
Expectoration—muco-purulent, and not abundant.
Dyspnoea.
Development of a condition similar to that of  phthisis.
Semi-comatose state—if pyaemia or septicaemia occur.
Protrusion of a tumor—between the ribs (which fluctuates and is
    red, if about to discharge externally).
Pneumonic signs—(if the discharge take place through the lungs)
    such as chill, cough, fever, profuse muco-purulent expectora-
    tion with blood, retraction of the chest-walls, etc.
                          Physical.
Same as those of the subacute form, excepting that the level of
    the fluid does not change so readily. 
hydro-pneumo-thorax.
91
               DIFFERENTIAL DIAGNOSIS.
  Is impossible,  except by aspiration.   Is chiefly mistaken for
pleurisy.
                        PROGNOSIS.
  Is bad.  It is stated, that one in every five recover from sponta-
neous openings ;  and one-eighth, where aspiration is resorted to.
Death occurs from exhaustion.

                       TREATMENT.
  Early aspiration.  The patient should be placed upon the  most
nutritious diet, and  only a  small amount of stimulants given.
Iron, quinine,  and cod-liver oil are the best medicinal agents to
rely upon.  Let the patient be in the open air as much as is possi-
ble, or order a change of climate.


              HYDRO-PNEUMO-THORAX.
                        DEFINITION.
  Is a condition, characterized by the  presence of fluid and air
within tne pleural cavity.

                    MORBID ANATOMY.
  The  changes are the same  as in empyema.  There may be a
great quantity of air and small amount of fluid  in the pleural
cavity, or the reverse.
                        ETIOLOGY.
  Traumatic perforation of  the chest-wall; perforation of the
lung by tubercle, cancer, etc; traumatic rupture of an emphyse-
matous lung; fracture of the ribs; or gangrene of the lungs.

                        SYMPTOMS.
                         Rational.
Dyspnoea—extreme (when the air first enters).
Pain—(intense and thoracic)  of the affected side.
Cyanosis—very marked at onset.
Collapse and death—may occur from shock, but continued dys- 
 92           DISEASES OF THE RESPIRATORY ORGANS.

    pncea; filling up of the chest with fluid (usually pus); general
    dropsy ;  or hectic fever most often follow.
 Symptoms of exhaustion or cyanosis (from pulmonary oedema).
                          Physical.
 Inspection—bulging of the affected side;  diminished movement
    of the chest.
Palpation—absence of vocal fremitus on the affected side.
Percussion—tympanitic, above the fluid ; flatness, below the fluid.
Succussion—(a splashing sound heard on shaking the patient).
Auscultation—"metallic  tinkle"  (due to the  dropping of  fluid
    from the  lung into the fluid below).—Amphoric respiration.
  The pathognomonic sign of fluid in the cavity is dullness on per-
cussion, and alteration of the dullness, due to the change in  posi-
tion of the patient.  This fluid may, however, be  held down  by
adhesions (or encapsulated), so that  its position is not altered, in
which case this sign will be absent.

                DIFFERENTIAL DIAGNOSIS.
  From pneumo-thorax; obstruction to a bronchus; emphysema
(if extensive); or a large cavity in the lung.

                        PROGNOSIS.
  Is unfavorable in every case;  and rapidly fatal, if due to pul-
monary gangrene or phthisis.

                       TREATMENT.
  Is palliative.  Inject morphine hypodermically.   If the patient
survive the first few  days, give stimulants and good nutritious
diet.  Paracentesis should only be  resorted to in  extreme cases.
In performing aspiration, place the arm of the affected side at
right angles across the chest, and insert the canula (for a distance
of two inches) at  a point  situated about the line of the sixth  rib
and at the junction of the infra-scapular and axillary regions; so
soon as the patient complains of restriction, stop the operation;
then wait for a day or two before performing it again.   This oper-
ation should be persevered in until the fluid gets below the line of
the scapula. 
hydro-thorax.                    93
                    HYDRO-THORAX.
                        DEFINITION.
   Is a non-inflammatory accumulation of fluid within the pleural
 cavity.
                         ETIOLOGY.
   It occurs in general dropsy of Bright's disease; in the course of
 general hydraemia; or chronic exhaustive  diseases; in valvular
 heart-lesions; or it may be due to mediastinal tumors.

                         SYMPTOMS.
                          Rational.
 Dyspnoea—steady and progressive.
 Cyanosis—increasing steadily.
 Respiration—gasping (when the fluid is excessive).
 Inability to lie down.
 Pulse—feeble and small.
 Temperature—not increased.
 Articulation—monosyllabic (in advanced stages).
                         Physical.
 Inspection—gradual impairment of motion of the chest, and bulg-
    ing of the two sides.
 Percussion—flatness, below the level of  the fluid, which changes
    with the  attitude of the patient.
 Auscultation—absence of the vocal sounds, below the level of the
    fluid.
               DIFFERENTIAL  DIAGNOSIS.
  From subacute pleurisy; and pulmonary oedema.

                       PROGNOSIS.
  Is modified by the cause, and condition of the patient.  It may
prove a direct cause of death in Bright's disease, or when a chronic
heart-affection exists. 
94
diseases of the respiratory organs.
                       TREATMENT.
  The use of hydragogue cathartics and diuretics, and those agents
which  are employed to remove fluid from the areolar tissue, has
been long in vogue; but the best mode of treatment is the aspirator.
                        PHTHISIS.
                        DEFINITION.
  Is a " wasting away" or molecular death of the lung-substance.

               VARIETIES AND SYNONYMS.
 "Catarrhal" or "chronic catarrhal pneumonia"—where the
    disease is a continuation of a pneumonia (catarrhal type).
 "Fibrous"  or "cirrhosis" or " induration "—where the con-
    nective-tissue growth is prominently developed.
 "Tubercular" or  "acute  miliary tuberculosis" — where
    miliary  tubercle is deposited within the lung in the lymphatic
    structure.
                    MORBID ANATOMY.
  Catarrhal form.—There has been a  previous  catarrhal or
 lobular pneumonia, which has not been followed by resolution dur-
 ing the third stage; but whose products have become caseous.   This
 caseous matter creates ulceration of the lung by acting as a foreign
 body, and, possibly induces  miliary tuberculosis by absorption.
 In rare cases, this caseous matter may become encapsulated and
 innoxious.
  Fibrous form.—There is (1) proliferation of new connective-tis-
 sue cells in the lung;  (2) organization of these cells and formation
of new  connective-tissue; (3) contraction of  this new connective-
 tissue, creating pressure on the vesicular structure.
  Tubercular form.—There is absorption of caseous matter from
 some other part of  the  body resulting in lymphatic formation
in the peri-vascular  spaces  of organs (especially of the lungs),
 which under the microscope shows giant cells. The tubercles
subsequently undergo ulceration and excavation (probably by the 
PHTHISIS.
1)5
 pressure  exerted on the  blood-vessels,  causing impairment of
 nutrition).
                          ETIOLOGY.
                     Predisposing Causes.
 Hereditary or acquired constitutional debility.—Bad hygiene.—
     Damp, cold climate.—Badly drained, or miasmatic soil.
                       Exciting Causes.
 Extension of a bronchial catarrah.—Pneumonia.—Subacute pleu-
     risy.—Inhalation of irritating particles or gases.—Exposure to
     cold, or sudden changes in temperature.

                         SYMPTOMS.
                           Rational.
 Constant elevation of temperature.
 Cough—dry, hacking or paroxysmal in early stages.
 Expectoration—streaked with blood, often slight in amount (indi-
     cating lobular consolidation).
 Haemoptysis.
 Emaciation—steady and gradual.
 Night-sweats—commence early in the disease.
 Dyspnoea—at first, only after exertion; but, later  on, a constant
     symptom.
 Pain in chest—due to local pleurisies.
 Hectic fever—when cavities are formed.
 Pulse—accelerated (100 to 140), corresponds to temperature.
 Disturbance of digestive function.
 A'omiting—usually due to reflex causes.
 Diarrhoea (bad symptom)—due (1) to indigested food ; (2)follicular
    ulceration of the small intestines ; (3) ulceration of the large
    intestines (occurring usually in later stages)
 Arrest of menstruation—(is often an early symptom).
Aphonia—partial (from ulceration of the larynx).
GEdema of legs and feet—(due to thrombosis in lower extremi-
    ties).
Clubbing of the finger  nails.
Fatty liver—(is possible), consists of simple deposit of fatty matter.
Face__peculiar clearness of the sclerotic. 
96          DISEASES OF THE RESPIRATORY ORGANS.
 Increased sexual desire.
 Cyanosis (when the disease is extensive).
                          Physical.
 Stage of Consolidation.
    Inspection—slightly diminished expansion of the chest.  De-
        pression in the infra-clavicular spaces.
    Palpation—vocal fremitus increased.
    Percussion—Slight dullness (as compared with the other side).
    Auscultation—Respiration, rude or bronchial.  Prolonged and
        high-pitched expiration.   Rales — subcrepitant,  mucous,
        crepitant,  or metallic.  Vocal resonance intensified.
  All of these symptoms of the first stage are important, as they
 often enable the practitioner to offer a favorable prognosis.  They
 should  be always  determined by a comparison between  the two
 lungs.
 Stage of Softening.
    Inspection—diminished expansion of the chest.  Respiration
        more  frequent.  Marked depression above and below the
        clavicle.
    Palpation—increased vocal fremitus.
    Percussion—dullness increased (wooden).
    Auscultation—bronchial breathing.  Abundant rales,  circum-
        scribed and bubbling.  Crackling sounds, at certain spots.
 Stage of Excavation.
    Inspection—retraction of chest-walls.
    Percussion- Dull, amphoric, or cracked-pot.
    Auscultatio n—Respiration,  cavernous   or bronchial,  and
        gurgles.   ' • Cavernous whisper."

                DIFFERENTIAL DIAGNOSIS.
  From bronchitis (all forms); croupous pneumonia, especially if
 at apex or  accompanied by typhoid fever; pleurisy; pulmonary
 infarction and haemoptysis.

                        PROGNOSIS.
  In the catarrhal form, the disease may often be arrested, in its
first stage, by  change of climate. 
PHTHISIS.                       97
  If the tubercular variety exist, the prognosis is unfavorable.
  If the fibrous form be developed, the prognosis is good as regards
duration of life.  If complications arise, as laryngitis, pulmonary
oedema, capillary bronchitis,  pulmonary  congestion,  or profuse
hemorrhage, the prognosis is bad.
                        TREATMENT.
  Is usually considered under three heads:
  First.—The prophylactic treatment.
  Second.—The medicinal treatment.
  Third.—The hygienic treatment.
  The most satisfactory results  are usually obtained where the
prophylactic treatment can be resorted to  early; for, if the patient
live in a district which subjects him to any form of depression, a
change of residence should be insisted upon. A phthisical, or deli-
cate mother should never be  allowed  to nurse her infant, but a
wet-nurse should be procured.  During childhood, the offspring
should be fed on cow's milk and removed to the country, where
it can have plenty of good fresh air, and physical training.  Those
who are predisposed to phthisis should never be allowed to breathe
an atmosphere laden with dust or charged with poisonous vapors;
neither should they be exposed to sudden changes in temperature.
This class of  patients should always sleep  in large and well-venti-
lated rooms, and  free from  overcrowding.  Physical exertion,
such as violent running, jumping, etc., should be avoided.   The
surface of the body should be always covered with flannel.   The
diet should be simple, and taken at regular intervals, and consist
of such articles as the stomach is able  to  digest without any sen-
sation of weight or pain.  Stimulants should  only be resorted to
in case of extreme fatigue or severe exposure to cold, as the con-
stant use of them  is injurious.  This class  of patients is very
susceptible to catarrh on the slightest exposure, and these attacks
should  be treated with  the greatest care; but,  if it  shall have
reached the smaller bronchi, there is nothing so certain to remove
the catarrh as a change in climate.  In  order to carry out this
form of treatment most effectively, the vital powers of the patient
should be sustained, so that he should not become susceptible to
the  local causes of phthisis. 
98          DISEASES OF THE RESPIRATORY ORGANS.

  Tixe Medicinal Treatment.—The worst symptom to be encoun-
tered in this disease is fever.  By the rise in temperature, it is
evident that a bronchitis has resolved itself into a broncho-pneu-
monia; by a still greater rise, the products are becoming cheesy;
and by the hectic fever and night-sweats, softening is commenc-
ing. It is therefore essential that the temperature should be at
once reduced, and the only drug which can be relied upon is sul-
phate of quinine.  This drug has also been regarded as a power-
ful agent in the relief of night-sweats; there is no  djubt that it
has this power, but it must be borne in mind that  night-sweats
are only a part of the fever, and that in controlling the one  you
control  the other.   When the  first elevation of  temperature
occurs,  quinine (gr. xx. per  diem, given  in  one or two doses),
rarely fails to control the temperature, diminish the frequency of
the pulse, and arrest symptoms which are  liable to result from
the fever.   It will be well to determine the  time  at  which the
highest temperature occurs and administer a large dose one or two
hours preceding the attack, and continue it for as long  a period as
possible without producing cinchonism or until the temperature
falls.  Cod-liver oil  is another  medicinal  agent.  If possible, it
should be given with an alkali in small doses, and  not often re-
peated.   A teaspoonful once or twice a day is sufficient to com-
mence with. It may be gradually increased  to a  tablespoonful
three times  a day.  Avoid administering  it  in connection with
stimulants,  unless the patient cannot take it in any  other way.
There are three forms which afford some clue to the mode of its
action.  First, unless the  patient gains weight while using it, it
seldom if ever proves remedial; secondly, flesh and weight maybe
gained during its administration and still the phthisical processes
steadily progress; thirdly, when it does act remedially, the weight
gained is  far greater than would  result from the  oil as a mere
element of nutrition.  The hypophosphates of lime are only ser-
viceable when intestinal digestion is  imperfect.  Iron is only of
service when there is no marked fever; since if administered when
there is fever the digestion will  be disturbed and diarrhoea prob-
ably ensue.  Stimulants may be given when  they  increase the
desire for food and assist digestion, or when their use is followed 
PHTHISIS.
99
by a feeling of increased strength and a disposition to take exer-
cise; but if they produce symptoms of fever and depression they
will do  harm.  Opium  should never be given  in any stage of
phthisis unless the cough is distressing and the patient  is unable
to obtain the requisite amount of sleep; under such circumstances
the inhalation of a few drops of chloroform is preferable to opium.
Vomiting after meals is often a troublesome attendant of this dis-
ease.   The best  means to be adopted in this case is to compel the
patient to take, every half-hour for forty-eight hours, about a tea-
spoonful of raw scraped beef made into a sandwich,  at the same
time keeping absolutely quiet in a recumbent position.
  The Hygienic Treatment.—This mode of treatment is by far the
most important to phthisical subjects.  It will be well to bear in
mind the following rules, which will greatly assist in alleviating
the sufferings of the patient:
  1. It is absolutely necessary that there should be a good supply
of pure and fresh air.
  2. Exercise in the open  air  should be resorted to daily, when
practicable.
  3. The climate in which such patients should live, must be uni-
form, sheltered, temperate, and mild (about 60%\  with a range of
not more than 10° to 15° during the year.   A cold,  dry climate
often agrees with some patients of this class; its beneficial effect
can be estimated by the relief  afforded to the cough and a  ten-
dency to produce healthy sleep.  The soil should be dry, and the
■drinking water pure and not hard.
  4. The dress should be of such a character as to equalize and
retain the temperature of the body.
  5. Late hours should be particularly avoided, as also indoor and
sedentary occupation.
  6. Cleanliness, which is reputed to be next to godliness, should
be scrupulously attended to.
  7. The diet should  be most  nutritious, easy of digestion, and
more or less varied; and  the  number of meals should not be re-
stricted.  Milk, eggs combined with milk, beef tea (as a concen-
trated nutrient), and koumiss (made from asses' milk), are higlily
recommended for this class of patients. 
 
DISEASES OF THE CIRCTJLATOBY
            SYSTEM. 
 
DISEASES  OF  THE  PERICARDIUM.
  The pericardium is composed of two layers (a fibrous and serous).
The fibrous layer is closely attached to the diaphragm: the serous
closely adheres to the internal surface of the fibrous layer, is re-
flected from the large vessels, and completely invests the heart.
               ACUTE  PERICARDITIS.
                       DEFINITION.
  Is an inflammation of the covering membrane of the heart

                   MORBID ANATOMY.
  The serous surface  is more or less reddened with ecchymotic
spots; the reddening may be  circumscribed or diffused; and the
discoloration is due to hyperaemia of  the sub-serous capillary
vessels.   There is also swelling and infiltration of the sub-serous
tissue ; while the epithelial covering is separated and thrown off,
thus losing its natural, brilliant appearance.  If the inflammation
is continued, an exudation is poured out on to the free pericardial
surface.
  The plastic exudations vary in thickness, accumulating on the
cardiac and parietal surfaces, or  the cardiac surface alone.  As
soon as the plastic material is poured out, it causes roughening of
the pericardium (commonly  called "hairy heart").   The  fluid
may be sero albuminous,  sero-fibrinous,  hemorrhagic, or puru-
lent.  There may often  be from three to twelve fluid ounces in
the sac (which is usually  sero-fibrinous in character); sero-albumin-
ous fluid  is very rare.  If the pericardium is filled with fluid, the
lung becomes compressed.  The effusions may undergo absorption,
or remain as cheesy masses.  Bands, or adhesions  may form, or
there may be agglutination of the surfaces and obliteration of the 
104         DISEASES OF THE CIRCULATORY SYSTEM.

pericardial cavity.   Myocarditis may be produced by extensive
and long-continued pericarditis, producing weakness of the walls
of the heart.  Dilatation of the cavities may also take place through
the weakened condition of the heart-walls, and hypertrophy may
be developed as a result of this weakening, or as a secondary
result of dilatation.
  Post-mortem shows, white spots on the external surface of the
heart, caused by a growth of connective-tissue beneath the cardiac
pericardium ; this is really a localized pericardial  inflammation
without adhesions.   The two surfaces of the pericardium may
also be found to be agglutinated, causing obliteration of the peri-
cardial cavity.
                        ETIOLOGY.
  It is always a secondary disease, and occurs chiefly in young
people.   It  may  arise from inflammation  of  the neighboring
organs, as in pneumonia; pleurisy; neurosis of the sternum and
the ribs ; and from certain blood-diseases, as acute rheumatism,
Bright's  disease,   scarlatina,  small-pox,  typhus,  tuberculosis,
syphilis, alcoholism, scurvy, purpura, etc

                        SYMPTOMS.
                         Rational.
It comes on insidiously, as a rule, on account of its frequent com-
   plication with other diseases.
Pain in the precordial space—slight or lancinating, involving the
   brachial plexus, extending  down the arm, and increased by
   pressing up the diaphragm.
Cough—dry, irritating, and a sense of constriction over the chest.
Dyspnoea—depends upon the amount of fluid effusion present.
Countenance— anxious.
Restlessness - if the effusion be considerable in amount.
Posture—half sitting, and leaning towards the affected side ;  or
   on the back with the head elevated.
Pulse—(before fluid effusion) full and strong (90 to 120); (after fluid
   effusion) feeble, suppressed, delayed, or intermittent.
Temperature — usually, about  100°;  sometimes below  normal,
    which is a serious symptom. 
ACUTE PERICARDITIS.
105
 Headache—frequent dizziness.
 Delirium—active (occasionally).
 Syncope—on moving, if the fluid be extensive.  This is probably a
     symptom of myocarditis.
 Heart's action—forcible and irritable.  There is an increased area
     of apex-beat.
 Palpitation—(due to compression of the heart).
                           Physical.
 Inspection—diminished respiratory movements, over the pericar-
     dial space.—If the pericardial sac be distended, there is arch-
     ing of the precordial region from the  second to the sixth
     intercostal spaces.
 Palpation—the apex-beat is raised and carried to the  left.—if ef-
     fusion exist—cardiac excitement  and friction fremitus dis-
     appear ;  the  apex-beat is feeble,  or imperceptible; and an
     undulating impulse is felt.
 Percussion—If effusion exist—dullness is increased laterally and
     vertically. — Laterally — from one nipple to the  other  (in
     marked cases).—reward—as high as the second or first rib.
     Downward—more than normal (displacing the diaphragm).
 During stage of Plastic Effusion.
     Auscultation.—Pericardial friction sounds, may be  single or
        double, and independent  of the heart-sounds; are super-
        ficial, and  may, or may not accompany the heart sound ;
        the maximum of intensity is at the junction of the fourth
        rib and the sternum on the left side.—The intensity of the
        friction sounds increases by change in position, and also
        by a full inspiration (due to pressing of the two pericardial
        surfaces together by the distended lung).
 During Stage of Fluid Effusion.
    An absence of respiratory murmur may exist (from  the lung
        being pushed to the right and left, by the distended peri-
        cardial sac), and the heart's sound may be rendered feeble
        or be entirely lost.
■Stage of Absorption.
    On recovery taking place, the bulging subsides ; the dullness
        decreases ;  the  sufaces come together and often adhere 
106         DISEASES OF THE CIRCULATORY SYSTEM.

       (due to the inflammatory process1); the friction sounds
       reappear;  the heart sounds are more distinct; the apex-
       beat becomes normal; the cardiac impulse returns ; and
       the respiratory and vocal sounds are again detected.

               DIFFERENTIAL  DIAGNOSIS.
Between pericardial friction sounds, and endocardial murmurs.
Between pericardial friction sounds, and pleuritic friction sounds.
Between pericardial effusion, and hypertrophy and dilatation of
    the right ventricle.
                        PROGNOSIS.
  There is generally complete recovery, except when it occurs in
connection with  Bright's disease, and septicaemic and pyaemic
conditions.  If pyaemia exist,  you  have a purulent exudation
which is rarely absorbed.  The  nature of - the  exudations deter-
mine the prognosis.  Acute pericarditis may become chronic, or
be accompanied by large serous effusions which disappear slowly
and  may be accompanied  by relapses.  It  may create extreme
dyspnoea and,  in rare cases, fatal syncope.  If there is a long con-
tinuance of the fluid, the heart softens, and there is degeneration
of its  muscular tissue; this  organ then becomes enfeebled,  its
force diminishes,  and death  ensues from  oedema of the  lungs,
possibly  associated with blood-changes, from  loss of red  blood-
globules  and fibrin.  If it occur from acute  rheumatism, it is
rarely fatal; but you have as sequelae, adhesions of the two sur-
faces, cardiac dilatation, and hypertrophy.   This dilatation is due
to a weakness of the walls of the heart from the inflammatory
process;  and the hypertrophy which follows the dilatation is com-
pensatory.   There are also further  sequelae,  such as abundant
exudations,  and extensive adhesions at the base of the  heart,
causing contraction, pressure, and possible obstruction through
the coronary arteries, producing fatty degeneration of that organ.

                        TREATMENT.
  You must support  your  patient.  First seek the cause and re-
move it.   If it be due to fevers and the resulting depression, or to
pyaemia, or septicaemia, give stimulants in moderation.  In the 
CHRONIC PERICARDITIS.
107
 early stages of the disease, hot anodyne poultices (opium, bella-
 donna, etc.) should be employed.  Give opium internally in small
 doses: the largest doses may be given at night in order to produce
 a quiet sleep, but it should never be carried to narcotism.  If there
 be effusion, it should be removed by medical measures, if possible.
 If you are able to sustain your patient, and there are no evidences
 of pulmonary congestion and oedema, immediate interference may
 be delayed.  Do not employ hydragogue cathartics, blisters, etc.,
 as the disease, in all cases, is due to some previous weakening dis-
 ease, and consequently these remedies  make it worse.  Iron and
 stimulants should be used in moderation; also concentrated nutri-
 tion.  The patient  should be placed in bed and kept perfectly
 quiet. The chest must be protected from cold, and anything that
 accelerates the heart's action be avoided.  In convalescence, the
 patient must be watched on account of the weakness of the heart's
 walls, and dilatation and  hypertrophy that are present.  If there
 be pus in the pericardium, then aspirate, and only for that condi-
 tion.


               CHRONIC  PERICARDITIS.
                    MORBID  ANATOMY.
  In some cases, the  pericardial  sac contains fluid, adhesions,
 chalky debris, and calcareous plates.

                         ETIOLOGY.
  If  the  acute  form does not terminate in three or four weeks, it
 may be considered as of the chronic type.

                        SYMPTOMS.
                          Rational.
 Obstructed circulation.
 Enlarged heart (as shown by percussion and position of apex-beat).
 Dyspnoea (from pressure on the lung and weak heart's action).
 Sense of weight in the precordial region.
Angina pectoris—(in some instances).
Palpitation—on slight mental or physical exertion. 
108        DISEASES OF THE CIRCULATORY SYSTEM.
                         Physical.
Inspection.—Depression of the precordial region may occur (from
    firm adhesions taking place between the pericardium and the
    chest-walls).
Palpation.—Apex-beat is indistinct, and often two inches higher
    than normal.   Displaced cardiac impulse, unattended by
    change of position of the  organ.   Irregular movement of
    heart, in systole and diastole.
Percussion.—Increased dullness, in the pericardial region.

                        PROGNOSIS.
  Is doubtful; especially when degeneration of the  cardiac walls
and valvular insufficiency exist.

                       TREATMENT.
  Limit the physical exercise so as not to overtax the heart.  The
diet must be  most nutritious, but not  stimulating ;  administer
iron.

                HYDRO-PERICARDIUM.
                       DEFINITION.
  Is a non-inflammatory sero-albuminous exudation  into the
pericardial cavity, rarely causing death.

                        ETIOLOGY.
  It occurs most often in renal diseases, which are liable to com-
plicate scarlatina; also in chronic Bright's disease; general dropsy;
and chronic cardiac disease, (result of venous congestion).

                        SYMPTOMS.
  The same  as those which occur in the stage of fluid effusion of
pericarditis, except that there is no febrile disturbance, neither
are there any friction sounds present at  any time during the pro-
gress of the effusion.
                        PROGNOSIS.
  Is a  precursor of death in chronic Bright's, and advanced car-
diac diseases. 
                TUBERCULOSIS OF PERICARDIUM.            109

                       TREATMENT.
   The same as in hydro-thorax.  Treat the disease that caused it.



               PNEUMOPERICARDIUM.
                       ee:-inition.
   Air in the pericardium, due to compound fracture of the ribs,
 or external wounds, or, to the ulcerative process of phthisis.

                       DIAGNOSIS.
   This rests almost exclusively upon  the tympanitic  percussion
 over the precordial space, and, the tinkling and splashing sound
 which is heard over the heart.

                       PROGNOSIS.
   Is always fatal—except when due to traumatism.


                H^MO-PERICARDIUM.
                       ETIOLOGY.
   Blood in the pericardial sac may be due to traumatism; rupture
 of the cardiac walls; or distention of the pericardium with blood
 from rupture of an aneurism, septicaemia, pyaemia, scurvy, pur-
 pura, etc.
                       PROGNOSIS
  Unless traumatic, is rapidly fatal.


        TUBERCULOSIS  OF PERICARDIUM.
                       ETIOLOGY.
  Is only met with  in acute  general tuberculosis, producing peri-
carditis.  It may be suspected, if general tuberculosis be present. 
 110         DISEASES OF THE CIRCULATORY SYSTEM.



         CANCER  OF  THE PERICARDIUM.
                        ETIOLOGY.
  This disease is always secondary to cancerous developments in
 other parts of the body.


               ACUTE  ENDOCARDITIS.
                       DEFINITION.
  Is an inflammation of the (serous) lining membrane of the heart,
 from blood-changes, causing alterations especially in the neighbor-
 hood of the valves, and, possibly, involving the whole endocardial
 surface of a ventricle or auricle.  Is most common in left heart.

                        VARIETIES.
  Acute, which gradually runs into chronic, with no defined line
 of separation; except, that the acute symptoms last three or four
 weeks, and then the disease  becomes chronic in character.

                   MORBID ANATOMY.
  1st.  There is hyperaemia of the endocardium,  most marked
 about the edges of the valves.
  2d.  A plastic exudation on the free surface (which is washed off
 by bloodj, occurs at the  same time; also a growth of new cells
 underneath the inflamed portion of the  endocardium, which by
 their presence produce irregularities upon the free surface of the
valves.  The valves  are also somewhat tumefied by inflammatory
 cedema.
  3d.  The elevations, on the free surfaces of the valves, produced
 by the new cell-growth  underneath  the endocardium, create a
 deposit upon them of  the fibrin of the blood, resulting in the so-
 called "vegetations."
  4th. The new cell-growth under the endocardium organizes into
new connective-tissue; and  this subsequently contracts, causing
an imperfect performance of the function of the valves. 
ACUTE ENDOCARDITIS.                  Ill
   5th. The free edges of the valves sometimes  become  adherent
 to each other, producing stenosis  or  the so-called  ' button-hole
 slit."
                         ETIOLOGY.
   All morbid changes in the blood, causing irritation to the free
 surface of the endocardium over which it passes; Bright's disease
 —from irritation produced  by the urea in  the circulation; and
 acute articular rheumatism  (sometimes).  Whenever it occurs, it
 is due  to  some changes in the salts of the blood, or to a distinct
 poison, acting as  an irritant to the valvular surface of the endo-
 cardium.  The primary seat of the inflammation is in the serous
 structure,  and the changes in the fibrous framework are second-
 ary.  It may occur in diphtheria, septicaemia, pyaemia, and fevers
 of all  kinds.  Secondary syphilis, which  causes catarrh of  the
 urinif erous tubules and amyloid kidney, may thus tend to create it.

                         SYMPTOMS.
                          Rational.
 Pain—in the joints (if rheumatism be present).
 Palpitation—over the precordial space (if  the muscular tissue of
    the heart is involved).
 Pulse—is sharp, quick, and irregular; but feeble and compressible
    when myocarditis occurs.
 Temperature—rarely over 103°.
 Dyspnoea—slight; the respiration is usually somewhat accelerated.
                          Physical.
 Inspection—Increased area of heart's  mpulse.  Irregular heart's
    action—indistinct later on in the disease.
 Palpation—Cardiac impulse is increased at  first, and afterward
    decreased.
Percussion.__The precordial dullness is normal (until the cavities
    are distended with blood from feebleness of the heart); then
    the dullness is increased.
Auscultation.—Systolic, ventricular valvular murmurs are heard.
    If it is produced at the mitral or tricuspid orifice, it is due
    to  the tumefied condition of their edges and  shortening of 
112         DISEASES OF THE CIRCULATORY SYSTEM.
    the chordae tendineae, or to adhesions.  If it  occur at the
    aortic orifice, it is due to a simple roughening of the endocar-
    dium covering the aortic valves, and a soft, blowing, systolic
    murmur is thus produced.

                DIFFERENTIAL DIAGNOSIS.
  First, determine if it is an old or recent murmur.  If it should
happen to be an old murmur, there will be compensatory hyper-
trophy of the heart.   If it be due to acute rheumatism, there will
be an endocardial murmur, which will come on while the case is
under your care.  Should there be a murmur at your first visit,
which is  systolic, soft, and blowing  in character, and no hyper-
trophy, it is  produced probably by an acute endocardial inflam-
mation: but  if the murmur is rough in character, diastolic, and
associated with cardiac hypertrophy, there is no evidence of acute
endocarditis.
  For the differential diagnosis from pericarditis (see acute peri-
carditis).
                        PROGNOSIS.
  Is good, so  far as imminent danger to life is concerned, but bad
as regards complete recovery.  Is rarely fatal, if occurring in
Bright's disease, or rheumatism (still there will always be per-
manent valvular lesions). Is fatal, if it occur in pyaemia, septi-
caemia, and diphtheria (the danger being perforation of the valves
or embolism).  The organs  which are most likely to be affected
frcm an embolus, during this disease, are the spleen, kidneys, and
the brain. Embolism of the spleen is characterized by pain or
swelling over the spleen; pain in the loins and  albuminuria mark a
similar condition of the kidney; sudden hemiplegia occurs from a
similar brain complication.  If ulcerations occur at the free border
or base of the valves,  they may cause  a rupture or tearing of the
valves; following this there is a tendency to weakness and typhoid
symptoms, extreme dyspnoea, cyanosis, and a sudden harsh regur-
gitant murmur, with the first or second sound of the heart.  The
disease may prove fatal in a few hours, or at  most from three
to four days, if such a condition be developed; the duration of life
depending upon the size of the abnormal opening. 
ULCERATIVE ENDOCARDITIS.
113
                         TREATMENT.
   If it be due to rheumatism, rheumatic treatment must be resorted
 to.  If from pyaemia, septicaemia, or diphtheria, quinine and iron
 must  be freely administered.   If from fevers, the temperature
 must  be  held  in check.   If  from Bright's disease, the  urea
 must be eliminated.  Opium should be given  moderately in order
 to secure rest.   The patient must always be kept perfectly quiet;
 the temperature of the room should never be below 70°; the chest
 should be covered with flannel, especially while examination of
 the heart is being made.  The  patient must be fed with the most
 concentrated nutrition.   Digitalis should  be administered if the
 heart become feeble.   Iodide of potassium has been recommended
 to absorb the fibrinous exudation.
   The most efficacious agents in the treatment of this disease will
 be found in rest,  opium, iron, the most nutritious  diet, and the
 occasional use of stimulants.


            ULCERATIVE  ENDOCARDITIS.
                    MORBID  ANATOMY.
   In this form of endocarditis the new cell-growth is  so rapid that
 the  connective-tissue is  not formed and pus results; under these
 circumstances the endocardium either ulcerates, or the  entire
 valve may be perforated.
                         ETIOLOGY.
   It occurs in  pyaemia,  septicaemia, puerperal fever, and in dis-
 eases characterized by great vital depression.

                         SYMPTOMS.
                          Rational.
 Chills—previous to the attack.
 pulSe_90 to 150 (at the time of the attack).
Temperature—105° to 107°.
Dyspnoea—extreme and sudden, when perforation takes place.
Posture—sitting. 
114         DISEASES OF THE CIRCULATORY SYSTEM.

Jaundice—(possible).
Spleen—enlarged.
Urine—scanty, highly colored, and albuminous.
Typhoid symptoms before death.
                         Physical.
Auscultation.—A hard regurgitant murmur is heard with the first
    or second sound, coming on suddenly.

                        PROGNOSIS.
  Usually fatal.  Death may result in a few hours, or three to four
days at most.


              CHRONIC  ENDOCARDITIS.
                        DEFINITION.
  Is a parenchymatous inflammation, marked by thickening and
induration of the endocardium (being of an acute origin); is prin-
cipally found in the endocardial covering of the valves, and that
portion lining the apex of the left ventricle.  It  occurs principally
in persons of a rheumatic history.

                   MORBID ANATOMY.
  The thickening — is the  immediate result of the increase of
connective-tissue.  It is most marked at the base of  the valves
and along the line of contact.  It may be very slight, or the valves
may be  so roughened, thickened, and hardened, as to impair or
entirely destroy their functional activity.
  The retraction—is the result of the changes in the new con-
nective-tissue formations, wherein it becomes of a fibroid charac-
ter, causing  rigidity, diminution in depth, and  puckering of the
valves.  Their edges  have  a  cartilaginous feel.   The changes
are most marked in the mitral valves, being chiefly detected at
the base of the valves, and around the valvular  orifices; the edges
of the valves are sometimes drawn  down and become fastened to
the walls  of the ventricles by a short tendinous cord,  causing
extreme regurgitation. 
CHRONIC endocarditis.
115
   THE ADHESIONS—occur with the retractions; and commence at
 the edges of the valves (as  above), and continue till all traces of
 the valves  may be lost, producing the button-hole slit. This is
 usually confined to the mitral and aortic orifices.
   The degeneration  of the valves.—After the cell-and new
 connective-tissue formation have gone on, and reached a certain
 point, fatty, granular, or calcareous  degeneration takes place,
 forming under the endocardium patches of fatty, granular, or
 calcareous substance.  These result occasionally in ulceration, and
 their removal is usually followed by extensive destruction of tis-
 sue, rupture of the valves, and regurgitation.  Calcareous degener-
 ation is mostly in the aortic orifice,  as the changes occur at a late
 period of life.
   These  growths are not superficial, but an increase in the tissue
 underneath the endocardium, being sometimes  half an inch or
 more in length. They are termed vegetations, often cause sudden
 and fatal regurgitation.  When separated from the valve, they give
 rise to emboli,  and development of infarction, and death of some
 portion of the various vital organs.  These vegetations are  of a
fibroid-tissue growth extending through the entire thickness of
 the cardiac walls, causing shortening, thickening, and contraction
 of the chordae  tendineae and columnse carneae.   They are due to
 inflammatory changes.

                        SYMPTOMS.
   The manifestations of this condition are  in the heart's sounds,
 indicating valvular changes.

                        PROGNOSIS.
  Depends upon the seat, and extent of the valvular lesion.

                        TREATMENT.
  Remove the cause.   Remove your patient from all excitement
and alcohohc stimulants.  Protect the body from sudden exposure
to temperature (see valvidar lesions for further treatment). 
116        diseases of the circulatory system.
                VALVULAR  LESIONS.
  These lesions are of two kinds.
  First. —Valvular thickenings, with slight retraction and ad-
hesions, and atheromatous and calcareous degenerations; which
give rise to murmurs,  and cause obstruction to the current of the
blood.
  Second.—Extensive valvular retraction, perforation, partial
detachment of the valves, rupture of the chordae tendineae, and
calcareous plates, causing the valves not to close, and thus allow-
ing of a return of the blood to the cavity, called ' insufficiency.''''
These alterations may co-exist, one being more extensive than the
other.

                AORTIC  OBSTRUCTION.
                       DEFINITION.
  An abnormal  condition of the aortic  valve,  obstructing the
escape of blood from the left ventricle into the aorta.  It is always
accompanied by  hypertrophy  of the left ventricular wall

                   MORBID ANATOMY.
  Changes take  place  in the aortic valves during  acute and
chronic endocarditis, as well as atheromatous  degeneration of
these valves; causing them to  become thick and rigid, and to pro-
trude into the current, thus  producing  a murmur with the first
sound of the heart.  There may be also vegetations on the surface
of the thickened  endocardium on the valves, obstructing the out-
going current,  or a development of calcareous plates underneath
the valves, also producing obstruction (stenosis).  All of these con-
ditions involve the left ventricle, producing gradual hypertrophy
of its walls (unattended by dilatation); and, after a time, insuffi-
ciency of the mitral valves follows (due to extension of the endo-
cardial inflammation). 
AORTIC OBSTRUCTION.
117
                          ETIOLOGY.
   It occurs in middle or advanced life, from acute or chronic
 endocarditis; or, from prolonged and severe muscular  exertion,
 and atheromatous degeneration of the aorta.

                         SYMPTOMS.
                           Rational.
 Pulse—small in volume, compressible, jerking, or intermittent.
 Syncope—(on account of cerebral anaemia)—may occur.
 Embohsm of the brain (if the vegetations become  detached and
     pass upward).
 (Edema of the feet (from defective venous return)—may occur.
                           Physical.
 Inspection.—The area of cardiac impulse is increased.
 Palpation.—The force of the heart is increased, and heaving; and
     the heart-beat is more to the left than normal.
 Percussion.—Increased area of dullness (to the left and downward)
 Auscultation.—There is a murmur with the first sound, directly
     over the aortic valve, behind the sternum at the junction of
     the third rib.  The murmur is heard with the greatest intensity
     at  the second costo-sternal  articulation of the right side, and
     along the carotids.  It may replace the first sound or follow it
     immediately.  The murmur is harsh in character.

                DIFFERENTIAL DIAGNOSIS.
  Rests upon the presence of a systolic aortic murmur; it may be
 mistaken for mitral, tricuspid,  aortic regurgitant, and anaemic
 bruit.
 Aortic obstructive.
    Is a systolic murmur, heard  at the apex, and the anterior por-
    tion of the chest. The maximum of intensity is heard at the
    second costo-sternal articulation of the right side, and along
    the carotids.
Mitral regurgitant.
    Is a systolic murmur heard at the base of the heart, with less
    intensity than at the apex.  The maximum of intensity is
   heard at the apex, and carried round to the left. 
118         DISEASES OF THE CIRCULATORY SYSTEM.
 Aortic obstructive.
     Maximum of intensity (see above).
 Tricuspid regurgitant.
     The maximum of intensity is heard at the apex, and is rarely
     audible above the third rib with the sternum.
 Aortic obstructive.
     Hypertrophy  of the  heart exists.  Increased force of apex-
        beat,  and jerky pulse may be  detected.
 Anaemic bruit.
     Is heard over the carotids and is a venous hum.   There is a
     feeble apex-beat; the pulse is soft, full, and compressible.

                        PROGNOSIS.
  If the rhythm of the heart is not destroyed, the chances as to
 duration of  life  are not bad;  otherwise they are, as the  patient
 may die of  cerebral anaemia, from the cutting off of the blood-
 supply. If  the murmurs  have lasted one or two years, you may
 be sure there are vegetations.

                       TREATMENT.
  See "Aortic Regurgitation."


              AORTIC  REGURGITATION.
                    MORBID ANATOMY.
  This is one of the gravest forms of heart-disease.   The semi-
lunar valves may be shortened, or shrunken, by chronic endocar-
ditis, preventing closure; or, there may be laceration, dilatation,
or adherence, causing a free opening. The regurgitation causes
over-distention of the left ventricle, producing dilatation of that
cavity from relaxation of the muscular fibres; and hypertrophy of
the left ventricle ensues, in order  to resist, and overcome the
obstruction to the circulation.  Over-dilatation of the arteries also
ensues from an abnormal quantity of blood being thrown into
them.  Endocarditis is developed; and  degeneration of the arterial
walls occurs, leading to the rupture of an artery, usually in the brain
(in case of over-excitement or excessive exercise), and the symptoms 
AORTIC REGURGITATION.
119
of cerebral apoplexy.  Tissue-degeneration of the heart also takes
place from  diminished  supply to the coronary vessels, through
insufficiency of the aortic valves.  Dilatation of the left ventricle
recommences and progresses (extensively); the mitral valves are
not strong enough to close the auriculo-ventricular orifice, and
regurgitation takes place through that orifice, on account of an
extension of the endocarditis, atheromatous change, chronic endo-
carditis, and shrinking  or shortening of  the  chordae tendineae.
Aortic  regurgitation thus becomes  modified, by failure  of  the
mitral valves.  There is a general dirturbance of the venous circu-
lation, late in the disease, resulting in cyanosis  and dropsy.

                         ETIOLOGY.
  Acute or  chronic endocarditis; bodily exertion; atheroma of
the aorta.
                         SYMPTOMS.
                          Rational.
Palpitation  of the heart—(which is not constant).
Hypertrophy—sometimes excessive,  producing excessive  heart's
    action, vertigo, headache, syncope, and spots before the eyes.
Pulse—quick, jerking, irregular, and intermittent.
Radial pulse—a little after the apex-beat, in point of time.
Dyspnoea—due to pulmonary congestion.
Anaemia—excessive (due to emptiness of the arteries).
Giddiness—(due to interference with the cerebral circulation).
Increase in the carotid pulsation.
Overloading of the veins (due to impaired return to the heart).
Cyanosis (when the lungs are excessively congested).
Dropsy (when the systemic circulation becomes impaired).
Death (from cerebral embolism, disease of liver and kidneys, apo-
    plexy, failure of heart, general dropsy, etc;.
                          Physical.
Inspection.—Increased area of the apex-beat, and carotid pulsation.
Palpation.—Heaving impulse about  the 8th rib,  and to the left
    of the left nipple.
Percussion.- Area of precordial dullness is to the left of, and below 
120
DISEASES OF THE  CIRCULATORY SYSTEM.
    the normal area, and is more oval than normal;  as dilatation
    comes on, the dullness will extend upward, and the apex-beat
    may be perceived as high up as the axillary space.
Auscultation.—A murmur is heard with  the second-sound, some-
    times immediately following it;  maximum intensity over the
    second intercostal space close to the right edge of the sternum
    over a large  area, or down to the xyphoid cartilage, or, along
    the spine.  It is heard, as a diastolic  murmur, at the base of
    the heart; when combined with aortic obstruction, there is a
    double murmur heard over a large area, at the second inter-
    costal space to the right, or left of the sternum.

                DIFFERENTIAL DIAGNOSIS.
  Rests on the diastolic murmur, and the presence of hypertrophy
and dilatation.  It  can only be confounded with mitral stenosis
(which has no hypertrophy,  nor dilatation of  the left ventri-
cle).  In pericarditis (confined to that portion  above the aorta), a
friction-sound resembling the murmur may be  heard,  but this
occurs only  during diastole,  and without  evidences of  either
hypertrophy or dilatation.
                        PROGNOSIS.
  It depends  on the age of the patient.  It  is exceedingly unfa-
vorable when occurring in those of middle age, especially if they
are engaged  in active pursuits.   The dangers are hypertrophy of
the left ventricle, augmenting  the distended force of the arterial
walls,  causing degeneration; degeneration of the hypertrophied
ventricular walls, from impaired nutrition,  on account of inter-
ference of the coronary circulation, causing excessive dilatation
and weakening of the heart; and an inability of the heart to over-
come the resistance, resulting in cyanosis, dropsy, and death.  In
old people, it gives rise to  very little inconvenience.

                   CAUSES OF DEATH.
  From hypertrophy and degeneration of the ventricular walls;
from cerebral embolism; from regurgitation, accompanied by vege-
tations on the valves ; from obstruction  to the systemic circula-
tion (producing sclerosis  of the  liver and  kidneys);  from pul- 
MITRAL OBSTRUCTION.
121
monary  oedema;  cerebral apoplexy:  or from  sudden syncope
{from obstruction to the return circulation).

                         TREATMENT.
  Absolute rest  is imperative.   There  must be avoidance of all
physical  and mental exercise, or intemperance in any form.  The
patient must have a nutritious diet,  chiefly  albuminous.   Care
must be taken not to disturb the heart's action.  The patient must
lead a quiet life.  Digitalis should never be resorted  to in this
disease.  Iron should be administered  if there are symptoms of
imperfect heart-power, and anaemia be  present.  For the relief of
dyspnoea and dropsy, see " mitral regurgitation."
                MITRAL OBSTRUCTION.
                        DEFINITION.
  Is a condition of stenosis, or obstruction, of the auriculo-ven-
 tricular orifice of the left heart; and is due partly to constriction
 at the base of the mitral valves,  and partly to adhesion of the
 valve-tips and chordae tendineae, following rheumatic endocar-
 ditis (it occurs principally in young children).
                    MORBID  ANATOMY.
  The new connective-tissue, by contracting, causes obstruction
to the flow of the blood from the auricles to the ventricles, by pro-
 ducing  incomplete opening of the auriculo-ventricular  orifice.
 In stenosis, the edges of the valves become adherent, as may also
 the chordae tendineae, forming the " button-hole slit" (the normal
opening should easily admit the ends of three fingers).  Dilatation
 and hypertrophy of the left auricle are thus produced from its over-
distention; also obstruction in the pulmonary veins, and dilatation
of the pulmonary capillaries, causing congestion of the pulmonic
circulation, or pulmonary congestion.  The lungs may be found
to be in a state of pigmentation  (" brown induration ").  Bronchor-
rhoea may also occur, due to hyperaemia of the bronchial mucous
membrane; and pulmonary apoplexy may even occur from rupture
of the pulmonary blood-vessels.  This latter complication may be 
122         DISEASES OF THE CIRCULATORY SYSTEM.

caused by exercise, since the pulmonary  hyperaemia  is  thus
increased.  Pulmonary oedema may be readily developed  when
this valvular disease is strongly marked, from walking against a
strong head-wind ; and may result in death.

                         ETIOLOGY.
  Mitral obstruction may be the result of acute or chronic endo-
carditis, in young people; and of all the morbid  changes in the
blood; such as Bright's disease (from  the irritation p roduced  by
urea in the circulation) ;  acute articular rheumatism ; sometimes
of changes in the salts ; or poisons, acting as an irritant to the
valves (as in diphtheria, septicaemia, pyaemia, and  all the fevers).

                         SYMPTOMS.
                          Rational.
Dyspnoea—(a result of the pulmonary congestion).
Cough—dry, hacking, unsatisfactory ; resembles a  nervous cough;
    is due to changes in the lungs (congestion), not to the heart.
Haemoptysis—of dark color, usually slight in amount.
Expectoration — profuse, watery, and  blood-stained (especially
    after exertion)—this denotes pulmonr r/ congestion.
Pulse—regular (if the ventricle be not affected, and only a slight
    stenosis exist); but may be feeble (if stenosis be extensive).
                          Physical.
Inspection.—Feeble cardiac impulse.
Palpation.—A distinct purring thrill preceaes the apex-beat.
Percussion.—Area of dullness increased upward, and  to the left.
Auscultation.—A loud blubbering murmur is  heard, just before
    the first sound; and is synchronous with the contraction of
    the auricle.  The maximum of intensity is heard a little above
    the apex-beat; is louder and longer than any other murmur.

                DIFFERENTIAL DIAGNOSIS.
  Depends upon the loud blubbering  murmur,  and the purring
thrill.  It is a presystolic murmur.  It may be confounded with
mitral and aortic regurgitation. 
                    MITRAL regurgitation.                123

                        PROGNOSIS.
  Is bad, especially if excessive dyspnoea be present.

                       TREATMENT.
  Same as in mitral regurgitation (see page 126).



              MITRAL  REGURGITATION.
                       DEFINITION.
  Is caused by thickening, induration, and shortening of the
mitral valve ; due to changes produced by  acute or  chronic endo-
carditis. It is the most common valvular lesion.
                    MORBID ANATOMY.
  The regurgitation is often caused by calcareous matter imbedded
in the valves.  The chordae tendineae become thick and short, and
the papillary muscles (which arc the terminations of the chordae
tendineae 1 become diminished in bulk.   The valves may be  torn,
the chordae tendineae ruptured, and the regurgitant current then
causes them to flap; or the valves may become adherent to the
ventricular  walls through shortening of  the  chordae tendineae.
The following changes take place in consequence:
1st.—Dilatation of the left auricle (as a result of excessive blood-
    pressure).
2d. —Compensatory hypertrophy of the left  auricle (to increase its
    power, and thus  to force blood through the narrowed orifice).
3d.—Disturbed pulmonary circulation, producing  congestion or
    brown  induration  (when the previous  hypertrophy proves
    insufficient).
ith.—Hypertrophy of the  right ventricle (to overcome pulmonary
    obstruction).
5th.—Dilatation of the right ventricle (as the result of too  great
    pressure).
6th.—Tricuspid regurgitation (due to an endocarditis excited, or
    to excessive dilatation of the ventricle). 
124         DISEASES OF THE CIRCULATORY SYSTEM.

7th.—Dilatation  of the right auricle (from the pressure of the
    regurgitated blood).
8th.—Compensatory hypertrophy of the right auricle (to overcome
    the previous dilatation).
9th.—Interference to the return circulation of the venous blood
    from the superior and inferior venae cavae.
    In superior vena cava.
        Producing, headache ; vertigo ; jugular pulsation ; promi-
        nent jugulars ; cyanosis ; oedema;  apoplexy ; etc.
    In inferior vena cava.
        Producing, nutmeg-liver; obstruction to the portal cir-
        culation ; hemorrhoids ; menstrual  disturbance ;  gastric
        catarrh ;  epigastric pulsation (which is hepatic, from re-
        gurgitation  into its vessels) ; intestinal catarrh ; ascites;
        jaundice; enlarged spleen; passive hyperaemia of the
        kidney, or desquamative nephritis (catarrhal);  and general
        anasarca.
  In order to overcome  these changes and keep up  the heart's
power,  hypertrophy and dilatation of the left ventricle finally
take place.

                         ETIOLOGY.
Primary cause.
    Acute endocarditis.
It may be secondary to
    some lesion of the aortic valves, either  from extension of the
    endocardial inflammation or to a valvulitis excited by the re-
    gurgitant  current from the aorta.  Enlargement of the left
    auriculo-ventricular orifice, which accompanies excessive dila-
    tation of the left ventricle, may produce it.

                        SYMPTOMS.
                          Rational.
  Are chiefly due to the regurgitation at the tricuspid orifice—and
are therefore developed late in the disease.
Cough—with watery expectoration which is sometimes stained
    with dark or blackish blood (a symptom of pulmonary dropsy). 
MITRAL REGURGITATION.
125
 Enlarged liver (due to interference with its return of blood).
 Pain and weight in the right hypochondrium (from hyperaemia).
 Jaundiced hue to the surface.
 Cyanosis—(a symptom of impaired venous return).
 Cerebral hyperaemia.
 Headache—due to hyperaemia of brain.
 Vertigo—due to hyperaemia of brain.
 Stupor—due to hyperaemia of brain.
 Delirium (temporary).
 Gastric and intestinal catarrh—due to hyperaemia
 Hemorrhoids—due to hyperaemia.
 Amenorrhcea—due to hyperaemia.
 Urine—scanty, high-colored, and casts.
 Rapid ascites - produced by a sero-albuminous exudation through
    the walls of the vessels; commencing in the lower part of the
    abdomen and extending upward.
 General anasarca (beginning at the ankles and extending upward).
 Irregular radial pulse—being at first exceedingly feeble, compress-
    ible,  and tremulous  on excitement.
                          Physical.
 Inspection and  Palpation.—Increased area of  cardiac impulse,
    which may be  forcible, or  diffused;  depending upon the
    amount of hypertrophy and  dilatation.  Apex-beat is more
    to the left than normal
 Percussion.—Precordial dullness increased,  extending to the left
    beyond the  nipple  and downward; showing more  or less
    hypertrophy and dilatation.   Area  of  superficial dullness is
    increased laterally and  downward.
 Auscultation.—A murmur takes the place of, or follows, the first
    sound, and is synchronous with  the systole of the ventricle,
    and due to regurgitation from the left ventricle to the auricle.
Diagnostic points.
    Its greatest intensity is at the apex-beat. Area of diffusion is
       to the left, and it is heard  with nearly the same intensity
       behind,  between the fifth and  eighth  dorsal  vertebrae,
       close to the left side of the spinal column.   The second 
126         DISEASES OF THE CIRCULATORY SYSTEM.

        sound is abnormally intense over the pulmonic valves
        a little above the third rib.
                   CAUSES OF DEATH.
  CEdema of the lungs, on account  of the feeble and irregular
heart action; hemorrhagic infarction (from pneumonia), the in-
flammation causing death; general anasarca;  or Bright's disease.
                DIFFERENTIAL DIAGNOSIS.
  From aortic regurgitation and obstruction, and tricuspid regur-
gitation; but the murmur, area of diffusion, and character of the
pulse, are sufficient to enable you to make a satisfactory diagnosis.
  In mitral regurgitation—the pulse is feeble and easily acceler-
ated.
  In aortic regurgitation—the pulse is hard and jerky.
  In mitral  regurgitation—the  murmur  occurs  with the  first
sound, is heard at the apex and carried to the left and backward
between the fifth and eighth dorsal vertebrae.
  Aortic obstruction—occurs with the first sound and  is conveyed
along the carotids.
  Tricuspid regurgitation—occurs with  the first sound  and  is
heard over the right ventricle and to the right of the area of the
heart.
                        PROGNOSIS.
  As far as the  duration of life is  concerned, the prognosis is
good, on account of compensating hypertrophy and the stationary
character of  the  exciting cause.   If oedema, cyanosis, extreme
dyspnoea, etc., be present, the prognosis is bad.
                        TREATMENT.
  The patient must lead a quiet  life, free from all  excitement;
and  have absolute self-control.  A change of  occupation  may
become necessaiy,  if  there  be  a predisposition to  pulmonary
hypertrophy or bronchial catarrh.  Forbid the use of the voice,
as in singing, etc., as there is a constant pulmonary  hyperaemia,
which such acts tend to increase.  If excessive pulmonary oedema
occur, venesection or hydragogue  cathartics should be resorted 
PULMONIC REGURGITATION.
127
to.   Give Inf.  Digitalis  I ss. every two hours  for twenty-four
hours; it relieves the hyperaemia and favors systemic circulation;
it regulates and increases the systolic action, by its action on the
muscles of the heart; it strengthens the right heart and enables
the left ventricle to resist the increasing dilatation.  It should not
be continuously employed, but only for twenty-four or forty-eight
hours, if good results be obtained.  If it  be judiciously used, it
may cause disappearance of the pulmonary oedema,  cyanosis,
anasarca, and scanty urine.
  Iron may be given with the food in full doses, but only in cases
of anaemia (Vallet's Mass gr. x.-xx t. i. d.)
 VALVULAR  DISEASES OF  THE  RIGHT HEART.
  These are all secondary to those of the  left heart,  and are very
 rare, as endocarditis seldom occurs on that side.  When endocar-
 ditis does occur on the right side, it is usually confined to the
 tricuspid  valve;  and is due to obstruction  in  the  pulmonic
 circulation from  diseass of the mitral valve, which induces an
 hypertrophy of  the right  ventricle  and  subsequent  valvular
 lesions.

                  PULMONIC  VALVES.
     PULMONIC OBSTRUCTION OR STENOSIS.

  Ts usually caused by mediastinal  tumors pressing on the pul-
 monary artery,  diminishing  its  calibre  and obstructing  the
 current.   The murmur occurs with the first sound,  and  the
 maximum  of  intensity  is  over the  seat  of  the valve.   The
 murmur is superficial and distinct, and the area of diffusion is
 toward the left shoulder.

            PULMONIC  REGURGITATION
  Is doubted by many eminent physicians, if this condition exist
M> such an extent as to constitute a pathological  lesion.  The 
128         DISEASES OF THE CIRCULATORY SYSTEM.

murmur occurs with the second sound, over the pulmonic valves;
and the area of  diffusion is carried down to the  xiphoid cartilage.
There is no jerking or pulsation as in aortic regurgitation

                        PROGNOSIS.
  Is theoretically bad.  If it occur as a primary disease, it causes
dilatation of the right ventricle, tricuspid regurgitation,  and
disturbance of the systemic circulation.
           TRICUSPID REGURGITATION.
                       DEFINITION.
  Is usually secondary to  mitral stenosis or regurgitation.   It is
preceded, as a rule, by hypertrophy of the right ventricle,  since
pulmonic obstruction has to be overcome.

                   MORBID ANATOMY.
  There is thickening and  shrinking of the valves; shortening of
the chordae tendineae;  and  more or less thickening and induration
at the base  of the valves, thus diminishing their size.   There  is
first dilatation and, secondly, a compensatory hypertrophy of the
right auricle; there is disturbance in the  circulation of the  venae
cavae, as shown under the description of morbid changes due to
mitral regurgitation (page 123); last of all, the left ventricle becomes
involved, on account of the increased work of the left heart from
the systemic obstruction.
                         ETIOLOGY.
  Its spontaneous occurrence is doubtful; pulmonary emphysema
causing interference with  the pulmonary circulation and subse-
quent endocardial inflammation, from abnormal stress thrown on
the valves at the auriculo-ventricular orifice, may produce it; and
also interference with the  pulmonary circulation  from any cause,
as mitral lesions, mediastinal tumors pressing upon the pulmonary
artery, etc. 
TRICUSPID REGURGITATION.
129
                         SYMPTOMS.
                          Rational.*
   When the venous return is interfered with, there may be
Enlarged liver—(due to venous engorgement)—nutmeg liver.
Dinginess on the surface of the body.          "
Urine—scanty.
Bright's disease (from passive hyperaemia of the kidney).
Headache (from passive hyperaemia of the brain).
Vertigo (from passive hyperaemia of the brain).
Dementia (from passive hyperaemia of the brain).
Irregular heart's action.
Cardiac palpitation.
Dyspnoea (from passive hyperaemia of the lung).
Face—blue  and turgid; with  stupor,  coma, and  cerebral  com-
    pression, if the patient be placed in a horizontal position.
                          Physical.
Inspection.—Increase in the visible cardiac impulse from the apex-
    beat to  the xiphoid cartilage and to the second  intercostal
    space.   Pulsation in jugulars.   Distended jugulars.
Palpation.—Indistinct apex-beat, unless hypertrophy of the left
    ventricle exist.  Epigastric pulsation.
Percussion.—Area of dullness is increased to the  right  of the
    sternum and to the second intercostal space.
Auscultation.— There is a blowing murmur taking the place of the
    first sound.  It is superficial and rarely heard above the  third
    rib.  The maximum of intensity is between the fourth and
    and sixth ribs at the left border of the sternum.  The second
    sound is increased in intensity, and heard  most distinctly
    over the pulmonic valve.

               DIFFERENTIAL DIAGNOSIS.
  From mitral  regurgitation; aortic  obstruction; and pulmonic
obstruction.

     * For the explanation of these symptoms see page 124 of this volume. 
130         DISEASES OF THE CIRCULATORY SYSTEM.

                        PROGNOSIS
  Is bad (see page 124 of this volume,  where dangers, due to
venous engorgement, are given in some detail).

                        TREATMENT.
  The patient must lead a quiet life, and reside in a warm climate;
where a free action of the  skin  can be  maintained.   When it
occurs in connection with emphysema, digitalis is not well borne,
as it increases the jugular pulsation and distends the veins of the
head and neck, but, should  it occur in connection  with mitral
regurgitation, digitalis is then of great  service.  Iron must be
administered, if anaemia exist (as mentioned under the  treatment
of mitral regurgitation). Drastic cathartics temporarily relieve
the  venous engorgement and cerebral oppression,  but,  should
anasarca be- developed, incision or needle  pricking is the  only
means of relief.


                 CARDIAC  MURMURS.
Rhythm of Murmur.
    Is the relation of the murmur to the sounds of the heart.
Heart-Sounds.
    First sound.—Is distinguished by the striking of the apex of
    the heart against the chest-wall, and is synchronous with the
    radial pulse.  It is longer in point of duration than the second
    sound, since it is due to the continued  effect of four causes, as
    follows: (1) The blow of  the apex upon the chest-wall; (2) the
    friction of  the muscular fibres of the ventricles; (3) the  rush
    of blood in the ventricles; (4) the closure of the auriculo-ven-
    tricular walls.  Should  there be a murmur  it will bear the
    same relation to the apex-beat and radial pulse as the first
    sound does.
    Second sound.—Is distinguished by a short, sharp sound which
    is produced by closure of the aortic and pulmonic valves.
  All murmurs either precede, take the place of, or follow immedi-
ately one of the sounds of the heart. 
CARDIAC MURMURS.                    131
                     Presystolic Murmur*
 Mitral obstructive.—Is heard with greatest intensity u>ei «, cir-
     cumscribed space at the apex.  It is characterized by a pur-
     ring sound, and is the loudest and longest of all the murmurs.
 Tricuspid obstructive.—Is heard with greatest intensity along the
     margin of the fifth and sixth costal cartilages, on  the  left
     border of the sternum.  Its area of diffusion is over the right
     ventricle and rarely above the third rib.
                      Systolic Murmurs.
 Mitral regurgitant.—Is heard with greatest intensity at the apex.
     Its area  of  diffusion  is carried  to the left, and is often heard
     between the fifth and eighth dorsal  vertebrae or at the angle
     of the scapula
 Tricuspid regurgitant.—-Is heard with greatest intensity between
     the fifth and sixth ribs along the sternum. Its area of diffu-
     sion is over the right ventricle and rarely above the third rib.
     It is a  loud blowing murmur.
 Aortic obstructive.—Is heard with greatest intensity at the second
     costo-sternal articulation of the right side.  Its area of diffu-
     sion is upward along the carotids.  Inaudible at the apex.
 Pulmonic obstructive.—Is heard with greatest intensity over the
     seat of the valves at the junction of the third rib and sternum
     of the left  side.   Its area  of diffusion is carried toward the
     left shoulder.
                     Diastolic Murmurs.
 Aortic regurgitant. — Is heard with greatest  intensity  at  the
    third costo-sternal articulation on the right side.   Its area of
    diffusion is carried down the sternum to the xiphoid appendix,
    and it may be heard at the apex.
Pidmonic regurgitant. — Is heard with  greatest intensity over
    the seat of the valve, at the junction of the third rib and the
    sternum of the left side, and is carried down to the apex.
  In addition to the above-mentioned murmurs there may also be
Anazmic murmurs—heard with greatest intensity in the carotids.
Ventral murmurs—-are produced  within  the left ventricle from
    roughening  of the  chordae tendineae, or  the ventricular sur- 
132
DISEASES OF THE CIRCULATORY SYSTEM.
    face of the mitral valves, or by an abnormal direction to the
    current of blood as it passes through the ventricle.  These are
    very rare.

              CARDIAC  HYPERTROPHY.
                        DEFINITION.
  Is the result of overwork,  and consists of a thickening of the
walls of the heart by an increase in the muscular tissue, involving
both the auricles and the ventricles, or either one alone.
                        VARIETIES.
  Simple—where there is thickening of the  walls, but no  increase
in the capacity of the cavities; it is confined to  the left ventricle
(occurs in Bright's disease and alcoholism).
  Eccentric—where there is thickening of the walls, and  increase
in the capacity of the cavities (occurs with valvular lesions).
  Concentric—where there is thickening of the walls, but  diminu-
tion in the capacity of the cavities; this is of very rare occurence.
                  MORBID ANATOMY.
  In the eccentric form.—There  is an increase in  the size of the
papillary muscles, and thickening of the septum.  A change takes
place in the shape of the organ, which corresponds with  the seat
of the hypertrophy.  If the hypertrophy be confined to  the left
ventricle, the heart will be  of a pyriform shape; if to the right
ventricle,  there  is an increase  in the  horizontal measurement,
making it oval and elongated.   The walls of the heart are stiffened,
and  do not collapse when opened after death ; and are redder
than normal.   Hypertrophy is simply a hyperplasia.   There may
be an increase in the size of the muscular  fibres, but the hyper-
trophy chiefly consists in an increase in their number.  The heart
may weigh 40 ounces more  than normal.
                        ETIOLOGY.
  It  seldom exists without valvular lesions, arterial changes, or
capillary obstruction.  Anything which tends to create dilatation
of the heart cavities or mechanical obstruction to the circulation
of blood may produce it. 
CARDIAC HYPERTROPHY.
133
                         SYMPTOMS.
                          Rational,
In Moderate Cases.
    Fullness of the arteries.
    Emptiness of the veins.
    Pulse—full and strong.
    Face—easily flushed;  and eyes brilliant.
    Carotid pulsation.
In Severe Cases.
    A sense of fullness in the chest, from pressure of the enlarged
        heart.
    Uneasiness—in the epigastric region—from pressure.
    Impaired digestion—from pressure.
    Dyspnoea—from pressure on the lung.
    Cardiac palpitation—under excitement.
    Headache—when under excitement.
    Vertigo—when under excitement.
    Tinnitus aurium—when under excitement.
    Atheroma—from extension of the endocarditis.
    Endarteritis — from extension  of the endocarditis (causing
        changes in the coats of the vessels).
                          Physical.
Inspection.—Increased and distinct area of impulse, and visible
    motion of the chest on cardiac pulsation.  In children—bulg-
    ing of the precordial space, and displaced apex-beat.
Palpation.—Increased area of apex-beat and the detection of a
    heaving, lifting character over the whole precordial space;
    which determines hypertrophy of the left ventricle.  If hyper-
    trophy of the right ventricle exist,  there will be a strong
    epigastric pulsation.   If  hypertrophy of  the left ventricle
    exist, the apex-beat will be to the left (three inches below and
   two or three inches to the left  of  the nipple).  In eccentric
    hypertrophy.—If the right ventricle be affected, the apex-beat
   is to the right and downward. If the left ventricle be affected,
   the apex-beat is to the left and downward.
Percussion.—Dullness is increased to the right, or  left,  or down-
    ward •  and when upward the auricles are hypertrophied  and 
 134         DISEASES OF THE CIRCULATORY SYSTEM.

    dilated, but it is rare.  If hypertrophy of the right ventricle
    exist, there is dullness to the right of the sternum.  If hyper-
    trophy of the left ventricle exist, there is dullness to the left
    beyond the nipple.   If eccentric—the dullness is increased  in
    both directions.
 Auscultation.—The first sound (if no  murmur be detected) will  be
    dull, muffled, and prolonged, with increased intensity.  The
    second sound is increased in intensity in both hypertrophy  of
    the left and right ventricle.  If there be hypertrophy of the left
    ventricle, it is heard with greatest  intensity over the aortic ori-
    fice; if there be hypertrophy of the right ventricle, it is heard
    with greatest intensity over the  pulmonic orifice. There  is
    absence of the respiratory murmur over the precordial space.
    In emphysema, there may not be much increase of force in the
    apex-beat; the heart's sounds will be diminished; and a venous
    pulsation in the neck  (due to hypertrophy and dilatation  of
    the right ventricle with tricuspid regurgitation) may be per-
    ceived.

                DIFFERENTIAL DIAGNOSIS.
  In eccentric hypertrophy  of the left ventricle.—The pulse will be
full and strong;  there will  be carotid  pulsation, the countenance
flushed; the eyes prominent and brilliant; the apex-beat forcible,
over an unnatural area, and carried to the left; the cardiac dull-
ness increased  to the left and downward; and there will be in-
creased intensity of heart's sounds, especially of the second sound.
  In eccentric hypertrophy of the right ventricle,  there  will be
forcible heart's  action noticed along the sternum and left lobe  of
the liver; the apex-beat  is carried to the right and downward; the
cardiac impulse is nearer the median line; there is somewhat  of
an epigastric impulse, increased area of dullness to the right; and
the pulmonic sounds are  increased.   The first  sound is  more
intense than normal and nearer the median line.
  In total eccentric hypertrophy.—Everything is the same as  in
hypertrophy of the left  ventricle, except that the dullness is in-
creased in  all directions, and the heart's sounds are more intense
than normal. 
CARDIAC  DILATATION.
135
  The condition of hypertrophy is to be further differentiated from
cardiac dilatation : thoracic aneurism ; mediastinal tumors ; con-
solidation of the lung-tissue ; and pleuritic effusions.

                        PROGNOSIS.
  Is more favorable than  in any other cardiac affection; simple
hypertrophy (unless from  aortic stenosis) may exist  for  years;
slight hypertrophy is very common; if degeneration of the hyper-
trophied walls exist, the prognosis is very unfavorable.   When
hypertrophy of the right ventricle is  accompanied by pulmonary
obstruction, the prognosis is bad.
                        TREATMENT.
  Alcohohc stimulants, immoderate eating, active and  prolonged
physical and mental exercise, must be strenuously avoided.  All
obstructions to the abdominal circulation must be removed. The
bowels  should be made to move freely, by regulating the diet so
as to  prevent  constipation  and straining.   If cerebral  symptoms
occur, they should be overcome by aconite in full doses.  Fleming's
tincture of the root, gtt. ij.—iij. may be given every three or four
hours, but should the  dilatation exceed the hypertrophy, do not
give it.   Digitalis should only be administered when the heart's
action is enfeebled.


                CARDIAC  DILATATION.
                        DEFINITION.
  A condition which is characterized by an increase in the capacity
of its cavities, and a diminution  in its contractile power.
                        VARIETIES.
  Simple—Where there is an increased capacity of the cavities
and no marked change in the walls;  it occurs in convalescence
from typhoid fever, or  any disease where  there has been great
impairment of nutrition.
  Hypertrophous—Where there  is an increased capacity of the
cavity;  increased thickness of the heart-walls; and diminished
contractile power. 
136         DISEASES OF THE CIRCULATORY SYSTEM.

  Atrophic—Where there is a marked increase in the capacity of
the cavities; the cardiac walls are  thinner than  normal;  the
ventricular walls diminished  to two  or  three lines, and the auri-
cles are almost transparent.
                    MORBID ANATOMY.
  This condition may occur in one or all the  cavities.  The heart
will be altered  in shape, and this will  depend  upon where the
seat of dilatation is situated.   It  occurs most frequently in the
auricles; next in the  right ventricle; and lastly  in the left ven-
tricle.  If the walls of the left ventricle be very much thinned,
they collapse when the ventricle is cut.   A heart  that is distended
with blood and  relaxed  by putrefaction may be easily mistaken
for a dilated heart; but,  in such instances, the heart  is extremely
soft and saturated  with  the  coloring matter of the blood,  and
there will be evidences of decomposition in other  parts of the
body.
                         ETIOLOGY.
  First cause —From internal pressure during  cardiac diastole;
from  weakness, as the  result of  prolonged  disease; from fatty
degeneration; from  abnormal  pressure,  producing  permanent
dilatation of its cavities; from degeneration, and an absence of
compensatory hypertrophy.
  Second Cause.—From loss of tone when the muscular tissue of
the heart is  the seat of primary fatty degeneration; as occurs
when there is first dilatation of the cavities with excessive blood-
pressure, and after myocarditis.
  Third Cause.—From degeneration of muscular substance of the
heart, which is the seat of eccentric  hypertrophy (occurring after
valvular diseases).
                         SYMPTOMS.
                          RATIONAL.
In simple dilatation.
    The cavities are increased, and labored heart's action exists.
    No increase in the heart's  force.
    Feeble radial pulse.
    Rhythm not disturbed. 
CARDIAC DILATATION.
137
In atrophic dilatation.
    Tlie cavities are dilated and thinned.
    Labored heart-action and feeble power.
    Marked feebleness of the radial pulse.
    Heart staggers—from increased amount of blood.
    Arteries—imperfectly filled.
    Veins—distended and engorged.
    disturbed rhythm.
    Radial pulse—is weak and intermittent.
Common symptoms.
    Cardiac palpitation—severe, and distressing syncope.
    Constant  and painful sense of pulsation of the heart.
    Dyspnoea—on slight exertion (which is constant in bad forms
       of this condition).
    Countenance—pale, languid, and anxious.
    Lips—livid, even when the patient is quiet.
    On excitement.
       Face and neck are livid.
       Pulse—irregular and intermittent.
       Loss of mental powers.
       Dyspeptic symptoms.
       Fullness in the epigastrium.
    Urine—scanty and albuminous.
    CEdema—causing the patient to sit up with the head forward,
       and resting on some support.
    Cyanosis—(when extensively developed).
    Yellow tinge of the surface—from disturbance of the liver.
    Delirium—(a late symptom).
   Death—from syncope, anasarca, or pulmonary oedema
                         Physical.
   Inspection.—Indistinct and increased area of impulse, (especi-
       ally in fat or ©edematous people).   Undulating movement
       over the precordial space (in thin subjects).  No prom-
       inence of the precordial region.  Irregular and distended
      jugulars (if the right heart be distended).
   Palpation. — Feeble cardiac impulse; absence of the lifting,
       forcible impulse,  as  in  hypertrophy.   Apex-beat is dif- 
138         DISEASES OF THE CIRCULATORY SYSTEM.

       fused, undulating, wanting in power, and resembling a
       feeble step.  Purring thrill with the apex-beat like mitral
       stenosis, if mitral regurgitation co-exist.
    Percussion.—Increased dullness laterally (one inch to the right,
       if the right side be involved;  or one inch to the left, if the
       left side be involved, often  extending into the axillary
       space). The precordial  dullness is oval in shape.  The
       area of superficial dullness is not increased, as in hyper-
       trophy.  If the auricles be dilated, an upward  increase
       in the  area of dullness  exists.  If the jugular  veins be
       permanently knotted, and dilated, there is  dilatation of
       the right auricle.
    Auscultation.—The first and second sounds are short, feeble,
       and nearly of equal duration; and the  second sound is
       often inaudible  at  the  apex-beat.  Asystolism  is often
       present after exercise.

               DIFFERENTIAL DIAGNOSIS.
  Rests upon the feeble action; undulating impulse; indistinct
apex-beat; lateral increase in the  area of percussion dullness;
short,  abrupt, feeble  heart's sound; feeble, irregular, and inter-
mittent pulse ; and the general symptoms of systemic  and pul-
monic obstruction.
  The differentiation must be made between cardiac  hypertrophy
and cardiac dilatation;  pericarditis with effusion, and cardiac
dilatation ; enlargement from dilatation or hypertrophy, in con-
nection with thoracic aneurism or mediastinal tumors.
  In thoracic aneurism  or  mediastinal  tumors—there is  the
direction of the increased  area  of dullness to assist, since it is
always upward, and to the right or left.
  In cardiac enlargement-there is  increased  area of  dullness,
laterally, and downward.  Consolidation of lung-tissue may give
rise to some of the signs of cardiac enlargement.
                        PROGNOSIS.
  Is bad,  and the danger increased in proportion to the excess of
the capacity  of the cavities over the  thickness  of their walls.
There is danger of death from dyspnoea and syncope. 
MYOCARDITIS.
13!*
                         TREATMENT.
   This is an incurable disease.   In order  to prevent flaccidity of
 the walls of the heart, nutrition  must be kept up to its highest
 point by a milk diet and stimulants: and,  if there be anaemia,
 administer iron.  Plenty of fresh air, the best possible hygienic
 surroundings and  stimulating baths,  to increase the  capillary
 circulation, should be afforded. All irregular and violent exercise
 must be forbidden; flannels must  be worn next to the skin; arrest
 all exhausting discharges; and, as the various complications in
 the liver and other abdominal  organs  arise, they must be treated
 separately.  If there be loss of appetite, etc., give vegetable tonics
 and mineral acids.   Digitalis is very serviceable in this disease in
 full doses, but if it cannot control the heart's action, then bella-
 donna and opium should  be given in combination with digitalis.
   In  the paroxysms  of  dyspnoea, hydrocyanic  acid,  cannabis
 indica, or ether may be given; and dry cupping along the spine.
 The drugs and treatment  upon which most reliance can be placed
 are digitalis and iron, and a good  wholesome nutritious diet.


                      MYOCARDITIS.
                         DEFINITION.
   Is  an inflammation of the  muscular  structure of the  heart;
 associated with degeneration and softening, which may be of two
 varieties:
   1. General or diffused—which is rare.
   2. Local or circumscribed—which is met with in connection
 with  pericarditis and endocarditis; usually involving  only  the
 internal or external surface of  the heart.

                    MORBID  ANATOMY.
  The left ventricle is   most  frequently affected; the muscles
 changing from dark-red  to gray,  and finally to dark-green.   It
terminates either in a connective-tissue formation, or in abscess.
The connective-tissue causes the   power of resistance of  the
ventricular wall to be diminished.   This connective-tissue during
diastole is gradually  and slowly  stretched;  and  thus, finally. 
 140         DISEASES OF THE CIRCULATORY'SYSTEM.

 aneurism of the heart results.  When the inflammatory process
 becomes degenerative, abscesses form, and rupture of the heart
 may take place.
                         ETIOLOGY.
                    Predisposing Causes.
 Rheumatism—terminating in connective-tissue formation.
 Endocarditis.
 Syphilis.
 Temperature—which must be high and continuously so.
 Extensive, and long continued, pericarditis.
                      Exciting Causes.
 Embolism of the coronary arteries.
 Pyaemia (terminating in abscess).
 Septicaemia.
 Typhus fever.
Typhoid fever.

                        SYMPTOMS.
                         Rational.
 Cardiac palpitation, and pain in the precordial region.
 Pulse—feeble, irregular, and intermittent.
 Syncope—on exertion.
 Failure of the heart's action.
                         Physical.
 Palpation.—The area of  the  precordial  duUness  is  increased
    upward and toward the left shoulder, as in hypertrophy, but
    there is no heaving impulse.

                        PROGNOSIS
  Is rapidly fatal if abscess occur;  more slowly so, if  the new
 connective-tissue formation is prominently developed.

                       TREATMENT.
  Absolute quiet should be enforced, and the nutrition carried to
 its  highest  point.   All  active and  prolonged physical exertion
 must be prohibited. 
FATTY DEGENERATION OF THE HEART.          141
    FATTY  DEGENERATION  OF THE  HEART.
                        DEFINITION.
  True fatty degeneration of this organ is a substitution of  fatty
 matter in place of the muscular tissue of the heart, to such an ex-
 tent as to interfere with its normal action.

                         VARIETIES.
  1st.  There may be a fatty degeneration of the primitive  mus-
 cular fibre (Quain's).
  2d. There is a fatty deposit in the areolar or connective-tissue of
 the heart which is simply replaced by fat, the muscular fibres be-
 ing unaffected.
                    MORBID  ANATOMY.
  " In Quain's fatty degeneration "—the degeneration is confined
 to the muscular fibre, the primitive fibre-bundles lose  their
 nuclei,  their  striated appearance disappears, and they become
 granular.  The sarcolemma becomes filled with granules, and the
 sarcous substance gives place  to fat-granules  and oil-globules.
 The  muscular-tissue assumes a yellow or dirty-brown color, and
 breaks down very easily under pressure.   The coronary arteries
 may be atheromatous, calcified, obliterated, or normal.
  In the second form—there may simply be  an increase of fat in
 the areolar tissue of the heart which does not interfere with the
 condition of the muscular fibre, except by its pressure; hence the
 heart is simply flabby, pale, or yellowish, and may be more bulky
 than usual.
                         ETIOLOGY.
  It may be a true fatty metamorphosis, due to interference of the
 heart's nutrition; or, secondly, an adipose condition of the heart
due to an excess of fat in the blood (although this is not, properly
speaking, a degenerative lesion). 
142         diseases of the circulatory system.

                    Predisposing Causes.
(1) Malnutrition, and interference with the  coronary arteries.
(2) Excessive or perverted nutrition (causing a deposit of fat in the
    organ);  or hereditary predisposition.
                      Exciting Causes.
Bright's disease.
Chronic alcoholismus.
Gout.
Phthisis.
Cancer.
Calcification of the coronary vessels.
Pericardial thickenings—causing external compression.
Poisoning by phosphorus, phosphoric acid, chloroform, etc.
General obesity.

                        SYMPTOMS.
                          Rational.
The same as those of defective heart-power.
    Complete exhaustion after exercise.
    Skin—pale, sallow, and livid.
    Arcus senilis.
    Enlarged liver.
    Muscular flabbiness.
    Respiration—feeble and irregular,  often sighing in character.
    Disturbed vision—from anaemia of the brain.
    Irritable temper—from anaemia of the brain.
    Dementia.
    Dyspnoea—from pulmonary hyperaemia.
    Giddiness—from anaemia or passive hyperaemia of the brain.
    Vertigo—from anaemia or passive hyperaemia of the brain.
    Syncope—from anaemia or passive hyperaemia of the brain.
    Feeble Pulse.
                          Physical
Inspection.—Feeble, sighing, or progressive respiration.  Apex-beat
    is indistinct and often invisible.
Palpation.—Tumbling,  rolling  motion of  the heart  (if hyper-
    trophied). 
CARDIAC THROMBOSIS
143
 Percussion.—Increased area of dullness (which is both superficial
    and deep), if hypertrophied—otherwise normal limits.
 Auscultation.—First sound is feeble or absent.  Second sound is
    feeble but distinct.

                DIFFERENTIAL DIAGNOSIS.
  Between cardiac dilatation, and simple fatty heart.

                        PROGNOSIS.
  There is always a fatal termination.  This may occur from sy&.
 cope, rupture of the heart, cerebral anaemia, or general dropsy.

                       TREATMENT.
  Iron, oleum morrhuce, good  nutritious  diet, fresh air, light ex-
 ercise, and  the avoidance of all stimulants is all that can be sug-
 gested  for the treatment  of this  disease, as the great and only
 object, to be obtained, is to improve, or increase the  tissue-making
power of the blood.
                CARDIAC  THROMBOSIS.
                    MORBID  ANATOMY.
  Heart-clots  may have existed for years, or only a short time
previous to death;  and vary in size from that of a pin-point to
that of a walnut.  They may be flat or round in shape.  When
small they are called vegetations, and when large, thrombi. They
may be found in either of the cavities, or on the valves.

                        ETIOLOGY.
  First—you may have obstruction to the flow of blood, which
may be due to valvular lesions,  dilatation, or  feeble contractile
power of the heart.
  Secondly—you may have abnormal changes in the composition
of the blood.
  Thirdly—you may have endocarditis  (causing a roughening of
the endocardial membrane and subsequent formation of thrombi). 
144
DISEASES OF THE CIRCULATORY SYSTEM.
                        SYMPTOMS.
                         Rational.
In grave cases.
    Heart—the action is frequent and irregular.
    Pulse—weak, small, and irregular.
    Syncope.
    Distended jugulars.
    Restlessness  and jactitation (with partial or  complete pul-
        monic obstruction).
    Delirium.
    Convulsions.
    Coma.
                         Physical.
Inspection and Palpation.—Irregular cardiac  impulse; dullness
    to the right of the sternum.
Auscultation.—Marked irregularity of the heart's action.  Mur-
    murs, indicative of either tricuspid or pulmonic obstruction,
    heard with greatest intensity  at the  xiphoid cartilage, and
    conveyed to the left of the sternum.

               DIFFERENTIAL DIAGNOSIS.
  From lesions of the valves, or rupture of the chordae tendineae.

                       PROGNOSIS.
  Is unfavorable.
                       TREATMENT.
  Carbonate of potash, or sesqui-carbonate of ammonia; orammon,
carb. gr. xxx. every two hours, and absolute quietude.


        NERVOUS  CARDIAC  PALPITATION.
                       DEFINITION.
  Is a neurosis of the heart, but is not, as a rule, dependent upon
heart-changes.

                        ETIOLOGY.
  Violent physical exercise.  Indulgence in alcohol. 
ANGINA PECTORIS.
145
   Too rapid growth in young people, producing a narrrowing of
 the chest.
   Debility, anaemia, excessive sexual intercourse, typhoid fever.
   It may be induced by late hours,  strong tea, coffee, tobacco,
 shock, fright, deranged digestion, flatulence, dyspepsia, gout, etc.

                         SYMPTOMS.
 Heart—the action is irregular and often intermittent.
 Palpitation—slight, quick, prolonged, or heaving pulsation.
 Sense of uneasiness—in the precordial region.
 Sense of constriction, weight, or pain in the region of the heart.
 Sinking and fluttering sensation in the epigastrium.
 Dyspnoea.
 Vertigo.
 Headache.
 Tinnitus aurium.
                         PROGNOSIS.
   Is good, if no organic disease exist.

                        TREATMENT.
   Remove the cause; and assure the patient that there is no dan-
 ger, provided organic disease be absent.



                  ANGINA PECTORIS.
                        DEFINITION.
  Is a neurosis, dependent upon heart-changes (principally organic
 changes), causing defective heart-power.

                    MORBID ANATOMY.
  It is associated  with  all the forms of  cardiac or  aortic disease,
 but especially with obstruction to the coronary circulation, and
fatty degeneration of the muscular-tissue of the heart.  It  is
claimed that there must be some nervous element present, having
its seat  in  the pneumogastric nerve or cardiac Dlexus, causing
cardiac spasm. 
146        DISEASES OF THE CIRCULATORY SYSTEM.
                        ETIOLOGY.
                    Predisposing Causes.
Obstruction to the coronary circulation from aortic regurgitation,
    or atheroma, or embolism of the coronary arteries.
Fatty degeneration with suddenly disturbed heart's action.
                      Exciting Causes.
Mental emotion.
Prolonged physical exertion.
Errors of diet.
Anything that disturbs the heart's action.

                        SYMPTOMS.
                         Rational.
Pain—intense, agonizing, stabbing, lancinating, shooting through
    the  back and along  the left  arm.  This is a reflex act of the
    pneumogastric and phrenic or cardiac nerves to the cervical
    ganglia, and conveyed onward to the brachial plexus.
Sense of suffocation.
Countenance—pale and anxious.
Face—livid, and covered with perspiration.
Pulse—faltering and almost imperceptible.
Patient  is usually unable to move (on account of the severity of
    the  pain), or even lie down.
No palpitation of the heart is usually present.
Dyspnoea—very extreme and agonizing.
Sense of approaching death.
Syncope and death—sometimes.
                         Physical.
Inspection.—Respiration short and hurried.
Auscultation.—A heart murmur (if the attack be due to a valvu-
    lar lesion).
               DIFFERENTIAL  DIAGNOSIS.
  From  spasmodic asthma; hysteria;  intercostal neuralgia;  my-
algia; first stage of pleurisy.
  In spasmodic asthma—the physical examination will determine
the absence of heart-lesions. 
BASEDOW'S DISEASE.
147
   In hysteria—the intermittent  and irregular pulse of angina
 pectoris will be wanting; and  the  pain and rational symptoms
 will be less severe.
   In intercostal neuralgia—there will  be the duration of  the
 attack; the direction of the pain,  and the absence of cardiac  dis-
 turbance, to assist in the diagnosis.
   In myalgia—the  condition of  the circulation, locality  of the
 pain, and the  physical signs,  are  sufficient to exclude angina
 pectoris.
                        PROGNOSIS.
   Is unfavorable.  The patient may recover from first attacks.
                        TREATMENT.
   Remove the exciting  cause and alleviate the symptoms.  The
 patient must be kept quiet and plenty of digitalis administered;
 also iron,  strychnia, or arsenic daily in small doses.


                 BASEDOW'S DISEASE.
                         SYNONYM.
   Exophthalmic goitre—Grave's disease.
                        DEFINITION.
   Is a disease characterized  by a  subjective sense of palpitation,
 accompanied by acceleration  of  the heart's action; pulsation of
 the veins  in the neck and head; swelling of  the thyroid gland;
 jnd protrusion  of the eyes from their orbits.
                        ETIOLOGY.
   The protrusion of the eye from the orbit is  caused by a  semi-
 paralysis  of  the vaso-motor nerves, thus affecting the  blood-
 vessels.  The muscles of the heart may be affected from the same
 cause (occasioning  many of the  other above-named symptoms).
 The eyes may also be caused to protrude by intra-orbital fat; by ab-
 scess or tumor in the areolar texture of the orbit; and by exostosis
 of the parietes of the orbit.   It may follow  menstrual disorders,
 or lack of red blood-corpuscles in the blood.  It is more common
among women  than men. 
148
DISEASES OF THE CIRCULATORY SYSTEM.
                         SYMPTOMS.
Palpitation of  the  heart—with remarkable frequency  of pulse
    (120 to 140).
Swelling of the thyroid gland.
Protrusion of the eyes.
Eyelids—incapable of covering the eyeballs (which may cause in-
    filtration or abscess of the cornea, or total destruction of the
    eye).
Loss of sight (sometimes) from abscess  and perforation of the
    cornea.
Spasmodic contraction of the levator palpebrae superioris.
Peculiar rustling sound in thyroid gland (on auscultation).
Blowing sound at the heart (blood-murmurs).
Oppression in the throat.
Dizziness.         "j

Cyanosis           lIn severe cases durin£ the full development
n                 i  of the disease.
Dropsy.
Extreme dyspnoea. J
                          DEATH.
  May occur with cerebral symptoms, or from an intercurrent
disease.
                       TREATMENT.
^  Strengthening diet; iron; secale cornutum (ergot); constant and
induced current to cervical portion of the sympathetic. 
DISEASES OF THE DIGESTIVE
          TEAOT. 
 
     DISEASES  OF THE  DIGESTIVE  TRACT.
  Under this heading I have included:
                1.  Diseases of the Mouth.
                2.  Diseases of the Pharynx.
                3.  Diseases of the Oesophagus.
                4.  Diseases of the Stomach.
                5.  Diseases of the Intestines.
                6.  Diseases of the Liver.
  The liver, being classed as one of the accessory organs of diges-
tion, can properly be included under this head.
          DISEASES   OF   THE  MOUTH.

            CATARRH  OF  THE MOUTH.

                      DEFINITION.
  Catarrh is a term applied to all simple inflammations of the
mucous membranes of the body; hence to the mucous membrane
of the mouth.
                  MORBID  ANATOMY.
  The mucous membrane is, at first, dark-red; subsequently be-
coming dry, and finally a copious, cloudy secretion takes place.
Early in the affection, there is swelling of the mucous membrane,
increased secretions, and an excessive formation of young cells.
There may be impressions of the  teeth perceived upon the sides
of the tongue.  A mucus, which is turbid  and foul, covers the
cheeks, gums, and tongue (called " coated tongue").
  On microscopical examination, the  coating of the tongue con-
sists of epithelial cells, containing fat-globules and brown granules. 
152
DISEASES OF THE DIGESTIVE TRACT.
                        SYMPTOMS.
                         Rational.
Burning and tension in the mouth.
Slimy, clammy taste (bilious).
Foul taste or smell (often perceived by the olfactory nerve of the
    patient J.
Craving for sour, salty, and highly-seasoned food.
In  children — it  may  accompany teething;  convulsions (reflex
    symptom) may also exist.

                        PROGNOSIS.
  Is favorable, except when the attacks occur during dentition.
  Unless the affection become chronic, it is usually curable in a
short time, provided the patient  follow the directions that  are
given.
                       TREATMENT.
  Remove all irritation (as sharp edges  of teeth, etc.).   Forbid
smoking strong cigars. When smoking is a confirmed habit,  the
cigars should be weak ones and a holder used.  If it occur from
mercurials, discontinue  them.  For obstinate  foulness of  the
mouth, the patient should chew slowly small pieces  of  rhubarb
before going to bed.



                        APHTHAE.
                        SYNONYM.
  " Croupous stomatitis "—a frequent disease of infants.

                   MORBID ANATOMY.
  It occurs on the anterior half of the tongue and inner surface
of the lips, cheek, and hard palate, in  gray or yellowish-white
deposits with a red border, which excoriates the parts, but does
not cause ulceration.  On the free surface of the mucous mem-
brane under the epithelium, are small sohd white spots with a red
border (consisting of exudations). 
CANCRUM ORIS.
153
                         ETIOLOGY.
  It occurs chiefly in weakly and badly-nourished children, or,
 may be due to dentition.   It may also occur as an epidemic.

                         SYMPTOMS.
 Fever.
 Restlessness.
 Loss of appetite.
 Pain—which is increased when the child is being suckled.
 Fetor of the mouth—from decomposition of the epithelium and
    the exudation which is thrown off.

                       TREATMENT.
  Chlorate of potash, gr.  iv.-vi.  should  be given, or the parts
 painted with dilute muriatic acid,  or a solution of nitrate of silver
 (gr. i. to 1 ss. of water).


                    CANCRUM  ORIS.
                         SYNONYM.
  " Diphtheritic stomatitis."

                       DEFINITION.
  Is a  fibrinous  exudation, accompanied by  sloughing of the
 mucous membrane, from compression of the vessels (due to exu-
 dation).

                    MORBID ANATOMY.
  In mild cases—it shows itself in the form of white spots along the
 lateral border of the tongue and on the parts of the cheek and
 hps which lie against the  teeth.   These spots after a time fall off
 and leave an ulcer.
  In severe cases —when the whole  mucous membrane is destroyed,
a large  portion of the mouth is  converted into a soft discolored
slough which may separate and leave an irregular border and an
uneven  base.  This may be replaced  by cicatricial tissue.  Ad- 
154
DISEASES OF THE DIGESTIVE TRACT.
hesions and false anchylosis may occur, and sometimes caries and
necrosis of the maxillary bones may ensue.
                         ETIOLOGY.
  From excessive use of mercurials.  It occurs as an epidemic in
Foundling Hospitals, Orphan Asylums, Barracks, Armies in  the
field, etc.
                        SYMPTOMS.
Severe pain—especially when there are ulcers formed.
Increased salivary secretion.
Insomnia—due  to the secretions going  into the larynx and pro-
    ducing fits of coughing, or suffocation.
The edges of the teeth are coated with a foul deposit.
Fetid odor to the breath.
Gums—dark, red, and swollen from excessive hyperaemia.
Teeth —loosened and bleed easily.
Diphtheritic pulpy deposit on the gums.
Lymphatic glands are swollen and painful.
GLdema of the lips and cheeks.
Saliva—bloody and discolored.
                        PROGNOSIS.
  When properly  treated, it runs a favorable course and heals.
  If  it be neglected, it may last for months.  Is fatal only when
complications occur.
                       TREATMENT.
  The cure is slow.   It will take eight to nine days to get the pa-
tient even in a comfortable state.  Wash the mouth out with cold
water,  or  water and red wine, or chlorate of potash 3 j- z j-ij dis-
solved in 1 vi. water.  Paint the mouth with a solution of nitrate
 of silver (gr. i.- f ss.), or touch the ulcers with  solid nitrate of sil-
ver.  This last treatment is exceedingly painful.


                         THRUSH.

                        SYNONYMS.
  " Soor," " muguet," or " sprue." 
NOMA.
155
                    MORBID  ANATOMY.
   There is a whitish, delicate, frosty coating on the inner surface
, of the  lips, tongue,  and roof  of the mouth, advancing to the
 larynx  and oesophagus.  It may extend,  downward, along the
 digestive tract.
                        ETIOLOGY.
   From fungus growing on the  mucous membrane of the mouth;
 diminished secretions of the mouth; and the neglect of cleansing
 the mouth.  It occurs most often in infants; and in adults, gener-
 ally before death.  It is always a bad symptom in adults if follow-
 ing some serious disease.

                        SYMPTOMS.
 Painful burning in the mouth.
 (In a child.)
    Diarrhoea—with pain in the abdomen.
    Stools—fluid, green, and acid.
    Anus—red, and excoriated.
                       TREATMENT.
  Cleanliness of the mouth; which must be washed out with wine
and  water after feeding.  Borax is often used as a  local applica-
tion.

                          NOMA.

                        SYNONYMS.
  "Water-canker," or " gangrenous sore mouth."

                    MORBID  ANATOMY.
  It  commences on  the inside  of the cheeks, over a hard spot
which has previously developed; the mucous membrane is red,
and  discolored, and vesicles filled with serum form on this spot.
The part becomes black, softens, and disintegrates; the gums are
destroyed, and also  the lips and base and edges of the tongue on
the affected side.  The teeth become loose  and fall out.  The
whole of one side of the face may have become a black slough (in 
156
DISEASES OF THE DIGESTIVE TRACT.
about five or six days).   On post-mortem examination, the blood-
vessels are filled with a fibrinous coagula.

                        SYMPTOMS.
CEdema—of the affected cheek and lips, with a hard, round nu-
    cleus at the seat of the disease.
Saliva—is bloody and black.
Pulse—small and frequent.
Delirium—at night.
Thirst—unquenchable.
Diarrhoea—is usually present.

                        PROGNOSIS.
  Recovery is rare; and, when it does occur there is a large cica-
trix left, often causing fearful disfigurement.

                       TREATMENT.
  Give the patient plenty of fresh air, good nourishment, wine,
«tc, and treat the gangrene locally by actual cautery.
  SYPHILITIC  AFFECTIONS  OF THE  MOUTH.
                        VARIETIES.
Primary--often due to nursing of an infant by a syphilitic nurse;
    the affection may appear during later years  in the form of
    ulcers and condylomata.
Secondary—occurs in the early stages, and both forms (ulcers and
    condylomata) often appear together.
Tertiary—occurs in the  later periods,  in the form of gummy
    tumors, or nodular syphilomata.  Caries of the hard palate
    may also be developed.

                   MORBID ANATOMY.
  The primary and secondary ulcers and condylomata spring from
circumscribed indurations, or syphilitic papules  of the mucous
membrane, giving a white appearance to the affected part.  They 
ULCERS OF THE MOUTH.
157
 occur especially at the corners of the mouth, and have the appear-
 ance as if the corners were torn.  Condylomata usually form on
 the  lateral edges or dorsum of  the tongue.  Gummy tumors fre-
 quently appear on the anterior third of the tongue which soon
 soften and rupture, leaving deep ulcers.

                        SYMPTOMS.
 Pain—on chewing, and sometimes of mouth.
 Mucous patches—these  often disappear and reappear on some
    other spot.
 Tongue—is unwieldly, and often rigid if extensively diseased.

                       TREATMENT.
  Mercury and iodide of potash.  Calomel as a dusting powder to
 the condylomata.   Fumigation  of the mouth with the vapor of
 calomel or the black oxide of mercury.


              ULCERS  OF  THE MOUTH.
                    MORBID  ANATOMY.
  There may be small vesicles at the end of the tongue, and ulcers
 showing catarrhal inflammation. Variolous ulcers may appear on
 the roof of the mouth, and herpetic ulcers may occur on  the in-
 side of the cheek; the bases of these ulcers have a yellow or larda-
 ceous appearance, and their edges are usually elevated, hard, and
 red.  Syphilitic ulcers (mucous  patches) are most frequent in the
 mouth or fauces.  There  may  be small excoriations, as if the
 mouth had  been  burnt, from  smoking, or drinking something
 hot.
                         ETIOLOGY.
  Follicular ulcers from stoppage,  swelling,  and ulceration of
mucous glands, may  occur at the menstrual epoch, or during preg-
nancy, or lactation.  The other  types depend upon special blood
conditions.
                        SYMPTOMS.
Great pain—when the ulcers are diffused and not syphilitic. 
158           DISEASES OF THE DIGESTIVE TRACT.

Disturbed digestion—(may occur) if the ulcers  be follicular  in
    character.
                        PROGNOSIS.
  Is rarely dangerous, although the ulcers may last for weeks.  If
syphilitic, they recur and tend  to  progress forward toward the
lips.
                       TREATMENT.
  Smoking, drinking hot beverages, eating highly-seasoned food,
etc., must be avoided.  The ulcers should be touched with  solid
nitrate of silver.   A weak solution of  corrosive sublimate will
often be found very beneficial.


                      SALIVATION.
                         SYNONYM.
  "Ptyalism."
                       DEFINITION.
  Is a disease where the increased secretion of the salivary glands
ceases to pass into the stomach with the ingesta; but flows con-
stantly out of the mouth,  if the case be severe.

                    MORBID ANATOMY.
  The saliva contains young and old epithelial cells.  The saliva
is alkaline, and contains fat and ptyaline, and sometimes sulpho-
cyanide of potassium and mucus corpuscles.  The  teeth become
loose, if due to mercury; the tongue is oftentimes so  swollen as
to  protrude; while  the  peculiar fcetor of  mercurial  is  very
marked.
                         ETIOLOGY.
  Simple salivation  may occur from irritation of the  mucous
membrane of the mouth,  or pharynx; from  introduction  of irri-
tating substances into the mouth; from irritation of the lingual
branch of the trifacial, or glosso-pharyngeal nerve; from  neural-
gia of the trifacial nerve;  from irritation affecting the gastric, or
intestinal mucous membrane, or uterus, or other organs;  from 
PAROTITIS
159
 mental influences  (disgust  and desire); from pregnancy; from
 disease, as typhus  or intermittent fever, etc.  The most marked
 type of salivation follows mercurial poisoning.

                         SYMPTOMS.
 Constant spitting—(at the onset).
 Emaciation.
 Constant  flow  of  saliva—sometimes  reaching from six to eight
     pounds in twenty-four hours.
 If due to mercurial poisoning—a swollen and protruding tongue;
     loosened teeth;  foetid breath.

                        TREATMENT.
  If it occur from misuse of mercury, give slight laxatives and
 purgatives, and an astringent gargle.
  If from affections of the stomach, etc., then treat  the disease.
  General baths, blisters, mustard to  the throat and nape of the
 neck, mouth washes of alum, sulphate of zinc, sage,  or oak-bark
 have been recommended, as also opium, to diminish the excita-
 bility of the nerves.


                        PAROTITIS.

                         SYNONYM.
  "Mumps."
                        VARIETIES.
  Idiopathic; symptomatic;  polymorpha or "mumps;" or metas-
 tatic.
                   MORBID ANATOMY.
  Idiopathic parotitis—Is believed to be due  solely to a serous
 exudation from a catarrh of the gland-duct, affecting the inter-
 stitial substance and connective-tissue about the gland.
  Symptomatic parotitis—Begins with hyperaemia, causing infil-
tration and swelling of the interstitial substance of the gland.
The gland becomes  tough and filled with a whitish or yellowish
substance,  which  soon  turns purulent, giving  the  gland the 
160           DISEASES OF THE DIGESTIVE TRACT.

appearance of lobules filled with pus.  Destruction of the tunica
propria takes place, and  suppuration  of  the  interstitial-tissue
occurs, which extends rapidly, and often results in a large parotid
abscess.  Sometimes there is destruction of the gland-tissue, and
gangrene attacking the neighboring connective-tissue, and mus-
cles  of mastication, and also the periosteum of the  maxillary,
temporal, and sphenoid bones, and sometimes the bones them-
selves.  The inflammation, in severe cases, often extends to the
brain, or internal and middle ear; this may take place along the
blood-vessels and nerve-sheaths, as well as the bones themselves.
It sometimes induces phlebitis and thrombus of the neighboring
veins (especially of  the anterior and posterior facial and external
jugular) and disintegration of these thrombi, thus producing em-
bolism and septicaemia.

                        SYMPTOMS.
Idiopathic form.
    General febrile symptoms for two days.
    Swelling—near the lobe of the ear, extending to the cheek
       and neck; and then to the other side of the face.  After
       five or six  days, the fever ceases and all the symptoms
       may disappear in ten days.  The tumor may become very
       painful,  hard, and dark-red; abscesses may form, which
       open outwardly, or into the external auditory meatus
    Testicles—may be affected (by metastasis).
    Pain—in the sacral and inguinal region may exist  and an ex-
       acerbation of the fever may occur.
    CEdema—of  the scrotum (in  men), and vulva and  breast (in
       women), and pain in the  ovaries.
    Meningitis—may sometimes occur and prove fata..
Symptomatic form.
    Occurs in various diseases, and is accompanied by a chill, or
       exacerbation of fever.  It usually affects only one side.
    When suppuration takes place, the swelling becomes uneven,
       nodulated,  and red.   Fluctuates at points;  may  open
       outwardly into  the meatus  auditorius externus, but
       generally into the mouth or pharynx; or it may burrow 
GLOSSITIS.
161
        down into the oesophagus, trachea, or chest.   While mor-
        tifying,  the skin  becomes  dark-blue and discolored,
        doughy in feel, and depressed.  On opening tumor there is
        evacuated a discolored pus with shreds of tissue.
                        TREATMENT.
   In the idiopathic form.—The bowels  and digestion should be
 regulated, and the patient protected from all injurious influences.
 The part should be  covered  with wadding,  etc.  Much  meat
 should not be allowed, only food which is easily digested.  If the
 tumor be hard and swollen, leeches  should be  applied; if fluctu-
 ant, it should be opened and poultices applied.
   In the symptomatic form.—-If the swelling be red or painful on
 pressure,  apply ice and cold water; if  fluctuant, open and apply
 poultices.

                        GLOSSITIS.
                        DEFINITION.
   Is a parenchymatous inflammation of the tongue.
                         VARIETIES.
   Acute—Chronic—Dissecting—and Superficial or " psoriasis."
                     MORBID ANATOMY.
   In  the  acute  form.—The whole tongue becomes  very large,
 darkened  in color, smooth, or  fissured, and covered with tough
 bloody exudations.  Abscesses may form and leave a scar.
  In  the  chronic form.—Only a part  of the tongue may be
 affected, especially  the  edges, where circumscribed spots  may
 project.
  In the dissecting form.—The tongue is divided into lobules by
 furrows, causing ulceration from lodgment of food, etc.
  In the superficial form.—The tongue looks glossy and smooth
as though it were varnished or scalded.
                        SYMPTOMS.
Tongue—is enlarged and projects often one inch beyond the teeth,
    and is white or dirty-brown on its upper surface, or dark-red 
162
DISEASES OF THE DIGESTIVE TRACT.
     on the under surface; ulcers may occur, or there may De im-
     paired movements and the speech unintelligible.
 Flow of saliva—is constant.
 Glands of the neck are enlarged.
 Face may be blue and swollen from obstruction to the jugulars.
 Impaired respiration—from stoppage of entrance of air into the
     larynx, due to swelling of the tongue backward, may occur in
     severe cases.
 In the acute form.
     High fever.
     Full pulse.
     Anxiety.
     Restlessness.
     Asphyxia.
 In the chronic form.
     Circumscribed dull pain, which may last for years.
                        TREATMENT.
   In the acute form.—Scarify deeply.   Then put ice in the mouth
 and give soothing washes.  If suffocation threaten, then perform
 tracheotomy.
   In the chronic form. — Remove all obstacles to recovery. Should
 this fail, an operation must be resorted to.
   In the dissecting form.—Treat the ulcer with  nitrate of silver
 in substance or solution.
   In the superficial form.—Do not give mercury, as it  increases
 the pain, but rinse the mouth out with a dilute  solution of car-
 bolic acid, and touch the fissures with pure carbolic acid.


                      TONSILLITIS.

                         SYNONYM.
  " Quinsy."
                        DEFINITION.
  Is  an inflammation of the interstitial-tissues of the tonsils, and
proliferation  of the  connective-tissue, which  may  be acute*or
chronic in character. 
TONSILLITIS.
163
                    MORBID ANATOMY.
  The tonsils sometimes swell to the size of a walnut, the surface
is nodulated, dark, and red, and covered with a glutinous exuda-
tion, or croupous deposits.  Suppuration may occur.

                        SYMPTOMS.
Chill and high fever (especially if pus be developing).
Temperature—104°, and sometimes even higher.
Pulse—frequent and full.
Throat—tense and sore.
Pain—piercing, and shooting toward the ear.
Difficulty and pain in opening the mouth, or in chewing.
Mouth—cannot be opened widely.
Respiration—is affected.
Uvula—may be deflected  to one side, and tonsils enlarged.
There may be severe headache.
Insomnia may be present in severe cases.
Delirium may be present in severe cases.
Symptoms  of  asphyxia—may occur, if extensive  suppuration
    occur.
                        TREATMENT.
  Powdered alum (two or three times daily) should be applied to
the affected part.  Rinse  out the mouth with a  solution of alum,
 3 iij.- 3 ss. to I vi. of  barley-water.   Apply nitrate of silver to the
affected part.  Cold applications may be used—as ice, cold water,
or cold compresses,  changing them  frequently.  If fluctuation
occur, a warm poultice should be applied, and the mouth washed
out with chamomile tea.  Open the abscess early with the finger-
nail, or lancet. ' Be careful in using  the knife, as the carotid
artery may be wounded.
  If there  be  cerebral  troubles,  give  laxatives.  If it become
chronic,  paint the parts with  a  solution  of alum, nitrate of
silver,  dilute  tincture of  iodine;  or  cold compresses  may be
applied. 
164
DISEASES OF THE DIGESTIVE TRACT.
                 ANGINA LUDOVICI.
                      DEFINITION.
  Is a phlegmonous inflammation of the floor of the mouth, and
intermuscular and subcutaneous connective-tissue of  the sub-
maxillary region, leading to gangrene and sloughing,  or ending
in abscess, or resolution.  It is  often termed '' Gangrenous in-
flammation of the neck."
                       ETIOLOGY.
  From periostitis of the lower jaw, or metastatic parotitis, oc-
curring in typhus and other infectious diseases, starting from the
submaxillary gland.
                       SYMPTOMS.
Swelling in the floor of the mouth (upward and downward).
Loss of motion of the tongue.
Inability to open the mouth (abscesses may form).
Fever and general constitutional  derangement.
Death—from oedema glottidis, suffocation, or septicaemia, etc.
                      TREATMENT.
  Apply a large  number of leeches near the seat  of the tumor.
When the tumor is fluctuating in character, the contents should
be evacuated as soon as practicable. If suffocation  be appre-
hended, then scarify. Tracheotomy may be resorted to in dan-
gerous cases.  If a hard tumor remain for a long time, then apply
blisters freely and repeatedly.


         DISEASES  OF THE PHARYNX.

               PHARYNGEAL  CROUP.

                      DEFINITION.
  Is a fibrinous  inflammation of the pharyngeal mucous mem-
brane. 
RETRO-PHARYNGEAL ABSCESS.
165
                    MORBID ANATOMY.
  White, or grayish-white membranous masses are seen on the
reddened mucous  membrane  of  the soft  palate,  tonsils,  and
pharynx,  like small  irregular round islands.  The  membrane
often adheres so firmly that, on detaching it, a bloody superficial
loss of  substance  remains.  This indicates a change from the
croupous to the diphtheritic form.

                        SYMPTOMS.
Diyness of the throat, local inflammation, and gray patches—
    which may be mistaken for ulcers.
Great pain—in the arches of the  palate, chiefly on attempts to
    swallow.
Uvula—elongated.
Nasal tone of voice.
Coated tongue, etc.
Pulse and temperature—-may be elevated, if the case be severe.

                       TREATMENT.
  If the attack be mild, it should be left alone; but if of a severe
type, apply moist compresses well wrung out, and covered with
dry cloth, or warm poultices, to the throat.  Wash out the mouth
with water, or a solution of alum, sulphate  of zinc, acetate of
lead, etc.  Cover the inflamed parts with powdered alum, or paint
them with a solution of nitrate of silver ( 3 i. to § i.  water).  If
it  accompany croupous laryngitis, remove the  membrane, and
cauterize it with nitrate of silver.


          RETRO-PHARYNGEAL ABSCESS.
                       DEFINITION.
  Is an abscess between the textures of the pharynx (its posterior
wall) and the cervical vertebrae.

                    MORBID ANATOMY.
  The posterior wall  of the pharynx is pressed  forward by pus, 
166          DISEASES OF THE DIGESTIVE TRACT.

causing contraction, or closure of the pharynx.  It may perforate
the pharynx, or even extend down to the pleura.

                       SYMPTOMS.
Difficult swallowing.
Restlessness.
Croupy coughing and choking.
Continual dyspnoea.
Large fluctuating tumor.
                  CAUSES  OF  DEATH.
  Complete closure of the glottis.—(Edema glottidis.—Opening of
the abscess  during  sleep.—Entrance  of its  contents into the
larynx. —Pleuritis. —Pneumonia. —Pericarditis.

                      TREATMENT.
  Open the abscess at once with the finger-nail, or lancet.
DISEASES  OF  THE  (ESOPHAGUS.
         STRICTURE  OF THE OESOPHAGUS.
  It occurs most frequently in the lower third, but it may affect
any part of the tract.  The walls are hypertrophied and the canal
dilated above the stricture; while the walls are thinned and the
canal collapsed below the stricture.

                    MORBID ANATOMY.
  It depends on cicatricial contractions and considerable loss of
substance (as in corrosions or ulcerations) or, on hypertrophy of
the muscular, or intermuscular connective-tissue; from chronic
catarrh  (which  on section gives a fan-like appearance) or, from
hypertrophy of the submucous-tissue.
                        ETIOLOGY.
  From  compression due to swelling of the thyroid body; swell.
ing of the lymphatics; dislocation of the hyoid bone; exostosis of 
DILATATION OF THE OESOPHAGUS.
167
 the vertebrae; abscess; tumor; aneurism; carcinoma of the lungs;
 dilatation  of the  right subclavian artery;  protrusion of new
 growths into its canal (carcinomatous); structural changes in its
 walls; previous inflammation and ulceration.

                        SYMPTOMS.
 Difficulty of swallowing.
 Pain about the manubrium and back.
 Regurgitation of food.
 Constipation from starvation.

                       TREATMENT.
   Dilatation—by mechanical means.



        DILATATION OF  THE CESOPHAGUS.
                    MORBID  ANATOMY.
   In total dilatation.—The canal may be the size of a man's arm,
 with hypertrophied or thinned walls.
   In partial dilatation.—That portion  of the  canal above the
 constriction is usually the largest.
   The diverticuli usually form near the bifurcation of the trachea,
 or where the pharynx terminates, and the oesophagus begins.

                        ETIOLOGY.
   It may be partial when  limited  to  a short distance, or total
 when the entire organ is affected.  When partial, only one wall
 may be affected.  Localized  enlargements may occur, developing
 into large sacs, communicating with the oesophagus, and termed
 diverticuli; these (diverticuli) are formed by foreign bodies that
 have stuck into the walls, and have been driven further in by the
 food as it  passes down, or, by the shrinkage of the bronchial
 glands which were adherent, when swollen, to the mucous mem-
 brane,  and, on contracting, draw  the  mucous membrane after
them.'  Total dilatation is  due to a chronic  catarrh, which in-
duces muscular paralysis. 
168
DISEASES OF THE DIGESTIVE TRACT.
                        SYMPTOMS.
In partial dilatation.
    Retention of food—then regurgitation (the food being mixed
       with mucus).  The food may sometimes be decomposed.
    Diverticuli—when present may be felt in the neck like a soft
       tumor.
    Dyspnoea—from the diverticuli causing compression of sur-
       rounding structures (as the pneumogastric, laryngeal, or
       phrenic nerves).
    Death—from starvation.
                       TREATMENT.
  Is of no use.  The stomach tube may be resorted to, provided
it can be passed through the diverticuli.  In this event, there
may be some slight hope of recovery.
     PERFORATION AND  RUPTURE OF  THE
                     CESOPHAGUS.
                        ETIOLOGY.
  May occur from within outward or the reverse.
From within outivard.
    From  breaking  down of a cancer; ulcer (caused by splinters
       of bone (rare)); deep sloughs (excited by corrosion),
From without inward.
    From aneurism of the aorta;  breaking down of a tuberculous
       gland at the bifurcation of the trachea; abscesses in the
       interior surface  of  the  spine;  caries of the  vertebrae;
       tuberculous cavities in the lungs.
                        SYMPTOMS.
Pain—severe and sudden, in the breast.
Chill.
Paleness.
Coldness of the extremities.
Faintings and attacks of  suffocation. 
           NERVOUS AFFECTIONS OF THE CESOPHAGUS.        169

 Profuse vomiting of blood (in case of aneurism),  or of pus (in
    case of abscess).

                       TREATMENT.
   None.


 NERVOUS  AFFECTIONS  OF'THE CESOPHAGUS.
 Globus Hystericus. —Hyperaesthesia, or increased excitability of
    the sensory nerves,  and feeling as  if the oesophagus were
    ligated, and a supposed inability to swallow.
 Hyperkinesis or Dysphagia Spastica.—Is an increased excitability
    of the motor nerves.  The spasm is reflex and forms a symp-
    tom of brain-disease, or of the  upper part of the cord; or, it
    may result from poisoning by narcotics or in alcoholism.  It
    usually occurs during eating.
 Akinesis.— Is a diminished  excitability of the motor nerves.  It
    accompanies diseases of the brain and cervical portion of the
    cord.  If complete paralysis exist, there  is inability to swal-
    low; but if incomplete paralysis, large  pieces  of  meat and
    food are able to be swallowed.

                       TREATMENT.
For Globus hystericus or Hyperkinesis.
  Belladonna, valerian, asafoztida,  musk, etc Also repeated and
careful introduction of the bougie.
For Akinesis.
  Probe, electricity, and strychnia (?).
DISEASES   OF  THE  STOMACH.
            ACUTE  GASTRIC  CATARRH.
                       DEFINITION.
  Is an acute catarrhal inflammation of the mucous membrane
of the stomach. 
170
DISEASES OF THE DIGESTIVE TRACT.
                    MORBID ANATOMY.
  The mucous membrane is reddened in spots, but the result is
generally  negative.   Beaumont's  observations  on St. Martin
showed the mucous membrane reddened and covered with tough
mucus, with traces of blood; the mucous covering became subse-
quently thickened, and th,e  gastric juice suppressed.   The walls
of the stomach, on post-mortem, may show spots  of softening,
and the mucous lining may be eroded from fermentation.

                        ETIOLOGY.
  It  occurs in fevers, pneumonia,  etc. (from neglect  of simple
dietetic rules, producing anorexia, and  capricious  appetite); in
debilitated and badly nourished persons (producing diminution
in the gastric juice from decreased amount of blood in the system
and hydraemia  resulting in a diminution of albuminates, of which
pepsin is made and which is the organic constituent  of the gastric
juice).  From excess in  drinking and error in  diet in children;
large quantities of easily digested food taken,  and diminution of
gastric juice causing decomposition of food; use of indigestible
food (producing decomposition);  substances that have commenced
to decompose before entering the stomach; irritation  of  hot or
cold articles, medicines, alcohol or spices; introduction  of articles
that weaken the gastric juice,  or retard the movement of the
stomach  (producing  abnormal decomposition of its contents), as
misuse of  alcohol,  etc.; from  narcotics  (producing   impaired
movements of the stomach); catching cold; and infection.

                        SYMPTOMS.
General malaise and  feeling of nausea.
Dullness and fretfulness.
Head—hot, and possible headache.
Ext remi ties—cold.
Pressing pain in the forehead, extending to the occiput.
Flashes before the eyes on stooping.
Pain at the pit of the stomach.
Distaste for food and great thirst.
Belching of sulphuretted hydrogen  and carbonic  acid gas. 
CHRONIC  GASTRIC CATARRH.
171
 Sour fluid occasionally rises in the mouth.
 Tongue—coated.
 Taste—stale and slimy
 Retching and vomiting.
 Severe diarrhoea.
                         PROGNOSIS.
   Previously healthy persons rarely die.   From repeated attacks,
 weakly and decrepit persons may die of gastric or catarrhal fever.
 In children,  it may end fatally.

                        TREATMENT.
   Watch the diet carefully.  Milk should be the principal  diet.
 If injurious  food has been taken, give an emetic of ipecacuanha
 or tartrate of antimony.
   Should there be prominence of the epigastrium and eructation
 of gases, give  ipec. 3i. and tart, antimony gr. i., but not where
 the fever is high and there are signs of typhus fever present.  If
 colicky pains, escape of flatus,  etc., exist, administer rhubarb or
 compound infusion of  senna or magnesia usta ( § ss. to  § viij. of
 water) one tablespoonful every hour or two.  If it should occur
 from excess of beer or wine, sodii bicarb, gr. v.-x. should be given.
 If the catarrh be slight  and there be characteristic vomiting,  give
 pulv. rhei co.; if diarrhoea be more severe, tr. rhei aquosa, or small
 doses of calomel (gr. ^-|) should be given two or three times daily,
 or R calomel, gr. iv.; pulv. jalapae, gr. ij.; sac. albi, 3 ss.; fiat pulv.
 viij.  Take one  powder in  water every two hours; or R argent.
 nit.,gr. \; aquae, § ij.  M.  Sig. 3  i- every hour.  If the catarrh be
 slight and no vomiting exist, R acidi tannici, 3ss.; aquae, § iij. M.
Sig. 3 i.  every two hours, may be administered.
           CHRONIC  GASTRIC  CATARRH.
                    MORBID ANATOMY.
  The mucous membrane is a reddish-brown, or slate color, from
transformation of the  haematin into pigment.  There is a coarse
anastamosis. or dilatation of the vessels.  The mucous  membrane 
172
DISEASES OF THE DIGESTIVE TRACT.
becomes hypertrophied and forms numerous folds.   There are
innumerable small prominences, separated by furrows, which are
most frequent in  the  pyloric end of the stomach.  A grayish-
white tough mucus covers, and clings to, the inner surface of the
stomach;  and, constriction of the pylorus  takes place, through
thickening of the walls of the stomach, from simple hypertrophy.

                         ETIOLOGY.
  From continued and repeated attacks of the acute form; habit-
ual misuse  of spirituous liquors (especially); congestion of the
gastric  mucous membrane; obstructed circulation in  the portal
vein or liver.  It accompanies phthisis and other chronic diseases:
cancerous or other degenerations of the stomach; and may extend
to the mouth and intestines.
                         SYMPTOMS.
Abnormal sense of pressure and fullness in the stomach (which i*
    increased  by eating).
Prominence of the epigastrium—(from gas).
Constant eructations—(from stricture of the pylorus).
Vomiting (rare)—occurs in drunkards as " water-brash."
Sensation of hunger is lost (in some cases).
Wolfish appetite (in some cases).
Mental depression.
Change in the urine—(difficult to understand) becomes scanty.
Death—may occur from marasmus (due to stricture of the pylorus
    or dropsy).
                         PROGNOSIS.
  Is rarely fatal.
                        TREATMENT.
  Never give  emetics.   Forbid  all  spirituous liquors.   Patient
should wear warm clothing, and take baths to excite the activity
of the skin.  Do not allow a vegetable diet, fat  meats, or sauces.
The diet should consist  of lean meat which must be slowly and
carefully masticated,  and only small quantities to  be  taken at a
time, or cold meat and a little white bread, or salt or smoked  meat
and sea-biscuits; milk, or butter-milk which is better (ad libitum). 
                  CARCINOMA OF THE STOMACH.              173

 Soda or Karlsbad water may be prescribed, or bismuthi nit. gr. x.
 Argenti nit. gr. i.-ij. before breakfast (while fasting).
   If there be atony of the gastric mucous membrane, give iron and
 mild stimulants, alsoipec gr. ss.-ij.; pulv. rhei gr. iij.-iv. in pills
 before meals.  If constipation be present, give an enema, or some
 laxative  such as aloes, ext. colocynth co.  or comp.  ext. rhei.
 Aloes and colocynth are the best.
   Never administer senna or oleum ricini.

          CARCINOMA  OF   THE  STOMACH.
                     MORBID ANATOMY.
   The cancer may vaiy in size  from about the size of a pigeon's
 egg to that  of a man's fist; it attacks the pyloric portion, princi-
 pally, and spreads transversely, causing an annular stricture.  The
 most  frequent form of  cancers are  the scirrhus, medullary,
 alveolar or  colloid (rarest).  The  colloid lasts a long time; induces
 ascites; and after tapping, may be felt as nodular masses appear-
 ing on the omentum.
   Scirrhus—begins  in the sub-mucous tissue, forming irregular
 nodules; it  has  the appearance  of a dull, whitish, dense mass  of
 cartilaginous hardness, which softens to a black pulp and then
 sloughs.
   Medullary—looks  like brain substance; on  section giving off a
 "cancer juice."  It spreads more rapidly than the other forms
 (often reaching the size of the hand).
   Alveolar or Colloid—occurs more frequently as diffused degener-
 ation.  Commences in  the submucous tissue and contains a gela-
 tinous fluid.  It  often  extends to other organs, especially the
 lymphatics,  pancreas, liver,  transverse  colon, or omentum.   It
 induces degeneration of the peritoneum and consequent ascites.
 Prior to adhesion to other organs, the  contents of the stomach
 may escape  into the abdomen,  if the  ulceration penetrate its
 coats.
                         ETIOLOGY.
  Is obscure.  It  is sometimes primary, but usually secondary, to
cancerous degeneration of other  organs.  It may be hereditary, 
174
DISEASES OF THE DIGESTIVE TRACT.
and occurs more in men, especially between forty and sixty years
of age.
                        SYMPTOMS.
Emaciation.
Feeling of pressure in the epigastrium.
Patient becomes apathetic.
Loss of appetite, and constipation
Vomiting.
Tumor in the epigastrium—(sometimes absent to the touch)—most
    of those that can be felt are at the pyloric end of the stomach,
    and hence the tumor  is generally on  the left of the median
    line of the body, or near the umbilicus, from sinking of the
    pyloric end; it is uneven, nodular, and movable, unless there
    be adhesions.
Dirty-yellow cachectic color of the skin.
CEdema of the  ankles.
Tenderness in the region of the stomach—which is increased by
    pressure, and after eating.
Coffee-ground vomiting—resulting from capillary hemorrhage,
    caused by  breaking  down of the  vascular growth.   The
    effused blood is  altered by the acid  contents of the  stomach
    into this black coffee-like mass.
Hard swelling of the supra-clavicular glands, (may be diagnostic).

                   CAUSES  OF DEATH.
  From exhaustion (when, prior to death, the tongue becomes red
and  dry, and aphthous deposits occur on the  tongue); cedema of
the legs ensues from obstruction to the femoral vein,  showing
that a clot has formed; frequently from peritonitis (due to  rup-
ture of the stomach); from complications; and secondary diseases.

               DIFFERENTIAL DIAGNOSIS.
  1.  From chronic catarrh of the stomach—but the tumor in the
epigastrium, and coffee-ground vomiting decides it; and there is
also the general condition of the patient to assist in the diagnosis.
  2.  From chronic ulcer of the stomach. 
NERVOUS CARDIALGIA.
175
                       TREATMENT.
  Milk should be  taken freely if it can be  tolerated, or broth.
The yolk  of an egg (always in small quantities) and red wine.
For acidity of the stomach, give soda water.  The best method of
administering food or other stimulants is by the rectum, as the
stomach is thus at rest, and irritation greatly relieved.
                NERVOUS  CARDIALGIA.
                        DEFINITION.
   Is a painful affection of the stomach, which is not dependent
 upon any perceptible changes in the structure; but upon hyper-
 esthesia of the pneumogastric nerve, or solar plexus of the sym-
 pathetic
                        ETIOLOGY.
   It occurs in anaemic persons and chlorotic women (from poverty
 of blood); from diseases of the uterus-such as dislocations, flex-
 ions, chronic inflammation, follicular ulcers of the os uteri, and
 inflammation of the ovaries occurring at the period of menstrua-
 tion; from  diseases  of  the  brain or spinal  cord; from organic
 changes of their pneumogastric or sympathetic nerves; from swell-
 ing of their neurolemma, or tumors pressing  upon them; from
 dyscrasia; from  excessive acidity, worms, certain medicines,
 beverages, etc.
                        SYMPTOMS.
 Paroxysms of severe pain.
 Peculiar feeling of pressure in the stomach.
 Severe griping pain in the pit of the stomach, extending to the
    back.
Feeling  of faintness.
Countenance becomes shrunken.
Feet and hands become cold.
Pulse—small and intermittent.
Epigastrium—puffed out, or sometimes retracted (with tension  of
   the abdominal walls). 
176           DISEASES OF THE DIGESTIVE TRACT.

Epigastric pulsation.
Pains in the thorax (sympathetic) under the sternum.
Exhaustion—severe (after the attack).
Eructation of gases and watery fluid (after the  attack).
Urine—red color and scanty.

                DIFFERENTIAL DIAGNOSIS.
  It may be confounded with ulcer of the stomach.

                        PROGNOSIS.
  Is favorable, unless complicated by some incurable disease.

                        TREATMENT.
  For those suffering from anaemia or  chlorosis, iron should be
administered at once in either of the  following forms: Ferri car-
bonas  sacch. (British), gr. iv.-x.; tine ferri chlor., gr.  x.-xxx.;
ferri sulph., gr. i.-iv. or Bland's pills, which consist of the follow-
ing ingredient: R Ferri sulph.  pulv.; potass, carb.purae, aa|ss ;
tragacanth, q. s.  M. fiat pil. xcvi. Take 3 pills three times a day.
  Should  this affection  occur- from  malaria, quinine should be
given.

                       DYSPEPSIA.
                        DEFINITION.
  Is an impaired state of digestion, arising without any percept-
ible change in the structure of the stomach.
                         ETIOLOGY.
  It may arise from restricted, too scanty, or abnormally increased
secretions.   It occurs in the aged from lack of material to form
the necessary secretions, or from diminished excitability of the
gastric nerves.  Over-feeding; too little exercise; excessive study:
emotional excitement; over-indulgence in spirits,  tobacco, etc,
may induce it.
                        SYMPTOMS.
Loss of appetite.
Flatulence. 
HEMORRHAGE FROM THE STOMACH.
177
Nausea—(sometimes).
Eructations—(bitter or acid).
Tongue—furred, flabby, large, or indented at the sides.
Headache.
Pyrosis.
Heartburn.
Constipation.
Hypochondriasis.
Palpitation of the heart.
                       TREATMENT.
  This consists principally in regulating the diet and slight medi-
cations.  The meals should be regular and never hurried  over;
they should be of a plain character, and easy of digestion.   The
food should be properly masticated and the stomach should not
be over-crowded with food; " it should be taken sparingly."  Ex-
ercise in the open air. daily is of the utmost importance.  Should
tonics  be required, quassia, or  Colombo,  are  the most  reliable
stomachics.  In order to overcome constipation, rhubarb  may be
given alone, or, with  extract of colocynth, aloes, or podophylli
resina; or any of the mineral waters maybe used.  Bicarbonate
of sodium  (gr. v.-x.), or bicarbonate of potassium (gr. ij.-v.), or
lime water ( 3 ij.), will be found of great service in case of  acidity.
Should there be any derangement of the liver, a blue pill at the
onset of the affection may often prevent further trouble.
       HEMORRHAGE FROM THE STOMACH.
                         SYNONYM.
  Haematemesis.
                    MORBID  ANATOMY.
  On post-mortem examination, there is a superficial softening of
the stomach from capillary hemorrhage, also superficial excava-
tions in the stomach (called hemorrhagic  erosions).  The mouth
of the vessels  may be gaping.  There are red clotted masses of
blood in the stomach if death be sudden, or there are brown  or 
178
DISEASES OF THE DIGESTIVE TRACT.
black clotted masses, as if the blood had escaped slowly and been
acted upon by the gastric juice.

                        ETIOLOGY.
  From rupture of over-filled blood-vessels; from arterial fluxion,
causing rupture (rare); from venous congestion of the  gastric
mucous membrane; from impediment to the circulation of the
liver (portal) by blood-clots;  from pressure due to cirrhosis of the
liver, or enlargement of the gall-ducts; from destruction of the
capillaries  by yellow atrophy of the liver: from rupture  of  dis-
eased vessels; from rupture of varices and aneurisms; from ex-
haustive diseases, as  yellow fever, scurvy, typhus, etc.; from
improper  living, as abstaining from meat and vegetables; from
erosion or injury to the walls of the stomach, as chronic ulcer.
cancer, etc.; from corrosive substances; from sharp instruments;
from blows and kicks;  from swallowing of blood in epistaxis and
haemoptysis; from miliary aneurism of the gastric artery.

                         SYMPTOMS.
Blood mixed with vomited matter.
Abnormal  sense of pressure about  the stomach,  and a desire to
    loosen the clothes.
Feeling of  constriction and nausea.
Paleness.
Tinnitus aurium.
Cold skin (if the hemorrhage be profuse).
Pulse—small (if the hemorrage be excessive).
Dizziness.
Fainting—(momentary fainting arrests the hemorrhage and favors
    the formation of coagula).
Nausea—accompanied  by a sweet taste in the mouth and by a
    feeling of warm fluid rising in the oesophagus.
Violent vomiting of blood—partly fluid and partly clotted.
Passage of blood from the bowels—(black and clotted, or black
    and tar-like).
Hydraemia and dropsy—from loss of blood. 
               CHRONIC ULCER OF THE STOMACH.            179

                DIFFERENTIAL DIAGNOSIS.
  Between haemoptysis and haematemesis.

                        PROGNOSIS.
   Favorable, unless complications exist.
                        TREATMENT,
   if the portal circulation be obstructed, leeches should be applied
 to the anus, or os uteri.  Cold ice-water should be drank, or ice
 eaten, and the epigastrium covered with cold  compresses, cr ice.
 The patient should lie flat in the bed.  If there  be syncope, let the
 patient inhale  ammonia  or eau-de cologne through the nose, or
 throw cold water on the face, and give cold champagne to drink.



        CHRONIC ULCER  OF THE STOMACH.
                         VARIETIES.
   See page 12.
                    MORBID  ANATOMY.
   It occurs in the stomach, or upper part of. the duodenum, gen-
 erally near the pyloric orifice, and on the posterior wall.  It has
-the appearance of a circular hole (like a terrace) extending from
 the sub-mucous coat toward the serous, with  sharp borders as if
 a, piece had been punched out.  The ulcer is from about a quarter
 to half an inch in diameter usually, and may be round, elliptical,
 or bulging.
                         ETIOLOGY.
   Disease of the walls of the vessels of the stomach; poverty of
 the blood and chlorosis; acute or chronic catarrh  of the gastric
 mucous membrane.  Long continued pressure,  as exists in sewing
 girls, from their position.
                         SYMPTOMS.
 Peritonitis—by perforation.
 Haematemesis—by  erosion of the large vessels.
 Oppression in the epigastrium—which is increased  by eating.
 Pains in  the epigastrium—which are steady  and increased on 
180
DISEASES OF THE DIGESTIVE  TRACT.
    pressure at one spot.  This  pain extends toward the back
    (called cardialgia) and occurs soon after meals.   If the pains
    occur directly  after eating, the ulcer is near the cardiac ori-
    fice.   If the pains occur one or two  hours after eating, it is
    near the pyloric orifice.
Vomiting—this, like the pain, indicates the position of the ulcer.
    Severe cardialgia and vomiting usually occurs directly after
    meals.  If blood exist, it shows the presence of a chronic ulcer.
    Severe cardialgia  may also  arise from adhesion of the stom-
    ach to some neighboring organ, impeding its motion.
Tongue—red and furrowed.
Increased thirst.
Habitual constipation.
Cachectic look and great debility.

                    CAUSES OF DEATH.
  Death may occur from perforation of  the walls  and escape of
the contents  of the  stomach into the  abdominal cavity,  with
sudden pain, cold skin, small pulse, sunken countenance, collapse,
and cyanosis  (indicating paralysis of the sympathetic system);
from hemorrhage  of  the stomach (rare); from erosion of  a large
artery; or  from gradual exhaustion, even when the  ulcer has
healed.
                DIFFERENTIAL  DIAGNOSIS.
  From chronic gastric catarrh, where it runs its course without
any pathological symptoms, and from stricture of the pylorus.

                        PROGNOSIS.
  Is on the whole favorable.

                        TREATMENT.
  The diet should be liquid in character, consisting of milk, bread
and milk, sour milk, essence of beef, or Trommer's malt extract.
No vegetables  should be allowed.  Karlsbad or warm mineral
spring waters may be  prescribed with advantage, but they should
be properly warmed before  drinking.  Morphia (gr. fa-fa doses), 
CATARRHAL ENTERITIS.
181
 for the relief of pain.  If the epigastrium be sensitive  to press-
 ure, then leeches or wet cups may be applied with advantage.
   If there be vomiting, morphia, or  ice, or ice-water or creasote
 (gr.  iv. to 1 vi. water in tablespoonful doses), or tr. iodini, gr. ij.-
 iij in sweetened water.  Abstinence  from all food and rectal ali-
 mentation has been highly recommended.


         DISEASES  OF  THE  IXTESTIXES.

               CATARRHAL ENTERITIS.
                        DEFINITION.
   Is an inflammation of the intestines, due to hyperaemia, causing
 excessive transudation of a salty fluid deficient in albumen, or an
 abnormal production of mucus and cells.

                         VARIETIES.
   Acute and chronic catarrhal enteritis; marasmus; typhlitis; and
 perityphlitis.
                    MORBID  ANATOMY.
   In the acute form.—The changes  that take place occur most
 frequently in the large intestine,  about Peyer's patches; less so
 in the ileum; and rarest in the jejunum and duodenum.  After
 death, Peyer's patches are found to  be swollen, as are also the
 solitary glands, causing them to project above the surface of the
 mucous membrane.  The contents of the intestines are, at first,
 a serous fluid with detached epithelial and young cells, or a cloudy
 mucus adherent to the  walls of the intestines.
   In the chronic form.—The mucous  membrane is of a brownish-
 red,  or slate color; puffed up and forming rectal polypoid protru-
 sions.  Hypertrophy of the  muscular walls often exists, causing
-constriction. The mucous membrane may, in some cases, appear
 as if sprinkled with bran (indicating  a diphtheritic type.)
  There may be  ulcerations, either  diffused or follicular.   The
diffuse form of ulcer may be due to foreign bodies, or retention of
faeces.; as in  typhlitis, where the arrest  is most probable to take 
182
DISEASES OF THE  DIGESTIVE TRACT.
place.  The follicular form occurs exclusively in the large intes-
tine, at the lower part, often causing great destruction of tissue.

                         ETIOLOGY.
  It accompanies obstruction of the liver circulation; disease of
the respiratory and circulatory organs, causing obstruction to the
vena cava; from disturbance of the external  circulation, causing
active  hyperaemia and catarrh, as caused by burns, or sudden ex-
posure to a low temperature.   It occurs in peritonitis, especially
the puerperal type, which leads to collateral oedema; from col-
lateral fluxion; from fluxion to the intestinal capillaries induced
by mental excitement; from local irritation, as in the case of pur-
gatives;  from retention of faecal matter, causing local peritonitis;
from epidemics; and, finally, it accompanies  various fevers.
                         SYMPTOMS.
In the  acute form.
    Accelerated movement of  the  intestines.
    Diarrhoea—preceded by rumbling; may consist of faecal matter
        mixed with cylindrical epithelial cells, or with undigested
        food.  It may be of a greenish color and contain blood.
    Pains in the abdomen.
    Abdomen—prominent.
    Fever—the temperature usually varying between 100°-103°.
    Rumbling and gases in the intestines—showing that the dis-
        ease has extended to the small intestine.
    Constant desire to defecate (if  the rectum be involved).
In the  chronic form.
    Secretions are scanty and  contain mucus.
    Constipation—is usually present.
    Debility.
    Emaciation.
    Complexion—pale, or dirty-gray color.
    Abdomen—tense and resistant.
    Respiration—impaired.
    Congestion of the brain—may occur, resulting in dementia
        and suicide.
    Secretions from the mucous membrane- may be increased. 
                   CATARRHAL ENTERITIS.                   J 83

     Peristaltic action—may be increased, (with diarrhoea).
     Death may result from exhaustion.
 In marasmus.
     Occurs from an  exhaustive and obstinate diarrhoea (is most
        common about the end of the first year and after weaning).
     Dejections—are thin copious, and watery; clay-colored; foetid,
        and mixed with undigested food.
     Child becomes flabby and emaciated ; fat and muscles are ab-
        sorbed, and patient looks prematurely aged.
     Excoriations about the anus.
     Aphthous rash appears in the mouth.
 In Typhlitis.
     This is due to the muscular coat of the intestine losing its
        power of contraction.
     Faeces are collected in the caecum and  ascending colon.
     Constipation and diarrhoea alternately occur.
     Passages of mucus or bloody mucous masses are frequently
        present.
     Nausea.
     Vomiting.
     Pain—in the right inguinal fossa.
     Tumor—"sausage shape," and is external to the median line.
     Inflammation—which may extend to the serous covering and
        neighboring organs, causing
    Abdominal  tenderness—often   indicating  Perityphlitis (for
        symptoms see page 187).
     Follicular ulcers—occur in cachectic  persons.  At  first  the
        symptoms are those of protracted catarrh of the large in-
        testine; but,  after a while, there will be found  peculiar
        translucent lumps resembling swelled sago in the mucus,
        and  their passage is preceded  by tormina with  slight
        tenesmus.
    Adhesion of the liver—producing distortions and contractions
        of the intestines.
                         PROGNOSIS.
  Is most unfavorable when there are follicular ulcers of the large
intestine, particularly if the patient be already cachectic. 
184
DISEASES OF THE DIGESTIVE TRACT.
                       TREATMENT.
  If it occur from constipation—leeches should be applied to the
anus.
  If from cold—send the patient to bed, give him warm drinks of
chamomile tea, and apply hot flannels to the abdomen.
  If from a damp climate—the patient should wear woollen
stockings, which should be changed when the feet get cold.
  If from improper nourishment—the diet should be regulated.
The patient should be fed on meat broths, and finely-shaved raw
beef,  with a little white bread, and a small quantity of good
wine.  Milk must not be allowed while there is diarrhoea.
  If from retention of fazces—commence with a purgative and
examine the passages.
  If the passages be bloody, etc.—give one  good  large dose of
oil and regulate the bowels.
  If from habitual constipation^&dminister pulv.  digitalis and
ext. belladonna, gr. fa to £, in the form of a pill.
  If from typhlitis—prescribe  ol. ricini, |ss.-i.  If there be no
vomiting, an enema, with  salt, oil, milk or honey, may be used;
and leeches and hot poultices applied over  the right  inguinal
region.
  If from cholera morbus—hot cloths well wrung out should be
applied  to the abdomen, also tannin  and nitrate of silver, enema
of sulphate of zinc, tannin, 3 ss. to § ij. water, or nitrate of silver,
gr. ij. to 1 vi. water.  In order to  arrest the diarrhoea, give mu-
cilaginous drinks, such as rice, oatmeal, or barley water, etc.; the
patient should have red wine, infusion of dried whortleberries,
and roasted acorns.  R Catechu, 3 ij.; mucilage, § vi.; M.  Sig.,
 3 i. every two hours; or opium, 3 j.- 3 ss. and mucilage § vi.; or
a weak solution of ipecac. M.  Sig., 3 i. every hour.



                  CHOLERA MORBUS.
                       DEFINITION.
  Is that form of acute  gastric catarrh which extends to the in- 
CHOLERA MORBUS.
185
 testinal mucous membrane, and which is characterized by profuse
 transudation of a fluid into the stomach and intestines.

                         ETIOLOGY.
   Occurs in the  summer, and  is usually epidemic  It is some-
 times excited by error of diet.

                         SYMPTOMS.
 Come on suddenly, usually at night, with a sense of oppression at
    the pit of the stomach.
 Nausea.
 Vomiting—often profuse in quantity, and possibly projectile in
    character.
 Borborygmi and  abdominal cramps.
 Stools—pulpy at  first, then thin and liquid.
 Intense thirst.
 Bloody evacuations—in severe cases.
 Urine—diminished in quantity.
 Calves of the legs painfully contracted.
 If evacuations continue, they become like rice-water  discharges.
 In children.
    Evacuations—are first acid, green or yellowish, then almost
        white.
    Vomiting—but not of curdled milk—resembles bile.
    Legs are drawn up.
    Convulsions—from anaemia of the brain.

                        TREATMENT.
  For the vomiting and diarrhoea, give opium; should they be ex-
 cessive, give gr. ss. doses in the form of a powder. For vomiting,
 ice should be eaten.  When there is collapse, stimidants should
 be given inwardly, and hot poultices applied outwardly.  For
 diarrhoea, use Squibbs' "tinct.  opii comp."  When injurious or
 decomposing food is in the stomach, an emetic should be given,
 and when it has passed into the intestines,  rhubarb or compound
infusion of senna should be administered. 
186
DISEASES OF THE DIGESTIVE TRACT.
        PERFORATING DUODENAL ULCER.
                   MORBID ANATOMY.
  The most frequent seat of this disease is in the upper horizontal
portion, but sometimes the descending  portion of the duodenum
is affected.  The edges of the ulcer are sharp  and not swollen.
There is a greater loss of substance in the mucous membrane than
the muscular coat.  The floor of the ulcer is sometimes formed by
neighboring organs, to which the duodenum has become adherent
before perforation has taken place.   The ulcer may communicate
with the gall-bladder and produce an external fistulous opening.
Stricture of the duodenum  may  follow, or obliteration of the
ductus communus choledochus.
                        ETIOLOGY.
  This disease is really a necrosis, and a solution of the necrosed
part of the intestine by the  gastric juice.  They occur more fre-
quently in men than  in women, while ulcer of the  stomach is
more frequent in women.  It is  said to  be the particular lesion of
burns occurring over the abdomen.
                       SYMPTOMS.
Are latent until perforation takes place.
Dyspepsia—(slight, and which has remained unnoticed) may have
    existed.
Pain—may have occurred in the right hypochondrium for several
    hours after  meals.
Perforation may produce sudden death.
                       TREATMENT.
  Strict regulation to the diet should be observed.  Alkalies and
alkaline mineral waters may be taken freely.

                   PERITYPHLITIS.
                       DEFINITION.
  Is an inflammation of the connective tissue attaching the caecum
and ascending colon to the iliac fascia. 
                        PERITYPHLITIS.                    187

                     MORBID ANATOMY.
   Abscesses may extend to the region of the kidneys, and, below
 Pouparc's ligament, to the inner part of the thigh.  The posterior
 wall of che caecum, ascending colon, anterior wall of the abdomen,
 or skin uf tne thigh, may be  perforated, or the contents of the
 abscess may escape into the abdominal cavity, and cause  peri-
 tonitis.  The exudation may be absorbed, and recovery ensue, or
 the inflammation ia<»y xead to necrosis of the inflamed connective-
 tissue.
                         ETIOLOGY.
   It occurs in typhus, &epeicaemia, puerperal fevers, etc., and may
 follow typhlitis.
                         SYMPIOMS.
 If from typhlitis, a painful tumor remains lying far  back in the
     abdominal cavity.
 Pain—is circumscribed, and a numbness often exists in the right
     leg, from pressure on the nerve -trunks.
 Inability to raise  the thigh—because the psoas and iliacus muscles
     are infiltrated.
 Patient lies on the right side, with the body bent forward (so as
    to relax the psoas and iliacus muscies).
 CEdema—from pressure on the veins (sometimes).
 Tumor in  the  abdomen or thigh—wnich may be fluctuating, if
    suppuration has taken place.
 Ulceration of the vermiform appendix; may occur, resulting in
    symptoms of  shock or collapse.
 Inflammation of  the  transverse coloi^ and sigmoid  flexure  may
    occur.
 Death—may result from exhaustion, or peritonitis.

               DIFFERENTIAL DIAGNOSIS.
  From typhlitis  (see page  183;.

                       TREATMENT.
  The abscess may be opened,  or the contents evacuated by aspira-
tion.  If the  contents escape into the ascending colon, recovery
usually ensues.  At the onset of the disease, it is advisable to 
188
DISEASES OF THE DIGESTIVE TRACT.
apply leeches several times, and, so soon as  fluctuation  takes
place, the tumor should be opened.


                    PERIPROCTITIS.
                       DEFINITION.
  Is an inflammation of the connective-tissue around the rectum,
which may develop in the course of an acute and chronic inflam-
mation of the neighboring parts; and as the result of degeneration
or traumatism of the rectum.
                    MORBID ANATOMY.
  Acute periproctitis usually leads to abcesses.  The chronic form
may terminate in thickening and induration of the inflamed con-
nective-tissue, which ends in partial suppuration, forming fistu-
lous openings, which are extremely difficult to heal.
                        ETIOLOGY.
  It accompanies affections of the pelvis or pelvic organs.   It is
developed sometimes in phthisical patients.
                        SYMPTOMS.
In the acute form.
    Tumor—which is hard and painful.  This may be felt in the
        perineum, or in the cavity of the coccyx.
    Infiltration  of the connective-tissue.
    Patient is unable to sit up.
    Pain—severe (on defecation).
    Tenesmus—severe (in some cases).
    Evacuation of purulent matter and formation of fistulae.
In the chronic form.
    Are obscure, till stricture of the rectum is induced.
    If abscess form, there is severe pain, with the above-named
        symptoms superadded.
                       TREATMENT.
  Cold may be applied, or poultices, or fomentations.  The  tumor
should be opened as early as possible to prevent perforation  of the
bladder or rectum. 
DYSENTERY.
189
                      DYSENTERY.
                         SYNONYM.
   "Bloody flux."
                        DEFINITION.
   Is an inflammation of the muscular and mucous coats of the
 large intestines.
                        VARIETIES.
   Acute (which is usually epidemic or sporadic); chronic; typhous;
 bilious; malarial; ulcerative; " strumous " or tubercular.

                    MORBID ANATOMY.
   There is usually a diphtheritic type of inflammation.  The dis-
 eased portions of the mucous membrane are infiltrated by a fibrin-
 ous  exudation,  and  consequent impairment of  nutrition and
 sloughing follow.
   In mild cases.—The mucous membrane of the large intestine is
 reddened  by ecchymotic injections, and infiltrated by a grayish
 soft  exudation which covers the epithelial coat and  has the ap-
 pearance of bran. The submucous tissue is swollen and infiltrated
 with serum.  The serous coat is cloudy and dull (from oedema).
  In severe eases.—The mucous  membrane is changed to a black
 friable charred mass, which may be thrown off.  The sub-mucous
 tissue may be infiltrated by a bloody serous fluid, or it may be
 pale.  The superficial blood-vessels are consumed  to a black pow-
 dered mass, and when this is thrown  off, the sub-mucous tissue
 appears infiltrated with pus.  The peritoneal coat loses its lustre
and is injected by dilated  capillaries covered by  a brownish dis-
colored ichorous exudation.  The intestine contains an offensive
coffee-ground fluid, and is either in a  state of passive dilatation,
or collapse.   The muscular coat is shrunken,  pale,  faded, and
easily torn, and the glands are swollen.
  The liver becomes hyperaemic, and abscesses may form within 
190
DISEASES OF THE DIGESTIVE TRACT.
it.  These are to  be explained as the  result of  the following
changes: (1) inflammation of the muscular coat of the bowel with
ulceration; (2) inflammation of the veins,  constituting "phlebi-
tis; (3) blood-clots ("thrombi") form in these veins; (4) suppura-
tion of these thrombi now occurs, causing their disintegration; (5)
these disintegrated thrombi are carried, as emboli, to the liver by
the portal vein; (6) infarctions of the liver are thus produced, and
are followed by suppuration; (7)  abscesses in the centre of each
infarction, or at the seat of obstruction to any of the portal vessels.
This secondary suppuration depends upon the suppurative origin
of the emboli in the  portal vessels.

                         ETIOLOGY.
  Is a disease of hot climates depending on  miasm.  It occurs
in the summer and autumn, and often depends upon some blood-
poisons, such  as purpura, cholera, fever, ague, syphilis, etc.  It
may  also occur from drinking  bad water;  from  atmospheric
changes; from inflammation of the colon;  from bad hygiene, ex-
posure, and hardships, as in  the army in the field, etc.  As in
cholera, the stools and water-closets are apt to cause it to spread
on account of the germs created therein (Niemeyer).

                         SYMPTOMS.
In the acute form.
    Chill—(which  is  usually preceded by a diarrhoea).
    Fever—slight, with great thirst.
    Countenance—anxious and distressed.
    Anorexia.
    Temperature—elevated.
    Pulse—(in severe cases) rapid, full, and  marked; (in slight
        cases) very little excited.
    Tongue—furred.
    Skin—(in  severe cases) is very hot  and dry; (in slight cases)
        cool.
    Stools —frequent  and semi-feculent; small; bloody, slimy,
        offensive,  and mixed  with mucus and pus and cast off
        epithelium;  often "jelly-like," or greenish. 
DYSENTERY.
191
     Great rectal tenesmus and purging.
     Irritability of the bladder—(strangury or retention).
     Urine—high-colored and scanty.
     Irritation of the vagina—(in female patients).
     Pain—griping in character and associated with tenderness on
         pressure (about the colon).
     Constipation, (alternating with diarrhoea) which may be per-
         manent if stricture of the intestine be produced.
     Nausea and vomiting.
     Collapse.
 In the chronic form.
     Is associated with a chronic diarrhoea.
     Rectal tenesmus—( f cen marked and distressing).
     Stools—same as in the acute form,  and also  loose and fre-
         quent.
     Discharges—alvine.
     Pain—griping.
     Emaciation.
     Extensive  inflammation of the mucous membrane of the
        colon.
     Examination of the rectum shows ulcers.
     Paralysis of the  sphincter muscles may occur.
     Death—may result  from paralysis of the intestines.

                        PROGNOSIS.
  In the acute form.—The  patient may die (if an epidemic exists)
in a short time.
  In the  chronic form.—The prospect of complete  recovery is
doubtful.
                       TREATMENT.
  In the acute form.—The patient should be  kept in bed, and fed
on  milk, arrow-root, broth, and  the whites of raw eggs, etc
Tincture opii should be  given in full doses; or oleum ricini et opii
in small doses.
  In the chronic form.—The patient should be put to bed and kept
perfectly quiet; he should  be fed  in the  same manner as in the
acute form.  Full doses of tinct. opii should be given to relieve 
192
DISEASES OF THE  DIGESTIVE TRACT.
the pain, and oleum ricini et opii  in small doses when the dejec-
tions contain no faecal matter for e day or two.  Should the dis-
charges be excessive and bloody in character, injections of starch
and laudanum, or starch and iodoform, or a suppository of morph.
gr. fa, ext. belladonna gr. ss. will frequently arrest this  symptom
in a very few hours.   Ipecac (gr. xxx. every half-hour till retained)
is highly recommended by eminent physicians in the East Indies,
where this disease is more prevalent than in any other part of the
world; and remarkable results seem to have been obtained by this
treatment.

                  ASIATIC  CHOLERA.
                    MORBID ANATOMY.
  There is, at first, terrible emaciation.   The skin is corrugated.
Black circles will be  seen around the orbit, and flattening of the
eye,  from absorption of its fluids.   Dryness of  the muscles exists
(from absorption of fluid), and contraction of the muscles after
death often occurs.   Elevation of the temperature takes  place
after death, and  the vessels are found to be filled with coagulated
blood.
  On opening the body,  the right heart will be found filled with
blood; the organs very dry; and the alimentary canal injected
and filled with the so-called '' rice-water " discharges.

                          STAGES.
  1st. Painless diarrhoea.
  2d.  Rice-water discharges and cramps.
  3d.  Collapse.
                         ETIOLOGY.
  The rice germ  is claimed to be the cause of this disease; and the
discharges of the patient are supposed to be contagious.  Mental
influence (fear, etc.) may predispose to it.

                        SYMPTOMS.
1st stage.—Painless and feculent diarrhoea.
2d stage.—Profuse rice-watery discharges from the bowels. 
CARCINOMA OF THE INTESTINES.
193
     Projectile  vomiting of  rice-watery discharges (this  is  char-
        acteristic).
     Terrific cramps.
     Insatiable thirst, (due to abstraction of water from blood.)
     Terrible emaciation (from extraction of water from the tis-
        sues).
     Premature aging of the patient (from the emaciation and ab-
        straction of fluids from the tissues).
     Stoppage of pulse  in the extremities (from thickening of the
        blood due to abstraction of its water).
     High temperature.
     Collapse—the symptoms of which are:
        Complete suppression of urine.
        Cessation of the "rice-water" discharges.
        Insensibility.
        Faeces passed involuntarily and in small quantities.
        Marked cyanosis.
3d stage.—Coma and death.
Duration.—From the time the rice-watery  discharges commence,
    24 to 72 hours may elapse before death occurs.
                        TREATMENT.
  Stop the diarrhoea, in the  first  stage, by  rest in bed; give large
doses of opium and remove the patient from all influences favor-
ing the disease.
        CARCINOMA  OF  THE  INTESTINES.
                    MORBID  ANATOMY.
  It affects the large intestines, especially at the sigmoid flexure
and rectum; it may also occur in the small intestines.
  The  scirrhus  form attacks the sub-mucous connective-tissue,
and, when it  has perforated the mucous  membrane, medullary
masses arise from the  scirrhus base, and form a ring-like struc-
ture.  The cancer may extend to the peritoneum, the mesentery,
or neighboring organs.   The intestines may become adherent to
the abdominal walls.  Faecal fistula, or perforation of the vagina 
194
DISEASES OF THE DIGESTIVE TRACT.
or bladder may occur through breaking down of the cancer (if
situated in the rectum).

                        ETIOLOGY.
  Is obscure.   May be due to hereditary predisposition.

                        SYMPTOMS.
Pain—sometimes sharp and lancinating, but usually dull and con-
    fined to one point.
Tumor—uneven, nodular,  hard, and painful; at  first it  may be
    movable.
Habitual constipation, (from  degeneration of  muscular coat).
Rapid loss of strength and emaciation.
Cachexia.
If it occur in the rectum.
    Pain-severe about the sacrum, extending to the back and
       thighs.
    Dilatation of the hemorrhoidal veins.
    Passage of bloody mucous.
    Habitual constipation or profuse diarrhoea, which cannot be
       stopped.
    Diminution of the rectal calibre (on a digital examination).

                       TREATMENT.
  Is palliative.  Castor oil may be given daily to evacuate the
bowels.   The  food should consist of concentrated broths,  soft
boiled eggs, and milk.  If confined to the rectum, surgical inter-
ference may be demanded.
            INTESTINAL HEMORRHAGE.
                   MORBID ANATOMY.
  The mucous  membrane is  suffused with blood, after capillary
hemorrhage takes place.   The blood is  usually of a chocolate-
brown color, or it consists of  a black, tarry mass.  Hemorrhoids
frequently occur, which are at first bluish in color, and with thin 
INTESTINAL OBSTRUCTION.
195
 waUs;  if  they continue for any length of time, and  become
 chronic, they lose  that  bluish look, become hard, since  their
 walls become thickened.
                        ETIOLOGY.
   From cirrhosis of  the liver; erosion of vessels from ulcerations
 (occurring in typhoid  fever, dysenteiy, and tuberculosis of the
 intestines); disease of the walls of the vessels;  from escape of
 blood from  hemorrhoids, caused by collection of faeces in the
 rectum, producing rupture of the hemorrhoids.

                         SYMPTOMS.
 Blood is frequently passed in smaU quantities, with the discharges
     of the disease with which it occurs.
 Hemorrhoids.—When this complication occurs, there will be pain
     when the  stools are hard (if the varices are small); the pain
     may be constant and the patient unable to sit down (due
     often to pressure of the sphincter muscle of the rectum upon
     them).
 Bleeding—occurs during defecation.

                        TREATMENT.
   Acetate of lead, with opium, may be given either by the mouth
 or rectum; tannic or gallic acid in the form of a pill  or solution;
 in this latter it is used as ah  injection;  or any of the astringents
 may be resorted  to.   Should  the patient  suffer greatly  from
 hemorrhoids, the diet should be regulated.  Meat and eggs should
 only be taken once a day, and then only in small  quantities; the
 principal diet should consist  of vegetables, fruit, rice, etc.  Stim-
 ulants  must be forbidden.   The patient should drink freely of
 water; take long walks, and resort to  energetic muscular exercise.


             INTESTINAL  OBSTRUCTION.
                    MORBID  ANATOMY.
   Above the constriction,  the intestines are dilated and elongated,
:and the walls hypertrophied  and thickened.  The  vessels are 
196
DISEASES OF THE DIGESTIVE TRACT.
 compressed, and great capillary congestion, and probably stasis,
 occurs, and, as a result, mortification of the part occasionally en-
 sues.  Below the constriction, the intestines  are empty and col-
 lapsed.
                          ETIOLOGY.
   From compression, resulting in contraction and closure, where
 the rectum is compressed by a retroverted uterus, tumors, abscess
 of the pelvic bones, or an overfilled portion of the intestine; from
 structural changes causing constriction, resulting from cicatriza-
 tion  of  intestinal ulcers   (catarrhal, follicular, dysenteric), or
 syphilitic ulcers of the rectum, or carcinoma; from closure pro-
 duced by volvulus, or from entanglement of the mesentery with
 the intestine; from internal strangulation, or incarceration; from
 bands resulting from peritonitis, especially  between the uterus
 and its surroundings; from invagination or  intussusception,  oc-
 curring both in  the large  and small intestine; from sedentary
 habits; from  impaction of faeces: from hernia; from passage of
 gall-stones; from rents in the  mesentery, etc

                         SYMPTOMS.
 If partial closure only  exist
    Defecation—tedious and difficult.
    Feet—may be very cold (from impeded return of blood  from
        the feet) d ue to habitual constipation.
    Habitual constipation.
    Menstruation—abundant (in women).
    Frequent erections and sexual emissions (in males).
    Neuralgic pains in the legs—(from overladen rectum).
    Small faeces—(like those of sheep, etc.) in case of stricture.
    Prominence of the abdomen (from tympanites).
If complete closure exist.
    Face—distorted and pale and ghastly.
    Hands—cold.
    Pulse—small and imperceptible.
    Prominence of the abdomen—(from typanites).
    Jactitations, or cramps.
    Obstinate constipation unrelieved by treatment 
WORMS.
197
    Vomiting—feculent in character.
    Death—may result from general paralysis.
 If closure exist with peritonitis.
    Abdomen—puffed up and extremely tense.
    Great pain—on the slightest pressure.
    All movements of the body are avoided.
    Temperature—high.
    Pulse—frequent, hard and tense.
    Respiration—hastened and shallow (from compression of the
        lungs by tympanites, and from the pain).
    Cyanotic look.
    Perforation — especially if  the disease occur suddenly, ac-
        companied by sudden pain  and symptoms of shock or
        collapse.
 If intussusception occur.
    Sausage-shaped tumor (felt  on palpation of abdomen in the
        right inguinal region).
    There may be bloody or mucous passages.
                        TREATMENT.
  For constriction.—The  diet should consist of eggs, meat, strong
 broths (muscular meat with delicate fibre), and evacuation of the
 bowels by laxatives or enema.
  For invagination.—Gastrotomy should be resorted to.


                         WORMS.
                        VARIETIES.
 Taenia solium—(long "tape" or "chain-worm") are  usually
    found in the small intestine, but  may occur in the large in-
    testine.
Toznia mediocanellata—are very  like the taenia solium.
Bothriocephalus latus -broad tape-worm, which closely resembles
    the taenia solium, and is also  found in the small intestine.
Ascaris lumbricoides—round worm—found in the large and small
    intestine, and may enter the  oesophagus, larynx, gall-duct, or
    ductus communis choledochus. 
198
DISEASES OF THE DIGESTIVE TRACT.
Oxyuris  vermicularis—(" thread-worm ")—found usually in the
    rectum.  They may enter the vagina from the anus, and be
    found in that canal.
Trichocephalus dispar—(" whip-worm")—found in the large in-
    testine, especially in the caecum.

                        SYMPTOMS.
In some cases the patient is in no way affected (especially in the
    case of tape-worms), while others may have any of the fol-
    lowing symptoms:
Severe abdominal pain—(as twistings and turnings).
Nausea.
Vomiting.
Emaciation.      Salivation in some cases.
Diarrhoea—and occasional passage of worms.
Dilatation of the pupil. "|
Epilepsy.              ^ most common in children.
Chorea.
Intestinal obstruction (from the round-worm).
Pruritus ani (especially late in the evening and during the night).
Incessant desire to defecate.

                       TREATMENT.
  Pork must be strictly prohibited.
  For tape-worm—Filix mas 3 ss.-i. t. d. s.  It should be taken
the first thing in the morning after fasting (the fasting must be
continued during the whole of the day), and the last dose to be
taken at bed time.  Next  morning, after the patient has fasted
twenty-four hours, a good  laxative of calomel, scammony, or \ i.
ol. ricini  should be administered.   Pomegranate-rind,  ? iv. to
O. i.-ij. water, and macerated for twenty-four hours, may be used.
This should be boiled till reduced to one-half of  the quantitv;
then it should be divided into three doses, and taken while fasting
for twenty-four hours. Should  the worms not have passed after
having taken the third dose, give  ol. ^ricini, 1 i.-ij.; or, oleum
terebinthi, 1 i.-ij. mixed with honey; or, ol. ricini at bed-time
will usually have the effect of removing them. 
INTESTINAL COLIC.
199
  For "round-worms"—Troches of santonin, ea. gr. ss.-i.
  For " thread-worms"—large enemata of cold  water and vine-
 gar, or corrosive sublimate, gr. 4- % ij. of water (used as an enemaj
 have been advocated.
  Prior to administering any of the  above remedies, the patient
 should  live moderately: his  bowels should be kept  open; and
 should be made  to  live on herrings, ham, onions, and  salty or
 spicy food.  Strawberries, huckleberries, or blackberries may be
 eaten freely.


                  INTESTINAL  COLIC.

                         SYNONYM.
  " Enteralgia."
                        DEFINITION.
  Is a term applied to all painful affections of the  intestines,
 which are not caused  by inflammation, or textural  changes of
 the intestinal walls,  but by irritation of the peripheral extremi-
 ties of the intestinal nerves.
                        VARIETIES.
  Those which are most common are lead, flatulent, and bilious
 colic.
                         ETIOLOGY.
  It occurs  in the middle and lower part of the abdomen, from
 structural disease of  the ganglia and plexus of  the sympathetic
 nerves;  from mesenteric neuralgia in females; from worms: from
 eating unripe fruit; from food which  is difficult of digestion; from
 accumulation  of  faeces; hardened faeces;  from obstinate consti-
 pation; from fright; from anger; from exposure  to cold; from
 affections of various organs, as a morbid state of  the  liver, kid-
 neys, bladder,  testicle,  uterus, ovaries, etc.; from an abnormal
 state of the  blood.
  Lead colic—occurs from poisoning by drinking water carried
through leaden pipes, producing disturbance of the motor (hyper-
kinesis), as well as of the sensory nerves (hyperaesthesia); also in
painters, and those employed in mixing  colors. 
200
DISEASES OF THE DIGESTIVE TRACT.
  Flatulent colic—occurs from distention of the intestines witl
gas.
                        SYMPTOMS.
Pain—from the navel extending over the abdomen; is of a tearing,
    cutting, pressing, twisting, pinching, or bearing-down char
    acter.  Is usually relieved by firm pressure.
Jactitations—patient seeks relief by compressing the abdomen.
Hands, feet, and cheeks are cold.
Features—pinched.
Countenance—agonized and distorted.
Pulse—small and hard.
Nausea.
Vomiting.
Desire to defecate.
Tenesmus.
Constipation.
Lead colic.
    Symptoms are generally preceded by those of lead poisoning.
    Skin—looks dirty.
    Pain—severe (extending to the back and extremities).
    Blue line along the gums and bad breath.
    Sweetish taste in the mouth.
    Pulse—slow.
    Voice—occasionally lost (aphonia).
    Constipation—obstinate (from constriction).
    Abdominal walls  strongly  contracted, and  the abdomen as
       hard as a board.
Flatulent colic.
    Pain—may be very  severe,  but relieved by pressure.
    Countenance—expression of anxiety.
    Body—covered with a cold sweat.
    Face—pale and distorted.
    Pulse—small.
    Nausea.
    Vomiting. I. present in some subjects.
    Strangury, j 
ACUTE PRIMARY PERITONITIS.
201
                       TREATMENT.
  Opium should be given in all forms ; it acts as an anaesthetic.
  For lead colic.—Sulphuric acids and sulphates, Glauber's salts;
iodide of potash, gr. xv., frequent bathing, and change of clothing.
The patient, if a painter, should be forbidden  to continue in the
business.
  For flatulent colic.—Warm teas should be given, made of either
chamomile, valerian, orpeppermint; they should be drank quickly
and very hot.  Enemas should be resorted to; also flannels wrung
out in hot water and sprinkled with turpentine, and applied over
the abdomen.
  For foreign bodies.—Ol. ricini, or an enema, should be given;
or warm compresses may be applied over the abdomen.

                      PERITONITIS.
  Is an inflammation of the peritoneum.   The peritoneum is the
largest serous membrane in the body; its office is to facilitate the
motion of the intestines.  Many gallons of fluid may be contained
in the peritoneum; as many as twenty quarts  are often removed.
Predisposition to peritonitis may occur from  any abnormal posi-
tion of the viscera.
                        VARIETIES.
  1. Acute primary peritonitis—which may be due to infection.
  2. Infectious primary peritonitis—which depends upon no local
cause, except blood changes, which cause its  development, as in
puerperal  and  scarlet  fever,  or  general  blood-infection from
severer poisons.
  3. Chronic peritonitis.—This form simply  differs  from  the
acute, in that  it is slower  of development, and associated  with
some  other cause, as cancer, tubercle, and various new growths.

          ACUTE PRIMARY  PERITONITIS.
                    MORBID ANATOMY.
  The same changes take place in this as in all serous cavities
which consist of <1) reddening of the surface—from changes in 
202           DISEASES OF THE DIGESTIVE TRACT.

the serous membrane and sub-serous-tissue—(2) loss of lustre of
the membrane—(3) shedding of epithelium and an infiltration of
the epithelial cells—(4) pouring out of  a plastic exudation, and,
underneath this, a layer of embryonic cells—;5) a serous exudation
takes place, which washes off the plastic exudation—(6) the form-
ation of new connective-tissue which contains new blood-vessels
with thin walls—(7) adhesions of the two surfaces, from the form-
ation of new connective-tissue.  When  these changes  take place
slowly, there will be  found under the plastic layer  projecting
prominences of connective-tissue which may touch each other,
causing adhesions between the walls of the abdominal cavity and
those covering the intestines, or, the bands may strike across the
intestines, causing contraction.  A loop of intestines may some-
times get caught in this stricture, producing internal hernia, etc.,
when  it  will be impossible to remove  the  adhesions  without
lacerating or tearing the intestines.  When  purulent exudation
occurs, and it is abundant, it may undergo absorption, or become
encapsulated. Calcareous exudation may take place in the cavity.
In addition to the adhesions and  bridles, there may be thicken-
ings of the peritoneum, which, in places, may become from one-
quarter to one-half inch thick.   Adhesions may form over an
organ, causing contraction, and  such  pressure  on  some of the
organs may produce disordered function.  These latter changes
are most  important when occurring in the uterus, since, after a
while,  they may result in constriction of the ovaries and Fallopian
tubes.
                         ETIOLOGY.
  From intestinal obstruction, perforation, and ulceration; typh-
litis and  perityphlitis; perforation of the intestines and stomach,
from any cause; perforation of the intestines in typhoid fever;
abscess of the liver; perforation of the diaphragm in emphysema;
rupture of the bladder or gall-bladder; from strangulated hernia;
inflammation of the muscular coat of the intestines or stomach;
rupture of an aneurism into the peritoneum; peri-nephritic ab-
scess; and, finally, the most common is a change in the vermiform
appendix,  as ulceration  and escape of gas into the peritoneal
cavity.  Such escape of gas  into the peritoneal cavity from  per- 
ACUTE PRIMARY PERITONITIS.
203
foration is always fatal, and that in a very few hours.  In addi-
tion to the causes above-named, inflammation of the liver; can-
cerous development of the stomach, from pressure on  the peri-
toneum  (localized peritonitis); inflammation of  the uterus,  or
ovaries, etc.; infectious causes, as pyaemia, septicaemia, puerperal
fever; and the abuse of  alcohol (when you may have a general
peritonitis) may prove exciting causes of this disease.

                        SYMPTOMS.
In the early stage.
    The ordinary  duration is from two to eight days—rarely over
       a week.
    Pain—in the right inguinal and umbilical regions, which, for
       a few hours, can  be covered with the palm of the hand;
       it gradually extends, in about  three or four hours, over
       the entire abdomen.  It is increased on firm pressure, es-
       pecially in the region where  it commenced (pressure
       should  be made  with the palm  of  the  hand,  and the
       countenance of the patient watched).
    Countenance—pale,  anxious, and  bears an expression  of
       anguish.
    Pulse—accelerated; and, at the end of twelve hours, rises  to
       100; is, usually, firm and incompressible.
    Abdomen—distended (after twelve hours),  especially in the
       region of  the pain.
    Legs—flexed on the abdomen—the patient keeps a position on
       his back, and does not move from it.
    Respiration—no abdominal movement; only thoracic breath-
       ing is perceptible (as the abdominal pain prevents motion).
    Fear of pain on attempt to. move patient.
    Tympanites—(due to accumulation of gas,  because the  in-
       flammation has arrested the peristaltic action of the in-
       testines).
   Vomiting—at  the  end  of twenty-four hours.  The  vomited
       material is regurgitant in character, and the expulsive
       effort increases the pain; there is at first a discharge of
       the contents of the  stomach, after which it assumes the 
204
DISEASES OF THE DIGESTIVE TRACT.
        characteristic  spinach-green  vomiting;  it  may be ster-
        coraceous in character.  This is an important sign, as this
        does not come on till late; but, should it come on early,
        it indicates that there is extensive intestinal obstruction.
        It  may be coffee-ground  in appearance (from capillary
        hemorrhage of the stomach), when there is inflammation
        around the stomach obstructing the  circulation (this
        may be due to infectious causes).
    Hiccough—may be present, due to the involving of that por-
        tion of the peritoneum covering the diaphragm.
At the end of the second day.
    Tympanites—(from the same cause as above) is increased.
    Pulse—accelerated 120 (usually small and thready).
    Countenance—more anxious.
    Cyanosis-
    Respiration—hurried and thoracic; may be short and catching
        (due to tympanites).
    Constipation—is a constant attendant of the disease.
By the fourth or fifth day.
    Patient lies motionless on the back.
    Pulse—very feeble.
    Respiration—short and shallow.
    Mind—clear up to the last; and, before death, is clearer than
        in  any other disease.
    Cyanosis—extreme.
    Perspiration—profuse.
    Collapse—(pulse is imperceptible and respiration more shal-
        low).
    Death—is quiet  and peaceful.
In case of perforation, the disease may not last more than twenty-
  four hours, and is accompanied by the following symptoms:
   •Shock—causing collapse.
    Symptoms are rapidly developed.
    Countenance—bears an anxious expression.
    Pulse—almost imperceptible.
   Abdomen—suddenly distended.
   Coldness—suddenly developed. 
ACUTE PRIMARY PERITONITIS.
205
     Cyanosis—suddenly developed.
     Vomiting—suddenly developed.
     Respiration—thoracic and shallow.
     Death—due to the effects of the shock on the nervous system.
        An apparent reaction may take place, in some cases, and
        life be prolonged for two or three days.
 From the discharge of pus into  the peritoneal cavity.
     The symptoms are rapid, but not so sudden or rapid as in per-
        foration.
                DIFFERENTIAL  DIAGNOSIS.
   It may be mistaken for enteritis; colic; passage of renal, or
 bilious caical;;  rheumatism;  hysteria;  or lead  poisoning.

                        PROGNOSIS.
   Depends greatly upon the variety.  If localized, and seen early,
 the prognosis is good; if from ulceration, which excites peritonitis,
 a moderately good prognosis may be given; if from typhlitis and
 perityphlitis, the prognosis is  good,  if there be no ulceration,
 otherwise it is bad.  Perforation of the intestines and entrance of
 gas into the peritoneum is fatal in a few hours.  In cases of trau-
 matism, where the intestines escape injury, the prognosis is good.
 So long as the disease is local in character, and not infectious, and
 no perforation exists, the prognosis is good; but, should it become
 general, even after it das been localized for some time, the prog-
 nosis is grave.
                         TREATMENT.
  The opium plan of treatment  is the only way of handling this
 disease; in may be givbji in gr. i.-v. doses, or hypodermically ttj, xx.
 of Magendie's solution <;very hour till the respirations reach twelve
per minute.   Opium a*;ts as a controlling  influence on peristaltic
 movement, also as an antiphlogistic, and it controls the inflamma-
tory conditions.  Wha< are the effects of opium, and what are the
doses that should be administered?  So soon as you obtain the
proper effect of the drug, you will observe the following symptoms
in the patient:  (1) contracted pupils; (2) suffusion of the eyes; (3)
dull  countenance; (4) profuse perspiration; (5) rash on the nose, 
206
DISEASES OF THE DIGESTIVE TRACT.
which extends down the neck, and is accompanied by intense itch-
ing;  (6) the  respiration should grow less and less until twelve a
minute has been reached, when great caution must be observed, as
the patient is semi-narcotized, and it  should always  be borne in
mind that the slowness of the respiration is the respiration of the
drug; (7) the pulse is less frequent, having reached 90 in a minute,
and full and strong, which, previous to the treatment, was  hard
and 110 in a  minute; (8) entire abolition of pain; (9) subsidence of
tympanites;  th is is the proof of the cure, and the treatment should
gradually be stopped.
  It is not the amount of sleep you have to fear, as the patient may
be so affected that from the very onset, but it is the profoundness
of the sleep; for, if you cannot rouse him or make him swallow, the
treatment should  be discontinued, and that  before he shall have
reached this  condition.  If the respirations  should ever drop to
four a minute, then stimulants  should be  given, and you must
wait and watch; but, in such a case as this, the heart is your com-
pass, for you will  find it beating steadily at 90, and you are safe.
Wait until the respiration has  reached  fifteen to twenty a minute
before commencing again, but still you must watch the patient,
and with the utmost care.  The bowels will be constipated, on ac-
count of the peristaltic quietening effect of the  drug you are
using, and, despite the  fact that the old women  will tell you to
move the bowels, see that they are not moved  for  two weeks.
After that time,  should  you deem it advisable to  have them
moved,  use the following enema: Warm water, O. i., and glyce-
rin, 1 i.-ij., rather than oleum ricini.  Never use cathartics.
  Turpentine stupes have been suggested and  used over the ab-
domen.  Leeches may be applied over the point where the disease
starts, and followed by  an ice-bag or heat; but  there is nothing
like opium and allowing the patient to remain in peace.


             INFECTIOUS  PERITONITIS.
                        DEFINITION.
  Is that form of peritonitis which depends upon  no local cause 
INFECTIOUS PERITONITIS.
207
 except the blood-changes which tend to favor its development, as
 in puerperal and scarlet fevers, or general blood-infection from
 some severe type of poison.

                         SYMPTOMS.
 Chill—long and continued.
 Temperature—high (even before the chill ceases).
 Pulse—120 to 140 (within the first twenty-four hours), and is fre-
     quent.
 Pain—is first localized, but soon becomes general.
 Expression—anxious.
 Abdomen—greatly distended.
 Vomiting.
 Diarrhoea—which is followed by constipation.
 Bladder becomes involved.
 Delirium.
 Cyanosis—after two or three days.
 Death.
                         PROGNOSIS.
   Is bad.
                        TREATMENT.
   In consequence of the symptoms of this disease being so sudden
 in their nature, opium is not sufficient to control the inflamma-
 tory process that takes place.  Furthermore, the depression  of
 the vital  powers is so great that the patient cannot be brought
 properly under its effect.
   It will be necessary to  reduce the temperature and pulse, and
 also to sustain the vitality of the patient until he has withstood the
 shock of the pus formation  and peritonitis.  In order to accom-
 plish this end, quinine should be given in antipyretic dose; and,
 in the event that this drug does not have the desired effect,  in
 from twenty-four to  forty-eight hours,  salicine should be admin-
 istered in its place.  In the event of this disease occurring from
puerperal  fever, the  saturated tincture of veratrum viride (gtt.
 iv.-v.)with opium  should be given in  order to allay pain.  This
 should be pushed (by giving one to two drops of ver. viride every 
208
DISEASES OF THE DIGESTIVE TRACT.
two hours), as, in a few hours or two days at the most, the vera-
trum viride will lose its power over the heart.  Fear of poisoning
need not be  entertained until vomiting takes place, when it will
be necessary to stop the treatment.  Stimulants should be admin-
istered early and freely in large quantities.   These are the only
four  weapons that you  will require  in attempts to overcome so
formidable a disease.


                CHRONIC  PERITONITIS.
                    MORBID  ANATOMY.
  Thickenings of the surfaces of the peritoneum take place, which
are interstitial in  character.  These thickenings may be one-half
an inch in thickness, resulting from connective-tissue formation.
These thickenings are usually associated with cancer and tubercle.
As regards the tubercle, it is the result of a tubercular inflamma-
tion which may extend over the whole of the internal, or partially
over the external surface, resulting in the omentum being full of
these deposits.   Adhesions of the two surfaces and binding of the
intestines may occur.  The  gut may be distended or diminished
in calibre. There  may be a sero-purulent exudation in the peri-
toneal cavity, or the effusion may fill the whole of the peritoneal
sac and only a slight quantity of pus  exist.  Should the peritoni-
tis be local in  character, it  affects the organs in the vicinity; as.
for instance, in the region of the liver, it will affect the capsule of
Glisson  and produce hepatitis, or the peritonitis may extend up-
ward from the pelvis to the liver, and involve each organ in its
course separately.
                        ETIOLOGY.
  It is usually a sequela of the acute form, a low grade of inflam-
mation, which has been left behind after an acute attack, produc-
ing interstitial changes.  It may also occur  from tubercular or
cancerous development, and from traumatism.

                        SYMPTOMS.
Obscure (if it does not follow the acute form). 
CHRONIC PERITONITIS.
209
Pain—if  it follow the acute form—which has lasted a long time;
    is increased on motion; and the patient maybe unable to take
    exercise.
Loss of strength.
Emaciation.
Digestion—impaired.
Mesenteric glands—enlarged.
Tumor—(localized, along the line of the intestines).
Fluid in the peritoneal cavity—(occurring late in the disease).
If tubercular in character.
    Pain—in the abdomen.
    Digestion—disturbed.
    Diarrhoea—(usually resulting in constipation).
    Abdomen—distended.
    Fever and sweating in the early morning hours.
    Impairment usually of some function;  thus the urine may be
       disturbed, or  even the stomach may suffer, if the peri-
       tonitis shall have extended so high up.

                        PROGNOSIS.
  If it be general in character, the prognosis is bad; but should it
be local, the prognosis will depend upon the amount of constric-
tion.  Complete recovery is rarely reached.

                        TREATMENT.
  For the general form—(as it is  usually accompanied by fluid in
the peritoneal cavity, with rapid emaciation and cachexia) you
will only be able to alleviate the symptoms.  In order to do this,
oleum morrhuaz and iron and tonics  should be given, and the
nutrition increased.
  For the local form—(provided  it be not due to tubercle or can-
cer)—a permanent counter-irritation should be established by a
seton  or  continuous  blister, and  the nutrition carried to the
highest possible point.   Should there be a large amount of fluid
in the peritoneal cavity, it must be removed with great care. 
210
DISEASES OF THE DIGESTIVE TRACT.
           DISEASES  OF  THE   LIVER.

            CIRRHOSIS  OF  THE   LIVER
                       DEFINITION.
  Is a condition characterized by excessive connective-tissue de>
velopment.
                         STAGES.
1st.  Enlargement—dependent upon hyperaemia and cell-prolifera-
    tion of connective tissue.
2d.  Organization of this cell-growth into new connective-tissue.
3d.  Contraction of the neio connective-tissue—producing atrophy
    of the liver-tissue from degeneration (on account of pressure
    on the blood-vessels).

                   MORBID ANATOMY.
  In the first stage—the liver is uniformly enlarged, firm, tough,
of a brownish-yellow color, with a smooth surface and rounded
edges.  The connective-tissue is increased throughout the organ.
  In the second and third stages—the liver is small, of a whitish
color, the surface is puckered, and the edges are sharp.
  On section—there will be great increase in the connective-tissue,
the  liver substance will appear insular, and of a deep-yellow color.

                        ETIOLOGY.
  Alcohol on an empty stomach.  The alcohol is  absorbed by the
stomach and  taken to the liver, causing irritation of its tissues,
producing cell-growth.  Syphilis:  hereditary tendency to cancel
or gout, etc.

                        SYMPTOMS.
In the first stage.
    Pain—on pressure, under the ribs.
    Sense of fullness and uneasiness in the abdomen.
    The liver is  found to be enlarged (due to cell growth). 
CIRRHOSIS OF THE LIVER.
211
In the second stage.
    Liver—{increased  in size and smooth in the first stage), after
       which there will be shrinking of the liver, and
       Portal obstruction, as shown by the following symptoms:
       In the inferior mesenteric vein—producing hemorrhoids.
       In the  superior mesenteric  vein — producing  intestinal
           catarrh (due to hyperaemia).
       In the splenic  vein—producing enlarged spleen.
       In the  gastric vein—producing gastric  catarrh, gastric
           hemorrhage, rupture, and intestinal hemorrhage.
       From pressure on the radicles of the portal system—pro-
           ducing jaundice, ascites, dropsy, caput Medusae, large
           superficial veins  (an evidence of an attempt to estab-
           lish collateral circulation between systemic and portal
           systems of veins).
   Collateral portal circulation (in case of such obstruction).
   1st. Between the superior and the middle hemorrhoidal veins.
   2d.  Between new  vessels formed by adhesions  between the
       liver and diaphragm, or, between the liver and the abdo-
       minal walls.
   3d.  Between the phrenic veins and some vessels on the sur-
       face of the liver.
   4th.  Between the renal and portal veins.
   5th.  By a dilatation of the umbilical  vein, thus joining the
       abdominal veins at the navel (caput Medusae).
   Palpation—the liver will be decreased in size, hob-nailed, and
       firm.
   Percussion—diminished area of liver  dullness;  spleen—en-
       larged.
in later stages.
   Ascites—as shown by enlarged abdomen; fluctuation; abdo-
   men becomes flat when the patient is lying down; absence of
   aortic pulsation; absence of  any local tumor; tympanites in
   front, which changes with the position of the patient; oedema
   of the limbs (from pressure on veins of pelvis and abdomen).
   Jaundice—Intestinal catarrh—Faeces, clay-colored—Anasarca
   .may be detected. 
212
DISEASES OF THE DIGESTIVE TRACT.
                    CAUSES OF DEATH.
  Death may occur from dyspnoea; repeated hemorrhages from the
stomach or intestinal canal;  intercurrent diseases, or exhaustion;
pulmonary oedema.

               DIFFERENTIAL DIAGNOSIS.
  Between cancer or tuberculosis of the peritoneum.  In first
stage, from waxy or fatty liver, or other enlargements of the organ.

                       TREATMENT.
  In tlie first stage.—Strictly forbid the use of liquors.  Leeches
may be applied at the anus (so as to affect the portal system).
Saline  cathartics  may be administered, such as mineral waters,
and alkaline carbonates (potash and soda), or, if the nutrition has
suffered, give iron (in the form of iron springs).
  In the second stage.—Alkaline carbonates should be  given to
overcome  the gastric and intestinal  catarrh  (they decrease the
toughness of the mucus, and enable the mucous membrane to get
rid  of  its  mucous coating  more readily).   Tapping should  be
resorted to for ascites if necessary (always compress the abdomen
during the operation and afterward by bandages). Improve the
strength and nutrition of the patient by nutritious diet and pre-
parations of iron.   The diet should consist of milk and eggs.


                        ASCITES.
  The accumulation of  fluid in the abdomen may be produced by
changes which take place in any of the following regions:  the
liver, heart, lungs, kidney, and peritoneum.  It  may also be due
to blood-causes.
                    MORBID ANATOMY.
  The amount of serum in the abdominal cavity varies from a few
pounds to forty, or even more.  The fluid may be clear  or cloudy
(due to cast off and fatty epithelium).  It is usually  of a bright
yellow color, and  rarely contains flocculi of coagulated fibrin.

                        ETIOLOGY.
  See page 26. 
JAUNDICE.
213
                        SYMPTOMS.
                          Rational.
Feeling of fullness in the abdomen (becoming painful to pressure).
Slight difficulty on deep inspiration (gradually increasing to dysp-
    noea, as the abdomen enlarges).
Constipation—from pressure of fluid on the rectum.
Urine—diminished.
Obstruction to the circulation of the lower extremities (from pres-
    sure on the inferior vena cava and iliac veins).
Superficial gangrene—may occur if the venous return be greatly
    embarrassed by the pressnre of the accumulated fluid.
                          Physical.
Inspection.—Distention of the abdomen, and  a change of its shape
    with position of the patient (due to the amount of fluid present).
Percussion.—General fluctuation throughout the abdomen.
Tympanites in front, when the patient lies on the back (on account
    of intestines floating upon the fluid).
Flatness or dullness at the sides (when the patient lies on the back).
Displaced cervix (perceived by digital examination) in the female.
                DIFFERENTIAL DIAGNOSIS.
  From ovarian  dropsy.—(Bamberger says between the crest of
the ilium and the 12th rib you find the sound of the large intes-
tine, which you  do  not observe in ascites.)  From  cancer; from
tuberculosis of other organs (the  urine will  decide this point, as
in tuberculosis it is normal, while in ascites the urine contains
traces of coloring matter of bile or abnormal pigment).
                        TREATMENT.
  Tapping should only be performed where life is immediately
endangered by obstruction of respiration or  threatened gangrene
of the skin.  Heim's pills will be found  advantageous in these
cases.

                       JAUNDICE.
                        VARIETIES.
  Hepatogenous—where there is obstruction  to the bile-ducts. 
214
DISEASES OF THE DIGESTIVE TRACT.
  Hematogenous, or "non-obstructive," where alteration occurs
in the blood-pigments, causing effects similar to those of bile
when absorbed.
                         ETIOLOGY.
  See page 25.
                         SYMPTOMS.
Hepatogenous variety.
    Liver and gall-bladder—enlarged.
    Urine—peculiar color (light-brown, like thin  beer, or dark,
        like porter).  After exposure to the air it becomes green-
        ish, and answers to tests for bile.
    Faeces—light, or clay color, or complete decoloration.
    Skin—golden-yellow (sometimes only slightly tinged); after-
        ward becoming greenish, or even mahogany color.
    Sclerotic of  the eye—yellow.
    Emaciation—rapid.
    Languor and sleepiness.
    Pulse—slow (due to the presence of bile acids in the blood).
    Itching of the skin—sometimes intense.
    Cerebral symptoms—(paralysis, delirium, coma, etc.)
Hematogenous variety.
    Faeces- may be normal, or very  dark color.
    Heart-beat and pulse—irregular and intermittent.
    Urine—discoloration is very slight in proportion to the color
        of the skin, and contains albumen.
    Disturbance of  the nervous system.

                    CAUSES  OF DEATH.
  May  occur from  intestinal hemorrhage;  gastric hemorrhage,
dropsy; or marasmus (senile).

                        TREATMENT.
  Improve the state of the patient by proper diet, such as cold
meat, strong  soup (neither fats, butter,  nor  gravies should be
allowed).  Slight drastics may be administered (such as inf. sennce,
rhei, et aloes) to keep the  bowels open.  When the urine is dimin-
ished, hitartrate of potash, cream of tartar, or acetate and car-
bonate of potash may be given. 
FATTY LIVER.
215
                     FATTY LIVER.
                        VARIETIES.
  1. From superfluous fat deposited in the liver-cells (Frerichs'
fatty liver).
  2. From disturbed nutrition ef the liver-cells by diseased paren-
chyma (the cells undergoing a retrograde metamorphosis).
                    MORBID  ANATOMY.
  In some cases the liver  will be  found  enlarged and appear
flattened, and its edges thickened and rounded ;  while in others
there may be only a slight alteration.  The  peritoneal covering is
transparent, smooth, glistening, and may be traversed by varicose
vessels.  The hver surface may be yellowish-red or yellow ; it feels
doughy and pits on pressure. On section, a coating of fat remains
on the knife-blade.   On microscopical examination, the  Hver lob-
ules may appear filled with fat globules, or individual cells, may be
distended by one large drop  of oily  matter. This infiltration be-
gins at  the periphery of the lobules near the interlobular veins
rarely extending to the vicinity of the central vein.

                         ETIOLOGY.
  From excessive nourishment and no exercise, thus  generating
too much hydrocarbons;  from spirituous  liquor (retarding  the
transformation of tissue): from tuberculosis of the lungs; from
incomplete oxidation of hydrocarbons and transformation into
fat; from tuberculosis of the bones; from tuberculosis of the in-
testines; from obesity.  (Budd and Frerichs say it may be due to
too much fat in the blood, or, when occurring with tuberculosis of
the lungs, from giving so much oleum morrhuae.)—Yellow Atrophy.

                        SYMPTOMS.
                          Rational.
Extreme debility.
Gastric and intestinal catarrh.
Diarrhoea. 
216
DISEASES OF THE DIGESTIVE TRACT.
                         Physical.
Inspection.— Fullness of abdomen.
Palpation.—The liver is enlarged and elongated, relaxed and pain-
    less, and has thick edges.  The liver of drunkards is thus en-
    larged, and there will be  fullness in the right hypochondrium.

                       TREATMENT.
  The patient should be made to have proper hours for exercise.
No afternoon naps or liquors should be allowed.  The meals must
be regular (no gravies, fats, butter, etc.).  Karlsbad or Vichy min-
eral waters, alkaline saline springs, or plenty of soda water should
be freely indulged in.

              CANCER OF  THE  LIVER.
  Is principally of the  medullary type.  It may be circumscribed
or sharply bounded; or diffused between the liver-cells, thus show-
ing no sharp line of demarcation.

                    MORBID ANATOMY.
  In the circumscribed variety—the tumor is rounded or globular,
and lobulated; is  inclosed in a delicate vascular connective-tissue
capsule, and, where it touches the peritoneum, is often flattened
or has a shallow  excavation, called "cancer navel."'  The tumors
may be solitary or innumerable, and may be from the size of a pea
to that of a child's head, thus giving the hob-nailed feel to the
liver.  They resemble brain substance, and contain a large amount
of " cancer juice."  They may be milk-white or reddish (on ac-
count of the number of vessels they contain), or dark-red (from
effusion of blood), or black (from the  amount of pigment con-
tained).  The unaffected portion of the liver is hyperaemic (caus-
ing increased size of the liver), and is usually of a yellow color,
from compression of the gall-ducts  and retention of bile.  The
liver-cells will be found to  have undergone fatty degeneration.
There may be adhesions and thickenings with  neighboring parts
(from chronic local peritonitis).  The medullary cancer may soften
and thus lead to a general peritonitis, or dangerous hemorrhage. 
CANCER OF THE LIVER.
217
   In the diffused variety—(infiltrated  cancer)—the  liver is con-
 verted into a white cancerous mass.  Atrophy of the liver-cells
 and obliteration of the vessels and gall-ducts takes place.  The
 liver-cells will be found  to  have undergone fatty degeneration,
 and to be colored by bile.
   Alveolar  or gelatinous cancer sometimes extends from other
 organs to the parenchyma of the liver, and may then transform
 the whole  into a shapeless  mass.  There  may also be cancer of
 the portal vein.
                         ETIOLOGY.
   Is obscure.   Is generally due to cancerous diathesis, occurring
 principally  in males.   Is generally preceded by cancer of some
 other organ.
                         SYMPTOMS.
                          Rational.
 Obscure at first.
 A sense of pressure and fullness in the right hypochondrium.
 symptoms of a local peritonitis (early).
 Pain—in the  region of the liver (often extending  to the right
    shoulder).
 Sensitiveness to pressure.
 Tumor—in the right hypochondrium (detected  by palpation and
    percussion).
 Ascites—from compression of the portal vein).
 Gastric and intestinal  catarrh—(from  obstruction to the portal
    circulation*.
 Enlarged spleen.
 Icterus—vfrom compression of the large bile-duct and the  ductus
    choledochus, or catarrh of the bile-duct).
 Distention of the superficial abdominal veins (an evidence of por-
    tal anastomosis, or of severe portal obstruction)
 Dyspeptic symptoms.
 Faeces—colorless (showing defective  secretion or escape of bile).
 Urine—peculiarly red or  bluish (from abnormal coloring-matter
    contained).
Cachectic appearance.
Emaciation. 
218
DISEASES OF THE DIGESTIVE TRACT.
QHdema of the ankles—(from obstructed venous return from the
    lower extremities).
                          Physical.
Inspection.—The ribs are displaced;  and the abdomen may be
    prominent.
Palpation.— The edge of the organ is indurated, with large and
    small protuberances.
Peritoneal friction may sometimes be felt.
                    CAUSES OF DEATH.
  Dropsy; thrombus of femoral  vein; follicular catarrh of the
intestines.  Thrush in the mouth often precedes death.
                       TREATMENT.
  This being an incurable disease, the  treatment at best can only
be palliative.   Leeches may be applied over the region of the liver
to alleviate the local peritonitis, and after their removal the sur-
face should be covered with warm poultices to facilitate the flow
of blood.  The pain should be relieved by opium, and the patient
supported with  good nutritive diet.   When ascites occurs, it
should be removed by tapping, and this should be done early


                     WAXY  LIVER.
                        SYNONYM.
  "Lardaceous;" " amyloid."'
                       DEFINITION.
  Is due to a deposit of a substance (resembling amylum or cellu-
lose) in the liver-cells, and in the walls of the hepatic vessels.
                    MORBID ANATOMY.
  The liver resembles fatty liver in form ; it will appear elongated,
flattened, thickened and sharply defined at the edges, hard as  a
board in consistence, and the peritoneal covering smooth and tense.
On section, the surface is dry and bloodless, almost  homogeneous,
and possessing a waxy lustre.  If a solution of iodine (Lugol's) be
applied to the cut surface, it will assume a peculiar reddish-brown
color; after the  addition of sulphuric acid,  well diluted with 
GALL-STONES.                     219
 water, there is a violet, and subsequently a blue color produced.
 There may be frequently fatty degeneration of the organ and also
 waxy degeneration of the spleen and kidney, occurring at the same
 time.
   On microscopiccd examination, the liver cells appear round and
 enlarged and filled with  a translucent homogeneous substance.
 The middle zone of the lobules of the liver are chiefly affected.
                         ETIOLOGY.
   It occurs in advanced  cachexia from scrofulous, cachectic, or
 syphilitic affections; from mercurialism; caries of bones; tedious
 suppuration; tubercular phthisis; and it is induced  by malaria.
 There ia also a degeneration of the spleen with this disease.
                         SYMPTOMS.
 Enlarged liver without pain (chiefly in scrofulous children).
 Ascites—{due to cachexia and the deposit of the amyloid material
    in the coats of the capillary blood-vessels of the hver, causing
    portal obstruction).
 Spleen—enlarged from waxy degeneration.
 Paleness of skin and mucous membranes.
 Kidneys affected (producing hydraemia).
                         PROGNOSIS.
   Is unfavorable.
                        TREATMENT.
   The preparsv'aons of iodine, especially syrup, ferri iodidi, are ex-
 tensively used; an are also alkaline baths and preparations of iron.


                     GALL-STONES.
                         SYNONYM.
  "Hepatic colli.'
                    MORBID  ANATOMY.
  The gall-stones may be from the size of a pea to a hen's egg and
vary considerably in number.  They may be smooth, round, or
rough, and some may have convex or concave facets. They are 
220
DISEASES OF THE DIGESTIVE TRACT.
 of low specific gravity, break easily, split when dry, and finally
 dreak down  into dust.  They may be white, pale-yellow, dark-
 brown, green, or black in  color.  The majority are composed of
 cholesterin and biliverdin, bile pigment and carbonate or phos-
 pate of lime.
   There may  be slight ulceration of the fundus of the gall-bladder,
 which may lead to perforation, thus entering the peritoneum and
 producing peritonitis.  The ulceration may possibly communicate
 with the intestines, or  perforate  outwardly,  after adhesions  have
 formed.  The walls of the gall-bladder are often thickened, and
 undergo cicatrical retraction, and biliary calculi may then be found
 imbedded  in a chalky mass, inclosed in a shrunken and atrophied
 gall-bladder.   Suppurative hepatitis  may occasionally  be pro-
 duced.
                         ETIOLOGY.
 Exciting causes.
   From  foreign bodies in the gall-passages (around which chalk
 with bile-pigment is  deposited);  from excess of chalk in the bile
 (due to  drinking lime-water); from lack of, or decomposition  of
 taurocholic acid; from accumulated secretion of bile; from an ex-
 cess of cholesterin and coloring matter.
 Predisposing causes.
   Advanced age; female sex; sedentary habits; habitual constipa-
 tion; over-indulgence in  food or drink;  cancer of the liver and
 stomach; catarrh, etc., of the gall-bladder, or ducts, interfering
 with the escape of bile.

                         SYMPTOMS.
   Begin suddenly and unexpectedly.
 Pain—griping, piercing, and intense;  extending from the  right
    hypochondrium over the whole of the abdomen to the right
    side of the thorax and right shoulder.  It is often localized  at
    a point on the free border of the ribs when a line drawn from
    the  right  nipple to the navel crosses it;  and seems to shoot
    through the abdomen, from  that  point, to the region of the
    back.
Patient  sighs  and moans; is doubled  up; rolls about the bed or
    floor; and presses on the abdomen. 
HYDATIDS OF THE LIVER.
221
 Pulse—small.
 Skin—cool.
 Face—pale, distorted, and anxious.
 Fainting (sometimes) and exhaustion.
 Tremblings or chills (spasmodic).
 Convulsions of the right half of the body (in rare cases).
 Vomiting—obstinate and sympathetic.
 Paralysis—has been known to occur.
 Permanent closure, inflammation, or ulceration of the excretory
    bile-ducts may follow and produce symptoms characteristic of
    these conditions.
 Jaundice—shght, and usually precedes the attack.
 Constipation—may occur.
 Faeces—may be colorless (from want of bile).

                     CAUSES  OF DEATH.
  Death may result from biliary obstruction, acholia, marasmus,
 or peritonitis from perforation of the gaU-duct.

                        TREATMENT.
  Karlsbad, Vichy, or any alkaline water should be given which
 will cause their evacuation,  or a preparation of ether, 3 iij.; oleum
 terebinthi, 3 ij.—dose, 3 ss. in the morning may be given; the dose
 should be increased till one pound of the mixture has been taken.
 Ether, 3 i.;  ol. terebinthi,  3 i. may be administered in drop doses;
 and, in order to relieve the pain, tincture of opium (laudanum), gtt.
 xiij. every hour till sleep is accomplished.  Morph. acet., gr. \
 every hour or two till slight narcotism is produced, has been re-
 commended.  Chloroform may b e inhaled.  Leeches may be ap-
 plied in the region of the right hypochondrium, after which warm
 compresses may be used to facilitate the flow of blood.  After the
passage of the stone, mild laxativeb may prove very beneficial.
             HYDATIDS  OF  THE LIVER.
  These usually occur in the right lobe, and may reach the size
of a child's head or even larger. 
222           DISEASES OF THE DIGESTIVE TRACT.
                    MORBID ANATOMY.
  There is a firm,  whitish, or  yellow fibrous vascular capsule
which is adherent to the surrounding tissue.  Within this capsule
is a delicate cyst, or bladder,  consisting of a hyaline  concentric
layer.  The most internal layer of this cyst is studded with minute
cells (called the germinal membrane or mother cell). Within this
mother cell is a quantity of fluid, consisting of a strong saline
solution, and floating in this  fluid are the daughter-cells (some
thousands).
                         ETIOLOGY.
  From ecchinococci, entering the hepatic lymphatics and develop-
ing there (Virchow); from ecchinococci, entering the blood-vessels
of the liver and  developing there (Leukart); from ecchinococci,
entering the bile-ducts and developing there (Friedreich).

                         SYMPTOMS.
                          Rational.
Are latent.
    A sense of pressure and fuUness in the  right hypochondrium.
    Tumor—in the abdomen yielding an hydatid fremitus.
    Jaundice—shght (is usually  present as the result of pressure
        upon the bile-ducts).
    Liver—enlarged.
    Ascites—(from obstruction to the portal circulation).
    Spleen—enlarged.
    Gastric and intestinal hemorrhage—(may occur).
                          Physical.
Inspection—reveals a tumor, which is lobulated  and usually of
    large size if fully developed.

                        TREATMENT.
  Is obscure.  They have been opened externally.  They may also
discharge spontaneously into  the intestinal canal, thus assisting
in the diagnosis.  They may burst into the peritoneal cavity and
<;ause death. 
ACUTE YELLOW ATROPHY OF THE LIVER.          223
   ACUTE YELLOW" ATROPHY OF  TEE LIVER.

                         SYNONYM.
   Black jaundice.
                        DEFINITION.
   Is a combined molecular and fatty degeneration of the organ,
 and the result of a severe constitutional affection.

                    MORBID ANATOMY.
   The liver will be found sunken against the posterior abdominal
 wall; it will have a dull yellow appearance ; it will be diminished
 in consistence and also  in bulk (occasionally about one-half its
 original size), and also diminished in thickness and appear flattened.
 Its serous covering will be loose and often in folds.   The gall-ducts
 and bladder usually contain a scanty mucous secretion; the con-
 tents of the intestines are often bloody ; the spleen is enlarged ;
 and eccyhmoses are frequent, especially in the peritoneum and gas-
 tric and intestinal mucous membrane.

                         ETIOLOGY.
  From continued biliary obstruction-producing distension of the
 bile-ducts from an excessive formation of  bile causing continued
 pressure on the liver-cells and consequent atrophy ; from intem-
 perance ; from venereal excesses ; from constant exposure to mal-
 arial poisoning, etc. Is a very rare affection, never occurs in
 childhood, more frequently in women and especially during preg-
 nancy.
                        SYMPTOMS.
In the first stage.
    Anorexia.
    Pressure and fullness in the epigastrium.
    Jaundice—(hepatogenous, but not in all cases). 
224
DISEASES OF THE DIGESTIVE TRACT.
In the second stage.
    Jaundice—which increases (hematogenous)'
    Liver—very sensitive topressure.
    Headache—severe.
    Restlessness and delirium (sometimes).
    Muscular twitchings—may occur (from extention of excite-
        ment to the motor nerves).
    Depression and lassitude—excessive.
    Temperature—very high.
    Pulse—frequent and subsequently small.
    Tongue and gums—dry, and covered with sordes.
    Involuntary evacuations.
    Haematamesis—may occur from destruction of the capillaries.
    Hemorrhage from the bowels—may occur.
    Deep sleep which gradually passes into a profound coma.
    Profuse perspiration.
    Death—usually from the second to  the  fifth day after the
        coma commences.
Physical examination shows very rapid decrease of liver dullness,
    the sole pathognomic  symptom of the disease.
Percussion sound—is at first very full in the epigastrium due to the
    diminution in the size of the liver commencing in the left lobe,
    but frequently no trace of liver  dullness can be found after a
    few days.   There is an increase  in splenic dullness vhich is
    important but does not always occur.

               DIFFERENTIAL DIAGNOSIS.
  From acute hepatitis—from catarrhal jaundice.

                        PROGNOSIS.
  The disease is generally a fatal affection.

                       TREATMENT.
  Medication is hopeless unless the disease be  detected in the first
stage when saline cathartics may be administered, leeches applied
at the anus, and cold compresses over the right hypochondrium. 
DISEASES  OF  THE  BRAIN  AISTD
       NERVOUS SYSTEM. 
 
CEREBRAL HYPEREMIA.
                         ETIOLOGY.
             Active or Fluxionary Hyperemia.
 Increased Heart's Action.
    From augmented energy,  as  in fevers, or bodily or mental
    excitement.—From cardiac hypertrophy, (as an independent
    disease).—From   cardiac  hypertrophy   accompanying  an
    obstructed   circulation  (compensatory).   From  too  slight
    resistant  power of afferent blood-vessels whether congenital
    or acquired (" Rush of blood to the head"').
 Collateral Fluxion or increase of Lateral Pressure in the carotids.
    From obstructed escape of blood from the aorta into other
    branches.—From  conatrctions or closure of aorta (due to
    compression of adominal aorta, and  its branches,  from dis-
    tended intestines and exudations).—From obstruction of cuta-
    neous circulation, as in  cold  stage of intermittent fever.—
    From severe cold.—From severe muscular exercise, by press-
    ure of muscles on the capillaries.
 Paralysis of Vaso-motor nerves (of cerebral vessels).
    From section of cervical portion  of the sympathetic.—From
    use of spirituous  liquors.—From poisons.—From  excessive
    mental emotions and activity (especially).—Atrophy of the
    brain following apoplexy.

             Passive or Congestive Hyper^emla
 Compression  of the Jugulars or Superior Vena Cava.
    From strangulation.—From enlarged thyroid glands.—From
    enlarged  lymphatic glands, affecting the  jugulars.—From
    aneurism of the aorta.—From enlarged glands, affecting the
    superior vena cava.
Energetic Expiratory Movements with Glottis contracted.
    From coughing, straining,  playing wind instruments, etc. 
226      DISEASES OF THE BRAIN AND NERVOUS  SYSTEM

Non-compensated Valvular Lesions of Heart.
    From capillary hyperemia (since over-filling of the veins ob-
    structs the flow from the capillaries).—From impeded return
    of venous blood.—From valvular disease of  right heart, pre-
    venting escape of venous  blood, and  increasing amount of
    blood in skull.—From valvular disease of left heart (causing
    delayed circulation in the lungs).
Lung Affections (interfering with circulation).
    Emphysema (especially last  stage),  producing general cya-
    nosis of brain.—Pleuritic effusion.— Cirrhosis of lung.
Plethora (by increasing the amount of blood).
    From a too free supply of food and drink (having a tendency
    to apoplexy).
                         SYMPTOMS.
Headache—more or less severe (due to irritation of filaments of
    the fifth nerve going to the dura mater).
Feeling of constriction in the head.
Great sensitiveness to bright lights and loud noises.
Flashes before the eyes.
Tinnitus aurium.
Dizziness.
Nervous irritabihty or depression—patient is  annoyed by the
    slightest irritation.
Face and conjunctiva—may be reddened.
Temperature—may be elevated.
Pulse—full and  rapid.
Hallucinations and illusions.
Respiration—retarded.
Sense o* formication in the lower extremities.
Slowness and sluggishness in the movements of the patient.
Delirium—(in the asthenic type).
Fullness of the meningeal veins.
Insomnia or disturbed dreams.
Restlessness.
Vomiting.
Convulsions—may occur, with loss of consciousness.
Paralysis. 
ANAEMIA OF THE BRAIN.
227
                        PROGNOSIS.
  Depends upon the cause.

                        TREATMENT.
  As this is simply a symptom which  accompanies so many dis-
eases, the cause must  therefore be treated.  General and  local
blood-letting,  cold to the head and derivation  to the  skin and
bowels have enjoyed a good  reputation, yet, neither the one nor
the other must be used indifferently.  Should there be collateral
fluxion to the brain, the obstructions to the circulation, by which
the  pressure of blood in the carotids is increased, must be re-
moved.  In adults, suffering  from constipation, headache, tinni-
tus aurium, etc., and especially in children, where constipation is
accompanied by convulsions,  evacuation of the intestines by  laxa-
tives or  enemata of vinegar  and water frequently has a wonder-
ful effect.  Should these means prove insufficient, depletion in the
adult, and leeches applied to the head in children, should be re-
sorted to if symptoms of depression occur.
  In  congestive hyperaemia,  resulting from compression of the
jugular veins or vena cava, venesection or leeches behind the ears
may be resorted to if the obstruction to the current of blood can-
not be removed.


              ANAEMIA OF THE BRAIN.
                    MORBID ANATOMY.
  If dependent upon embolism; emboli are almost always found
in the left fissure of Sylvius  (producing  hemiplegia  during  life).
The  brain is discolored, and the gray substance is paler  than
normal, and softened in the region of the embolus.
                        ETIOLOGY.
  It may occur from spasmodic contraction of the arteries, or be
due to obstruction to the carotid and vertebral arteries (by an
embolus  or as the  result of thrombosis): to obstruction to the
arteria fossae Sylvii (by an embolus or thrombus), causing obstruc-
tion in the circle of Willis; to obstruction from pressure, as in 
228      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

the case of a tumor, or the presence of oedema around an apoplec-
tic  clot,  or a point  of inflammation,  or softening;  from  com-
pression of the capillaries by extravasation of blood, tumors, etc.;
and from diseases contracting the space within the skull, as exos-
tosis, cancer, etc.
                        SYMPTOMS.
Premonitory symptoms.
    Disturbance of the  circulation (probably due to the contrac-
        tion of cerebral vessels, or to senile cerebral atrophy).
    Pain—in the head.
    Dizziness.
    Tinnitus aurium.
    Flashes appear before the eyes.
    Loss of  memory and power of thought.
    Patient is apathetic and indifferent.
    Inclination to sleep (which is disturbed and uneasy).
    Aphasia —which is usually of the amnesic variety (in case of
       an embolus of the left middle cerebral), and hemiplegia.
    A sense of formication, or of certain limbs going to sleep.
    Contraction or paralysis of the limbs.
Of disease of the posterior cranial fossa.
    Pains—in  the back of the  head (from filaments of  the fifth
       nerve to the tentorium cerebelli).
    Sympathetic vomiting.
    Peculiar dizziness (when moving about).
    Diminution of sensibility and motor power (but not complete
       paralysis).
    Impaired articulation and deglutition.

                        TREATMENT.
  Promises very little, if any benefit, should thrombosis and em-
bolism occur, as therapeutic remedies cannot remove the obstruc-
tion, and absorption is all that can be hoped for.   Should there be
no symptoms of irritation, a strengthening and stimulating treat-
ment is indicated; but, if there be symptoms, such as severe head-
ache, contractions, etc., cold has been suggested, and also the ap-
plication of leeches behind the ears. 
APOPLEXY.
229
                        APOPLEXY.
                        DEFINITION.
  A condition characterized by complete functional inactivity of
 the brain; produced either by  swelling of the vessels (miliary
 aneurism) or extravasation of  blood  into the  brain-substance.
 Symptoms of a similar character may be produced by serous effu-
 sions, or by organic diseases of the brain.

                        VARIETIES.
  Sanguineosa;  serosa;  and  nervosa;  the  first  being the most
 common.
                    MORBID ANATOMY.
  There  may be small, numerous, closely packed effusions, which
 denote capillary rupture, or a larger  quantity  of blood, denoting
 rupture of the larger vessels.   If it should result from capillary
 rupture, the brain-substance is dotted over with dark-red punctate
 extravasations;  it may cause the brain-substance to appear of a
 yellow or reddish color, and to become moist, relaxed, or broken
 down (causing  red softening).   Small  clots press on  the  brain
 filaments, but  large clots break  up  and  mix  with the brain-
 substance.  The blood may escape into the ventricle, or even in
 the sub-arachnoidean space. The most frequent seats in which  the
 clots are found are in the corpus striatum, the optic thalamus,  the
 peduncle of the brain, and the large medullary  masses of  the
 hemispheres.   The clot,  which varies  from the size of a hemp-
 seed to that of a man's fist, consists of blood  and broken-down
 brain-substance, which may be either fluid  or  partly coagulated.
 The clot is often inclosed by a new formation of connective-tissue,
 starting from the neuroglia, there is also a delicate connective-tissue
 which surrounds the walls and  traverses the clot.  After a time
 a cyst  forms, inclosing the clot, and the serum may ultimately
 be absorbed.  The injuries to the brain-substance often produce a
gradual diminution of mental power,  said to be due to atrophy 
230     DISEASES OF THE BRAIN AND NERVOUS SYSTEM.
 of the brain-substance, associated with degeneration, extending
 into the spinal meduUa.
                         ETIOLOGY.
  It occurs principally from -rupture of the smaller arteries or
 capillaries from  structural disease (endarteritis); from increased
 pressure (due to a fatty degeneration of the walls of the arteries),
 in cachectic, badly nourished, chlorotic persons (producing fragil-
 ity of the vessels); from small dissecting aneurisms ; from weak-
 ness of the cerebral vessels (as in typhus fever and scorbutus);
 from gradual atrophy  of  the  brain-substance;  from  plethora
 (where there is  a morbid  fragility of the vessels); and from in-
 creased pressure and existing atheromatous changes.
  It  may occur  at any age  and time of the year, and without
 any appreciable existing cause.
                        SYMPTOMS.
 Premonitory symptoms.
    Headache—or fullness of the head.
    Tinnitus aurium.
    Flashes before the eyes.
    Dizziness.
    Insomnia.
    Formication
    Irritability.
Symptoms of attack (modified by seat and extent of hemorrhage).
    Fit—(which  is  due to anaemia of the brain-substance from
       sudden compression of the capillaries), comes on at  the
        onset, or may not  come  on till after paralysis  has oc-
       curred, or it may come on suddenly with  coma, or rapidly
       developing coma.
   Breathing—loud and stertorous.
   Respirations—diminished.  •
   Vomiting—at the commencement  of the attack.
    Pulse—very slow.                              j  compres-
    Pupils—irregular.                            J   sion.
    Pulsation of the carotids—more marked than in health.
    Aphasia—(of the amnesic type) may occur,  if Broca's centre
       be involved (3d frontal convolution).
due to general or partial
hyperaemia of the brain.
symptoms
of cerebral 
APOPLEXY.
231
    Temporary paralysis of muscles, or any group of muscles-
        may exist, (the various types of monoplegia).
    Paralysis of the arm and leg of one side (hemiplegia)—from
        destruction of the corpus striatum,  optic  tkalami, or
        peduncles of the brain on the opposite side, by a clot.
    Loss of will and previous capabilities of thought.
    Facial paralysis of Bell—where the  corner of the mouth
        hangs down  on the affected  side, and is raised on the
        sound side—Tongue, if protruded, goes  toward the paral-
        yzed side.—Eye of the affected side cannot be closed.
    Anaesthesia—from compression of the sensory nerve fibres of
        the brain (posterior third of internal capsule).
    General convulsions—(may occur) if the clot acts as an irri-
        tative lesion to the motor area of the cortex, and does not
        affect the deeper parts.
    Death—may  result from  hemorrhage into the  pons, if the
        hemorrhage be of considerable amount; from hemorrhage
        into the medulla, if the hemorrhage be slight.
    Instead of improvement in  twenty-four hours, the symptoms
        usually increase, if the clot be large or the damage to the
        brain be extensive.

               DIFFERENTIAL DIAGNOSIS.
  From embohsm; cerebral softening ; and all causes of coma.
                        PROGNOSIS.
  This depends on the extent of  the extravasation  and its seat.
 One attack is, usually, soon followed by another, since the vessels
 of the brain are diseased.

                       TREATMENT.
  During the attack—venesection may be performed, but only if the
 heart-impulse be strong and the sounds loud, with a regular pulse
 and no oedema.  Stimulants should only be administered if  weak
 heart and irregular pulse  occur.   Mustard plasters may be ap-
 plied to the chest and calves  of  the  legs.  The skin should be
rubbed vigorously. Dash cold water on the breast, or drop melted
sealing wax on the chest (Niemeyer).
  After the fit.—The diet should be mild.  The  bowels should be 
232      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

kept open.  Cold should be applied to  the  head, leeches behind
the ear, and the induced current to the paralyzed muscles.


                      MENINGITIS.

                        VARIETIES.
  See page 9.

                 ACUTE  MENINGITIS.
                        SYNONYM.
  " Simple meningitis of the convexity."

                       DEFINITION.
  Is an acute form of inflammation of the coverings of the brain.

                   MORBID ANATOMY.
  On removing the calvaria, it will be found to be adherent to the
dura mater.  The brain-substance will be of  a greenish color, due
to the infiltration of serum, fibrin, and pus into the meshes of the
pia mater. It is  most marked at the  convexity and along the
course of the vessels.  The dura mater  will be found thickened
and slightly adherent to the calvaria.  The arachnoid is opaque,
its surface roughened, slightly adherent to the dura mater, and
covered with  punctate spots.  The cerebral vessels and  their
branches are  injected and prominent.   The ventricles will be
found empty.  The  brain-substance will be softened, in various
parts, from the pressure of the exudation.  The sulci will be deep-
ened and the convolutions sharpened.

                        ETIOLOGY.
  It usually occurs between the  ages of  18 and 20, and 40 and 50,
and is more frequent in men than in women.  It is rarely an in-
dependent disease; but is usually secondary  to some injury, dis-
eases of the skull, and dura mater,  or other diseases.  It occurs
in cachectic persons  from long exhaustive illness.  It may occur in
pneumonia, pieurisy. acute exanthematous and infectious diseases 
ACUTE MENINGITIS.
233
 (typhus  especially, from  the tendency toward cerebral engorge-
 ment), and Bright's disease; from exposure of the head to the rays
 of the sun, or very low temperature; from the misuse of liquors;
 from caries of the petrous portion of the temporal bone, or from
 over-taxation of the mental faculties.

                           STAGES.
  1.  Headache.  2.  Delirium.   8. Coma.

                         SYMPTOMS.
 Stage of headache (lasts from 24 to 72 hours).
    Rarely ushered in with a chill.
    Headache—is severe and increases.
    Photophobia.
    Pupils—contracted (due to congestion of the brain, producing
        reflex manifestations).
    Pulse—elevated (120 to 140), small, hard, and regular.
    Abnormally acute sense of  hearing.
    Intolerance to noises.
    Nausea and vomiting (possible).
    Constipation or diarrhoea (may occur).
    Tongue—moist and coated.
    Gait—unsteady.
   Face—pale at first, but afterward flushed.
Stage of  delirium (lasts from a  few hours to three days).
   The delirium may be muttering or active.
   Patient is constantly trying to get out of bed.
   Talks to imaginary objects or persons.
   Pupils—unequally contracted.
   Pulse—frequent, intermittent, or irregular.
   Constipation.
   Insomnia.
   Alternating flushes and  pallor of the face.
   Convulsions (may occur).
   Patient becomes gradually stupid, and after three days coma
       usually takes place. 
234      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

Stage of coma.
    Pulse— slow 40-60 (in the first stage,  afterward becoming
        very rapid).
    Temperature—may fall below normal, but rapidly rises.
    Loss of  sensation and voluntary motion.
    Delirium—may be slight and muttering.
    Pupils—dilated (from inter-cerebral pressure) in this stage.
    Flapping of  the cheeks (in the first part of the coma).
    Face—turgid.
    Constipation.
    Eyes—wild and brilliant.
    Sphincters—may be relaxed.
    Blueness of  the fingers and hps.
    Profuse perspiration.
    Retention of urine.
    Capillary  circulation—poor.
    Respiration—sighing and marked.
    Heart's sounds—indistinct.
    Tongue—dry and brown  (from not breathing  through the
        nostrils).
    Patient passes into collapse, finally resulting in death.

                DIFFERENTIAL  DIAGNOSIS.
  This  disease may be confounded with typhus  fever;  acute
uraemia; small-pox (for the first few days); or delirium tremens.
  In typhus fever—the delirium comes on late in  the disease; the
pulse will be frequent and small;  and the countenance dull and
heavy.
  In acute urazmia—there will be the small amount of urine, con-
taining albumen and casts; and the pulse will be  soft and slow.
   In  small-pox—you will  have pain in the head, back and loins,
the eruption occurring along the roots of the hair, and at the alae
of the nose after thirty-six hours.
                        PROGNOSIS.
  Is unfavorable^especially when pus, serum, and lymph are de-
posited in the arachnoid. 
SUB-ACUTE MENINGITIS.
235
                        TREATMENT.
  Various methods have been suggested, but it has been found of
late years that the best treatment is to keep the patient quiet in
bed, and relieve the pain by hypodermics of morphine.


              SUB-ACUTE  MENINGITIS.
                    MORBID ANATOMY.
  In this form of meningitis no pus is exuded, and the cell exuda-
tion  is slight, but  there is a sero-fibrinous exudation under the
arachnoid into the meshes of the pia mater.  Floccules of lymph
will also be found along the line of the vessels. The arachnoid
will have lost its  brilliancy and become opaque and thickened,
and when held up to the light, white spots may be seen, chiefly in
the lines of the vessels, together with spots of ecchymosis. The ves-
sels may be engorged.  Congestion may occur,  but this will de-
pend upon  the amount of serous effusion present.  Effusion into
the ventricles may occur. It should be borne in mind that  no
effusion is inflammatory unless it be found  to contain fibrin, and
the arachnoid be thickened and  opaque, with little spots of ecchy-
mosis and enlargement of the vessels.

                        ETIOLOGY.
  It may be secondary to Bright's disease; typhus fever; malaria;
or any exanthematous disease.  When  it occurs in Bright's, the
slow pulse usually precedes the coma.

                         STAGES.
  Same as those of the acute form.

                        SYMPTOMS.
Stage of Headache.
   Is not present, as a rule; or if it should be, is not prominent.
Stage of Delirium—(lasts from a few hours to one or two days).
   Delirium—is not  active, but  stupid and  senseless.  Patient
       gets out of bed and is easily put back again, and then gets
       out again after a short while. 
236      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

Stage of Coma (comes on rapidly).
    Pulse— slow, at first, afterward becoming very frequent (due
        to a failure of heart's power).
    Respiration— sighing.
    Tongue—dry, dark-brown.
    Pupils—dilated.
    Collapse and death.
                        PROGNOSIS.
  About one-third of the cases recover.  Should  it be due to
Bright's disease, it will be progressive, and terminate in death.
If to pyaemia, it will be slowly fatal.
                        TREATMENT.
  Should it occur in connection with any of the fevers, the patient
should be kept in bed, with the head  slightly elevated.  Only one
person should be in attendance, and the room kept perfectly dark
and quiet.   Counter-irritation should be applied to the feet in the
form of a  mustard foot-bath; the feet should be kept in it for
about one hour or until redness of the surface is produced. Should
there be constipation,  cathartics  axe  indicated.   Blisters  and
counter-irritants may be applied to the back of the neck.  Stimu-
lants may be administered freely if* it occur from typhoid or typhus
fever.   Iodide of potassium (in gr. xx. to xxx. doses) every three
hours are especially indicated should syphilis be suspected.


                CHRONIC  MENINGITIS.
                         SYNONYM.
  " Pachy-meningitis."  Is termed externa and interna (or hema-
toma of  the dura mater) according as  it may effect the external
or internal surface of the dura mater.

                   MORBID ANATOMY.
  In the externa—the dura mater is thickened and opaque (from
an increase of connective-tissue development) and adherent to the
cranium.  It ij red and vascular.  Pus will be found between the
dura mater and the skull.  Pia mater may be greatly inflamed. 
                    CHRONIC MENINGITIS.                    231

   In the interna—there may be haematoma (resulting from inflam
 mation) between the dura mater and the cranial bones, having its
 origin in the dura mater or underneath the archnoid.  The haema-
 toma  is produced by rupture of the small vessels in the new con-
 nective-tissue.  There may be a destruction of the  arachnoid  and
 the formation of abscesses containing three or four ounces of
 pus, resulting in pyaemia.

                         ETIOLOGY.
   Advanced stage of syphilis; caries or fissure of the petrous por-
 tion of the temporal bone; suppuration of the orbit; extension oi
 inflammation from the internal ear; chronic alcoholism; chronic
 Bright's disease.

                        SYMPTOMS.
 Present in all varieties.
     Are often vague.
     Pain in the  head—which is localized, and increased by exer-
        cise,  mental labor,  excitement,  etc.,  may usually be
        detected, at the vertex and forehead.
 If due to alcoholismus.
    The vision and special senses are disturbed.
    Tinnitus aurium.
    Gait—unsteady.
    Hyperaesthesia or anaesthesia.
    Delirium  slight.
    Talks—incoherently.
    Sleep is disturbed, at first; then the patient becomes disposed
        to sleep and  gets stupid.
    Inequality of the pupils—(or may be contracted).
    Slight facial paralysis.
If due  to otitis media or acute otorrhaza.
    Perforation of the tympanum and discharge of pus from tht
        ear.
    Slight stiffness of the muscles at the back of the neck.
    Pupils—slightly irregular.
    Vomiting.
   Temperature—shghtly below normal. 
23*      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

    Pulse  about 80 or a little below normal, and may be inter-
        mittent or irregular on movement.
    Peculiar expression of countenance—(pyaemic in character).
    Skin—pale, dingy yellow.
    Face—puffed.
    Delirium of an hysterical type—may occur.
If from syphilis.
    Patient wanders, gets out  of bed,  and there may be facial
        paralysis (from .n;;r-ce.e'oia pre sure).
  In all cases having cerebral  symptoms assuming an hysterical
type, with an intermittent pulse,  and discharge from the ear,
chronic or pachy-meningitis may always be anticipated.

                        PROGNOSIS.
  Is usually unfavorable.
                        TREATMENT.
  Is usually hopeless, if the disease be extensively developed.



              ACUTE  HYDROCEPHALUS.
                         SYNONYMS.
  Tubercular or basilar meningitis, or " dropsy of the brain."

                    MORBID  ANATOMY.
  There is congestion on the surface of the brain, with a serous
effusion extending  into the ventricles.  At the base of the brain,
there is a sero-fibrinous exudation (sometimes sero-purulent) which
is most  marked at the optic chiasm and fissure of Sylvius.  The
arachnoid is  thickened and opaque, and the dura mater is also
opaque.   The convolutions are flattened, and the sulci deepened.
Nodules will be found  in the meshes of the pia mater (tubercle),
both of the brain and spinal cord which vary in size from that of a
pin's head to a pea, and which later on, may undergo degeneration.
  The characteristic lesion is an effusion of serum and lymph, and
a tubercular  deposit at the attached surface of the arachnoid 
ACUTE HYDROCEPHALUS.                239
(most marked at the optic commissures and island of Reil) at the
base of the brain along the fissures, causing thickening and extra-
vasation into the pia mater.
                         ETIOLOGY.
  It occurs in children of a scrofulous diathesis between two and
five years of age; in old age; in alcoholismus; and  from bad food
and air; and want of cleanliness.  This disease usually lasts from
ten to fourteen days or even three weeks.
                          STAGES.
  This disease has three stages:—1st. Delirium. * 2d. Coma.  3d.
Collapse.
                        SYMPTOMS.
Premonitory symptoms—(of great diagnostic value).
    Change in the disposition of the child, stops in his play, and
        wants to be held.
    Rests his head on the mother's knee or on his own hand.
    Gnashes his teeth in his sleep.
    Thumbs—flexed on palms of the hand during sleep.
    Ptosis (the upper lid falling, giving the eye the appearance of
        being half closed).
    Head thrown back and bored into the pillow.
    Moans during sleep and rolls the head from side to side.
In the stage of delirium.
    Patient is fretful and uneasy.
    Pains in the head—patient puts the hand to the head.
    Pupils—contracted.
    Photophobia
    Patient answers slowly but rationally.
    Vomiting—is projectile.
    Jactitations.
    Pulse—firm, hard, and regular (110 to 140); can be accelerated
        by very slight excitement.
    Abdomen—retracted.
    Temperature—may be remits >t or normal.
    Respiration—sighing. 
240      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

In the stage of coma.
    Disposition to sleep—(after two or three days).
    Involuntary evacuations.
    Pupils—do not respond to light (as at first).
    Pulse—becomes slow (60 to 70).
    Hydrocephalic cry.
    Convulsions—probable.
    Eyebrows —contracted.
    Slight paralysis—(may occur).
    Picking at the bed-clothes.
    Head rolls from side to side.
    Lethargy  increases gradually.
  A strange remission may occur before the third stage, wherein
the child may appear to be recovering;  it is only temporary, how-
ever, as the patient passes into a  deeper coma.
The stage of collapse.
    Pulse—increases (160  to  200), small, frequent, intermitting,
        and not easily compressed.
    Paralysis—may occur of  one arm or leg, or even hemiplegia
        may be developed.
    Strabismus.
    Sphincters—relaxed.
    Eyes—rolled up.
    Head—rolled to one side.
   One-half of the body may be hot, and the other half cold.
   Pupils—irregularly dilated.
   Inspiration—rapid.
    Expiration—imperfect.
    Imperfect capillary circulation.
    Death—frequently occurs with convulsions.

                        PROGNOSIS.
  About seven-eighths of the cases die,  and those who recover are
usually crippled.
                DIFFERENTIAL DIAGNOSIS.
  It may be confounded with infantile remittent fever; Bright's
disease (in children); spurious hydrocephalus. 
'CHRONIC HYDROCEPHALUS.
241
                         TREATMENT.
   The patient should be kept  in  a dark,  quiet, well-ventilated
 room.  The diet must consist of milk, or milk and lime-water.  A
 piece of  ice should be put in a bladder and laid on the pillow a
 short distance from  the  head.   The feet should be  placed  in a
 mustard  foot-bath.   Blisters may be  applied  early behind the
 ears.  Iodide of potassium may be given in full doses, but it has
 no effect.  Small doses of morphine (gr.  -2J4) have been recom-
 mended by Hasse.  In order to prevent this disease if possible,
 especially if the parents  are of a  tubercular  diathesis, the child
 should be sent at once into the country and  kept there for at least
 two years.  A good strong wet-nurse should be  obtained, or else
 the child should be fed on milk from the bottle  for the first eigh-
 teen months; no mixed diet  should be allowed.  Cod-liver oil
 should be given continually especially  during the cold months.
 Care should be taken to see that the child is properly clad.  If  at
 the end of two years the child begin to be fretful, the whole habit
 of life should be immediately  changed.



             CHRONIC  HYDROCEPHALUS.

                         VARIETIES.
   1st.  Intra-uterine.    2d. When it occurs after  birth, before
 closure of the sutures.  3d. When it occurs some time after birth,
 when the sutures have closed.

                    MORBID ANATOMY.
   There is failure of the fontanelles to close; enormous growth of
 the cranium quite out of proportion to the face; separation of the
 sutures;  and fluctuation between the fontanelles.  There is an
 accumulation of fluid  in the ventricles  and in the meshes of the
 pia mater.  It is said  to  be external when the fluid  is in  the
meshes of the pia mater, and internal,  when  the fluid is in the
 ventricles. 
242     DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

                       SYMPTOMS.
First Variety.
    The head is not much increased in size, but is of a peculiar
       shape.
    The child is often weak-minded—as it has a very small amount
       of brain.
Second Variety.
    The head increases in size.
    Eyes—sunken.
    Fontanelles—protruding: fluctuation  may occur between the
       anterior and posterior fontanelles.
    The child is precocious for the first year or two, when nervous
       symptoms appear, and death usually occurs about the age
       of four or five years.
Third Variety.
    Gradual growth of the cranium out of proportion to the face.
    Gait—unsteady.
    Paralysis—in some cases (from inter-cerebral pressure).
    Involuntary evacuations.
    Child may reach adult life,  but it is always a misery  and
       trouble to every one.
                       TREATMENT.
  Tapping,  bandaging,  counter-irritation,  and  various  other
methods  have been tried, but all have amounted to nothing.



           CEREBRO-SPINAL MENINGITIS.
                        SYNONYM.
   "Spotted fever."
                       DEFINITION.
  Is an infectious disease, characterized by an inflammation of
the meninges of the brain and spinal cord.   It may be of an epi-
demic or sporadic type.
                    MORBID ANATOMY.
  On opening the skull, there will be seen a green exudation on 
CEREBRO-SPINAL MENINGITIS.
243
 the surface of the brain, which is most marked at the base, and
 which extends  down the cord.  The sulci will be found to be
 deficient and the convolutions sharpened.  The dura mater will
 be tense and covered with hemorrhagic deposits.  There is an exu-
 dation extending into the meshes of the pia mater of the brain
 and spinal cord, which may be fibrinous, sero-fibrinous, or sero-
 purulent in character, and is very plentiful in the region of the
 optic chiasm, fissure of Sylvius,  base of the  cerebellum, and the
 fissures of the cerebrum embedding the nerves.

                         ETIOLOGY.
   The attacks are more frequent  in  the winter than in summer,
 as the disease disappears as the summer comes  on.   It occurs
 most frequently in children (from 12 to 20) and middle life, and is
 extremely rare in the aged.  Bad  hygienic surroundings are great
 predisposing and exciting causes to this disease, especially of the
 epidemic form.
                         SYMPTOMS.
 Chill or rigors.
 Pain—in all the  bones.
 Headache—which is severe and increases.
 Photophobia.
 Pupils—contracted.
 Jactitations.
 Nausea—and perhaps vomiting.
 Pulse—80 to 100, hard, wiry, and increasing—later on may be
    slower than  normal.
 Te mperature—moderate.
 Respirations—30 to 40 a minute and increasing.
 Countenance—pale and anxious (associated with knitting of the
    brows).
 Eruption—appears early on the mouth, cheeks, eyelids, ears, and
    occasionally  on  the extremities (but that depends upon the
    severity of the case).  Is usually  herpetic in character..
 Delirium—slight.
Pain—in the back of the head and along the spine.
Muscles of the neck—are rigid. 
244
DISEASES OF THE BRAIN AND NERVOUS SYSTEM.
 Opisthotonos—may occur.
 Thighs may be flexed on the trunk and the leg on the thigh.
 Arm is drawn across the chest, fore-arm is flexed on  the arm,
    and the fingers are clinched.
 Abdomen—is first swollen and then shrunken.
 Great sensitiveness of the skin.
 Deafness—(may occur)—from inflammation of auditory nerve.
 Blindness—may occur from keratitis.
 Coma -may occur (when the following symptoms will be noticed).
    Pupils—unequally dilated.
    Respiration—sighing.
    Urine—is passed involuntarily, or may have to be drawn off.
    Constipation or involuntary evacuations—may occur.
    Capillary circulation is imperfect.
    Patient is aroused with difficulty, and may possibly take food.
    Eruption—may appear only in this stage.
    Emaciation—is rapid.

                   CAUSES OF DEATH.
  Death may occur from  acute  oedema of the  lungs, bronchitis,
or pneumonia. Any of these may occur on the first or second
day, but usually about the fourth or fifth day.  In some cases,
death appears in a few hours after the  symptoms have set in,
from paralysis or marasmus.

                    COMPLICATIONS.
  1. Croupous pneumonia—with no rational complications.
  2. Croupous nephritis-from the cerebro-spinal axis affecting
the parenchyma of the kidney.
  3. OMema and congestion of the lungs—due to paralysis of the
muscles of the chest.

                        SEQUELAE.
  I. Impairment or loss of hearing and speech.
  2. Impairment or loss of  sight—due to inflammation of the
retina, or from corneal ulcer.
  3. Chronic hydrocephalus (especially in children).
  4. Paralysis and great emaciation. 
EPILEPSY.
245
  5.  Neuralgic pains—about the head in the region of the cranial
nerves.
               DIFFERENTIAL DIAGNOSIS.
  It  may  be confounded with other forms of meningitis; with
pneumonia in children.  Sporadic cerebro-spinal  meningitis may
be mistaken for tubercular meningitis.
  The sporadic form is ushered in by a chill and rapid  pulse,
whereas, in tubercular meningitis, there is no chill, and the pulse
is slow at the beginning.
                        PROGNOSIS.
  Is  uncertain.   The  character of the  epidemic  must be  taken
into  account.
  In severe cases, the prognosis is bad.  In mild cases, recovery is
possible.
                       TREATMENT.
  It is the custom among the Germans to apply ice-bags to the
head and spine, while others prefer hot applications.  Quinine is
of little or no use; it will not even lower  the temperature   The
patient should be kept  in  a large,  quiet room.   The best and
largest quantity  of  the most  nutritious concentrated diet must
be given.  The temperature should  be reduced by sponging the
surface; and the only remedy that  can  be employed is opium
(atropine, gr. -6'ff, and morphine, gr. T^) hypodermically; the patient
must be kept thoroughly under its influence until death or recov-
ery ensue.


                       EPILEPSY.
                       SYNONYMS.
  Falling sickness; morbus sacer; haut or grand mal; and petit
mal,
                       DEFINITION.
  Is  a chronic disease, characterized by  a complete loss of con-
sciousness and sensibility, accompanied, in the severe type, by a
sudden falling, and distortion of the countenance,  and convul- 
246      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

sions.  Petit mal is characterized by incompleteness of the above
symptoms, viz.: no convulsions, only twitchings; it is also termed
epileptic vertigo.
                     MORBID ANATOMY.
  Often shows asymmetry, such as imperfect development of the
skull; diffuse thickening or  exostoses; the  dura mater may  be
thickened, adherent, and calcified;  tumors,  or deposits  in the
brain ; chronic hydrocephalus ; cerebral hypertrophy ; changes in
structure of the spinal cord and medulla ; sometimes alterations
in the substance of the brain; scars, etc.

                         ETIOLOGY.
  Excitement of the motor nerves, proceeding from the medulla
oblongata and the portion of the brain lying upon 'the base of the
skull; from dilatation of the arterioles and  capillaries  of the
medulla, with thickenings of their  walls, producing  irritation;
from cutting off the blood supply (anaemia), or causing afflux of
arterial blood to the medulla; tumors pressing on the peripheral
nerves; cerebral tumors and other  cerebral diseases; a morbid
state of the medulla; venous engorgement and over-charging of
carbon  dioxide, from spasmodic closure of the glottis; from in-
sanity,  intemperance, cachexia, onanism, mental emotion, vio-
lent fright, wounds,  syphilis, worms  in the intestines, etc.;  or, it
may be hereditary, often affecting several generations.
  It occurs particularly in females, from infancy up to thirty
years of age.
                        SYMPTOMS.
Ara usually ushered in by
    Aura epileptica—maj appear as a sense of vapor arising from
        the extremities  toward the  head;  or like a creeping,
        warm, or numb sensation; or like a darting pain in the
        brain; or like peculiar odors.
    Aura motor—resembles twitchings or palsy.
    Aura mental—like hallucinations; sparks or colors appearing
        before the eyes; or tinnitus aurium; or dizziness.
    Patient utters a shrill cry.
    Loss of consciousness and sensation. 
EPILEPSY.
247
    Convulsions.
    Tonic contractions—the patient may fall backward, sideways,
       or forward.
    Head—is drawn to one side.
    Mouth—is firmly closed.
    Face—cyanosed.
    Eyes—wide open, rolled upward or inward
    Pupils—dilated.
    Thorax—fixed.
    Respiratory movements—arrested.
    Jugulars—distended.
    Clonic spasms and convulsions.
    Grating of the teeth.
    Tongue—is bitten.
    Foaming at the mouth.
    Blood mixed with  the foam (from  biting of the tongue) ap-
       pears at the mouth.
    Thumbs—turned in on the palms of the hands.
    Head—jerked from side to side.
    Heart's action—accelerated.
    Pulse—small and irregular.
    Skin—bathed in perspiration.
    Involuntary evacuation of the bladder and rectum.
    Involuntary erections and seminal emissions.

                        PROGNOSIS.
  Depends upon the cause.  Some cases recover perfectly, while
others withstand all remedial measures.  The epilepsy of infants
and young children gives a better prospect of recovery than when
developed late in life.
                       TREATMENT.
  No epileptic mother should ever be permitted to nurse her child;
a vigorous wet-nurse should be obtained, and their home should
be in the country.  Regulate the system and surroundings.  For-
bid mental occupation of any kind.  The only condition of suc-
cess is patience, both on the part of  the physician and on that of
the patient.   It is necessary to be very stern as regards excessive 
248      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

sexual intercourse, onanism, drink, etc.  If anamia occur, nour-
ishing diet, wine, iron, and moderate  exercise in the open  air,
are indicated.   If.it  occur from scars,  foreign bodies, etc., etc.,
they  must be  removed.  The  following  methods  of  treatment
have  been suggested, with more or less  beneficial  results, viz.:
setons, moxa, pustulating ointments, cupping, blisters, etc.; four
leeches applied to the back of the neck at  a time,  every fortnight
or three weeks; or R atropine, gr. ij.; sp.  vini rect., 3 iiss ; com-
mence with gtt. i. every two or three hours, and increase till gtt.
xx. are given at a dose; or, gtt. v. nitrite of amyl pearls; these are
crushed on the handkerchief just as an attack is  coming on,  and
the patient made to inhale it.
  Bromide of potash, in large doses, or bromide  of sodium (this
latter is three times as strong as br.  potash).
  Preparations  of oxide of zinc or arsenic.
  When it is complicated with syphilis, iodide of potash or iodide
of  lime will be found serviceable.  Iodide of  lime  comes in
whitish-yellow  cakes, and must be kept from the light, because it
deliquesces and becomes brown, on account of the iodine.
               CEREBRAL  SOFTENING.
                         VARIETIES.
  (1) White or non-inflammatory.  (2) Red or inflammatory.  (3)
Yellow.
                        DEFINITION.
  Is a disease characterized, during life, by  impairment of the
mind, sensibility or mobility, and after death by softening and
degeneration of the cerebral substance.

                    MORBID  ANATOMY.
  The cerebral  substance is a moist, gelatinous, trembling pulp,
which may be of a white or grayish-white color, or, possibly, red
or yellow.   The yellowish color is said to depend on capillary
hemorrhage or fatty degeneration (is  due to infiltration of the 
MYELITIS.
249
disintegrated brain-substance with escaped  and altered coloring-
matter of the blood, or to a close aggregation of fatty matter).

                         ETIOLOGY.
  Is due to necro*sis (resulting from obstruction of the vessels and
insufficient development of the collateral circulation, or to local
inflammatory changes); occurs generally in the  greater  hemi-
spheres, chiefly  in the  medullary substance. It  may  follow  a
rupture of  the cerebral arteries; this latter  occurs chiefly in the
aged and decrepit,  from disease of the  vascular  walls, which
generally induces thrombosis.

                        SYMPTOMS.
Peripheral arteries—rigid, turgid, and contracted (in the old).
Large arteries—dilated (if atheroma exist in the vessels).
Impairment of mind, sensibility, and mobility.
Paralysis—which may precede or follow the  mental impairment).

                        PROGNOSIS.
  Is unfavorable, unless  dependent upon some local cause which
can be overcome.
                        TREATMENT.
  Same as in anaemia of the brain, (page 228).


                        MYELITIS.
                        DEFINITION.
  It is  a red softening of the .spinal cord, in circumcribed spots;
which becomes yellow, after a lapse of time, from fatty degener-
ation of the broken-down nerve-elements; it may produce abscess
of the spinal cord. It may be either acute or chronic

                    MORBID ANATOMY.
  A cavity may be formed in the spinal medulla filled with serum,
and traversed by connective-tissue;  or there may be an induration
from connective-tissue proliferation.  On section—-the  gray sub- 
250      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

stance of the cord is darker, redder, and less consistent than nor-
mal.  The medulla is swollen, and in its centre is a reddish, rusty,
or yellow pulp.  The tissues are broken down and often absorbed,
so that there may be a cavity filled with serum.

                         ETIOLOGY.
  Inflammation extending from the vertebra to the membranes
and thence to the medulla; curvature of the spine; wounds; con-
tusions;  syphilitic exostoses;  cold; sexual  excesses; excessive
straining; dissolute habits; suppression of perspiration of the feet;
masturbation.
                         SYMPTOMS.
Severe fever—at the  onset.
Extensive pain in the back and extremities.
Tetanic spasms of the neck.
Clonic spasms of the extremities.
Dyspnoea—(if the disease be situated very high up).
Paraplegia and anaesthesia (partial).
Numbness and irritation.
Vague pains.
Sensation of pricking.
Formication.
Painful contraction of the extremities.
Spasmodic twitchings—due to irritation  from  inflammation ol
    the motor nerves.
Pain—like a cord tied  round the  waist—dull at the point of in-
    flammation.  This pain is increased by pressure on the spinous
    processes and not by the movement of the spinal cord.
Paralysis—becomes complete; the bladder and  rectum are para-
    lyzed,  and atrophy of the paralyzed muscles takes  place—
    heaviness and helplessness of the lower extremities.
Urine—will be alkaline.  Digestive powers—are good, unless the
    disease is high up in the spinal cord.
If cervical region be affected — then the upper extremities and
    and respiratory muscles are involved.
If the dorsal region be affected—then the sphincters may be in-
    volved. 
LOCOMOTOR ATAXIA.
251
 If the lumbar region  be  affected—then the lower extremities are
    involved.

                 SYNOPSIS OF SYMPTOMS.
 Gradual paralysis—extending upward.
 Pain—in the back on pressure, (not increased on motion of spine).
 Sense of heat on the affected portion, whether heat or cold be ap-
    plied.
 Sensation as if a tight cord were tied round the body, correspond-
    ing to the seat of disease.
 Overflow of urine—from  paralysis of the bladder.

                   CAUSES OF DEATH.
  Death may occur from bed-sores, cystitis (from stagnation of
 urine due to paralysis); tuberculosis, or some intercurrent disease;
 pyelitis; ammonaemia.
                        PROGNOSIS.
  May run on for years and then remain stationary.  Recovery is
 rare.  Gradual advance to death from complications.

                        TREATMENT.
  Is of very little service.  The actual cautery and hot iron should
 be applied near the supposed seat  of inflammation.  A sponge
 dipped  in hot water may be placed along the spine, especially
 where the inflammation is most severe, with some benefit.



                LOCOMOTOR  ATAXIA.
                        SYNONYMS.
  " Tabes dorsualis,"—or gray degeneration, or softening of the
posterior columns of the cord.

                        DEFINITION.
  Is a disease characterized during life by imperfect co-ordination
of muscular movement and sensory manifestations; and after death
by disease of the posterior columns of the cord. 
 252     DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

                    MORBID ANATOMY.
   The disease is confined to the posterior columns of the cord; the
 dura mater is thickened and opaque.  The arachnoid is moder-
 ately opaque, and there is fluid in the sub-arachnoidean space.
   The pia mater is thickened,  opaque, and  adherent over the
 affected part.  The posterior columns are degenerated, the degen-
 erated portion is wedge-shaped, with its apex directed toward the
 centre of the cord.  It appears as a  reddish,  soft  mass.  The
 posterior roots of the spinal nerves are degenerated and the antero-
 posterior diameter of the cord may be shortened, due to degener-
 ation and possibly sclerosis.
  The microscope shows few nerve filaments in various stages of
 atrophy, and, between the cells,  nucleated connective-tissue from
 proliferation.

                         ETIOLOGY.
  It may follow exposure to dampness, as in the case of fisher-
 men; abuse of alcohol; syphilis; masturbation; excess of venery;
 severe muscular strain, as in long marches, etc.

                         SYMPTOMS.
Premonitory symptoms.
    Tearing localized pains in the lower half  of  the trunk which
        are more or  less paroxysmal (may last for  a long time,
        even for years, before ataxia occur).
    Delayed sensation and absence of '■•patellar reflex."
    Sense of formication in the lower limbs.
    Sense of numbness in the lower limbs.
    Sensation as if a ligature were tied around the body.
 If the disease be high up.
    The upper extremities may be affected as well as the lower,
        although the lower limbs are chiefly involved.
    Sense of insecurity in walking—especially when  any sudden
        movement is required, as in crossing a street.
    Abnormal sensation in walking—as if walking on  air or wool.
    No dragging of the limbs exists—but  the limbs are  forcibly
        lifted and thrown in the wrong direction.
    The patient is liable to fall if the eyes be closed—or if walking
        in the dark (this must not be  considered pathognomonic
        of this disease). 
                     LOCOMOTOR ATAXIA.                    253

     No motor paralysis, or atrophy in any special muscles—as you
        can move and put the limb in any position and retain it
        there in spite of a counter-extending force.
     Sexual intercourse is often decreased,  but priapism may be
        present.
 In the advanced stage.
     Walking—is almost impossible ; the feet are swung in a circle,
        the heel striking the ground first, and then the sole of the
        foot; the gait is jerky in character ; the patient may fall
        from inability of co-ordination of the muscles, and often
        loses his equilibrium.
     If the upper part of the cord be affected, the patient  cannot
        button his coat or collar, neither can he carry a glass of
        water steadily to his mouth (since co-ordination of move-
        ment is demanded)  and the handwriting  is markedly
        affected.
     Paralysis of the sphincter vesicae (incomplete enuresis, due to
        too long retention).
     Diploplia
     Strabismus  > from paralysis of the third and sixth nerves.
     Ptosis
     Pupil fails to respond to  light, but alters its size  in  efforts of
        accommodation of vision.
     Cerebral disturbances.
                    CAUSES OF DEATH.
  Death may occur from  bed-sores (from enuresis); severe cysti-
tis; pulmonary consumption; and intercurrent diseases.

                         PROGNOSIS.
  Recovery is extremely rare.

                        TREATMENT.
  If  there be a suspicion of syphilis, use the anti-syphilitic reme-
dies.  If from having taken  cold, leeches and blisters should be
applied along the spine;  sweating in moist clothes may be of
benefit; and the continuous current along the spine and the course 
254      DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

of the spinal nerves may possibly prevent the extension of the
disease.


       PROGRESSIVE  MUSCULAR  ATROPHY.
                     MORBID ANATOMY.
  The muscles are decreased in size, pale, and yellow, with bun-
dles of atrophied and degenerated tissue; and  in  the later stages,
degeneration of the whole muscles.
  The microscope shows  paleness of the muscular fibrillae:  no
transverse  stria*, fine granular fat-globules in the centre of the
fibrillae; later on, collapse of the sarcolemma and fat-globules in-
closed.  The muscles of the heart, intestines, or bladder are never
affected.   It affects  principally the muscles of the hand, hip, or
shoulder.   It may affect one muscle, or group of muscles.

                         ETIOLOGY.
  It is a primary disease of the muscles, and degeneration of the
anterior roots of the spinal nerves, due to disease of some small
part of the brain, or spinal marrow, and over-work of the muscles.
It attacks all ages and both sexes.

                        SYMPTOMS.
Increased feeling of weakness in certain muscles or group of mus-
    cles.
Rapid disappearance of  muscles—commencing in  the hand, hip,
    or shoulder, causing alteration in the ball of the  thumb, flat-
    tening of the shoulder, and prominence of the  spinous pro-
    cesses of the vertebrae.
Loss of muscular action of the affected side.
A peculiar  fibrillar twitching (as though the skin were alive) in
    the weak and atrophied  muscles, but no  movement of the
    joints.
A loss of sensory muscular nerve power.
The electric current does not fail to induce contraction until the
    muscle is entirely atrophied (pathognomonic). 
SUNSTROKE.
253
 The thigh may become even smaller than the calf of the leg when
     the muscles are greatly atrophied.
 Intellect is clear throughout.
 In advanced cases.
     Patient cannot walk or change position.
     Patient requires to be fed.
     Arms hang loosely to the sides of the body.
     Loss of expression of the countenance ) evidences  of  exten-
     Sahva flows from the mouth         \   ^sion of sPinal,
                                       )  changes upward.
     Speech is indistinct (due to extension of disease to medulla).
     Tongue cannot pass the food into the pharynx,  even after it
        is placed in the mouth.

                    CAUSES OF DEATH.
   Death may occur from atrophy of the muscles of respiration,
 and deglutition, causing failure in the performance of their func-
 tion
                        TREATMENT.
   The induced or constant current should be frequently applied
 with great patience and perseverance.


                      SUNSTROKE.

                        SYNONYMS.
   Coup de soleil;  Calenture ; Insolation ;  Sun fever; Heat apo-
 plexy ; Egyptian starstroke ; Heatstroke ;  Thermic or heat fever.

                       DEFINITION.
   Is a disease characterized by a more  or  less sudden  attack of
 unconsciousness due to exposure  to high temperature under ad-
 verse circumstances.

                    MORBID ANATOMY.
  In most cases of fatal sunstroke the blood is  found to have re-'
mained uncoagulated ; the lungs intensely congested ;  the right
side of the heart loaded with blood ; and generally more or  less 
256       DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

engorgement of the vessels of the brain.  The body also loaes ita
heat very slowly after death.  Some observers assert that a shght
increase usually takes place.
                         ETIOLOGY.
  Exposure to an intense heat where the atmosphere is damp and
impure, and the patient exhausted by over-exertion or from any
means which impede the free  action of the respiratory muscles.
In tropical climates it frequently occurs from exposure to the
direct sun rays and want of acclimatization.  It is also very com-
mon at night-time among those subjected to close, over-crowded,
ill-ventilated barracks, tenement houses, ships, etc; soldiers ex-
posed to long marches in the heat of  the day.  Intemperate and
debilitated persons and those who drink largely of iced-cold water
when greatly exhausted are very liable to be affected.
                       SYMPTOMS.
Onset may be  sudden but  frequently preceded by premonitory
    symptoms.
When onset is sudden.
    Patient falls unconscious.
    Head—intensely hot.
    Skin—pale, cold and moist.
    Respiration—gasping and is apt to be stertorous.
    Pulse—extremely feeble and rapid.
    Temporal arteries—greatly distended.
    Temperature internal—above normal.
    Convidsion may precede death which takes place very rapidly
       or even quite suddenly.
Wlxen onset is gradual.
    General malaise—which may be present for several days.
    Skin—dry and hot.
    Nausea.
    Frequent desire to micturate.
    Restlessness or insomnia.
    Face—flushed.
    Eyes—congested.
    Constipation. 
SUNSTROKE.
257
    Vertigo.
    Headache—intense.
    Vision becomes dim.
    Weakness in the limbs and great prostration.
    Coma—which may be partial or complete, when
        Breathing—stertorous.
        Pupils—contracted.
        Face—pallid.
        Skin—intensely hot.
        Temperature—varies from 100 to even 109°.
        Pulse—rapid and full and  as death approaches becomes
            weak, irregular but very rapid.
        Convulsions—sometimes.
        Bowels—relaxed.
        Vomiting—not infrequent.

                        SEGUELC3.
  Headache; chorea-like affections of the muscles; epilepsy; and
riorne degree of mental imbecility ; amaurosis.

               DIFFERENTIAL DIAGNOSIS.
  From apoplexy; delirium tremens ; insaniiy; eclampsia; par-
alysis.
                        PROGNOSIS.
  Is unfavorable,  the mortality being very heavy, exceeding, it is
said, forty per cent.
                       TREATMENT,
  Depletion should never  be resorted to.  The patient should be
placed in a cool room ; his clothes removed and a cold shower bath
administered.  The  shower being at least from four  to five feet
above the patients head.  When removed from the bath the head
should be shaven and cold  applied to the head.  If there be
dyspnoea dry cups placed  on the thorax in front and  behind will
be of service. Bromide of potassium gr. v.-xxx. should be given
in all stages of the affection and in  mild cases (gr. v.-x.) may be
administered every half an hour to an hour until the grave symp-
toms disappear;  if  the patient be unable to swallow it can be 
 258         DISEASES OF THE BRAIN AND NERVOUS SYSTEM.

 given by injection remembering that the dose should always be
 increased one quarter more than -when administered by the mouth.
 Stimulants such  as brandy and milk,  or brandy and ammonia,
 should be given  whenever exhaustion is prominent and the cold
 douche dispensed with whenever the skin is cold.  After return of
 consciousness, blisters or sinapisms should be applied to the back
 of the neck or behind the ears.  The bromide should be continued
 for at least two weeks after the return to consciousness.   When
 convenient, the patient should be sent  to a cool district and free
 from all  excitement  or  mental or physical  exertion.  Regular
 habits and exercise should be enforced. In order to prevent or
 lessen the danger from nervous affections which are apt  to  follow
 sunstroke, a continuance of this treatment  for  some months
 should be adhered to.


 COMA—ITS  PRINCIPAL  CAUSES   AND  DIFFER-
                 ENTIAL DIAGNOSIS.

  The most frequent causes of coma, (see page 26), comprise, syn-
 cope, cerebral concussion and compression, asphyxia, epilepsy,
 apoplexy, embolism,  hysteria, catalepsy,  uraemia, alcohol, and
 opium.

                         Syncope.
  Pulse, feeble; face, pale; respiration, quiet; duration,  short.
                   Cerebral Concussion.
  Pulse, rapid and feeble, and intermittent; skin, pale  and cold;
respiration, feeble and sighing; pupils, usually contracted;  coma,
incomplete, is usually immediate, and rapidly decreases, as a rule;
temperature,  lowered; eyelids, usually open and movable; vomit-
 ing,  frequently present; incontinence of urine and involuntary
 evacuations occur; duration, short.
                   Cerebral Compression.
  Pulse, full and slow; skin, usually warm and moist;  respiration,
 slow and stertorous; pupils, may be natural, dilated, or  irregular; 
COMA.
259
 ooma, profound, may not directly follow the injury, and is station-
 ary or increasing; temperature,  normal or increased;  eyelids,
 closed  and immovable; vomiting, rare; retention of urine and
 obstinate constipation ; paralysis (modified by seat of lesion).
                           Asphyxia.
   Face, livid;  Hps, blue ; extremeties, blue and cold ; respiration,
 distressed.
                           Epilepsy.
   Epileptic cry on onset; tongue, ragged;  history of previous
 attacks ; pupils,  dilated; mouth,  bloody froth exudes;  spasms.
 tonic and clonic ; body, one side more convulsed than the other,
 reflex sensibility present; duration, short, and followed by a deep
 sleep ; loss of consciousness of short duration.
                          Apoplexy.
   Coma, may  occur at onset  or develop rapidly, and deepens;
 hemiplegia: pulse, slow and full; face, flushed; pupils, irregular;
 respiration, stertorous; condition of arteries, usually atheroma of
 those which are superficial; age, usually occurs at about 50 years;
 history, high living, etc.; muscles,  rigidity or relaxation.
                           Embolism.
   Advent, is sudden, with consciousness; paralysis, usually of the
 right side; improvement,  is usually marked within twenty-four
 hours (due to collateral circulation); face, pale or normal; respira-
 tion, sighing; aphasia, usually present either of the amnesic or
 ataxic variety; age, may occur at any time; pupils, dilated or
 irregular; history, may be  rheumatic, or evidence of mitral or
 aortic disease may be detected on auscultation.
                          Hysteria.
  Globus hystericus; large amount of pale urine in the bladder,
 which is passed after the attack; a previous history of attacks of
hysteria; most  common in females.
                          Catalepsy.
  Limbs, at first rigid, then become loose and  will remain in any
position in which they may be placed. 
260      diseases of the brain and nervous system.

                          Uraemia.
  Is of gradual onset; face, pale and waxy; pupils, dilated; eyes.
closed; coma, complete; oedema, of face and limbs; uramiic odor
of the body, and especially  of the  breath; urine, contains casts
and albumen; history of convulsions.
                          Alcohol.
  Pulse, rapid;  face, flushed; skin, warm and moist; respiration,
stertorous and  puffy;  pupils, dilated,  and respond  to light; no
paralysis; breath, alcoholic;  vomiting, occasional; eyes, injected;
temperature, below normal;  feet, are drawn back when tickled;
history of drinking.
                           Opium.
  Onset is gradual; face, dusky ; skin, moist; pulse, slow and full;
pupils contracted, (pinhole);  respiration, slow and irregular, and
there may be an interval between expiration and  inspiration;
patient can be roused till coma deepens ;  vomiting (the matters
vomited have the odor of opium); breath, has the odor of opium ;
the attack tends to deepen,  the respiration gradually becoming
slower and slower as the drug exerts its influence.   The patient,
when roused, answers questions rationally, in marked contrast to
some other forms of coma (especially alcoholism). 
DISEASES OF THE BLOOD. 
 
      ETIOLOGICAL DIVISION  OF FEVERS.
1. Miasmatic contagious.
    The poison must be deposited in decomposing organic matter
    exterior to the body, so that, when once in a body or system,
    whose condition is impaired or weakened, the poison is re-
    produced.  It can only be conveyed through the excrements
    of the sick, or through decomposing organic matter exterior
    to the body, with which such excrements have come in con-
    tact. They may be endemic or sporadic (as in typhoid and
    yellow  fever).
2. Malarial or miasmatic non-contagious.
    Where the morbific agent is developed exterior  to the body
    (as  in  simple  intermittent, simple  remittent,  pernicious,
    dengue, and typho-malarial fevers).
3. Contagious.
    Where the morbific agent is developed in the body, and can
    be transferred through the  atmosphere to another (as in ty-
    phus,  measles, small-pox,  relapsing,  scarlet, and miliary
    fevers.


                  TYPHOID  FEVER.
                      DEFINITION.
  Is one of the miasmatic-contagious fevers.
                       SYNONYMS.
  Autumnal, abdominal-typhus, enteric, gastric, gastro-enteric,
forty day, dothenenteria, ilio-typhus,  typhoid affection of Louis.
                   MORBID ANATOMY.
  There  is the change in the blood which becomes darker in color,
imperfectly coagulable, and the serum is of an unnaturally yellow
color.  Through  these blood changes,  the various  tissues and 
262
DISEASES OF THE BLOOD.
organs in which the  process of repair and waste are carried on
become affected, as the spleen, liver, kidneys, heart, lungs, bron-
chial tubes, larynx, brain, stomach, muscles, and salivary glands.
  Spleen.—Is sometimes enormously increased in size (for about
three weeks),  becoming soft, of a dark jelly-like mass,  easily
broken down (from congestion); or  there may be infarctions and
rupture, but if recovery take place, the spleen will  return  to its
normal size.
  Liver.—May be normal, or soft and flabby, with more or less
granular, fatty, and lymphoid cells; or there may be catarrhal or
diphtheritic inflammation, or ulceration of the lining membrane
of the gall-bladder.
  Kidneys.—Degeneration may take place, especially in the epi-
thelial elements of the cortical substance, but not so markedly as
in typhus.
  Heart.—Parenchymatous changes are more marked than in any
other organ (from faulty nutrition); becomes soft and flabby, and
of grayish  or brown color; is easily broken down,  and the walls
of its cavities readily fall together (on account of granular degen-
eration); its muscular fibres have an amyloid appearance, which
does not answer to  the iodine test (this change also takes place in
the voluntary muscles of the body).  There may be thrombi in
the heart, or vegetations on the valves, or chordae tendineae, pro.
ducing infarctions and feeble heart-sounds, and the first sound
may be entirely absent.
  Lungs.—Undergo splenization; they may be of a dark reddish.
blue, black, or brown color, harder and  drier than normal, and
when cut,  a dark watery fluid  oozes out  (due to  stasis  in the
capillary circulation).
  Death may ensue from  pulmonary infarctions.   These infarc-
tions in  the recent state are dark and feel like consolidated lung-
tissue, but later may change to a yellow color, or may soften and
break down.
  Bronchial tubes.—There is extensive catarrhal inflammation of
the larger  tubes, generally giving rise to capillary  bronchitis or
broncho-pneumonia.
  Larynx.—There  may be  extensive  catarrhal  inflammation. 
TYPHOID FEVER.
263
  Ulcers  (called typhoid  ulcers) may  occur, causing  extensive
  hemorrhage (this type of ulceration may affect the mouth and
  pharynx, or even the epiglottis or mucous membrane of the Eus-
  tachian tube, producing deafness).
   Brain and nervous system.—OEdema of pia mater and brain-
  substance may exist, with extensive adhesions to dura mater (not
  much, however, is known of these lesions).
   Stomach.—Changes in  this  organ are  sometimes  extensive.
  Softening and  degeneration of  its  glandular  structure  occur,
  which are the causes of disturbances in digestion during the fever
  and even during convalescence.
   Muscles (voluntary).—There may be granular or fatty degenera-
  tion; or a waxy or amyloid degeneration.   The muscular  fibres,
  in both  instances, become thick  and friable, and  are  yellowish-
  white in appearance.  The want of muscular power of  fevers de-
 pends on the nervous disturbance, but  the excessive loss of mus-
 cular power in convalescence is due to muscular changes.
   Salivary glands.—These become enlarged, tense, and firm; are
 of brownish-yellow color, and later on they become red (due, first,
 to cellular hyperplasia, and secondly, to degeneration).
   Intestinal lesions are the most important of all the lesions, and
 are characteristic.   The poison  acts on the mucous membrane of
 the  small intestine, producing  catarrhal  inflammation and
 changes  in  its structure.  These changes  are  modified by the
 duration of the fever, and their nearness to  the  ileo-coecal valve.
 They are most marked in the patches nearest  the valve (ileo-coecal).
   The intestinal changes in the regular course of a severe case may
 be thus summarized:
  First week.—The mucous membrane around Peyer's  patches
 becomes  congested and swollen;  the glands become more and more
 elevated; and the surfaces are of  a dark-red color, interlaced by
 white  lines  ("shaven beard appearance").   These changes are
most marked nearest the ileo-ccecal valve.
  Second week.—The mucous membrane of the intestines becomes
less red;  the  solitary glands more elevated; the white lines on
their surface  disappear; and are  uniformly  red.  There is an ex-
cessive cell growth in the follicles (due  to rapid development of 
264
DISEASES OF THE  BLOOD.
lymphoid cells, principally within their structure, causing pressure
on the capillaries and interfering with the circulation  of gland-
tissue). Toward the end of the second week, degenerative changes
are established in the new tissue, which may become disinte-
grated, absorbed, and undergo resolution; or the follicles may rup-
ture into the intestines, or more frequently the dead tissues slough
and ulcers are formed.
  Third week.—These ulcers are yellowish on account of staining
by bile.  When sloughing takes place, the entire gland and mucous
membrane surrounding it are removed and the muscular coat laid
bare.   The edges of the ulcers are sharp, swollen, and overhang
the floor of the ulcers, and may terminate in perforation of serous
coat and fatal peritonitis.  These ulcers may be hemorrhagic,
and destroy life in this manner.
  Fourth week.—Cicatrization  commences.  The  swollen  edges
subside.  Granulations spring up from the base of the ulcer (which
is the muscular coat of the intestine);  connective-tissue is formed;
edges unite at their base, and are covered with a layer of  epithe-
lium.  The cicatrix is  depressed, becoming more  and more pig-
mented, but seldom causes any puckering or diminution in the
calibre of the intestines.  Death may result from prolonged ulcer-
ation.
  Mesenteric glands.—Those  nearest the  ileo-coecal  valve  are
affected secondarily to the  intestinal glands.   They are first con-
gested, then lymphoid and large cells are produced, causing en-
largement and acute cellular hyperplasia; and, about the end of
the second week, the glands become disintegrated.  They are often
about  the size of a walnut or  hen's egg.  Some of the glands
shrink to their normal size, others  soften and are absorbed, and
leave a fibrous cicatrix.  When of very large size, absorption may
be incomplete, and a dry, yellow cheesy mass is left;  salts of lime
are often deposited in them, and they become inclosed in a fibrous
capsule; or they may become fluid, their capsules destroyed, enter
the peritoneal cavity, and produce peritonitis.
  Suppurative inflammation in the cellular-tissue, on the surface
of the body, may be another lesion  occurring  during convales'
cence,  accompanied by redness and pain.  A tumor of a fluctu' 
TYPHOID FEVER.
265
 ating nature is formed wherever there is the greatest pressure, or
 two or more of them may coalesce.
   Bed-sores (in later stages) occur from imperfect skin nutrition
 and prolonged high temperature.  They are most frequent over
 the trochanters or sacrum, or wherever there is pressure, and may
 involve the muscular structures.
   Gangrene of the toes may occur, due to thrombosis or embolus,
 from pressure on circulation of lower extremity.

      SYNOPSIS OF THE PATHOLOGICAL  CHANGES.
   The pathognomonic lesion  is confined to  Peyer's patches and
 mesenteric glands.  In these, the following changes occur:
   1st.  Congestion of Peyer's patches (producing " shaven beard "
 appearance).
   2d. Hyperplasia and hardening of these glands.
   3d. Softening of glands from fatty degeneration.
   4th. Absorption or rupture, with evacuation of contents.  In
 case of rupture, an ulcer is left, whose long axis is parallel to the
 length  of  the  intestine; the edges are ragged and undermined,
 and the floor is formed by the muscular wall  of the  intestine.
 The ulcers are on the unattached border of the intestine.
   5th. Cicatrization of these  ulcers, and a pigmented cicatrix.
 In severe cases, perforation at the seat of ulceration  may occur.
 The mesenteric  glands undergo enlargement,  and  softening
 through fatty degeneration.
   All of the organs are generally softened and fatty, and the
 muscles are  in a state of fatty degeneration. There  is extreme
 emaciation, and the common  lesions of all  fevers exist (see page
 316).
                        ETIOLOGY.
  The poison, which is contained in  the  faecal discharges of the
 sick, if fresh, undergoes development outside the body, especially
 in soil saturated with organic matter, and gains access to the sys-
 tem by the air we breathe and the water we drink.  The period
 of incubation is  from fourteen to twenty-one days.   It is more
frequent in the autumn than any other time of the year.   It oc- 
266
DISEASES OF THE BLOOD.
curs more frequently between the ages of 15 to 25.  Exposure,
bad nutrition, and debility of system favor its development.

                         SYMPTOMS.
Early symptoms of general malaise.
    Vomiting of greenish fluid.
    Headache (lasts from seventh to twelfth day).
    Intolerance to light.
    Pains in limbs (all over the body).
    Chills and fever, but not well marked.
    Slight diarrhoea.
    Variations in temperature.
Temperature—
    First week.—Gradual and steady rise morning and evening
        In mild cases 103°.  In severe cases 105° to 106°.  High in
        morning (from 12 to 6 P.M.). Low in evening (from 6 p.m.
        to 8 a.m.).  Pulse 98 to 110, and increases about five beats
        for every degree of temperature.
    Second Week.—Temparature and pulse remain at their maxi-
        mum till the end of this  week when a decline usually
        occurs ; may be rapid and feeble.  Pulse may go to 120 to
        140.   If 140, it denotes feebleness of heart's power, and is
        a bad omen if it remains so for five or six days.
    Third week. -Variations are remittent in character.  If pulse
        and temperature keep high, is fatal.   Heart-sounds  may
        be  inaudible, and prompt attention to the patient is then
        indicated.
    Fourth week.—Variations are intermittent and exacerbations
        not so severe.
Eruption—begins from sixth to twelfth day, and remains till the
    fourteenth day; consists of lenticular spots scattered over abdo-
    men and chest, are of a bright rose-color, and disappear on the
    slightest pressure and return directly. Each spot remains three
    days and then disappears, when another batch takes its place.
    The latter  is the distinguishing point of the eruption.  Da
    Costa says it resembles flea bites.
Delirium—low muttering, and often becomes maniacal at night. 
TYPHOID FEVER.
267
 Diarrhoea—if slight throughout, is not a bad sign, but excessive
     diarrhoea is an unfavorable symptom.  Generally commences
     about  second week, is alkaline,  and of a yellow-green color •
     (pea soup).
 Stupor.—This is a common symptom.
 Great emaciation is marked, if the disease be typical.
 Subsultus or twitchings of the wrists, picking at the bedclothes,
     may be present.
 Involuntary evacuations and micturition.
 Tongue—is at first of a light white color, then red on the tip and
     sides, and dry in the centre; then heavily coated, ivith sordes
     on  teeth and sides of the mouth.   May become clean and
     shining like raw beef, or the tongue and lips  may be dry
     and cracked, and the mouth covered with dark incrustations.
     Hemorrhage, from the  gums may also occur.
 Countenance-pale, olive, or leaden look.  Eyes  dull and pupils
     dilated.  Conjunctiva  congested, hectic flush, and  a sunken
     and anxious expression.
 Tympanites—(from gas in the intestines, due to changes in mucous
    membrane), indicates danger, if excessive.
 Pain and tenderness  in right iliac  fossa—about  the sixth day
    (never press with  the tips of the fingers lest the  intestine be
    ruptured);  pain may be due  to perforation, when there will
    first be sudden diarrhoea, and aggravated pain on pressure in
    the abdomen; the pain of typhoid may be located, at first, in
    right iliac fossa, but soon extends over entire abdominal cavity.
 Intestinal hemorrhage—from a trace to 16 or 18 ounces, is pre-
    ceded by sudden rise in temperature and extreme fall. If pro-
    fuse, it is due to the opening of an  artery with an intestinal
    ulcer, and preceded by fall of temperature, etc.
 Nausea—(later on in the disease).
Vomiting—(later on  in the disease) which  may be  due to acute
    gastric catarrh or general peritonitis.
Cyanosis and collapse—(later on in the disease).
Epistaxis—may occur during the first week and is of little impor-
    tance, but when it occurs during the third week it may be
    so profuse as to destroy the life of the patient. 
268
DISEASES OF THE BLOOD.
Somnolence.
Muscular prostration and, in severe cases, paralysis may develop.
Aphonia.
Deafness — due to ulceration  of mucous membrane lining  the
    Eustachian tube.
Perverted taste.
Excessive hyperaesthesia.
Enlarged spleen.
Urine—is first diminished and then increased.  Albumen very rare.
Lungs—typhoid  rale, a sonorous, dry, ringing sound, is often
    present and is due to a bronchial complication.
  If convalescence take place, the edges of the tongue will be
moist, this moisture extending all over the tongue.
              SYNOPSIS OF THE SYMPTOMS.
  First Week.— Temperature, mild cases, 103°.   Severe cases, 105"
to 106°.   Pulse, 98 to 110.  Epistaxis; slight diarrhoea; tympanites;
and tenderness over right iliac fossa and gurgling (bad omen).
  Second Week.— Temperature and  pulse  may fall to normal, or
pulse go up to 120 to 140 (about the seventh day).  Eruption (from
sixth to  eighth day) generally commences at this time and re-
mains till the fourteenth day; appears on abdomen and lower part
of the  chest, may be scanty and is of a bright rose color,  etc.
Marked diarrhoea (resembling pea soup).  Delirium—low mutter-
ing, or maniacal.  Coma vigil.  Subsultus tendinum.  Picking of
the bed-clothes.  Symptoms of bronchitis; tongue brown, dark,
and incrusted; sordes on teeth, etc.
  Third Week.— Epistaxis,  or intestinal hemorrhage (alarming),
and other fatal symptoms.   If convalescence take place, the erup-
tion disappears gradually, as do also the other symptoms.   There
is, in the  convalescent stage, danger of perforation for six months.
               DIFFERENTIAL DIAGNOSIS.
  In early stages, with typhus, relapsing, typho-malaria, acute
tuberculosis, pyaemia, septicaemia, pneumonia, gastro-enteritis, or
trichonosis.
Acute Tuberculosis.
    Temperature—106° or 107°, (and no remissions).
    Spleen—not enlarged.
    No eruption. 
TYPHOID FEVER.
269
 Typhoid Fever.—Temperature, rarely 106 (with remissions).
    Enlarged spleen.—Eruption, red-rose color.
 In trichonosis.
    No eruption ; pain in the joints (resembling acute articular
 rheumatism); and by taking a piece of the pectoral  muscle and
 placing it under the microscope the parasite will be seen, which
 determines the diagnosis.
 In Pyozmia and Septicaemia.
    Jaundiced hue to surface; no eruption; early symptoms  of
        profuse sweating; emaciation; delirium, etc.; history.
 In Typhoid Pneumonia.
    Typhoid  symptoms; coma in  later stages; cough and expec-
        toration; no variation in temperature.
 In Gastro-enteritis.
    Diarrhoea and vomiting precede the  fever, and the tempera-
        ture  is never  higher than 103°.
                         PROGNOSIS.
   So  long as abdominal symptoms last,  the patient is not out of
 danger, as changes are still going on.  If the temperature be not
 higher than  104D to 105° on the eighth day, and is regular  in  its
 development—the prognosis is favorable.
   In all cases, the heart is the guide; for, if pulse be 110 to 115,
 and there be  a distinct first sound; and, at the end of second week,
 the temperature be even 106°—favorable.  If pulse be 120 to 130,
 feeble apex-beat, first sound indistinct or obscure, and tendency
 to cyanosis—be on your guard.
  It  is  the rise  and fall in pulse that denotes the danger.   The
 prognosis is  always bad, in fat persons and gouty subjects, or if
 complicated  by kidney troubles.   There is great danger of peri-
 tonitis from  ulceration and hemorrhage,  if the attack be severe.
 Bad prognosis, in alcoholists and  when occurring in connection
 with chronic  diseases.  Bad, in complications, as diminished heart's
 action from muscular degeneration, favoring pulmonary and other
hypostatic congestions.  Bad, in intestinal perforations, capillary
bronchitis, oedema of the lungs, latent pneumonia, laryngitis (from
protracted fever and  prostration, causing ulceration of mucous
membrane) pyaemia, acute gastric catarrh.  Bad, if brain symp-
toms occur, as oedema, hemorrhagic extravasations, hemiplegia, 
270
DISEASES OF THE BLOOD.
and paraplegia, also in parenchymatous nephritis, severe catarrh
of bladder, cellulitis, and bed-sores.
  Death may result from toxaemia, asthenia (debility), suppression
of excretory functions of kidney, hyperaemia, and oedema of the
lungs, intestinal hemorrhage, exhaustive diarrhoea, intestinal per-
foration, peritonitis, with or without intestinal perforations; re-
lapse from reabsorption; and from cathartics, if given during first
week.
                        TREATMENT.
  Always use a porcelain bed-pan, covered over the bottom with
a  layer of powdered sulphate of iron, and, directly after the dis-
charge, cover it all over with muriatic  acid (about equal to one-
third of the mass).  Dig trenches, but not near a privy or drain,
and  empty contents of bed-pan into these trenches.  Remove all
soiled bed-clothes, immerse them in chlorine water, and boil  them
within twenty-four hours.  Examine the pipes,  wells, etc., etc.,
and see the house sewer-pipes do not leak.  Disinfect thoroughly,
for after the  poison has once entered the system there is no pre-
ventive.
   Arrangements of the sick-room are of the utmost importance.
An experienced n urse. Large well-ventilated room.  Remove all car-
pets and all superfluous things. Temperature of the room 60°. No
fruit or solid food.   Patient must be kept in bed.  Milk, ad libitum.
In early stage (temperature 103p), sponge surface with cold or tepid
water.  Keep down  temperature with  quinine  and cold (using
bath, packs, and affusions).  If temperature rise above 103° in
axilla, then warm bath, 70° to 80°, and gradually lower  the tem-
perature of the bath by ice or water till patient begins to feel the
effects; probably it will have to go to 60°, but not below this.  If
temperature  fall rapidly to 103% remove patient at once; but, if
slowly, do not remove patient till temperature of 101° be reached,
and apply cold to head; this should only  be done during first and
second week.  Cold pack should be thus applied:  wring  out a
sheet in tepid water, and one in cold water, and  wrap round the
patient; or apply  ice-bags to abdomen.  Be very careful  when
using cold applications.
   Quinine, in large doses, 30 to 40 grains within  two hours,  or 10 
TYPHOID FEVER.
271
grains every half-hour for four doses, but do not continue it when
once temperature is reduced, unless it be  105% then reduce to
101% and  keep it there.  If, after the third week, you fail to re-
duce the temperature, add gr. ic.-xx. pulv. digitalis, unless pulse
be frequent and irregular, then only use quinine.
  If weakness and failure of heart's power occur during the third
week,  and the temperature be about 101% pulse 140, with  first
sound  inaudible, subsultus, dry tongue, etc., use stimulants, bid
be very careful of the first few  doses,  and see your patient every
two hours, so that, if he be restless, delirium more active, temper-
ature higher, pulse more and more rapid, stop it at once;  but, if
pulse become fuller and more regular,  heart-sounds more dis-
tinct, less delirium, and restlessness, then continue it.
  Nutrition.—No beef-tea—cannot digest it, and little  nourish-
ment in it; give milk and lime-water, which is an antiseptic.
  Diarrhoea  denotes  intestinal  changes  from inflammation and
subsequent intestinal catarrh.  In early stages, leave it alone for
first or second week.  If it commence late (during  latter part of
third or fourth week), it  is due to ulceration or sloughing.  It
should be arrested or held in check by opium hypodermically, in
small doses, and not by astringents.  Stimulants can be  adminis-
tered at this stage.
  Tympanites.—Use turpentine stupes to abdomen.   Dip a piece
of  flannel in boiling water, wring it out, pour turpentine over it,
and apply to abdomen.
  Intestinal hemorrhage may cause death from exhaustion.  If
occurring  late, should be promptly arrested.   Patient  must be
kept in bed, and semi-narcotized with  opium, given in small doses
at intervals; must remain perfectly still in bed.   If hemorrhage be
profuse, patient must be kept  under the influence of opium for a
week or ten days.
  Peritonitis.—Death occurs  as a result of  general peritonitis
from perforation in twenty-four hours.   If without perforation,
then semi-narcotize your patient for seven to ten days. Be careful
of  cathartics and enemata; do not use them, even if no passage
occurs for two or three weeks.   If stomach be irritable, use hypo-
dermic injections of morphia over abdomen, sufficiently large to
Kjheck peristalsis. 
272                DISEASES OF THE BLOOD.

  Bronchitis.—If capillary bronchitis,  apply dry cups to chest,
and ammon. carb. internally.
  Pneumonia.—Stimulants should be given, or increased, if pre-
viously used, at the time pneumonia occurs.
  Laryngitis.—Small blister below the angle of the jaw, and a
poultice round the  whole neck.   If suffocation  seem  likely to
occur, then perform tracheotomy.
  Subacute gastric catarrh. — Rest the stomach; give 3 i. milk at a
time, and hot fomentations over epigastrium.
  Bed-sores.—Scrupulous cleanliness and bathe the parts in spirits
of camphor, and relieve the points of attack from pressure.  If
the sores penetrate the soft tissues, then wash frequently  with
carbolic acid, or brush the part over with equal parts of balsam of
Peru and copaiba, and cover with dry  lint and vaseline.  If gan-
grenous,  use continuous warm bath,  and  so  soon  as  sloughing
takes place and parts separate, dress the parts with  lint saturated
in balsam of Peru and carbolic acid.
  Delirium.—Chloral, gr. x.-xx., and perhaps repeat in two hours,
or give stimulants, if associated with insomnia, and especially if
there be anaemia.
  Jactitations, etc.—Inject hypodermics of sulph. ether (3 i.) in
four different parts of the body.
  Convalescence.—Eat often and little, such  as milk, cream, jellies,
gruel, animal broths.  No solid food; and, if diarrhoea be present,
only milk and cream.   No exercise, except walking  about in sick-
room.  Patient should be kept in semi-recumbent position for two
or three weeks after convalescence.   If convalescence be slow,
give small doses of quinine, iron, and oleum morrhuoz after food,
If diarrhoea occur, keep patient in bed, give catechu and haema-
toxylin, and,  if convalescence be delayed, then send  him away for
change of ah.


                   YELLOW  FEVER.
                       DEFINITION.
  Is a miasmatic-contagious, and also an infectious disease. 
YELLOW FEVER.
273
                    MORBID ANATOMY.
  The characteristic lesions, after death, will be found in the liver,
kidneys, and the blood.
  Liver—is sometimes the color of fresh  butter, mustard, coffee
and milk, or chocolate.  This change may be confined to one lobe
or  portion of the lobe, or it may extend over  the whole  liver.
The organ contains less blood than normal, and  is  dry in appear-
ance, softer than normal,  and breaks down easily upon pressure.
  The microscope shows  the hepatic  cells  infiltrated with oil
globules, or there may be a granular change and  disappearance of
the cell-nuclei.  This change is called "acute fatty degeneration."
  Stomach.—The mucous  membrane is thick, red, and soft.
  Heart.—Is soft, flabby,  lighter in color  than  normal, and the
outline of the fibres is lost (from a  degeneration which is taking
place).
  Lungs.—Axe the seat of hemorrhagic infarctions.
  Kidneys.—Are increased in size, due to an increase  in the cor-
tical substance.   It is a time parenchymatous nephritis, in v.hich
the fatty stage is rapidly reached.  The microscope shows  the
Tiriniferous tubules crowded with oil-globules; in  some places they
are denuded of the epithelium, and in  others filled with broken-
down epithelium, which is  undergoing a fatty and  granular change.
  Brain.—Will be found hyperaemic
  Spleen.—Is darker, softer, and slightly enlarged, if at all.
  Skin.—Varies from a bright yellow to a dark orange-color.
  Blood.—Is changed in color; darker than in health; the globules
have not the usual rounded outline; their edges are  serrated; they
break down easily, and rapidly undergo  ammoniacal changes.
The blood coagulates less rapidly and less perfectly than normal
(this  is due to a diminution or loss of  the  coagulating power of
its fibrin).
  Other organs.—There is  acute catarrh of the mucous membrane
of the intestinal tract and  larynx.  The veins become turgid from
intense hyperaemia often resembling varicosities.

                         ETIOLOGY.
  This disease is rarely met with north of  40° north latitude,  or 
274
DISEASES OF THE BLOOD.
south of 20° south latitude, and for its production it is necessary
to have decomposing animal  or vegetable  matter,  a certain
amount of moisture, and a temperature which must be above 77%
together with the specific poison.  When the southerly winds pre-
vail, the  epidemic spreads and increases in severity, and  when
the northwest winds prevail, it is  arrested, and its ravages are
stopped so soon as the frost sets in.  It is a portable disease, and
occurs in sea-port towns.  Its period of  incubation varies from
twelve hours to four or five days,  or even several weeks.
                          STAGES.
  Invasion—Remission—Exacerbation.
                        SYMPTOMS.
Ushering in Symptoms.
    General malaise—which occurs for two or three days previous
        to the attack.
In mild cases.
    Chill—with or without rigors.
    Fever—continues from a few hours to two or three days.
    Temperature—varies from 102 to 110° F.: reaches its maximum
        at the end of second day (which is rarely higher than 105°).
    Pulse—seldom above 100.
    Tongue—moist and somewhat coated.
    Headache—supra-orbital and intense.
    Vomiting—which is not prominent till late in the disease.
    Tenderness on pressure over the epigastrium.
    Constipation—which may be intense.
    Delirium—rarely violent.
    Pain—in the lower limbs especially in the calves of the legs.
    Eyes—red, irritable, watery or tearful.
    Fever abates or ceases after two or three days when a remis-
        sion occurs, commonly termed the state of calm.
In severe cases.
First stage.
    Pains, etc., may cease.
    Temperature—rises rapidly, may reach as high as 110°. 
YELLOW FEVER
275
    Pulse—seldom higher than 110—termed the  "gaseous pulse.''
        Is easily compressed and uncertain in character and vol-
        ume. It may  fall below normal (even to 30 or 40), is
        small, weak and vibratory.
    Lividity of back—due to hypostatic congestion.
    Vomiting—projectile or regurgitant,  a most  constant  and
        characteristic symptom.  It comes on after the chill, con-
        tinuing throughout the whole course of the fever; at first
        it consists of the contents of the stomach, and is alkaline,
        then of a thin liquid which may be of a red,  claret, or
        brown  color.   Finally the black vomit appears, which
        may occur on the second or third  day (but usually ceases
        from twelve to twenty-four hours*before death); consists
        of pigment  (produced by changes in the blood by the gas-
        tric juice) and globules (resembling blood); also  epithelial
        cells from the mucous membrane of the stomach, degene-
        rated lymphoid ceUs and white blood globules.  It is acid
        and has an acid taste without bitterness  ; it may be acrid
        and excoriate the throat, tongue and lips.
    Tenderness over the epigastrium—which may be extensive.
    Tongue—usually red, dry and cracked but may be moist and
        covered with a creamy coating.
Second stage (stage of remission—may last from a  few hours to
        two or three days).
    Temperature—by the fourth  day falls very rapidly, but usu-
        ally not below 100°.  It again rises quickly to 104°, re-
        mains stationary for 24 or 48 hours  then falls to normal
        till convalescence is established.
    Evacuations—brownish  or  nearly  black (due to presence of
        blood passing through the intestinal canal).
    Diarrhoea—rare.
    Albuminuria—frequent in grave and fatal cases.
    Urine—usually  scanty and  contains  hyaline  and  granular
        casts, red blood corpuscles and renal and vesical epithe-
        lium.  It is  acid in the early stage and afterward alkaline
        due to the presence of bile when it may be  of an orange
        color (from bile staining and blood).  Previous to a fatal
       termination there is always complete suppression. 
276
DISEASES OF THE BLOOD.
    Surface of the body—yellow  (occurs after the paroxysm of
        fever).
    Eyes—red (like a ball of fire) and watery, and have a brilliant
        glassy transparent look.
    Jaundice—hepatogeneous (usually in fatal cases).
    Hemorrhages  may occur from the stomach, intestines, kid-
        neys, bladder, uterus, nostrils, gums, etc.
    Petechioe and vibices—sometimes observed.
    Coma and convulsions—may occur (due to uraemia).
    Delirium—may occur (usually during the fever).
    Muscular prostration.
    Facies—suffering ;  dejection ; anxiety ; anguish ;  despair;
        terror ; stupidity ; vacancy , astonishment; sullen ; etc.
Third stage—(stage of collapse or exhaustion).
    Prostration and feebleness.—Pulse, irregular.
    Extremities, cold.—Delirium, low.
    Indifference and apathy (as in epidemic cholera) showing ten-
        dency to death by asthenia.
    Restlessness—jactitations and great distress may occur.
    Death or convalescence.
    If convalescence occurs it is slow and preceded by fever with
        typhoid symptoms.
                DIFFERENTIAL DIAGNOSIS.
  From malarial fever; relapsing fever;  bilious  remittent; and
acute yellow atrophy of the liver.

                        PROGNOSIS.
  Is unfavorable.  The duration of the fever is usually about six
days.  It often destroys life in three clays.   The average ratio of
mortality is that, in every three cases during an epidemic, death is
the result.
                       TREATMENT.
  The patient must be quarantined; quinine administered daily
(ingr. x. doses).  Counter irritation  should be  applied over the
region of the  kidneys at  the commencement of  the attack, and
calomel administered  as a cathartic.  It  is better to  combine
the calomel with  the  quinine, giving gr. x. of  each at a dose.
Administer milk and lime-water, in order to overcome, if possible, 
SIMPLE INTERMITTENT FEVER.
'277
 the nausea and vomiting.  Should there be restlessness with toss-
 ing and rolling of the head, it is best controlled by the hypodermic
 use of sulphate of morphine.  As soon as the stomach can receive
 food, the composition of the blood should be improved by giving
 a most nutritious diet  combined with wine, quinine, and iron.

                  MALARIAL  FEVERS.
  In order to produce these fevers, there must be a certain amount
 of  vegetable matter and moisture on the surface of or in the soil.
 A temperature ranging from 58" to 65° is required for its develop-
 ment. These fevers occur especially in marshy districts when
 covered  by a thin sheet  of water, and  exposed directly to the
 sun, or when they have dried up; also when salt and fresh-water
 become mixed in the marshes; in damp-bottomed lands that are
 ■exposed to an annual overflow; or when new lands are opened up.
 The malarial poison may be conveyed by rivers which have their
 course in and flow through malarial districts, or it may be trans-
 mitted by the wind for a distance of about  four miles and three-
 quarters.  The limit for malarial fevers is 63° north and 57° south
 latitudes, seldom above an  altitude  of 2,500 feet.   It can be
 prevented by free drainage, and may be  arrested by cold.  It  is
 less virulent during the day than the night. The poison may be
 introduced into the system through the  air we breathe and the
 food and water consumed.  It is most liable to attack the weak,
 anaemic,  and drunken.   Taking cold over fatigue,  sudden changes
 in the temperature, etc., are apt to predispose one to an attack.

         SIMPLE  INTERMITTENT  FEVER.
                        DEFINITION.
  Is a condition due  to a malarial poison  taken into the body
 through the lungs, food, etc.

                    MORBID ANATOMY.
  The following are the constant pathological changes: Conges-
tion of the internal organs; enlarged spleen and liver (due to hy-
 peraemia); more or less hyperaemia of the kidneys and mucous
membrane of the intestines. 
278
DISEASES OF THE BLOOD.
                        ETIOLOGY.
  The predisposing causes are intemperance; exposure to the night
air; excessive fatigue; bad hygiene; and general depression.  In
children it is generally ushered in by convulsions.
                           TYPES.
  (1) Quotidian—(most  common)  occurs in the  morning.   A
paroxysm takes place every twenty-four hours, and lasts from
eight to ten hours.
  (2) Tertian—occurs about noon, with a paroxysm every forty-
eight hours, and lasts from six to eight hours.
  (3) Quartan—occurs in the afternoon or evening.   A paroxysm
takes place every seventy-two  hours, and lasts  from four to six
hours.
  (4) Quotidian Double.—There are two paroxysms daily; the one
severe and the other mild.
  (5) Tertian Double.—There  are  two paroxysms  every second
day; as to-day, a severe chill  and slight fever; to-morrow, a severe
fever and slight chill,  and so on.
  (6) Also a fever which  occurs every  seventh day,  or multiple of
seven.
                         STAGES.
  Each of the types in  this  disease are characterized by a cold
stage; a hot stage;  and a sweating stage.
                        SYMPTOMS.
Cold stage—(lasts from half an hour to three hours).
    Creeping coldness  in the  back, extending to the extremeties.
    Headache—(supra-orbital).
    Chills—lasting from  half an hour to three or four hours.
    Urine—abundant and pale.
    Temperature - (elevated in the axilla or rectum).
    Surface temperature is below normal.
    Temperature per rectum is often 104°.
    Livid appearance of  the  skin, face, etc—eyes sunken.
    The so-called " Goose-flesh "  may exist, due to the erection of
     the papillae of the  derma.
Hot stage—(lasts from half an hour to two hours).
    Temperature—rises  suddenly 106°-107° in the axilla. 
SIMPLE INTERMITTENT FEVER.
279
    Pulse—rises.
    Tongue—dry.
    Great thirst.
    Intense heat and redness of the skin.
    Carotid pulsation.
    Great restlessness and uneasiness.
    Urine—high-colored and scanty; almost suppressed.
Sweating stage—(lasts from one to two hours).
    Commences first on the forehead, when the patient goes off
        into a sleep, and wakes up much exhausted.
    Temperature—is about normal.

               DIFFERENTIAL  DIAGNOSIS.
  From remittent fever and pyaemia.

                        PROGNOSIS.
  In the simple form the prognosis is good.  If malarial cachexia
be developed, there is the enlarged spleen, and  liver, and  pig-
mentation of tissue, which prejudices the life of the patient.

                       TREATMENT.
  The patient must be kept  in bed.   Opium should be given in
moderate doses hypodermically early in the cold stage, to diminish
the severity of the attack.  Quinine, gr. xxx., should  be admin-
istered between the termination of one paroxysm and the hour
when another is expected.
  In the cold stage.—The patient should drink hot water, or some-
thing hot, and be  covered with blankets, and hot water bottles
applied to various parts of the body.
  In the hot stage.—The blankets  should gradually be removed,
and the patient be given  cold drinks.  When  there is vomiting,
opium  should be used hypodermically.
  In the sweating  stage.—The patient must be left  alone.  In
order to overcome the paroxysms, give quinine, gr. xxx., one
 our previous to the expected paroxysm, if possible, in the form
of a solution, as follows: gr. x. just before the sweating stage (or,
gr iij. hypodermically), and gr. xx. one hour before the paroxysm. 
280
DISEASES OF THE BLOOD.
 Keep the patient under cinchonism for a few days, or even one
 month, by giving quinine, gr. xv. every day, about two hours
 before the expected paroxysm. Remove the patient if possible,
 from the district.
   It is always of great advantage to give a good dose of calomel,
 gr. x., and jalap, gr. xv. at the commencement of the  illness, as
 it will oftentimes avert the paroxysms; then resort to the quinine
 after the bowels have been evacuated.  Pilocarpine, gr. £,  may be
 given hypodermically, to break up an attack.  If the quinine does
 not act, commence by giving Fowler's solution, gtt. v., and increase
 the dose one drop every day till you reach gtt. xxx.; having at-
 tained this maximum, commence  again with gtt.  xv.  Philorid-
 zine, gr. xv.-xx. (the active principle of the apple-tree bark) may
 be given before each  meal  in cases where quinine has failed to
 afford relief.  This drug is very little known, but has proved suc-
 cessful in the hands of many.


                 PERNICIOUS  FEVER.
                        SYNONYMS.
  Congestive;  climatic; ardent; African;  tropical typhoid.

                       DEFINITION.
  It is the most severe and dangerous form of malarial fever.  It
 may assume any of the types of a periodical  fever, but the quo-
 tidian and tertian are the most common forms.

                        VARIETIES.
  Comatose; delirious; gastro-enteric; algid;  icteric;  hemor-
 rhagic; and colliquative.

                   MORBID ANATOMY.
  Is similar to the changes of intermittent and remittent  fevers,
 but differs very much in degree, and will depend upon the severity
 of the fever.   In the blood, the pigmentation is more abundant,
and the  pigment material may be in  the  form of granules, or
plates, or have a cellular outline.  On post-mortem, in some in- 
PERNICIOUS FEVER.
281
 stances, the brain-substance will be more or less stained with pig-
 ment material; in others, minute blood  extravasations, scattered
 throughout the substance of the organs,  will be detected.  Small
 blood extravasations into the  spinal cord, with more or less pig-
 mentation, may produce tetanic spasms during life.  Every organ
 in  the  body may be  pigmented.   The  various  organs may be
 markedly engorged.   The spleen may be found softened, as well
 as enlarged, or it may have infarctions scattered through its sub-
 stance.   The kidney and lungs are sometimes the seat of extensive
 hyperaemia, causing great interference in their functions.

                         ETIOLOGY.
  It differs from the simple forms  of malaria only in degree.  It
 prevails only in localities where the average range of  temperature
 is 65%
                         SYMPTOMS.
 These frequently commence in the same manner as in intermittent
    or remittent fever.
 Comatose variety.
    After a remission,  the patient passes  into a state of stupor.
    Face—flushed.
    Conjunctiva—congested.
    Pupils—dilated.
    Respiration—slow, deep, stertorous,  and, later'on, increased
        in frequency.
    Pulse—slow (which becomes frequent as the disease advances).
    Temperature—105° to 107° (in the axilla).
    Urine—retained.
    Bowels—move involuntarily.
It is usual,  in  about twelve hours, for a remission to take place,
    and the patient to awake, in a profuse perspiration, to con-
    sciousness; but, with the next exacerbation, the  same symp-
    toms appear only with increased severity,  and the patient
    passes into a fatal coma.
Delirious variety.
    Delirium—violent in character.
    Face—flushed. 
282
DISEASES OF THE BLOOD.
    Carotid pulsation.
    Eyes—in j ected.
    Tetanic spasms—may occur.
    Conjunctiva—congested.
    Memory of what has transpired seems lost.
    Pupils—dilated.
    Distinct intermission—may occur.
    Pulse—full and hard.
    Temperature—107° to 108°.
Attacks of delirium  may be repeated three or four times.
Gastro-enterie variety.
    Vomiting—excessive  and purging.  The materials  vomited
        and discharged from the bowels are blood-stained.
    Sense of weight and burning in the stomach.
    Cramps—in the calves of the legs.
    Coldness and blueness of the surface.
    Pulse —small and almost imperceptible.
    Eyes—sunken.
    Face—resembling that of cholera.
    Thirst—intense.
    Inspirations—double, followed by a double sighing expiration.
  When fully developed, few patients recover.
Algid variety.
    Surface of the body is cold.
    Rectal temperature—104° to 107°.
    Sensation of  burning.
    Thirst—intense.
    Cold perspiration cevers the body.
    Pulse—slow,  and finally disappears at the wrist.
    Tongue—white,  moist, and cold.
    Breath—cold.   Voice—feeble and sunken.
  When once this type is established, it progresses to a fatal term-
ination, unless arrested early by treatment.
Icteric variety.—This stage usually  lasts three hours, and often
    terminates in death.
    Chill—long and continuous.
    Jaundice—appears first in the eye, but rapidly passes over the
        entire body. 
PERNICIOUS FEVER.
283
    Copious vomiting of bile and a bilious diarrhoea.
    Headache—intense.
    Delirium—low and muttering in type.
    Pain —in the region of the liver and spleen, and over the kid-
        neys.
    Feeling of numbness in the limbs.
    Pulse—small,  frequent, and hard.
    Urine—deep- colored.
  As the hot stage approaches, the
    Pulse—becomes more frequent.
    Respiration—labored.
    Temperature—106° to 107°.
    Thirst—intense.
  If the sweating stage is reached, recovery usually takes place.
  Death usually occurs during two or three paroxysms.

                DIFFERENTIAL DIAGNOSIS.
  The comatose  and delirious varieties may be  confounded with
 cerebral apoplexy, meningitis,  or acute  uraemia; the  gastro-
 enteric and algid with Asiatic cholera; and the icteric with yellow
 fever.
 Cerebral apoplexy.
    Hemiplegia —is usually present.
    Coma—sudden.
    Pulse—slow.
 Comatose and delirious varieties.
    Hemiplegia—rare; but, if present, occurs late.
    Coma—later; and, with the coma, a rise in temperature.
    Pulse—rapid.
Asiatic cholera.
    Vomiting—projectile.
    Discharges—rice-watery.
    Urine—albuminous.
    Temperature—not  so high as in the  gastro-enteric and algid
        varieties.
Gastro-enteric and algid varieties.
    Vomiting—excessive and blood-stained. 
284
DISEASES OF THE BLOOD.
    Discharges—blood-stained.
    Urine - does not contain albumen.
 Yellow fever.
    New comers are almost certain to contract the disease.
    Jaundice—late.
    Urine—rarely bloody.
Icteric variety.
    Those are seized who have  been longest under the influence
        of  the malarial poison.
    Jaundice—early.
    Urine—frequently contains blood.
                        PROGNOSIS.
  Is unfavorable, unless you can control  the disease before the
second paroxysm conies on.
                       TREATMENT.
  On account of the alarming symptoms which follow so rapidly
on each other, prompt and vigorous measures must be resorted to.
Depletion in every form should  never  be practised.  The only
remedies which can  be relied upon for controlling every variety
of this  disease are  quinine and  opium, which should  both be
given hypodermically.  The following formulae for  the  solution
of quinine are those employed  by the English surgeons for this
disease: R quiniae disulph., gr. 1.; acid, sulph., nt v.; acid, carbolici,
Tq, ij.; aquae dest., \ i.; or, R quiniae sulph., 3 i.; acid, hydrobromici,
 3ij.; aquae dest.; 3 vi.  Thirty  minims  represent from three to
four grains of quinine. From five to seven grains should be given
every hour till the paroxysm  has  passed; after that, it should
be given in three grain-doses  every four hours.  One-fourth of a
grain of morphine should be administered with the first injection
of quinine, and continued until  the patient is brought fully under
its influence.
  Warburg's tincture is claimed  by many to  have  more control
over this form of fever than quinine or morphia.  One half ounce
of this  mixture  is given undiluted  after the bowels have been
evacuated by  a  convenient purgative, drinks of all  kinds being
withheld, and in three or four  hours after, the other half is ad- 
DENGUE FEVER.
285
 ministered in the same way, when profuse, but  not exhaustive
 perspiration, rapid decline  of temperature, and abatement of
 headache take place.  A second ounce of this tincture is seldom,
 if ever, required.


                    DENGUE  FEVER.
                        SYNONYMS.
  "Break-bone fever;" and " dandy" fever.

                    MORBID ANATOMY.
  Is the same as that of the severer types of malaria, excepting
 that there is an exanthematous eruption which commences on the
 palms of the hands, extending rapidly over the entire body;  it is
 also accompanied  by arthritic changes, and enlargement  of the
 external lymphatic glands.
                        ETIOLOGY.
  It may be either epidemic or sporadic, and attacks all classes
 and ages.  It is a portable disease (some say it is contagious,
 which is questionable).  It may be the precursor of yellow fever.
 It occurs particularly in the Southern States of America, and the
 severity of  the attack depends upon the intensity of the poison.
 Its period of incubation is from three to five days.

                          STAGES.
  Initiatory; fever; remission; and secondary fever and convales-
cence.
                        SYMPTOMS.
Initiatory Stage.
    Headache.
    Photophobia
    Great restlessness.
    Chilliness.
    Pain—in the back, limbs, and joints.
    Swelling of the small joints, and soreness of muscles.
    Fever—which lasts from twelve hours to four days. 
286
DISEASES OF THE BLOOD.
    Temperature—may reach 107°.
    Pulse—120 to 140.
    Face—flushed.
    Eyes—red and watery.
Stage of Fever.
    Pain increases after the fever has lasted twelve hours and ex-
        tends down the sciatic nerve.
    Nausea and vomiting.
    Pain—in the epigastrium.
    Glands—swollen (axillary, inguinal, and cervical).
    Epididymitis—in some cases.
Stage of Remission.
    Profuse sweatings—may occur.
    Diarrhoea—may occur.
    Epistaxis—may occur.
    Pains, etc.—diminish.
Stage of Secondary Fever and Convalescence.
    Fever, and pains, etc.—return with greater intensity.
    Eruption—appears about the fifth  day, first on the palms of
        the hands, then on the neck,  and spreads.   It  is of a
        papillary form, resembling scarlet fever.
    Tongue—is coated and dark-brown (like in typhoid fever).
    Heart—becomes intermittent.
    Glands—may suppurate.
               DIFFERENTIAL  DIAGNOSIS.
  From rheumatism, remittent and relapsing fevers.
  From rheumatism—by the febrile symptoms which precede the
arthritic pains, and the fact that the fever prevails epidemically.
  From, remittent fevei—by the persistency of the rheumatic and
neuralgic pains, eruption, and character of the remissions.
                        PROGNOSIS.
  Is usually favorable.  Is only unfavorable  in the aged, and feeble
infant.
                       TREATMENT.
  It is customary in this disease to administer ipecac, calomel, and
colchicum every night in  cathartic doses.  Calomel should never 
TYPHO-MALARIAL FEVER.
287
 be given alone if its specific effects are likely to be produced.   In
 order to relieve the pain in the head and limbs, colchicum should
 be given in combination with spirits of nitre and nitrate of potash
 (as a diaphoretic), in connection with an effervescing draught.
 During the remission, keep the bowels open by a saline cathartic,
 and give quinine combined with an alkali at stated intervals. For
 insomnia, narcotics may be given in small doses.   Should there be
 exhaustion, the free use of wine  and beer may be resorted to, and
 nutritious  diet administered at  stated intervals, day and night.
 The lymphatic  enlargements (if any) should be painted with
 iodine.
   Citrate of quinine and iron will be found of great service dur-
 ing convalescence.  Should the joints remain swollen and tender
 for a long time, blistering the parts has been recommended.


              TYPHO-MALARIAL  FEVER.
                        DEFINITION.
  Is a fever produced by the combined action of a septic and
 malarial poison.
                   MORBID ANATOMY.
  The  changes which  occur in  this disease are confined to the
 blood, and the various internal organs.
  Blood.—The changes that occur in the vital fluid are similar to
 those in typhoid fever, combined with the presence of free pig-
 ment granules.
  Liver.—Is increased in size, and, on section, resembles the nut-
 meg-liver.  It may resemble the liver of yellow fever or the
 bronzed liver of  remittent fever.  The microscope will show free
fat, and brown pigment granules in the hepatic ceUs.
  Spleen.—Is enlarged, softened,  and almost black in color. The
 Malpighian bodies are prominent.
  Kidneys.—There will be found  a state of marked hyperaemia  in
 the cortical substance.
  Lungs.— There  will be a hypostatic congestion at the most de-
 pendent portion of each organ. 
288
DISEASES OF THE BLOOD.
  Heart.—Will be pale and flabby.  There will be a granular de-
generation of its muscular fibres.  In  its cavities will be found
exsanguinated clots.
  Intestinal lesions.—As the follicles enlarge, there is a tendency
to the deposit of a black pigment.  Extensive ulcerations of these
follicles also take  place, and they may invade  the adjacent
mucous membrane.   These ulcerations are found  principally in
the ileum, and involving Peyer's patches; their edges are irregular
and everted, and their base  is of  a grayish color,  often mottled
with dark spots.  They may extend into the sub-mucous tissue,
involve the muscular coat of the intestine, and even perforate the
peritoneal covering.
                         ETIOLOGY.
  It is only met with  in malarial districts.   Its  development  is
favored by bad hygienic conditions, such as improper diet, over-
crowding, bad sewerage, etc.; it is never  propagated by contact,
or by morbid excretions, but it is a distinct malarial poison.   It is
really a combination of two well-recognized forms of fever.

                        SYMPTOMS.
When the malarial element is predominant.
    Distinct chill, malaise, and pain in the limbs and back.
    Countenance—waxy, clay-colored, or of a yellowish tinge.
    Temperature—rises to 103° to 104r in a few hours.
    Pulse—full and forcible (usually about 100).
    Mental disturbance.
    Delirium—sometimes.
    Tenderness in the right iliac fossa.
    Nausea.
    Vomiting.
    Epigastric tenderness.
    Diarrhoea—usually present, and may precede the chill.
    Tongue—is at first pale, flabby, and has a smooth surface;  it
       soon becomes covered with a  yellowish-white coating;
       later, it becomes red and with a brownish coating, and  in
       severe cases, it may suddenly become clear, red, and shin-
       ing.  Sordes may collect on the teeth and lips. 
TYPHO-MALARIAL FEVER.
289
    In fatal cases—towards the second or third week, the symp-
        toms resemble those of fatal typhoid fever, and the pulse
        reaches  130-140; is feeble and irregular; and coma and
        death ensue.  In cases that recover, signs of amendment
        may be noticed about the tenth or twelfth day.
 When the septic element is predominant.
    General malaise.
    Chill — is  distinct, or a complete  intermittent  or remittent
        paroxysm may be produced.
    Temperature—may rise gradually or suddenly to 104° to 105°
        within twenty-four hours.
    Remissions occur on every second or third day.
    Hepatic tenderness.
    Spleen—enlarged.
    Pulse—first  week  full,  rarely  above 100;  but.  during the
        second and third week, is small and compressible; and, in
        severe cases, it becomes intermittent (ranging from 110 to
        130).
    Tongue—swollen at first, with red projecting papillae and a
        hght white coating; afterward it  resembles closely the
        tongue in typhoid fever.
    The surface of the body becomes dry and harsh.
    Skin—is of a bronzed hue.
    Jaundice—well marked.
    Urine—high-colored and scanty.
    Diarrhoea—may occur at any period, but is not usually exces-
        sive until the second or third week.   The discharges have
        a  very foetid odor,  are watery and dark-colored, and, in
        the later stages,  may contain blood.
    Delirium—(which follows  the headache) may be present, and
        is muttering in character, and other typhoid symptoms.

                DIFFERENTIAL DIAGNOSIS.
  It may be  confounded  with  typhoid,  remittent, relapsing,
typhus, and yellow fevers.
Typho-malarial fever.
    The advent is marked by a distinct chill; the rise in tempera- 
290
DISEASES OF THE BLOOD.
        ture is sudden; there is a peculiar eruption which remains
        throughout the course  of the fevers;  there is a distinct
        periodicity in the febrile action; a jaundiced hue to the
        surface; and the blood contains free pigment.
Typhoid fever.
    The symptoms come on  insidiously; there is a typical range
        of temperature;  on the sixth or eighth day a rose-colored
        eruption appears.
Typho-malarial fever.
    There will be enteric symptoms early; typhoid symptoms are
        developed as the fever advances.
Remittent fever.
    There are no  enteric symptoms, but it yields more promptly
        to the use of quinine than typho-malarial fever.
  Typho-malarial fever may be easily diagnosed from yellow fever,
as, in the latter, the range of  temperature is lower, and falls sud-
denly on the third or  fourth day; there will  be also the circum-
orbital pain; the appearance of  the eye; the peculiar color of the
skin;  the character of the matter vomited; the absence of diar-
rhoea; the presence of albumen  in the urine; and, finally, by the
fact, that it is a portable disease, and prevails epidemically.

                        PROGNOSIS.
  The septic  is more fatal than the malarial type.  The hygienic
surroundings, previous habits of the patient, and range of atmo-
spheric  temperature will of course aid your prognosis.  The
average mortality is given as one in every twelve or twenty-four.
The average  duration  of cases terminating in recovery is from
three  to four weeks.  Capillary bronchitis  and  pneumonia are
very dangerous when developed during  the third week.

                        TREATMENT.
  Depends entirely upon the type of the disease. Prevent the over-
crowding in the houses: remove your patient, if possible, from his
present  surroundings;  improve his diet thoroughly; and  by these
means you will prevent the development of a  poison which gives
to this fever its typhoid type.   In cases where the malarial ele- 
TYPHUS FEVER.
291
 ment is prevalent, administer quinine (grs. xx.-xxx.) in two or
 three doses of gr. x. each every hour until the desired quantity
 has been given.  In the septic variety, quinine has no effect.  By
 some, arsenic is claimed to have a specific influence over this form
 of the  disease, but its  beneficial effect is due to its power over
 malarial affection, and not to its specific influence over the fever.
 In fact, the treatment may be said to be almost identical with that
 of typhoid fever.


                    TYPHUS  FEVER.
                         SYNONYMS.
   Ship  fever; hospital fever:  jail fever;  camp fever;  petechial
 fever; putrid fever; continued fever; fourteen days' fever; cerebral
 typhus; exanthematous fever.

                    MORBID  ANATOMY.
   The first changes that take place are  in the blood,  which is
 darker  than  normal, and when drawn during  life, coagulates im-
 perfectly or not at all; but, if it does, the clot is of the consistency
 of putty.  The fibrin is diminished and loses its power of coagu-
 lation.  The  red globules first increase, and then diminish, and
 urea and ammonia are found  to be  in excess.  The blood when
 drawn rapidly undergoes ammoniacal decomposition,
   The microscope shows the red blood-globules to have lost their
 outline; they have serrated and irregular edges, and undergo de-
 generation.  The coloring  matter passes through the walls of the
 vessels and stains surrounding tissues.
  Parenchymatous  degeneration  next takes place.   The blood
 rapidly undergoes decomposition after death, even sooner than in
 typhoid fever, often  beginning before death.  The muscles are of
 a brownish color, dry, and granular.  The liver and spleen under-
 go similar degeneration.  In the kidneys, the changes are much
 more extensive and  constant than  in typhoid fever; the cortical
 substance is swollen, opaque, and fatty, and is marked by a cloudy
 swelling of the epithelium in the renal tubes.  This cloudy swell-
ing also occurs in the heart-fibres,  causing flaccidity, and giving 
292
DISEASES OF THE BLOOD.
to the heart a dark-brown color.  There is often serum in the peri-
cardium ; clots occur in the cavities of the heart, and thrombi on
the walls of the  veins.  Ulceration of the mucous membranes of
the mouth  and larynx ensues, involving the sub-mucous tissues.
Splenization of the lungs takes place, and the cerebral vessels be-
come congested.   The sinuses and blood-vessels in the brain are
engorged, so that  they will  stand  out prominently when the cal-
varia is removed,  and there will be more or  less effusion in the
meshes of the pia mater (often from eight to ten ounces). If the effu-
sion be turbid, it is an indication that there has been meningitis.
If the effusion be abundant, the sulci are deepened  and the con-
volutions are sharpened in outline.
  Abdominal lesions.—Intestinal changes are absent.  There is no
ulceration  of the  glands excepting  changes  which have  taken
place from congestion (causing the shaven-beard appearance in
Peyer's patches).
  Complications.—These may be pulmonary,  cerebral, or spinal.
  The  pulmonary  include bronchitis, catarrhal pneumonia, pleu-
risy, congestion, oedema, pulmonary gangrene (from pneumonia),
and laryngitis (from extensive bronchitis).
  The  cerebral or  spinal include  meningeal  inflammation with
serum in the meshes of the pia mater; but, besides this sub-arach-
noidean effusion, there must be also plastic exudation; the arach-
noid has lost its shining color and is thicker than normal.
  There will be active delirium; contracted pupils; pulse, slow, full,
and then rapid, and irregular, and intermittent, and the urine is
often passed with difficulty.  The parotid, sub-lingual, and glands
of the neck become greatly enlarged, so as to interfere with deglu-
tition and to often cause death.  The inguinal glands may become
so enlarged as to interfere with the return circulation. There may
be a swelling of the lower limbs from degeneration and feebleness
of the heart, causing retarding of  the circulation and thrombi in
the superficial veins. Suppuration and. cellulitis may occur, result-
ing in extensive abscesses. 
TYPHUS FEVER.
293
    SYNOPSIS OF  THE  FOREGOING  PATHOLOGICAL
                         CHANGES.
  The changes that take place occur in the skin,  organs, and
blood.
In the skin—the mulberry rash will be present on the side of the
    chest and abdomen, and  possibly on the extremities;  it dis-
    appears on pressure (for three  days) and the spots are dark in
    color and somewhat elevated.
In the brain—there is hyperaemia of the vessels of the convexity;
    meningeal exudations: serous  effusion into the meshes of the
    pia mater and ventricles;  the  arachnoid becomes opaque and
    dotted with yellowish spots.
In the alimentary canal—changes take  place in Peyer's patches
    (producing the " shaven-beard" appearance).
Complications.—Bronchitis, pneumonia,  splenization of the lung,
    pleurisy, oedema, meningitis, parenchymatous nephritis, and
    finally ulceration of the  larynx,  pharynx, and  mouth, and
    enlarged cervical and probably inguinal glands.
In the blood.—AU the common lesions of  fevers (see page 316), and
    a marked increase in urea.
                        ETIOLOGY.
  This disease is due to a specific poison, communicated from the
sick to the healthy by contagion  only.   Over-crowding and bad
ventilation favor the spread and  increase the severity of the dis-
ease.  The poison passes into the  blood  mainly through respired
air.
                        SYMPTOMS.
Initial symptoms—come on suddenly, and include:
    Vertigo.
    Loss of appetite.
    Chill.
    Steadily increasing frontal headache.
    Pain—in all the limbs (especially the thighs).
    Extreme prostration.
   Tottering gait—the patient is then  compelled to take to his
       bed. 
294
DISEASES OF THE BLOOD.
1st Week.—Temperature—104°-105°, morning and evening varia-
    tions are slight;  it rises one or two degrees.
2d Week.—Temperature—is liable to sudden depression, but gener-
    ally falls at this period.  If it continue, it denotes development
    of cerebral symptoms, commencing with this sudden depres-
    sion.   It is usually highest on the second or third day of the
    disease.
Tongue—is first swollen, white, and coated ;  then of a yellowish-
    brown color, and thick ; and, later on,  becomes dark, dry and
    fissured.
Delirium—low, muttering, or active (often becomes furious about
    the eighth day);  it comes on early and  continues  till the end
    of the disease.
Coma-vigil—patient  has horrid  fancies and  visions, and is  abso-
    lutely indifferent as to what is going on, and lies with his eyes
    wide open.  Is usually followed by a fatal termination.
Headache—severe and persistent for the first ten days.
Stup or and somnolence—seldom absent.
Paralysis of the sphincters of the anus and bladder or, of the
    mucous coat of the bladder (causing retention).
Dysphagia and partial or complete aphonia.
Picking at the bed clothes, and subsultus tendinum.
Heart—the first sound may be inaudible.
Pulse—during the second week the pulse may be small and feeble
    140 or 150, which is unfavorable; is generally 100, frequent,
    soft,  rapid, easily compressible, and irregular;  if 120 for three
    days in the first week, it denotes danger.
Urine—is first diminished, and then increases, and will contain a
    small amount of albumen; or, if it be a severe case, albumen
    will  be large in quantity, and there will be renal casts, also
    epithelium and fatty casts of the uriniferous tubes.
Eruption—(called the mulberry rash)—consists of small,  irregular-
    shaped, dark, brick-dust spots; is slightly elevated at first,
    and remains  throughout the disease.  It appears on the fifth
    to the seventh day of the fever, and disappears on pressure (for
    the two first days of the eruption).   Is present upon the sides
    of the chest, abdomen, and possibly on the extremeties. 
TYPHUS FEVER.
295
 Constipation.
 Countenance—dull, heavy, and, later on, of a mahogany color.

                   CAUSES OF DEATH.
   Death may result from meningitis, pneumonia, capillary bron-
 chitis, gangrene, exhaustion from  the effects of poison, Bright's
 granular kidney, coma and syncope.
                DIFFERENTIAL  DIAGNOSIS.
   From typhoid and relapsing fevers; measles; pneumonia; acute
 Bright's disease; meningitis; delirium tremens; erysipelas; pyae-
 mia; and septicaemia.
                        PROGNOSIS.
   Is always  grave.  It depends upon the age of the patient, the
 character of the epidemic, and the complications.  With the in-
 temperate, it is likely to prove fatal.
   In cases where debility exists from advanced age, intemperate
 habits, privation, previous disease, mental depression, over-crowd-
 ing, bad ventilation, and gouty diathesis, the prognosis is always
 dangerous.
                        TREATMENT.
   Quarantine your patient, as  it is a contagious disease.  Thor-
 oughly disinfect the premises for  two or three days, at the time
 and after the disease.   The patients should be placed in pavilions
 or tents in order that they may have plenty offresh air.  Remove
 all windows regardless of cold, and supply plenty of blankets.
  Medical treat men t. —Fresh air is the only remedied agent.  First
 reduce the temperature, and then sustain the heart's power.  Ad-
 minister quinine and  apply cold to the surface.  Milk should be
 the only diet, and water may be drank freely.  If the temperature
 be 104°, put the patient in a bath 10° lower than the temperature
 of the body.  Ice or cold water may be added to the bath till  the
 temperature falls to 68° or 70°, and the patient kept in it till his
 temperature falls to 101° or 102°;  then  he should be taken out,
 dried quickely, and put  into bed.  Should  the  temperature rise
again,  repeat the  bath.   If there  should  be intense pain and
delirium after taking the bath, put ice-bags to the head. 
296
DISEASES OF THE BLOOD.
  Give quinine—gr. Ix. in two hours, with gr. x. pulverized digi-
talis added.
  Stimulants (?).—Patients under twenty-five years of age rarely
require it unless they happen to have been intemperate prior to
the attack. To the old and feeble, when occasionally administered,
it probably does good.  You should always watch your patient
when administering stimulants,  as in typhoid fever.  One ounce
in twenty-four hours is all that is necessary, and then only to sus-
tain the heart's power.
  Cardiac sedatives.—Veratrum, aconite, and  digitalis may  be
administered.   For failure of the heart's  power, give  digitalis
3 iv.-vi. in twenty-four hours, or quinine and digitalis in the same
proportions.
  For insomnia—keep the room dark and quiet, give opiates in
full doses, and apply cold to the head.
  For insomnia and delirium—give chloral gr. x.-xv.
  For stupor—if occurring early, give coffee, musk, camphor, or
cold douche.
  For coma—valerian and phosphorus may be given,  but they
are not efficacious.
  If the patient cannot take quinine by the mouth, give it by the
rectum, about one-third more than  by the mouth, thus, quinine
dissolved in acid causes it to become disulphide or in the form of
a suppository of the bisulphide by the rectum.

                  REMITTENT  FEVER.
                        SYNONYMS.
  Southern;  Western ;  African ; continued ; bilious ;  and accli-
mative.
                        DEFINITION.
  Is one of the malarial fevers, characterized by a sudden invasion
and persistent  high  febrile symptoms ; temperature frequently
rising to 105°-106%
                    MORBID ANATOMY.
  It is the result of malarial poisoning ; consequently there is di-
minution in the  red blood-corpuscles; and pigment  granules
exist (due to hoemoglobin which has escaped from the red  blood-
corpuscles in  the  vessels, and developed in the liguor sanguinis, 
REMITTENT FEVER.
297
 and which may infiltrate into the adjacent tissues and cells).  The
 changes resemble  those occurring  in intermittent fever.  The
 principal lesions will be found in the spleen, liver, stomach and
 intestines.
 Spleen.—Is enlarged and bronzed (though  not  so much as in in-
     termittent fever), from congestion of the vessels, and an excess
     of pigment.
 Liver.—(called the " bronzed liver ") is not much increased in size.
     The peculiar color is  due  to pigmentation of the  tissues
     throughout  the organ.   This  is  the characteristic lesion of
     the fever.
 Stomach.—The mucous membrane is more  or less congested,
     thickened, and softened.
 Intestines.—The mucous membrane  is more or less congested
     thickened, and softened.  Peyer's patches are enlarged  and
     have the  '' shaven beard " appearance.  Sometimes ulceration
     of the intestines occurs, or there may be simple hyperaemia of
    the mesenteric glands, due to a catarrhal inflammation.

                        ETIOLOGY.
  The predisposing cause is malarial fever.  Remittent fever may
 pass into intermittent during convalescence.  It occurs chiefly in
 63° north and 57° south latitude.   It prevails  along the banks of
 rivers.   The miasm may be conveyed  by the winds.   It occurs in
 marshy regions where there is but little water.

                        SYMPTOMS.
                     Remittent Fever.
Premonitory symptoms.
    Oppression in the epigastrium.
    General malaise and sudden development of symptoms.
Cold stage.
    Chill—short and not severe (a general coldness).
    Temperature—rises about 3° above normal during the chill.
    Headache—intense.
   Pain in the back and  limbs.
ffot stage.
   Fever—which follows the chill, when temperature rises  rap-
       idly and within 12 hours may have reached 105° or 106°. 
298                 remittent fever.

    pMZse—increases with the temperature (reaches 110 to 130).
    Face—flushed.
    Eyes—suffused.
    Con j uncti va—con j ested.
    Great restlessness.
    Nausea—persistent and distressing.
    Vomiting—consists first of contents  of  the  stomach, then
       stringy mucus tinged with greenish matter, and  finally a
       slight black vomit.
    Great oppression and  tenderness in  the epigastrium, unre-
       lieved by vomiting.
    Symptoms increase in severity for 12 hours, when follows the
Remission stage.
    Perspiration—not profuse—commences on the forehead, ex-
       tending over the  entire body.
    Tempered ure—i&lls 1° or 2° (but there are  still evidences of
       fever, as it does not reach normal).
    Pulse—suddenly  falls 10 or 20 degrees.
    Thirst—diminishes.
    limiting—decreases.
Period of exacerbation—occurs at the same time on the f ollowing
    day when all symptoms return with increased severity.  This
    constant change  may continue for a week and the  fever be-
    comes a continued one  when
    Tongue—may be parched and sordes may be present  upon the
        teeth.
    Countenance—dull and heavy.
    Distress and pain and tenderness in the epigastrium.
    Constipation—which may give  way to diarrhceal discharges
        of a brownish character with fullness of the stomach and
        local tympanites.
    Typhoid symptoms—then come on as in the third week of
        typhoid fever.

                     Bilious Remittent.
     Vomiting—bilious.
    Jaundice of the skin—like yellow fever.
    Tenderness over the region of the liver. 
SMALL-POX.
299
               DIFFERENTIAL DIAGNOSIS.
  From intermittent fever ; typhoid fever ; bilious remittent fever;
yeUow fever ; pyaemia; septicaemia and typho-malarial fever.

                        PROGNOSIS.
  In a simple case the prognosis is always good.  Even cases of
severe types should recover if properly managed.  The average
duration of this fever is two weeks.

                       TREATMENT.
  The patient must be placed under the best possible hygienic sur-
roundings, and the same arrangements carried out respecting the
sick room as in typhoid fever.  Quinine must be given during the
exacerbrtion (paroxysm) or remission, in doses varying from gr.
x-xx according to the severity of the fever, and repeated every two
hours till cinchonism is produced.  If, after the free use of quinine
the exacerbations  be  more  severe, the remissions less frequent
and typhoid symptoms manifesting themselves, stimtdants may
be  resorted to, and probably in large doses, while passing through
this period.
  The  surface of the  body should be sponged with cold water if
the exacerbations be intense,  the headache  very severe and the
restlessness or fever are not relieved by the quinine given in large
doses.



                      SMALL-POX.
                        SYNONYM.
  "Variola" or "varioloid."

                        VARIETIES.
  Variola discreta (separated variola).
  Variola confluens (the spots running into each other).
  Variola hemorrhagica (the eruption being black, on  account of
hemorrhagic effusions). 
300
DISEASES OF THE BLOOD.
                    MORBID  ANATOMY.
  1st. There is congestion  of the organs, as of the brain, lungs,
liver, spleen, and kidneys.
  2d. There is the state of granular or acute fatty degeneration
(resembling changes due to phosphorus poisoning).
  3d. There is  the  state of fatty degeneration of the liver,  kid-
neys, and heart (which is usually yellow, flabby, and brittle).
  4th. There are small hemorrhages into nearly every viscera,
with ecchymosis of the serous  membranes and fluid blood in all
the cavities.
  The characteristic lesion  is the eruption upon the mucous mem-
brane and skin.  At first, a congestion of the papilla, sometimes
uniform, and sometimes in spots, giving rise to little red spots on
the surface, may be perceived, which are surrounded with cells
rapidly undergoing granular degeneration.  These papules are due
to changes in the surrounding cells in the rete Malpighii, and in
the capillaries,  and to certain new cell infiltrations.
  A serous infiltration on the surface of the papule now develops,
called the  vesicle (consisting of blood  serum, which has escaped
through  the walls of the capillaries).  The centre of the vesicle
becomes umbilicated (depressed), due, probably, to the serous in-
filtration taking place more rapidly at the periphery of the vesicle
than  at the centre, causing elevation of the periphery, although
it has been explained in other ways (adhesion of centre of vesicle
to the hair of the skin, formation of lymph-bands in the vesicle,
etc.).
  The vesicle next changes color, due to migration of white blood
and pus corpuscles from the capillaries into the surrounding
tissue, and then becomes  a pustule.   Destruction of the tissues at
the point where the papillary congestion first occurred takes place.
If the superficial layer of the skin be only affected, there  is no
scar left; but, if the inflammation  extend  to the deeper cellular
tissue, sloughing occurs,  resulting in cicatrix and pitting.
  After the pustules have formed, the inflammatory products dry
down, and a crust is formed, which contracts in  the central por-
tion.  These crusts separate when the inflammatory process sub-
sides, and recovery takes place. These lesions are not confined to 
SMALL-POX.
301
 (he skin, as they may also form on the mucous membrane of the
 stomach, intestines,  bronchial tubes, larynx, and  conjunctiva,
 urethra, etc.

              SYNOPSIS OF THE FOREGOING.
  The lesions of this disease occur in the skin, mucous membrane,
 organs, and blood.
 In  the skin.—All the stages of the eruption may exist, which in-
    clude the macule, papule, vesicle, umbilicated vesicle, pustule,
    scab, or  cicatrix; also, possible abscess, ulceration, and local
    sloughs.
 In  the mucous membrane.—The same conditions  are possible in
    the urethra,  eye,  nose, mouth, alimentary canal, and middle
    ear.
 In  the  organs. — Parenchymatous  nephritis,  oedema  glottidis,
    evidences of  complications, as pleurisy, pneumonia, peri- and
    endo-carditis, meningitis,  and bronchitis, and  fluid  blood,
    may be found in some of  the capsules.
 In the blood.—The common lesions of fevers (see page 316).

                         ETIOLOGY.
  It is propagated only by contagion; by means of  the breath and
exhalations from the skin; the poison may pass through the at-
 mosphere for a distance of about two and a half feet in the open
 air.  It may be contracted by entering a contaminated room.  It
 can be conveyed by clothing, but the clothing must contain pus
or crusts from the small-pox virus.  It  attacks ah  periods of life.
  Stage  of  infection.—This may occur during the period of sup-
puration, or the  stage of desiccation, or even during incubation.
The poison is absorbed by the mucous membrane of  the respiratory
tract during respiration.
  The period of incubation varies from ten to thirteen days; if the
poison be introduced from inoculation, forty-eight hours may only
elapse before the stage of initiatory fever takes place.

                          STAGES.
  Incubation.  Invasion.  Eruption. Suppuration.  Desiccation, 
302
DISEASES OF THE BLOOD.
                        SYMPTOMS.
                     VARIOLA DISCRETA.
Period of incubation and invasion.—(The invasion may be sud-
  den or gradual.)
    Chill and pain in the head, back and loins.
    Temperature—elevated, 104°-105° (may reach as high as 107°).
    Pulse—may rise from 100 to 120, and even 140 per minute,
        and may be full or more frequent.
    Nausea and vomiting.
    Soreness of the throat and pain in the pharynx.
    Delirium—about the third day (may occur).
    Face—flushed.
    Photophobia.
    Headache.
    Throbbing of the carotids.
    Conjunctiva—congested.
    Great restlessness.
    Countenance—anxious and flushed.
    Somnolence.
    Respiration—short, frequent, and labored.
    Cough—stridulous.
    Voice—husky, if the larynx be involved.
    Vertigo and convulsions (in children).
    Excessive languor.
    Anorexia.
Stage of eruption—on the third day after the initial fever.
    Eruption—usually  commences first along the edges of the
        hair; next on the forehead, nose, and upper lip; then on
        the body and extremities, a day or two  later; and, lastly,
        on the hands and feet.  It is of a, pale-red color, resem-
        bling flea bites, and about the size of a millet-seed or pin's
        head;  there is a sense of burning or itching on the sur-
        face, and it is less abundant on the  body and extremities
        than on the face.  On the second day, it becomes darker,
        elevated,  and  papular.   On the third day, it becomes
        more  conical,  and a vesicle forms  at its apex.  On the
        fourth and fifth days,  it is spherical and about the size 
SMALL-POX.
303
        of a pea, and as it enlarges, becomes umbilicated, the
        fever then subsides, and all pain is gone.
Stage of suppuration, or secondary fever,
    Suppuration—begins about the eighth day of the eruption
        with the following symptoms :
    Chill.
    Temperature—rises rapidly, perhaps higher than it did during
        the initial fever, sometimes as high as 108°-109°;  it reaches
        its maximum when suppuration  is at its height (about
        the ninth day) on the extremeties.
    Pulse—becomes frequent.
    Face—is a shapeless mass  and swollen (if the eruption  be
        abundant).
    Itching—intolerable.
    Breath—sweetish and of a sickly odor.
    Skin—becomes red and tumefied; and if the spots be thickly
        set, they become confluent.
Stage of desiccation.
    Desiccation—commences from the eleventh to  the fourteenth
        day of the eruption, when the pustule either ruptures,
        discharges its contents,  dries up  and forms a yellow crust,
        or shrivels and dries up without rupturing.
    The symptoms abate.
    Scabs—come off (about the eleventh to the fourteenth day).
    Skin—is of a red-brown color (lasting from five to six weeks).
    Appetite—returns.
    Convalescence—is established.
                    VARIOLA CONFLUENS.
  The duration is short and severe, only lasting about  forty-eight
hours.
Stage of eruption.
    Eruption—appears simultaneously all over the body; the spots
        are very numerous, especially on the face and hands.  On
        the first day they are almost confluent; on the second day
       the skin is  intensely red, and swollen, and vesicles form
        which  become confluent.  It may involve the mucous
        membrane of the mouth, throat, nares, and larynx, re-
       sulting in impossible deglutition. 
304
DISEASES OF THE BLOOD.
    Temperature—rises to 103,-104° till suppuration takes place.
    Typhoid symptoms set in.
    Tongue—becomes dry.
    Patient is semi-comatosed with sub sultus, low delirium, and
        intense nervous depression.
    Urine—albuminous.
    Glands—parotid and sublingual enlargements may occur.
    CEdema glottidis—may suddenly develop, which  will cause
        death, unless laryngotomy be performed early.
Stage of suppuration.
    Suppuration—steadily follows, forming flattened yellow-col-
        ored confluent patches, which run together.  Large bullae
        filled with sero-purulent fluid  are thus produced,  and
        these may spread over the face so as to render the patient
        perfectly unrecognizable.
    Temperature—is higher than in the stage of eruption.
    Vomiting—may be violent.
    Diarrhoea.
    Delirium.
    Coma.
Stage of desiccation.
    Desiccation—is slowly reached;  large  concentric  crusts are
        formed, adhering  to  the skin, and  beneath there is sup-
        puration of the papillary layer, with extensive destruction
        of the true skin, causing ugly pits and scars.
    The initial fever often reaches 106° to 107% and in severe types
        110°, and pulse is frequent and feeble.

                     COMPLICATIONS.
  Inflammation of the serous membranes,  especially pleurisy,
peri-carditis, croupous and catarrhal pneumonia, severe bronchial
inflammations, and uraemia.
Variola hemorrhagica.
  This is a modified form of the other two varieties, only differing
in the
    Eruption—which is very dark over the whole body.   There is
        also 
SMALL-POX.
305
    Hemorrhage—from the various mucous membranes of the
        body ; and in females profuse menorrhagia.
    Suppuration—is seldom reached.
    Death—results from exhaustion, due to hemorrhage, or  from
        the effects of the small-pox poisoning.

                   CAUSES  OF  DEATH.
  Death from small-pox may occur from oedema glottidis; general
bronchitis; pneumonia; or acute fatty degeneration of the kidneys.

               DIFFERENTIAL  DIAGNOSIS.
  It is more prudent to wait till the third day of the fever before
venturing on a diagnosis, when the eruption will be well out and
the vesicle found.  It may be mistaken for measles, typhus, and
meningitis, petechial eruptions, and chicken pox.
  Small-pox—commences with chill and  elevation of tempera-
ture; the temperature is very high, 106°-107% and  falls as soon as
the eruption appears.
  Measles—commences with coryza, sneezing, redness, and suffu-
sion of the eyes; the temperature rises after the eruption appears.
  Small-pox—the eruption appears on the third day, and is first
seen on the face and forehead.
  Typhus fever—(is difficult) there  is greater loss of  muscular
power, and the eruption is first seen on the abdomen.
  In Small-pox—the face is pale, and bears an anxious look.
  In Meningitis—the face is flushed and deepens.

                        PROGNOSIS.
  Depends upon the eruption, type of the disease, and age of the
patient. In variola discreta—unless complications exist, recovery
usually takes place (from one to five die).  In variola confluens—
the prognosis is more grave; one-half of the cases are generally
fatal.  In variola hemorrhagica—is  usually fatal in forty-eight
hours; and is more fatal in summer than in winter.  If the patient
has been of intemperate habits, is syphilitic, or a chronic case,
the prognosis is bad.  Whenever there is an abundance of the
eruption, the prognosis is bad.   When the urine  becomes scanty 
300
DISEASES OF THE BLOOD.
and high-colored at the commencement of the stage of suppura-
tion, you  may be sure there are  kidney complications, and con-
vulsions may occur, resulting in coma and death.
                        TREATMENT.
  The best mode of procedure is to treat the special symptoms as
they arise.  The patient should be quarantined, placed in bar-
racks,  or  large well-ventilated apartments, at a temperature not
below 60°  F , and where plenty of fresh air can be  obtained.  If
the temperature rise to 107° or 108°, apply cold to the surface, and
give antipyretic doses of quinine.  Should the headache be severe,
and the face flushed, ice-bags  applied to the head  may wonder-
fully relieve the patient.  For vomiting, let him  drink iced car-
bonic acid water, and should it be attended with restlessness and
delirium,  morphine, administered hypodermically,  is  indicated.
When  there is depression,  stimulants must be  given. If  the
mouth and  pharynx become involved,  ice, cold carbonic acid
water,  may be given, and  use a solution  of muriated tinct. of
iron, or carbolic acid, or permanganate of potash, as a gargle.
  In order to prevent pitting, cold applications, and  rupturing
each vesicle before  it becomes a pustule, has been found bene-
ficial.
  As a preventive  to  the disease, vaccination should be per-
formed with bovine virus or lymph.


                   SCARLET  FEVER.
                        DEFINITION.
  Is an inflammation affecting the tegumentary investment of
the entire  body, both cutaneous and mucous, and accompanied by
fever of an infectious or contagious character.
                        VARIETIES.
  Scarlatina simplex; scarlatina anginosa; scarlatina maligna.
                    MORBID ANATOMY.
  The lesions occur in the skin and mucous membranes.
  The eruption appears on the second and third days of the fever; 
SCARLET FEVER.
307
 it consists of closely aggregated points about the size of a pin's
 head, with  normal skin  between these aggregations.  The  red
 spots are circular, and tend to become confluent.  The skin may
 be turgid  and swollen.   The color changes with  the fever, show-
 ing, when very red,  that there is  a high fever.  The  redness
 will,  during the first forty-eight hours, if  respiration be unim-
 peded,  disappear  under  firm  pressure,  and reappear almost
 directly.  The eruption  may only appear on the face.  The period
 of desquamation follows the period of decline in two or  three
 days, and is due to an excessive production of newly-formed epi-
 dermis.  The most frequent change in connection with those of
 the cutaneous surface is catarrhal pharyngitis.  The tonsils  become
 red, swollen, of a dry  appearance, and covered with tenacious
 mucus.  These changes  may disappear in a few days, or become a
 dark livid color, and oedematous (associated with dysphagia, from
 oedema); inflammation of the parotids and other  glands may also
 occur, often terminating in suppuration, or diffused necrosis, or
 gangrene  of the tonsils, followed by  abscesses,  destroying the
 cell-tissues and sloughing of the skin in  that region, and fatal
 hemorrhage.
   This disease, in the  early stages, is often complicated by diph-
 theria.  During the eruptive stage, the ear  (middle ear), as well
 as the throat, may be greatly affected.  The  kidneys are  more
 affected in  this disease than any  other  organ; catarrh of the
 uriniferous tubules, or croupous inflammation of  the same in the
 cortical substance, commencing in the  Malpighian tufts, may be
 developed.  In a well-marked case of scarlatina nephritis, the
 epithelial cells of the tubules will be clouded, enlarged, changed in
 shape and position, and destroyed.  The kidney may have the
 appearance of  an interstitial nephritis.   On post-mortem examin-
 ation, there  is found to  be congestion of the brain, liver, spleen,
etc., and softening of  the  liver and spleen.   The mucous mem-
brane of the intestines  has become affected, and there is the
 "shaven beard" appearance in Peyer's  patches.

             SYNOPSIS OF THE  FOREGOING.
  The pathological lesions are confined to the skin, mucous mem-
brane, organs,  and blood. 
308
DISEASES OF THE BLOOD.
In the skin—you may have the characteristic  eruption  before
    death, and evidences  of desquamation in  patches, or of local
    abscesses.
In the mucous membrane—there  may be suppuration  in the
    vicinity of  the throat; ulceration of the tonsils, Eustachian
    tube, middle ear, and possibly of the cornea.
In the organs—desquamative nephritis, and evidence of some of
    the possible complications, such as pneumonia, pleurisy, peri-
    and endo-carditis, and neurosis of the middle ear.
In the blood—all the common lesions (see page 316).

                         ETIOLOGY.
  This is a frequent disease of childhood, but may occur  at any
age.   It is of a contagious nature, and may be conveyed directly
from the affected to the healthy by contact; also  through the at-
mosphere, or by clothing which  has become  saturated with the
poison.  It is apt to attack any or every member of a family, and
is most infectious at the period of desquamation.  The period of
incubation is from two to ten days, but generally from four to
seven days.  Its regular course is from tw* to three weeks.

                          ..JAGES.
  Stage of invasion—eruption—desquamatk \.

                        S!?MPTOMS.
Stage of Invasion—(from tv^ive hours to tour to five days).
    Chilliness and slight rigor.
    Headache.
    Temperature—elevated, 103°-104°
    Pulse—accelerated, 120-130
    Face—flushed, dry, and red.
  .  Throat—sore.
    Neck—stiff.
    Joints—tender.
    Vomiting—projectile in  character
    Thirst.
    Tongue—red, and strawberry color. 
                      SCARLET FEVER.                    309

    Lassitude and pain in the back and limbs.
    Restlessness.
    Convulsions—in the very young or in the aged.
    Delirium—in the very young or in the aged.
    Coma—in the very young or in the aged.
Stage of Eruption.
    Eruption—comes on twenty-four hours after the fever of in-
        vasion, and is of a bright rose color, if the attack be mild;
        or deep red (boiled lobster) color, if  the  attack be severe;
        it appears, first, on the neck and  upper part of the chest
        and coalesces, extending over the body, face,  and ex-
        tremities.
    On the fourth day, if you draw your finger across the surface,
        a well-defined fine remains (sure sign).
    Eruption remains for five or six  days, beginning to fade on
        the fourth day, and disappears on the sixth day, when
    There is a decrease in all the symptoms.
    Urine—scanty, suppressed, high-colored and casts.
    Blueness of the  finger ends (showing defective  oxygenation
        of the blood).
    OMema of  the  tonsils,  uvula,  and posterior walls of  the
        pharynx,  or ulcerative pharyngitis.
Stage of Desquamation.
    Desquamation commences and the fever subsides.

                    IRREGULARITIES.
  The most frequent are
    Overwhelming of the cerebro-spinal system, which shows
       itself  in convulsions, stupor, delirium, restlessness, blue-
       ness of  the finger ends, picking at the bed-clothes, etc.
    QMema of the throat.
    Temperature—excessive,  may rise to 107° or  108°.
    Pulse—greatly accelerated; may reach 140.
    Interference with the return circulation.
    Typhoid symptoms may occur from septic poisoning, and an
       ichorous discharge from the nose, indicating a sloughing
       pharyngitis (which is a very unfavorable sign). 
310
DISEASES OF THE BLOOD.
    Ulcers of the mouth.
    Inflammation of the middle ear—producing delirium, intense
        pain, and rolling of the head (indicating acute meningitis).
    CEdema glottidis.

             COMPLICATIONS AND SEQUELS.
  Scarlatina nephritis may develop, resulting in anasarca about
the time of convalescence, showing itself first on the face.  This
condition commencing with restlessness,  nausea, vomiting, then
pain in the head, anorexia, photophobia, insomnia, and elevated
temperature, followed by  stupor: the urine becomes scanty and
high-colored, containing casts of the  exudative variety, or blood
casts and albumen, or epithelium, denoting inflammation of the
uriniferous tubules, convulsions, coma, and death, may terminate
the case.
  Other complications may occur, such as bronchitis; pneumonia;
inflammation of the serous membranes; ulcerative  endo-carditis;
rheumatism; suppurative inflammation of the joints; diphtheria;
suppuration of the middle ear; uraemia; and anasarca.

                   CAUSES  OF DEATH.
  Death may result from pyaemia; septicaemia; pneumonia; phthi-
sis; or general anasarca.

                DIFFERENTIAL DIAGNOSIS.
  From measles; small-pox; erythema of surgical diseases; rose-
ola, in this the anterior  part of the pharynx is  affected, and
the symptoms are milder in character.  In scarlet fever, the pos-
terior part of the pharynx is affected.

                        PROGNOSIS.
  Is uncertain.   It depends upon the prevailing epidemics.
  If the symptoms of  the eruption appear within forty-eight
hours; if it reaches its minimum on the second day; if the throat
symptoms are mild; if slight dysphagia and slight  glandular en-
largements exist; if  the temperature be not  higher than 104°;
pulse, 120; if the cerebral symptoms are not severe or of long dura- 
                        SCARLET FEVER.                    31J

 tion, and a steady decline  of  temperature occur, with disappear-
 ance of the  eruption, the prognosis is favorable,  even if slight
 nephritic symptoms have been present, as they will disappear in
 from four to six weeks.
   Should the temperature reach 105°, with extreme frequency of
 the pulse, dyspnoea, cold surface, small pulse, eruption of a livid
 hue, hemorrhage of the skin, suppurative pharyngitis (especially
 if extending to the nasal passages), copious coryza, nervousness,
 with typhoid symptoms, persistent vomiting, diarrhoea, nephritic
 symptoms, dropsy, complete suppression  of urine, and the tem-
 perature inclined to rise, the prognosis is bad.
   Is bad,  if occurring from infancy to five years of age; in preg.
 nancy; in organic diseases; or when complications exist.

                        TREATMENT.
   Is both preventive and medicinal.
   Preventive.—Strict quarantine is absolutely necessary, and the
 same precautions relative  to the sick-room as in  typhoid fever.
 The patient should have plenty of fresh air and free ventilation.
 Every article that may carry the infection must  be thoroughly
 disinfected.  Frequent sponging and rubbing the body over with
 oil after each sponging will prove a great comfort to the patient
 during the period of desquamation.  He must not be allowed to
 go out till desquamation is completed, which usually takes three
 weeks after desquamation  has commenced.  After recovery has
 taken place, the whole of the premises, and every article that has
 been in use, must be scrupulously disinfected.
  Medicinal.—Your  duty is to stand by  and watch and guard
 against complications as they arise.  The bedding and body linen
 should be frequently changed.  A warm  bath should be given
 once a day, and the body well washed with carbolized soap when
 desquamation sets in, as it aids desquamation, and the kidneys
 are thus relieved.  Never  allow the  temperature  to rise to 104°
 more than twenty-four hours without reducing  it by cold sponge
 or tepid saline baths, and also administer large doses of quinine
(see typhoid fever, page 270).  Do not use the cold bath unless the
temperature rise to 105°. 
312
DISEASES OF THE BLOOD.
  For throat complications.—In  the  early stage, give cold car-
bonic acid water as  a beverage, or allow ice to be held in the
mouth.   In the advanced stage, cloths wrung out in tepid or hot
water may be applied to the throat.  Warm water gargles and in-
halations may be used with great benefit at the same time.  It is
better to use hot rather than cold applications in  every case; but,
whichever plan is adopted, use either cold internally and externally,
or hot internally and externally.  Should there be ulcerations in
the throat, spray them with carbolic  acid, muriated  tincture of
iron, chlorate of potash, tannic acid, or any of that class of reme-
dies.  Should there be great pain, bromide of potassium or ether
used in  the  same way will afford relief.   Stimulants  may be re-
sorted to early should there be feeble heart's action.
  For kidney sequelce.—Dry or wet cups, followed by hot foment-
ations, should be applied in the lumbar region, the temperature of
the sick-room raised to 73°, and the same treatment adopted as in
nephritis; or small doses of calomel may be given with a diuretic,
and water should be drank freely.  Should convulsions occur, opium
should be administered either hypodermically or by the mouth.  In
this disease, symptoms of Bright's disease are now detected by the
sphygmograph, showing increased arterial tension and develop-
ment of uraemia.

                        MEASLES.
                    MORBID ANATOMY.
  The blood  is dark-colored, fluid, and poor  in  fibrin.   The red
corpuscles are diminished, and the white  increased.  There is a
tendency to  congestion of the internal organs.  The liver and
spleen are enlarged.  There may be capillary bronchitis and pneu-
monia, which should be considered as  part of the catarrhal affec-
tion of the respiratory organs.  The  eruption at first is papular,
showing especially on the chin and gradually extending over the
body; it is of a bright-red color, sometimes shading off into blue,
disappearing on pressure, and returning again immediately.  When
the spots assume a  dark-red color and do not disappear on pres-
sure, capillary hemorrhages have taken place into the papules.
The spots entirely disappear  in from  one to five days, leaving a
yellow or brown stain behind which is due to pigmentation. 
MEASLES.
313
             SYNOPSIS OF THE FOREGOING.
  The principal lesions are in the skin, organs, and blood.
In the skin.— You have the eruption and a bran-like desquama-
    tion.  There is catarrhal inflammation of the conjunctiva and
    mucous membrane of the respiratory passages; and there may
    be black or hemorrhagic spots on the skin.
In the organs.—Some of the complications which are possible,
    such as capillary bronchitis, pneumonia, phthisis, gangrene,
    and abscess of the lung.  Otorrhoea and  effusion into the
    serous cavities may be present.
In the blood.—AU the common lesions of fevers (page 316) will exist.
                        ETIOLOGY.
  It  is a contagious  and portable disease, and  more easily con-
tracted than small-pox or scarlet fever.  The period of incubation
is eight days.  It may be induced by slight or prolonged exposure
even with patients in the incubative stage.
                          STAGES.
  Premonitory.  Eruptive.  And desquamative.
                        SYMPTOMS.
Premonitory stage.
    Coryza.
    Languor.
    Chill (may be very indistinct).
    Convulsions in children.
    Eyes—suffused and red.
    Photophobia.
    Sneezing and pain over the frontal sinuses.
    Bronchial catarrh.
    Cough—dry, hoarse (iron cough).
    Fever and catarrh—which last about forty-eight hours.
Eruptive stage.
    Eruption—from bright rose-red to mahogany, and, on  fading,
       becomes yellowish-red; appears first on the chin and face,
       then on the  legs and arms, and lastly on the back of the
       hands;  it takes four days to spread, and disappears about
       the sixth day.  There are little red dots which are con-
       fluent, crescentic, and papillary, with swelling, itching,
       and a burning sensation. 
314
DISEASES OF THE BLOOD.
Desquamative stage.
    Desquamation—occurs in fine dust-like flakes.  At this period
        the pulse is about 120 to 140, as a rule; the temperature
        usually about 103° (it rarely rises to 106°-107°).
                DIFFERENTIAL DIAGNOSIS.
  From scarlet fever and roseola.   The catarrhal symptoms are
the most prominent means of diagnosis in this disease.
  From typhus (in children) when  the mucous membrane of the
pharynx settles it; as it is more injected than in typhus.
                        PROGNOSIS.
  If there be no complications, the prognosis is good.
  If dentition  be progressing, it may render the prognosis bad.
  If the hemorrhagic ulceration be of the typhoid variety (black
measles), the prognosis is grave.
  If it occur in pregnancy, or when there is profuse hemorrhage,
the prognosis is bad; and in chronic diseases it is unfavorable.
  Death usually occurs in the second week.
                        TREATMENT.
  The patient must be quarantined, and kept in  a  large, well-
ventilated room at a temperature of about 63°-65° F., and dark-
ened so that the eyes may not be exposed to the light.  The diet
must consist  of  milk.   Should there be itching and burning,
sponge the body over with tepid water, as it aids in reducing the
temperature.  Convulsions may occur and cause death. Stimu-
lants should never be  used  unless there be great prostration and
bronchial affections.  The utmost cleanliness must be observed.
If the temperature rise to 103°-104° it must be reduced by tepid or
cold sponging, and quinine.  If the thirst be  great, cold water
may be given in  small  quantities  as a beverage.  If posterior
pharyngeal catarrh, capillary bronchitis, or croupous laryngitis oc-
cur, inhalations of steam will be found very beneficial  in relieving
the symptoms. Should there be catarrhal pneumonia, stimulants
must be given with judgment.  If pulmonary complications arise,
the patient must be protected from exposure.   If there be great
restlessness, give pulv. Doveri (small). If typhoid or hemorrhagic
symptoms occur, use stimulants early. 
ROTHELN.
315
                        ROTHELN.
   This disease may be confounded with measles and scarlet fever.
                          STAGES.
   Invasion.  Eruption.  Desquamation.
                        SYMPTOMS.
 Stage of Invasion.
    Shivering.
    Nausea and vomiting.
    Sore throat.
    Weakness.
    Premonitory fever—which is short, and relieved  when the
        eruption appears.
 Stage of Eruption.
    Eruption—appears simultaneously over the whole body;  is
        sudden, less marked on the limbs than on the trunk, and
        fades in about four days without desquamation.  On the
        first day, the eruption is like measles (minute dots); on the
        second day, irregular patches occur, varying from the size
        of  a three-penny piece to that of a shilling; and on the
        third day, these are elevated and dark-red in the centre.
    Temperature—is  highest on  the  first day, never  exceeding
        102°; it falls  on the second day to 100°; and on the fifth
        days becomes normal.
 Stage of Desquamation.
    Desquamation only occurs in rare cases; it resembles bran,
        and commences in the centre of the patch.
                        SEQUELAE.
  Swelhng  of the lymphatic glands; in rare cases, suppuration and
 dropsy.
                        PROGNOSIS.
  Is favorable.                  _ ,„
                       TREATMENT.
  Avoid exposure to cold draughts of air, and protect the body
with flannel.  The medicinal treatment must be indicated by the
symptoms which are most prominent. 
TABLE  CF  DIFFERENTIAL  DIAGNOSIS  BETWEEN
            TYPHUS.

           CONTAGION.
Is contagious,  infectious,  and  not
  portable.
           SYNONYMS.
Ship; jail; camp; putrid; hospital;
  fourteen  day;  petechial; cerebral
  typhus; exanthematous and  con-
  tinued fever.

      MORBID  ANATOMY.
The principal changes will be found
  in the skin, organs, and blood.
Skin.—Mulberry rash present on the
  sides of the chest and abdomen, and
  possibly on the extremities. It dis-
  appears on pressure (for three days),
  and the penumbra  is dark in color
  and somewhat  elevated.
Brain.—Hyperaemia of the vessels of
  the convexity.  Meningeal exuda-
  tions.   Serous  effusion of the pia
  mater and into the ventricles.  The
  arachnoid is opaque  and dotted
  with yellowish spots.
Alimentary  Canal.—The  changes
  are principally confined to Peyer's
  patches and   the  solitary glands
  which are found to be congested,
  and to have the "shaven beard"
  appearance.
The evidences of complications are:
  bronchitis,  pneumonia,  spleniza-
  tion, pleurisy,  oedema, meningitis,
  parenchymatous nephritis, ulcera-
  tion of the larynx, pharynx, and
  mouth, and enlarged cervical glands
*Blood.—Common lesions.
                                               TYL'IIOID.

                                               CONTAGION.

                                     Is non-contagious, but infectious. It
                                      requires prolonged exposure, gain-
                                      ing access to the body, through the
                                      air we  breathe and the water we
                                      drink, thus becoming contagious.
                                               SYNONYMS.
                                     Autumnal;  abdominal  typhus; en-
                                      teric; gastro-enteric; gastric; forty
                                      day ;  dothentherica ;  ilio-typhus;
                                      and typhoid affection of Louis.
                                           MORBID ANATOMY.
                                     The changes are confined  to the skin,
                                      organs, and blood.
                                     Skin.—The eruption is confined to
                                      the abdomen,  but it may appear on
                                      the chest, consisting of  crops  last-
                                      ing three days each;  they are few
                                      in number, slightly elevated, and
                                      called the rose rash.
                                     Organs.—The pathognomonic lesion
                                      is confined to Peyer's patches, the
                                      solitary and  mesenteric glands,
                                      which  undergo  the  following
                                      changes:
                                     1. Congestion and the "shaven-beard"
                                      appearance.
                                     2. Hyperplasia and hardening.
                                     3. Softening of the glands from fatty
                                      degeneration.
                                     4. Absorption or  rupture of  glands
                                      and evacuation of contents through
                                      sloughing  or  suppuration;  which
                                      may result in perforation or forma-
                                      tion of  typhoid ulcers.  The ulcer
                                      having its long axis parallel to the
                                      long axis of the intestine.
                                     5. Cicatrices, etc., may  form.
                                     Brain.—Hyperaemia of vessels, oede-
                                      ma,  and punctate extravasations
                                      and appearance.
                                     The evidences of complications are
                                      intestinal  hemorrhage,  peritonitis
                                      from perforation, pneumonia, par-
                                       enchymatous   nephritis, spleniza-
                                       tion of the lung, and catarrhal in-
                                      flammation of the bronchi.
                                     *Blood.—Common lesions.
  *]N. A,..—ihere are certain lesions common to all fevers  such as  decrease in
blood-corpuscles; staining of the surrounding tissues with haematin; soften-
                                  316 
THE  FIVE  PRINCIPAL ERUPTIVE  FEVERS.
SCARLET.
    CONTAGION.
Is contagious, infectious,
 and portable.
     SYNONYMS.
Scarlatina simplex; scar-
  latina anginosa:  scar-
  latina maligna, and red
  rash.
 MORBID ANATOMY.
The changes are confined
  to the skin, mucous
  membranes,   organs,
  and blood.
Skin. — There  are  evi-
  dences of a peely des-
  quamation,  local ab-
  scesses, and character-
  istic  eruption  before
  death.
Mucous  Membrane. —
  Suppuration  in the vi-
  cinity of the throat; ul-
  ceration of the tonsils,
  Eustachian tube, mid-
  dle ear, and possibly of
  the corneae.
Organs.—Desquamative
  nephritis,  and some of
  the possible complica-
  tions,  as  pneumonia,
  pleurisy,  peri-carditis,
  endo-carditis,  and ne-
  crosis  of  the middle
  ear.
*Blood. — Common le-
MEASLES.
     CONTAGION.

Is contagious, infectious,
  and portable.
     SYNONYMS.
Rubeola.
 MORBID ANATOMY.
The changes  are in the
  skin, organs and blood.
Skin.—There will be the
  characteristic eruption
  and bran-like  desqua-
  mation ;  catarrhal in-
  flammation of the con-
  junctiva, and  mucous
  membrane  of the res-
  piratory passages, and
  black or hemorrhagic
  measles on the skin.
Organs. — Some of the
  complications possible,
  as capillary bronchitis,
  pneumonia,  phthisis,
  gangrene,  otorrhoea,
  abscess, and effusion in
  the serous cavities.
*Blood. — Common  le-
    SMALL-POX.

     CONTAGION.
Is contagious, infectious,
  and portable.
     SYNONYMS.
Variola discreta; variola
  confluens; variola hem-
  orrhagica, and  vario-
  loid.

 MORBID ANATOMY.
The changes  are in the
  skin,  mucous  mem-
  branes,  organs,   and
  blood.
Skin.—All the stages of
  eruption which may be
  macule, papuie,  vesi-
  cle, pustule, scab, or
  cicatrix; also, possible
  abscess, ulceration and
  local slough.
Mucous  Membrane. —
  Within  the  urethra,
  eye, nose, mouth, and
  middle ear,  the  same
  conditions are possible.
Organs. — Parenchyma-
  tous  nephritis, oedema
  glottidis.  Evidences of
  complication, as  pleu-
  risy,  pneumonia, peri-
  carditis, endo-carditis,
  meningitis, bronchitis,
  and fluid blood, may be
  found in  some of the
  serous cavities.
*Blood.—Common   le-
the fibrin and albumen of the blood, disorganization and serration of the red
ing of the mucous membrane of the alimentary canal and the various organs.
                                  317 
TABLE  OF DIFFERENTIAL  DIAGNOSIS  BETWEEN
TYPHUS.
           ETIOLOGY.

Is epidemic, and produced by some
  animal poison arising from human
  effluvia;  from  overcrowding, and
  filth;  is  communicable by direct
  contact.
            STAGES.
Incubation, invasion, and eruption.



            ADVENT.
Suddenly,  with  intense chill  and
  marked symptoms, and steady in-
  creasing  headache,  delirium  and
  great prostration.
           DURATION.
Fourteen days.


             CRISIS.
On twelfth day, accompanied by a
  sudden termination of  symptoms
  and a healthy sleep.

        TEMPERATURE.

Very  high; on the second day 104%
  frequently 105° to 107°, about third
  day; remains so till convalescence.
  Is a higher temperature than any
  other affection but sunstroke and
  bilious   remittent  and  relapsing
  iever.

             PULSE.

First week about 110 to 120.
Second week generally 100, frequent,
  soft, rapid, and easily compressible.
  It may be irregular.
TYPHOID.
           ETIOLOGY.

Is endemic, and due to decomposing
 organic  matter,  mixed  with  ty-
 phoid material.
            STAGES.
Incubation, invasion, and eruption.



            ADVENT.
Insidiously,  with  general malaise,
  vomiting, headache, photophobia;
  chill is rare; five days elapse  be-
  fore patient takes to his bed.
          DURATION.

Twenty-one to forty days.


             CRISIS.

None.  Tympanites gradually disap-
  pearing, and the  tongue gradually
  clearing.
        TEMPERATURE.
Very little increased at onset.
Is exacerbating, seldom above 104° or
  105°, and  reaches  its  maximum
  about the  seventh  day; begins to
  fall about the end of third week,
  and becomes normal at the end of
  the fourth week.
             PULSE.

During first week 98 to 110.
In second week falls, or may even rise
  to 140.
Third week is variable.
Fourth week falls to about normal.
318 
THE  FIVE  PRINCIPAL  ERUPTIVE  FEVERS.
     SCARLET.

     ETIOLOGY.
Contagion direct and by
  the clothes.  11 m ay go
  through a whole fam-
  ily.  Is most infectious
  :-t th<j time of desqua-
      STAGES.
fncubation,    invasion,
 eruption, and  desqua-
 mation.

      ADVENT.

Period of incubation is
 from two to ten days,
 but  generally  four to
 seven.  Commences in
 children  with  head-
 ache, vomiting, gen-
 eral malaise, rash, and
 sore throat.
     DURATION.

Twenty-one to  twenty-
  eight days.

       CRISIS.
About  the  fourteenth
  day. (?)

   TEMPERATURE.

May reach 105°  or 107%
  is higher during the
  eruption, and begins to
  subside about the tenth
  day. It has no second-
  ary fever.

      PULSE.
Accelerated; may even
 reach 140.
MEASLES.
      ETIOLOGY.
Is a portable disease, and
  more  tenacious  than
  scarlet fever and small-
  pox.
       STAGES.

Premonitory  or precur-
  sory; eruptive and des-
  quamative.

      ADVENT.

Period of incubation is
  eight days.
Commences  with  chill,
  coryza, frontal head-
  ache, lassitude, harsh
  cough and fever, which
  usually lasts about for-
  ty-eight hours.
     DURATION.

Fourteen to twenty-one
  days.
       CRISIS.
None.
   TEMPERATURE.
May reach 105% and sinks
  to normal twenty-four
  hours after appearance
  of the rash.  It has no
  secondary fever.
       PULSE.

Slightly accelerated.
SMALL-POX.
      ETIOLOGY.
 Is propagated by conta-
  gion: by the breath and
  exhalations from the
  skin (at two and a half
  feet distant in the open
  air) ; can be conveyed
  by clothing, etc., and
  attack all ages.
 Is more infectious during
  the stage of suppura-
  tion c r diminution, or
  even incubation.

       STAGES.

Incubation ;   invasion ;
  eruptioa; suppuration;
  desiccation.

       ADVENT.

 Period of  incubation  is
  from ten to thirteen
  days.   If from inocu-
  lation  (48 hours.  It
  commences  with  an
  initiatory stage of chil-
  liness,  severe pain in
  the back, loins, head,
  and nausea, etc.

     DURATION.

 Four to five weeks.
       CRISIS.

About twenty-first day.
  (?)
   TEMPERATURE.

Is  often  106° at  onset,
  and may reach  109°.
  After eruption appears,
  it usually falls to 100°.
Secondary  fever  very
  high on the eighth day,
  and falls slowly.

       PULSE.

May rise from 100 to 120,
  or even 140.
319 
TABLE  OF DIFFERENTIAL  DIAGNOSIS  BETWEEN
TYPHUS.
           ERUPTION.

Small,  irregular-shaped, brick  dust
  spots, slightly elevated at first,
  called the "mulberry rash."   Re-
  mains throughout the disease.  Ap-
  pears on  the fifth to the seventh
  day of the fever, and disappears on
  pressure for the first two days of
  the eruption.  Appears chiefly on
  the sides of the chest and extremi-
  ties.
    CEREBRAL SYMPTOMS.
Active delirium and terrific  head-
  ache from the onset.
  CONDITION OF THE PUPILS.
Contracted.
          EPISTAXIS.
Rare, and of no importance.
   CONDITION OF  TONGUE.
First, swollen rind white-coated; after
  a day or two, becomes of a yellow-
  ish-brown  color and  thick; later
  on, dark, dry, and fissured.
        COUNTENANCE.
Dull and heavy, and  later  on of a
  mahogany color (drunken face).

        DESQUAMATION.
None.
TYPHOID.
           ERUPTION.
Lenticular spots, slightly elevated.
Bright rose color.
Appears  in  successive  crops  (each
  crop lasting three days), and disap-
  pears,  when another  crop  takes
  their place.  It  disappears on the
  slightest pressure, and  reappears
  instantly.  A ppears on the abdomen
  chiefly about the seventh day.
     CEREBRAL SYMPTOMS.
Are not present till about the second
  or third week, and appear as a
  muttering delirium.
  CONDITION OF THE PUPILS.
Dilated.
           EPISTAXIS.
A frequent and  grave  symptom, if
  appearing late in the disease.

    CONDITION OF TONGUE.
Is first of a light white color; then
  red on the tip and sides, and dry in
  in the centre; then heavily coated
  with sordes on the teeth and mouth,
  and,  after a time, becomes  clear
  and shining, like beef.

        COUNTENANCE.
Pale, olive, or leaden look.


        DESQUAMATION:
None. 
PRINCIPAL  ERUPTIVE  FEVERS.
THE  FIVE
SCARLET.
     ERUPTION.

Appears 24 hours after
  the fever of invasion.
If the attack be mild, the
  color is bright rose; but
  if severe, it will  be a
  deep-red lobster color.
  If  the  fingernail  be
  drawn over the erup-
  tion,  a white line will
  remain, which will last
  for two or three min-
  utes.
It appears  first on  the
  neck, and spreads rap-
  idly.
  CEREBRAL SYMP-
        TOMS.
Vrequent and grave.
CONDITION  OF THE
       PUPILS.
May be contracted.

     EPISTAXIS.
Absent.

CONDITION  OF THE
      TONGUE.
"Strawbe-ry" tongue.
   COUNTENANCE.
Flushed, dry, and  red,
  and headache.

  DESQUAMATION.
Occurs in large patches,
  especially  from  the
  hands  and feet, with
  itching, and successive
  desquamation   (peely)
  may occur.
MEASLES.
     ERUPTION.

It appears on the fourth
  day as little dots, like
 flea bites, of a rose-red
  or  mahogany  color.
  May be confluent, cre-
  scentic,  and  papular.
  If the  fingernail  be
  drawn over the erup-
  tion,  a  line  appears,
  which disappears  as
  quickly as the pressure
  is removed.
It  appears  first on the
  face, round the mouth,
  and on the neck, then
  on the legs and arms,
  and lastly, on the back
  of the hands.

  CEREBRAL SYMP-
        TOMS.
Usually absent.
CONDITION  OF THE
       PUPILS.
Normal.

     EPISTAXIS.
Absent.

CONDITION  OF THE
      TONGUE.
Coated, and red on  the
  edges.  Throat is sore;
  coryza; and bronchitis.
   COUNTENANCE.
Suffusion and redness of
  the eyes, and coryza.

  •DESQUAMATION.
Is bran-like, and has an
  odor of mouldy cheese
  (mealy).
321
SMALL-POX.
      ERUPTION.

Appears about the third
  or fourth day.
1st. As a macule.
2d.   Papule.
3d.   Vesicle.
4th. Vesicle becomes um-
  bilicated.
5th.   Vesicle changes col-
  or,   and  becomes  a
  pustule,   which  may
  slough,  and result  in
  cicatrix  and pitting; or
6th.   Scab.
It appears first at the root
  of the hair, lips, palate
  or fauces.
  CEREBRAL SYMP-
        TOMS.
Frequent; delirium prob-
  able  about  the third
  day.
Convulsions in children.
CONDITION  OF THE
       PUPILS.
May be contracted.

     EPISTAXIS.
Infrequent.

CONDITION  OF THE
       TONGUE.
Coated and swollen, and
  red on the edges. Sore
  throat and dry cough.
   COUNTENANCE.
Anxious and flushed; pho-
 tophobia and headache.

  DESQUAMATION.
Scabs, crusts, and thick
  scales in large quanti-
  ties,  with  intolerable
  itching (scaly). 
TABLE  OF DIFFERENTIAL  DIAGNOSIS  BETWEEN
  TYPHUS.

EMACIATION.
Slight.
 TYPHOID.

EMACIATION.
 CONDITION  OF THE BOWELS.

Constipated; no tympanites nor ten-
  derness.
  INTESTINAL HEMORRHAGE.
Rare.

     CHANGES  IN URINE.
Is first diminished, then increased;
  and suppression may occur later on
  in the disease.
There are vesical, renal, and fatty
  casts; and albumen and urea are
  increased.
        COMPLICATIONS.

Subacute  meningitis;   pulmonary
  gangrene:   capillary   bronchitis;
  pneumonia; pleurisy;  congestion;
  oedema; laryngitis;  and Bright's.
           SEQUELS.
None.
      CAUSES OF DEATH.

Coma; syncope; capillary bronchitis;
  gangrene of the lung; meningitis;
  pneumonia; exhaustion, from  the
  effects of the rcison; Bright's gran-
  ular kidney.
Great.
 CONDITION OF THE BOWELS.

Diarrhoea (pea soup).
Tympanites.—This is a bad sign; it
  indicates gas in the intestines.
Pain and gurgling in the right iliac
  fossa.


  INTESTINAL  HEMORRHAGE.
Fn quent.

     CHANGES IN URINE.

Increased in quantity.
No albumen; casts are rare.
Urea is  diminished  at first, and in-
  creased later on.
        COMPLICATIONS.
Peritonitis; abscesses; pleurisy, with
  pus exudation; simple bronchitis;
  catarrhal pneumonia.
322
           SEQUELS.
None,
      CAUSES OF DEATH.

Toxaemia; debility; suppression of the
  excretory function of the kidney;
  hyperaemia  and  oedema  of  the
  lungs; intestinal  hemorrhage;  ex-
  haustive diarrhoea; intestinal per-
  foration; peritonitis, with or with-
  out  perforation;  relapse from ab-
  sorption of the poison; cathartics, if
  given during the first week 
THE FIVE PRINCIPAL ERUPTIVE FEVERS,
SCARLET.	MEASLES.	SMALL-POX.
EMACIATION.	EMACIATION.	EMACIATION.
Slight.	Not marked.	Great.
CONDITION OF THE	CONDITION OF THE	CONDITION OF THE
BOWELS.	BOWELS.	BOWELS.
Not specially affected.	Not specially affected.	Not specially affected.
INTESTINAL HEMOR-	INTESTINAL HEMOR-	INTESTINAL HEMOR-
RHAGE.	RHAGE.	RHAGE.
Absent.	Absent.	Absent.
CHANGES IN URINE.	CHANGES IN URINE.	CHANGES IN URINE.
In the latter stages, urine becomes scanty, high-colored ; contains casts, as epithelial, small hy-aline, blood, and blood-globules; indicating the inflammatory stage of parenchymatous ne-phritis.	None.	May be scanty and high-colored, and contain casts at the commence-ment of the stage of suppuration; indicat-ing the first stage of parenchymatous ne-phritis.
COMPLICATIONS.	COMPLICATIONS.	COMPLICATIONS.
Pleurisy (frequent); bron-chitis; pneumonia (in rare cases); inflamma-mation of serous mem-branes ; oedema glot-tidis; ulcerative endo-carditis and diphtheria.	Pneumonia (frequent); lo-bar pneumonia; phthi-sis; ophthalmia; capil-lary bronchitis; abscess of the lung; gangrene of the lung ; Bright's ; gastric catarrh; profuse hemorrhage.	Pneumonia (in rare cases); bronchitis (general j; oedema glottidis.
SEQUELS. Bright's ; dropsy ; deaf-ness; conjunctivitis ; phthisis; chronic diar-rhoea; and glandular enlargements.	SEQUELS. Chronic bronchitis; con-junctivitis ; phthisis; otorrhoea.	SEQUELS. Chronic diarrhoea; ab-scesses; glandular en-largements ; various diseases of the eyeball and eyelid.
CAUSES OF DEATH.	CAUSES OF DEATH.	CAUSES OF DEATH.
Convulsions, from exces-sive blood-poison; bron-chitis; pneumonia; py-aemia; diphtheria; sep-ticaemia; phthisis; gen-eral anasarca; and Bright's.	Any of the above com-plications, especially capillary bronchitis in children, and phthisis in the adult.	CEdema glottidis; gene-ral bronchitis; pneu-monia; pyaemia; serous inflammation of the brain and heart. Acute fatty degeneration of the kidney.
323 
324
DISEASES of the blood.
                     INFARCTIONS.
                       DEFINITION.
  Are wedge-shaped spots of discoloration and consolidation in an
organ; dependent upon capillary obstruction and collateral hyper-
aemia.  Their base usually looks toward  the periphery of the
organ in which it occurs, and the apex toward the centre.
                        VARIETIES.
  1st. Thrombic—in which  the veins, where the seat of stoppage
occurs, are distended and  engorged.  The obstruction, in  this
form, is dependent upon a mechanical or inflammatory stasis.
  If  a vein be plugged  by a thrombus, the arteries rupture from
collateral circulation.
  2d. Embolic—the obstruction usually takes place in the arteries-
A clot is first formed in a vein, and passing onward to the heart,
is forced into the lung, or other organs, and plugs some artery of
those organs.  It may be due to a vegetation from  the valves of
the right heart.
  If  an artery be plugged by an embolus, the veins usually rup-
ture  from collateral circulation.
  3d. Pyozmic—which may be  either one of the  above-named
varieties, for explanation see pages 326 and 327.  This type of in-
farction usually  suppurates; as  the  obstruction in the vessels, if
due to thrombosis, depends on a poisoned condition of the blood;
while, if due to  an embolus, it depends upon a suppurative phle-
bitis of some point more or  less remote from the lungs, which has
caused a disintegration of a blood-clot (thus causing emboli).



                      SEPTICEMIA.
                       DEFINITION.
  Is  a blood-condition dependent upon absorption of decomposing
animal matter by the lymphatics, when placed in actual contact 
SEPTICEMIA.
325
 with a living membrane (example—decomposing placenta in the
 uterus).
                    MORBID ANATOMY.
   The severity of the disease depends upon the amount of poison
 absorbed.  It is a disease that may produce death in twenty-four
 hours if a large quantity of the poison has been introduced into the
 system, or it may become a continued fever when small quantities
 are gradually introduced.  It may be recovered from, in some cases,
 by arresting the development of the poison, or by the removal of
 the cause.  The principal lesion in this disease occurs in the blood
 which will be found to  lose its normal  power of coagulating, is
 darker than normal, and undergoes decomposition when drawn
 from the body; but should coagulation take place, the  coagula
 will be found to break down very easily.  On post-mortem ex-
 amination, the liver will usually be  found congested and cedema-
 tous; the spleen and mucous membranes softened; the salivary
 glands enlarged; and the muscles of the  heart weakened.

                         ETIOLOGY.
  It can only occur when decomposing  animal matter is brought
 into direct contact with the living membrane.  It occurs in  gan-
 grene and abscess of the lung; suppurative endocarditis;  retained
 placenta; dead foetus in utero; post-mortem wounds; diphtheria;
 introduction of sulphuret of ammonia into the system; decompos-
 ing urine in the bladder; typhoid ulcers, etc.

                         SYMPTOMS.
 Chill—but not distinct (rather rigors).
 Sudden fever.
 Temperature—(depends  upon the amount of poison absorbed) in
    mild cases, 102°-103% in severe cases, 105°-107°.
 Pulse—may rise to 120 or 140.
 Stupor—the patient answers questions stupidly.
 Profuse perspiration.
 Dinginess and dryness of the surface  (following the profuse per-
    spiration).
Typhoid symptoms. 
326                DISEASES OF THE BLOOD.

Jactitations.
Delirium—low muttering; the patient probably passes on to coma.
Diarrhoea—profuse watery (is an effort of elimination on the part
    of Nature).
               DIFFERENTIAL  DIAGNOSIS.
  From pyaemia—from which  it differs in not resulting in meta-
static abscesses; although there are chills, still they are not re-
current as in pyaemia.
                        PROGNOSIS.
  Depends upon the amount of poison present in the system.  It
is fatal when the poison is intense.

                        TREATMENT.
  Same as in pyaemia (see page 329).



                         PYEMIA.
                        DEFINITION.
  Is produced  by a miasm, generated by decomposing pus, and
characterized during life by chills (recurring), fevers, and sweats,
and, after death, by metastatic abscesses all over the body.
                    MORBID ANATOMY.
  There is a peculiar jaundiced appearance to the skin, which is
characteristic of the disease.  The  blood,  as  a result of the
miasmatic infection, exhibits a tendency to  coagulate spontane-
ously, especially where the current is slowed, as in the capillary
vessels.  Fine coagula will be found in  the heart, also an inter-
lacing of the chordae tendineae. In the various  organs through-
out the body, there will be infarctions, which result in abscesses.
The mucous membranes of the body will be found to be thickened.
                         ETIOLOGY.
   It is often due to a suppurative capillary phlebitis, occurring in
 persons suffering from  disordered or low conditions of the blood.
 It may be either local or general; should it be local, the symptoms 
PYJEMIA.
327
will be rapid, but if general, it will take some time  before thor-
ough development of the symptoms takes place.  It may occur
in either closed or open wounds in the following manner:
  In closed wounds—(1) from a blow (say on the head); (2) phlebitis
of the diploe ensues; (3) a clot  is formed in the veins at the seat
of the injury; (4) suppuration of the clot  and breaking down of
the same takes place  (this causes  loosening of the  clot,  whose
particles pass through the large blood-vessels to the heart, and
thence to the lungs), resulting in (5) an embolus of the lung or
other organs, which causes (6) an infarction, This condition is evi-
denced by a wedge-shaped spot of discoloration and consolidation,
dependent on capillary obstruction and collateral hyperaemia; its
base usually looks toward the periphery of the organ, and its apex
toward  the  centre.  The embolus having been a  poisoned one,
since it was due to unhealthy suppuration, the infarction under-
goes a similar suppuration; its coagula break  down and multiply
emboli in the blood, which are carried through the left heart into
the general circulation.  It is in this manner that metastatic ab-
scesses are formed all over the body, since these emboli become
lodged in other organs, and then  generate infarctions  which
again suppurate.
  In open wounds.—Pyaemia, is due (1) to some miasmatic atmo-
spheric  conditions (probably generated in decomposing pus); (2)
the miasm is probably absorbed by the blood-vessels, ar,d not by
the lymphatics; (3) the effect of the miasm  is shown  by a ten-
dency in the infected blood to coagulate spontaneously  in the
small capillary vessels where the current is  slow; (4)  the small
coagula thus formed (thrombi) in different parts of the body cre-
ate suppurative and metastatic abscesses, on account of their
poisoned character.   The duration of the disease is from eight to
ten days, or it may even extend to three weeks.

                        SYMPTOMS.
Initial symptoms—are usually well marked.
Chills—which are sharp, long, and recur at intervals for several
    days.
Profuse sweating—which follows every chill. 
328
DISEASES OF THE BLOOD.
Temperature—rises before the chill occurs to 104° or 105°.  This
    rise either precedes or  accompanies the chill, and also the
    perspiring stage; but, after the perspiring stage, the  temper-
    ature may even  become normal, as occurs in the puerperal
    type, or it may have a marked r se, 107°.
Pulse—rapid (140 to 200), small, feeble, and rarely irregular.
Restlessness.
Delirium—which will be of a low and muttering character.
Cellulitis—especially in the glands with loss of vitality of adjacent
    tissues and subsequent suppuration,
Exhaustion—extreme.
Jaundice—(of  the hematogenous variety)  due to  the changes in
    the red globules of the blood from the action  of the  pyaemic
    poison, or to the action of the poison on the nerve-centres.
Respiration—hurried, especially just before a chill or sweat.
Breath—has a sweet, nauseating odor.
Perspiration—has a sweet, nauseating odor, staining the clothing
    to a dirty  yellow color.
Urine- is at first scanty and high-colored,  then becomes  more
    abundant; the high color is due to changes in the coloring of
    the blood.
Diarrhoea—profuse watery.
Cough.
Expectoration—sometimes streaked with blood, or may oe pneu-
    monic.
Emaciation  and feebleness.
Tongue-is  at first glairy, and subsequently heavily coated with
    sordes, and further symptoms of a typhoid variety ensue.
                DIFFERENTIAL DIAGNOSIS.
  Is easily made.  It may be confounded with some of the in-
fectious fevers as septicaemia; but, in this latter case, you rarely
have a second chill, and, if you do, it always follows the fever.
There is  also the peculiar hue to the skin to enable the diagnosis
of pyaemia to  be made. It may also be mistaken for acute  artic-
ular rheumatism, or for those cases  of scarlet fever when sup-
puration occurs.
                        PROGNOSIS.
  Is worse than in almost any other disease. 
ERYSIPELAS.
329
                        TREATMENT.
   The prophylactic treatment will only interest the surgeon, and
 also the physician, during the puerperal stage.  When there is an
 unhealthy suppuration, antiseptic treatment will tend somewhat to
 stop it. Of all the curative remedies, fresh air stands first to over-
 come these diseases.  Let the patients be placed in tents or pavilions,
 where they will have as free ventilation  as  in tents, and use  all
 the means of disinfection.  Diaphoretics and diuretics have been
 advised, but it was found that  the patients went much more
 quickly into a state of collapse than when they were left alone.
 Sulphurous acid has been advised, but this was so difficult to ad-
 minister,  that  sulphites (gr. xx.-xxx. doses)  of sodium, calcium,
 and magnesium were administered, as they were claimed to neu-
 tralize the poison, but this treatment was not found by clinical
 experience to have the desired effect.  Quinine has been suggested
 on account of its having such a wonderful effect in malarial
 diseases, and this, like its predecessors, has been found to be of no
 avail, and has also been  abandoned.  Stimulants should be ad-
 ministered early and  in  large quantities, and so keep up the
 patient's strength as much as possible.  Opium should  be given
 hypodermically to quiet the restlessness that occurs prior to the
 chills and sweatings.   The patient's  body, bed, and linen should
 be kept scrupulously clean.  The  diarrhoea and perspiration
 should not be checked.  Good nursing is indispensable, and con-
 centrated liquid food, as milk with lime-water, eggs, beef-tea, at
 short intervals.


                      ERlrSIPELAS.
                        DEFINITION.
  Is a diffuse erythematous inflammation of the skin or the mucous
and serous membranes, which rapidly spreads, and is attended
with febrile symptoms.  It is both contagious and infectious.

                        VARIETIES.
  (1) Cutaneous or simple; (2) phlegmonous;  and (3) internal. 
33C
DISEASES OF THE BLOOD.
  Cutaneous variety—attacks the  superficial portion of the skin.
  Phlegmonous variety  attacks the sub-cutaneous areolar tissue,
as well as the cutaneous surfaces.
  Internal variety—where the serous and mucous membranes are
involved, producing  cellulitis, also involving the fasciae, aponeu-
roses, etc., etc.

                         ETIOLOGY.
  Predisposing causes.—Bad hygiene; filth;  deprivation of food,
etc.; over-fatigue; over-anxiety; intemperance; sedentary habits;
indolent  life;  high living; diabetes; albuminuria; drinking bad
water, etc.
  Exciting  causes.—Change of  temperature; cold or damp air;
wounds.
                        SYMPTOMS.
Cutaneous variety.
    Face—chiefly affected (which becomes red, oedematous, and
       distorted).
    Chill.
    Temperature—rises to 103°-104%
    Nausea.
    Vomiting.
    Stupor.
    Eyes—closed by swelling and oedema.
    Delirium.
    Typhoid symptoms—which abate in about  eight to  twelve
       days.
    Skin—grows pale, scaly; abscesses or boils may form.
    The beard falls out and frequently returns.
    This variety also  occurs from wounds in  the head.
Phlegmonous variety.
    Skin—over the affected portion becomes tense, shining, and
       subsequently sloughs, and exhaustive suppuration ensues.
    Duration depends upon the  severity of the attack.

               DIFFERENTIAL DIAGNOSIS.
  From phlebitis—which gives the feeling of a hard cord running 
ERYSIPELAS.
331
across the inflamed part.  It attacks the walls of the veins in-
stead of the tissues and lymphatics, as in erysipelas.
                        PROGNOSIS.
  The cutaneous or simple variety generally gets well, but it may
attack some other organ, as the lungs, peritoneum, or pelvis, or
even the brain.  In the strong and healthy, the duration is from
seven to fifteen days; the first four days it usually tends to spread;
the second four days it gradually clears up, and it takes two days
more to get well.
  In the phlegmonous variety, the prognosis is unfavorable, as
you have  suppuration; and especially unfavorable if occurring
in young children, and those addicted to intemperance and bad
living.
                        TREATMENT.
  Is both preventive and curative.
  Preventive. —First remove all  obstacles.  Keep the patient in
bed in a large, well-ventilated room;  perfect cleanliness must be
observed.   The diet should be nutritious, and stimulants avoided,
if possible.
  Curative.—This is divided into constitutional and local treat-
ment.
  Constitutional.—Be on your guard  against fever.  The patients
must be supported in moderation, should there be any signs of an
asthenic (debilitating)  fever, by giving stimulants, such as milk
punches, egg-nog, port wine (by the bottle), strong beef-tea,  bark,
ammonia, etc.  Large doses of tr. ferri mur., gtt. xv.- 3 ss. every
two or three hours day and night.
  Local.—In the simple form the inflamed parts should be painted
over with butter-milk;  it cools and protects them from the air, or
bathe the parts with the following lotion:  R plumbi  acet., 3 i.;
opii, 3 ss.; aquae, O.i.; or a lotion made of ipecac and water.  Do
not use iodine, as it only irritates the  parts, nor nitrate of silver,
as it is of no service.
  In the phlegmonous form.—Incisions should be freely resorted to.
Do not be afraid of free incisions, as it greatly relieves the patient;
afterward poultice  the part  with linseed meal.  Keep the limb 
332
DISEASES OF THE BLOOD.
well covered over with cotton wool, and so soon as the discharge
is well carried away, and the parts assume a healthy appearance,
commence the process of healing by strapping.
                     RHEUMATISM.

   Is a disease dependent upon a morbid condition of the blood,
 due to a poison (probably lactic acidi, which is developed within
 the body, having the power of rendering the secretions and ex-
 cretions acid, and associated with an  alteration in  the various
 salts, favoring an increase in the fibrin of the blood.
                        VARIETIES.
   Acute and  chronic articular; deforming  articular; muscular;
 and gonorrheal.


         ACUTE ARTICULAR RHEUMATISM.
                         SYNONYM.
   "Flying gout."
                        DEFINITION.
   Is an  inflammatory disturbance of nutrition, located  in the
 synovial capsule of one or more of the joints of  the body.
                    MORBID ANATOMY.
  On post-mortem examination, the  synovial  capsule  of  the
affected joints may be found to be of a dark-red color (due to hy-
peraemia or ecchymosis); it will also be relaxed and puffed up, and
the joint dilated and filled with purulent fluid.   The blood in the
heart and  large blood-vessels shows  large deposits of  fibrin.
Heart lesions  are frequently developed  in  the course  of  this
disease.
                        ETIOLOGY.
  It is a disease which occurs principally among the poorer classes
(as in fishermen, etc.). It usually occurs between the ages of fif- 
ACUTE  ARTICULAR RHEUMATISM.
333
 teen and forty years, from possibly an hereditary tendency, the
 mode of life, or a faulty digestive process.  Its exciting causes
 are exposure to cold, by suddenly wetting the  heated body; by
 exposure to a draught;  or  living in damp places.  The duration
 of the disease is usually from two to six weeks.

                         SYMPTOMS.
 Usually of sudden advent.
 Chill—rare.
 Fever.
 Pain—in one or more of the joints, which usually increases, and
     is worse on motion.
 Swollen and tender joints—the  large joints are principally af-
     fected.
 Skin over the joint—may be normal, of a light or dark-red color.
 Temperature—usually 100°-101%  may rise to  104°-105%
 Pulse—full and soft, 90-100; may rise to 130.
 Perspiration—peculiar acid.
 Great thirst.
 Urine—scanty, high sp. gr.; urea increased.

                     COMPLICATIONS.
  Peri-carditis ; endocarditis; myo-carditis; pleurisy; pneumonia;
 cerebral  and spinal meningitis ; and pyaemia, from suppuration.

                    CAUSES OF DEATH.
  Death may occur from complications, or sudden coUapse from
 an effect upon the nervous  system.

                DIFFERENTIAL DIAGNOSIS.
  From synovitis; arthritis; and gout.

                        PROGNOSIS.
  It  usually terminates  in complete recovery, provided there be
no complications.  Young subjects are very liable to have cardiac
complications from endo-carditis and endarteritis. 
334
DISEASES OF THE BLOOU.
                       TREATMENT.
  The patient should live in a country where the atmosphere is
dry, and with a temperature ranging about 70'; his body should
be covered with flannel.  The affected joints should be packed in
a poultice made of bicarb, sodii, bound round with cotton wool,
and covered with  oil-silk.  All animal food  should be withheld,
and the diet consist of  milk with an alkali.  Lime juice may be
drank, or lemons eaten, with advantage, as in the  body this acid
is changed into an alkali. In some cases a hot pack may be found
to greatly relieve the sufferings of the patient.   Should there be
great pain, opium may  be given, and in the event of swelling, the
parts may be painted with iodine.   If meningeal troubles occur,
leeches and cold compresses should be applied to the head.  In a
few cases, salicylate of soda will sometimes  stop the disease.
Pulv. sodii bicarb, and pulv. acidi  tartar, may be given as an
effervescing drink.  The Germans advise giving salicylate of soda
(gr. x.-xv.) every  four hours, or capsules of salicylic acid, gr. x.,
every two hours, and crowding them continuously.
       CHRONIC  ARTICULAR  RHEUMATISM.
                    MORBID ANATOMY.
  The synovial capsule and ligaments of the joints will be found
to be thickened;  hypertrophy or degeneration of the membranes
may exist; the cartilages are often relaxed and shaggy; and the
synovial fluid cloudy.  It may attack  only one joint at a time,
sometimes inducing comparatively little  anatomical change.  It
may lead to suppuration of the joint, and caries of the end of the
bone.
                        ETIOLOGY.
  It may  occur  from  congenital predisposition; from previous
attacks; t>om  catching cold;  or remaining in cold, damp, windy
places.
                        SYMPTOMS.
Pain—constant and increased, especially at night, on pressure or 
CHRONIC  ARTICULAR RHEUMATISM.
835
    active motion; or it may only occur at every change of the
    weather.
 Crackling sensation or crepitation felt if the hand be placed on
    the joint when motion is made.
 Swelling—(from increase of synovia, and thickening of the cap-
    sule and ligaments).
 Prominence of the joint—which may be swollen and painful.
 Fever—may occur, with frequent pulse, and profuse perspiration.
 Urine—thick and sedimentary.
 Emaciation.
 It may be complicated with neuralgia and paralysis.

                DIFFERENTIAL DIAGNOSIS.
  From chronic gout.
                        PROGNOSIS.
  This disease often ends in a permanent deformity.

                        TREATMENT.
  Flannel should always be worn next to  the body.  Iodide of
potassium, guaiacum, oil of turpentine, and cod-liver oil are largely
 used  in this affection, but local treatment is found to give more
 relief.  The inflamed part may be painted with the tincture of
 iodine or  a lotion composed of tr. iodine, 3ss.; pot. iodide,  3 ss.;
 aquae, § iij. may be applied;  or  a liniment containing oil of tur-
pentine, oil of sassafras, ammonia, and laudanum diluted with
 soap liniment; or when the pain is excessive, chloroform or aconite
 liniment may be used. Blistering may even be resorted to in bad
 cases.  Where  there  is rigidity of the joints, and even pain in
 them, or,  in  the muscles,  hot water may be  constantly poured
 over the  parts.   Some prefer the hot water or vapor bath and
 others the hot dry air bath at a temperature of about 130° to 200%
 as a means of  affording great relief.   In  order to  aid in the
 restoration of the stiffened parts, electricity should be resorted  to. 
336               DISEASES OF THE BLOOD.
             MUSCULAR RHEUMATISM.
                        ETIOLOGY.
  It is a rheumatism of the muscles, fascia, periosteum, and other
fibrous tissues; the changes consisting chiefly of hyperaemia  and
scanty exudations.   It is  diffcult to say whether the sensory
nerves traversing the  muscles are morbidly excited  by changes
in the muscles and sarcolemma, or whether simultaneous changes
occur in the neurolemma.
                        SYMPTOMS.
Pain—designated as stretching or tearing; it is increased by mo-
    tion and cold applications; diminished by pressure and warm
    applications, and may be wandering or fixed.
Neck—may be stiffened (as its muscles are most often affected).
                       TREATMENT.
  The parts should  be painted with  iodine, or a blister in sOme
form.  One of the most effective rubefacients is the application of
the induced current by means of the electric brush.  Vapor baths
may prove of great relief to the  patient.   Should  there be great
pain, the hypodermic use of morphia can be resorted to.
                      DIABETES.
                      VARIETIES.
" Mellitus " and " Insipidus."

              DIABETES  MELLITUS.

                      SYNONYMS.
'' Glycosuria;" '' milleturia."
                      DEFINITION.
Is characterized by excessive and saccharine urine. 
DIABETES MELLITCS.
337
                    MORBID  ANATOMY.
  Is obscure. Physiologists claim, from experiments, the probable
seat of the disorder is in the liver (due to its glycogenic function).
It is also claimed that, by irritating the  fourth ventricle of the
brain, sugar can be produced in the urine.  It is also regarded as
a nervous disease, through the  pneumo-gastric nerve; for if you
cut the pneumo-gastric, no sugar will  be found in the  liver after
death.
                         ETIOLOGY.
  Predisposing causes.—It occurs more frequently in men than in
women, especially the young and middle-aged adults.   It may be
hereditary, or occur from nervous shocks.
  Exciting causes.—Exposure to wet or cold; drinking cold water
in large quantities when  the patient  is heated; intemperance;
fevers; injuries to the brain and spinal cord (through the pneumo-
gastric).
                        SYMPTOMS.
Come on slowly with malaise.
Thirr-t -incessant (a prominent symptom).
Emac iation.
Insatiable hunger.
Excessive micturition.
Tjrine_pale straw color, sp. gr. 1030 to  1050.   Patients have
    been known to pass  seventy to  eighty pints in twenty-four
    hours.
Anaemia.
Dyspeptic symptoms—due to faulty secretion of the  gastric juice.
Palpitation of the heart.
Vertigo.
Tongue—is glazed and furrowed.
Mouth—clammy.
Failure of mental and sexual powers (the latter may be sometimes
    increased).
                     COMPLICATIONS.
  Tubercular phthisis; furuncles and  anthrax;  gangrene of the
lower extremities;  defective vision; cataract;  pruritus  vulvae;
erysipelas,  etc 
338
DISEASES OF THE BLOOD.
                   CAUSES OF DEATH.
  Fever; oedema; diarrhoea; and probably (edema of the lungs, OT
over-working of the kidneys  or some other organ may produce
death.
                        PROGNOSIS.
  Is unfavorable, although recovery is not impossible, usually lasts
from one to three years.

                        TREATMENT.
  The tests applied for sugar in the urine are principally Moore's
Tromer's, and Fehling's.   It is  the  weight of the patient that
denotes improvement in the disease and not in the amount of
sugar passed.  Prohibit the use of sugar or starchy food, as bread
(except bran bread), potatoes, cabbage, broccoli, celery,  lettuce,
spinach, and onions.  Milk and liver should also be amongst the
number.  The patient should be fed on meat, eggs, butter, jellies,
aerated bread, tea and coffee not sweetened.   Stimulants must be
avoided, but water may be used ad libitum.
  Medicinal agents are of no use, excepting opium.  Codeia espe-
cially.  Oleum morrhuaz may be  given to keep up the strength of
the patient, or rub the surface of the body with oil.  The radical
cure for this disease has not yet been discovered
                 DIABETES INSIPIDUS.
                        SYNONYM.
  "Polyuria."
                       DEFINITION.
  There is  an excessive amount of urine passed, which is of a
light color, light in weight, and contains neither sugar nor albu-
men, but is accompanied by excessive thirst (polydipsia).
                    MORBID ANATOMY.
  Is obscure.  There is generally atrophy of the kidney or renal
congestion associated with this variety  of diabetes.   It is stated
that the immediate cause of this disease is dilatation of the capil-
lary vessels of the kidneys, due to disturbance of the ganglio- 
SCURVY.
339
 nervous system which controls the circulation of that organ.
 The disease may last from a few weeks to many years, and may
 be congenital.
                       ETIOLOGY.
  From blows on the head; exposure to cold; drinking cold fluids
 when the patient is heated; cerebral disease;  intemperance.

                         SYMPTOMS.
 Usually sudden.
 Intense thirst.
 Skin—dry and harsh.
 Great emaciation and debility.
 Excessive urination—about fifty to seventy pints (passed in a day).

                       TREATMENT.
  No specific cure has yet been discovered.  The only treatment
 is to hold the disease as much in check as possible.   The follow-
 ing drugs have  been suggested: nitrate of potassium, valerian,
 ergot, iron,  alum,  lime-water, tannic and gallic acid, bromide of
potassium, etc.  Also blistering the nape of the neck.



                         SCURVY.
                         SYNONYM.
  "Scorbutus."
                       DEFINITION.
  Is a peculiar form of anaemia, arising from  deficiency of veget-
 able diet, attended with a tendency to  the occurrence of hemor-
 rhages,  impairment  of nutrition, and  great mental  and bodily
 prostration.
                    MORBID ANATOMY.
  The body will be found to be greatly emaciated.  Slight oedema
 will exist, especially of the lower extremities.  Extravasations of
 blood may be found not only in the superficial regions of the body,
 but in the substance of the lungs, beneath the pleura, in the walls 
340
DISEASES OF THE BLOOD.
of the heart, in the intestinal parietes, and beneath the perito-
neum.  There may be ecchymosis between the serous and muscu-
lar coats of the intestines.  The  mucous membrane of the intes-
tines is reddened, swollen, and relaxed.  Bloody serum may form
in the serous cavities.  The blood is of low specific gravity; there
is a diminution in the red blood-corpuscles and an excess of fibrin.
The joints are greatly enlarged.   The gum* irill exhibit typical
changes.
                        ETIOLOGY.
  From insufficiency of or a total absence of fresh vegetables;
from a decrease in the alkaline salts of the blood (salts of  potash);
from  the constant use of salt meat, and long-continued exposure
to privation, fatigue, and mental anxiety.
                        SYMPTOMS.
Anaemia—rapid and progressive.
Skin—has a dirty-looking, pallid, or earthy aspect.
General debility and cachexia.
Pains in the back and limbs.
Mental apathy and depression.
Tongue—large, flabby, and indented.
Constipation.
Spots—(petechial) first on the legs, and then extending over  the
    surface.
Puffy swellings—in different parts of the body, due to deep-seated
    hemorrhages, especially in the popliteal space and elbows.
Bleeding and swelling of the gums, also ulceration  or sloughing.
Loosening and dropping out of the teeth.
Foetid odor of the breath.
Later on.
    Puffiness of the face.
    Anasarca of the extremities.
    Dyspnoea.
    Palpitation of the heart
    Sudden syncope.
    Offensive diarrhoea.
    Disturbed vision. 
PURPURA.
341
    Tinnitus aurium.
    Vertigo.
    Want of sleep.
    Delirium.
                   CAUSES OF DEATH.
  Death may occur from exhaustion or sudden syncope.
               DIFFERENTIAL DIAGNOSIS.
  From purpura.
                        PROGNOSIS.
  Is good.  These patients usually recover rapidly when fed on
lemon-juice, fruits, and vegetable food.
                       TREATMENT.
  Patient should have plenty of vegetables, lime-juice, and wine.
Administer tinct. ferri  chlor. in moderate doses.   For the gums,
a wash of tannic acid or tincture of myrrh in dilute  glycerin; or
alum, brandy, and  water.  Rub the body, or parts  where the
eruption  is, with salt and whiskey.


                       PURPURA.

                        SYNONYMS.
  Purpura haemorrhagica; morbus maculosus Werlhofii.
                       DEFINITION.
  Is an affection characterized by the extravasation  of blood in
the form of spots beneath the surface of the skin.   These are
unaffected by pressure.  When they are small and round in shape
they are  termed "petechia;" when  elongated in  strips (like a
whip), "vibices;" when diffused or irregular (like a bruise), "ec-
chymomata."
                   MORBID  ANATOMY.
  Is obscure.  Hemorrhages, like those of the skin, are sometimes
discovered in the sub-serous  and sub-mucous tissues, and less so
in the various organs.   The primary morbid condition is probably
in the capillary and other small vessels, rather than in the blood, 
S42
DISEASES OF THE BLOOD.
and the blood escapes into the tissues in consequence of capillary
rupture.
                         ETIOLOGY.
  It occurs at all  ages, but chiefly in  young children, who have
delicate skins.  It is thought by some to arise from bad hygienic
surroundings, and in those who are  under-fed, and sickly, and
jet is  observed among those who live with every comfort and
good hygenic surroundings.  One feature in this disease is that it
is very apt to recur.
                        SYMPTOMS.
Usually ushered in with general malaise and fever.
Pain—in the lower extremities (especially in the legs).
Swelling of the affected limbs.
Skin -studded with red spots, usually about the size of a millet
    seed, which do not fade on pressure, but generally disappear
    in  a few days.
Epistaxis—may occur.
Bleeding of the gums.
Loss of muscular strength.
Mental dejection.
In, a severe case.
    Bleeding from various organs.
    Countenance—pallid.
    Pulse—increased and jerking.
   Tinnitus aurium.
   Pupils—dilated.
   Headache.
   Muscae volitantes.
   Delirium.
   Mania.
   Convulsions or death.
                   CAUSES OF  DEATH
  Death may occur  from asthenia or syncope.
                       TREATMENT.
  In mild cases  the  patient usually gets well without any treat- 
GOUT.
343
ment.  Among the remedies which have been extensively used as
styptics areperchloride of iron, acetate of lead, arsenic, digitalis,
turpentine, and gallic and sulphuric  acids.  The body should be
sponged with alum and brandy, or whiskey and water, at a tem-
perature that is not chilling, and yet is sedative to the circulation.



                           GOUT.
                        SYNONYMS.
  "Podagra;" and "arthritis."

                    MORBID ANATOMY.
  There is an inflammation of the joints with deformity, and in-
crustation of the serous sacs of tho joints,  with a chalky material
(urates of  soda).  It usually commences first in the joint of  the
great toe, although any joint may be affected.   Fibroid degenera-
tion of the blood-vessels may also ensue.  The left ventricle of
the heart may become hypertrophied.

                        ETIOLOGY.
  It is said to be caused by an excess of uric acid in the system.
It seems to arise from an hereditary tendency; from too high living;
from the consumption of too much nitrogenized food and  an  in-
sufficiency of oxygen introduced into the system; from plugging
of the uriniferous  tubules, producing subsequent atrophy of  the
kidneys.   It usually occurs in men, after thirty years of age, who
have led a luxurious and idle life.

                        SYMPTOMS.
Malaise.
Pain—severe, piercing, burning most often in the great toe.  The
    attacks usually begin about midnight.
Joint—swollen and red.
Fever.
Pulse—full and bounding.
Skin—dry. 
344
DISEASES OF THE BLOOD.
 Thirst—intense.
 Mental excitement.
 Leg—swollen (by oedema).
 Chalky deposits about the joints (occur late).
 Hands and arms—become involved (later on).
 Cachectic look.
 If in the stomach.
    Cardialgia.
    Vomiting.
    Haematemesis.
 If in the brain.
    Apoplexy, or circumscribed headache.
    Dizziness.
 If in the heart.
    Irregular and feeble action.
    Disturbed circulation.
    Dyspnoea.
    Fainting.
  The bladder and kidney may be affected by the gouty diathesis.
                    CAUSES OF DEATH.
  Death usually results from complications or internal gout

                        PROGNOSIS.
  Is unfavorable as to a permanent cure.  Patients are apt to die
 between the ages of forty-five and sixty years.

                        TREATMENT.
  The patient should be placed under a certain  regime.   The fol-
 lowing system will greatly aid in relieving the sufferer:
  (1) The diet  should consist principally  of vegetables, soups,
 cream, and milk; meat may be taken sparingly  once a day.
  (2) Wines, spirits, and fermented liquors should be forbidden,
 and even tea and coffee.
  (3) The patient should drink water  freely (as  it irrigates the
kidneys), also Vichy, or any  mineral water, and  should eat lemons
or take iced acid drinks.
  Tincture of colchicum, gtt. xx.-xxx., may be  given  three times 
DIPHTHERIA.
345
a day or colchicum and  iodide of potassium in combination ;  or
Reynold's or Seville's specific or Lee's  lithontriptic pills; these
latter have proved to be a great source of comfort to the patient;
or R ipecac,  hydrarg. chlor. mite, aa gr. i.; aloes, extractum colch.
acet. ext.  nucisvom., aa gr.}£.  Fiat pil.   Sig.  Give one every
four hours till purged.
  To reheve the pain, opii gr. j. or morph. sulph. gr. 34 may  be
given.

                      DIPHTHERIA.
                        SYNONYMS.
  "Pseudo-membranous angina;"  "putrid sore  throat;" "diph-
theritis."
                        DEFINITION.
  Is a disease  characterized by a membranous exudation, which
usually appears first on the tonsils.  It may extend backward and
upward, involving the posterior nares;  or downward, involving
the oesophagus and stomach, or respiratory tract.   It may occur
wherever mucous membranes exist, or even on a blistered surface.

                    MORBID ANATOMY^.
  On examination, the first thing that will be noticed is a redden-
ing of the mucous membrane,  which  soon  becomes  purple  in
color (from passive congestion), and a slight infiltration of serum
into the tissues (oedema) simultaneously  appears. The epithelium
covering the mucous membrane soon becomes cloudy and gran-
ular (resembling in appearance  a light gauze which has  been
thrown over the mucous membrane).  In  the mildest cases the
disease may stop at this stage, because this granular  surface  is  of
a low vital power, and cannot, therefore, organize.
  In the next  stage, the sub-epithelial layer becomes infiltrated
with the same granular substance, which continues to progress
until the whole of the  mucous  and sub-mucous tissues are in-
volved.
  The exudation varies in color  and extent; it may, in one case,
be pearly white, and  cover  over the surface; in another, it may 
346
DISEASES OF THE  BLOOD.
assume the buckskin appearance, covering the pharynx or tonsils;
while in another it may be dark-gray  in color, resembling gan-
grene, indicating extensive blood changes (the amount of exuda-
tion foretelling the severity of the disease).  When the exudation
is granular in character, the cells are changed tissue-cells, giving
it the appearance of a mixed exudation.  This is the lowest grade
of inflammation, from which recovery is hardly possible;  it re-
sembles a caseous material, which cannot be  re-absorbed, and is
only removed by the removal of the epithelial covering.  Should
the exudation occur in the mucous and  sub-epithelial tissues, and
not  be very abundant, it may be  arrested by overcoming the
poison.  When this has been accomplished, simple epithelial and
sub-epithelial cell development occurs, with a rapid suppurative
process, terminating in a suppurative infiltration.
   In addition to these local changes,  on post-mortem examination,
the blood will be observed to be much darker  than normal.   It
undergoes rapid ammoniacal changes, and does  not coagulate.
   The heart will be found to be soft, and a granular degeneration
of its muscular fibres will usually exist.
   In the stomach, the mucous membrane will be found soft and
©edematous.
   In the intestines, the glands and Peyer's patches will  be soft and
enlarged.
   The lungs will be congested (splenization), and the bronchi may
contain the exudation.
   The liver will also be congested,  and the spleen enlarged and
softened.
   In addition to the foregoing changes in the blood and organs,
there may also be those which resemble typhoid fever so closely
that it will be almost  impossible to  distinguish the two diseases.
Under these circumstances,  the exudation must  be  present to
decide it.
  The first action of this disease is to destroy life, which it does
by attacking the epithelial, sub-epithelial, and mucous  tissues.

                         ETIOLOGY.
  The questions which naturally arise are: 
DIPHTHERIA.
347
  First.—Is diphtheria a contagious disease ?  There is no doubt
that it is a contagious disease, and can be developed by inocula-
tion in the same manner as small-pox.
  Second. —Is it  a constitutional disease  primarily, and  local
secondarily, or vice versa ?  It cannot be weh denied that it is first
a constitutional, and, secondly, a local disease; for it seems proven
there is a local manifestation of a constitutional  development by
the fact,  that  the disease cannot be destroyed by taking off the
various layers of the mucous membrane.   It is unquestionably a
constitutional disease, and the local changes depend entirely upon
the amount of infection.
  Third.—Is it of spontaneous origin ? It is like typhus and ty-
phoid fevers,  requiring a poison through decomposing  animal
matter, which fills the air.  That it also occurs in connection with
sewer poisoning there is no doubt, still the profession is very un-
decided on this point.  It is a contagious disease, and has no ap-
parent governing law.  It may be communicated and produced,
or transmitted, by the exhalations.  It is claimed by some  that
this disease is due to some special germ.  (This is not yet proven.)
                        SYMPTOMS.
Local.
    Chills, fever, and active symptoms, with rapid pulse, in some
       cases precede the disease; while in other cases it comes on
       insidiously, and, only for the exudation, it might escape
       observation.
    Exudation (is characteristic)—usually commences on the ton-
       sils.   It may extend backward and upward, or to the soft
       palate and pharynx, and into the posterior  nares, or
       downward into the oesophagus and stomach, or  into the
       larynx, and even to  the lungs.
    Pricking sensation  in the tonsils, often extending down the
       throat.
    Pain—in the throat and pricking sensation in the larynx.
    Difficulty  of deglutition—(from  extension of the exudation
       into the oesophagus).
    Voice—becomes changed, husky, and, finally, lost (from ex-
       tension of exudation into the larynx). 
348
DISEASES OF THE BLOOD.
   Respiration—difficult both on inspiration and expiration, and
       wheezing  in character  (from extension of  the  exuda-
       tion into the larynx).
   Cough—abortive  and stridulous (from extension of the  ex-
       udation into the larynx).
   Restlessness and jactitations—(indicating changes in the oxy-
       genation in the blood).
   Cyanosis.
   Stupor and coma— (from excess of carbonic acid in the lungs).
   Glands of the neck—enlarged (sub-maxillary gland is involved
       only when the exudation is on the tonsils, pharynx, and
       posterior nares, from extension of the poison through the
       lymphatic channels\
   Puffing of the face may occur.
   Death—may result from croupous laryngitis.
Constitutional—vary with the amount of poison in the system.
   Pain in the bones.
   Chilliness or violent chills.
   Temperature—may rise  to  105-106% or may not  rise over
       102°-103°.
   Pulse—accelerated from 100 to 150.  In some cases becomes
       irregular and intermittent.
   Countenance—has a lethargic expression (in some cases).
Special symptoms—indicative of danger to the patient.
    1. Extension of the exudation  into the larynx—(from which
       few  ever recover), producing change  in the voice and  a
       stridulous cough, which tells of danger and almost cer-
       tain death.
    2. Appearance of the  exudation—which  may  be dark-gray,
       greenish, or  black, involving  the whole of the posterior
        walls of the pharynx and nares.  It often emits an odor,
        resembling  gangrene when the  danger is  great.  Septic
       symptoms then develop, with fever and a high range of
        temperature, etc.  Septicaemia may be ushered  in by a
        chill, and followed by lethargy, stupor, peculiar offensive
        odor, disposition  to  a  typhoid  condition, and delirium 
DIPHTHERIA.
349
        terminating  in death (which is due  to  long-continued
        blood-poisoning).
    3. Vomiting.—If it occur early, is not of very great  import-
        ance; but, if late, then it is a grave symptom, indicating
        danger.  It is not due to the shock of  the  poison, but to
        a secondary poison, and  the patient often passes  rapidly
        into collapse.
    4. Nausea and diarrhoea—occurring late in the disease, are
        grave symptoms.
    5. Pulse.—This is of three varieties:
        1st.—It may be rapid from the  beginning and continue
        throughout at 140 to 180.  This is due to the action of the
        poison on the pneumogastric nerve.
        2d.—It may be rapid from the beginning and suddenly go
        down to  60 or 80, and  afterward become intermittent.
        This is due to the action  of the poison on the sympathetic
        system.
        3d.—There may be marked irregularity from the onset. It
        may be intermittent  and rapid at first, then becoming
        slow, or vice versa.  This is due to the action of the
        poison on the cerebro-spinal system.
    6. Paralysis of the muscles of  the larynx, neck,  arm, etc
    7. Low  temperature and  cold surface,  accompanied by a
        cyanotic condition.  Even if the pulse be  rapid  and not
        intermittent and  irregular, this is  unfavorable.  It de-
        notes action of the poison on the nerve-centres.

                         SEQUELAE.
  The most frequent is that of paralysis of the pharynx,  larynx,
arms, lower extremities, bladder, penis, etc.  There are no medi-
cal means which can restore the  normal power, the action of the
muscles seems to be lost for a certain time, and then to return
to their normal condition; thus clearly proving that there  is no
great structural lesion in the nerve-centres.
  Another sequela is parenchymatous nephritis, which com-
mences in the uriniferous tubules.  These are filled with an ex-
udation the same  as in other infectious diseases.   There may be 
350
DISEASES OF THE BLOOD.
a granular exudation of the uriniferous tubules, going on  from
one step to another until it produces total destruction and intense
engorgement of the kidneys, resulting in blood in the urine, etc.
Uraemic symptoms will then be developed, and the patient may
die in convulsions from uraemic  poisoning.  The diphtheritic
renal changes are sometimes the  cause  of  chronic Bright's,
having its origin in a parenchymatous inflammation from the
result of diphtheritic inflammatory changes.
                     COMPLICATIONS.
  Endocarditis.—This is usually of an ulcerative type, and occurs
after the  exudation  has disappeared.  It requires more than a
simple irritation of the blood passing over the endo-cardial surface
to produce it, and denotes very extensive constitutional poisoning.
  Meningitis.—If it occur at all, appears early in the disease.
  Hemorrhage of the bowels.
  Jaundice.—(From extension of the exudation along the line of
the hepatic duct). The inflammation occurs in the smallest tubules
of the liver.
  The inflammatory process may occur in the smallest bronchi in
the lungs, extending downward from the larynx, or it may com-
mence in the bronchi and extend upward.   There is no mucous
membrane in the body that may not become involved.
               DIFFERENTIAL DIAGNOSIS.
  Rests entirely upon the presence of an exudation, which usually
shows itself first on the pharynx.  Unless the exudation be per-
ceived on  some mucous surface, and there  be marked constitu-
tional disturbances, the diagnosis of diphtheria cannot be made.
It may  be diagnosed from  catarrhal pharyngitis, membranous
croup, typhus or typhoid fevers, and ulcerative endo-carditis.
  In catarrhal pharyngitis—you have no gray exudation, and the
patient gets well in from four to five days.
  In membranous croup—the membranes are superficial,  and
there are no constitutional disturbances.  They are simply local.
  In typhus and typhoid fevers.—It is very difficult to decide
such cases as these, for, whenever the  exudations  occur, it will
always be along the intestinal tract, and a'l that can be done 
DIPHTHERIA.
351
 under these circumstances, is to watch the discharges for two or
 three days, and also the matter that may b e vomited, when the
 exudations may be perceived.
   In ulcerative endocarditis.—The patient first complains of  sore-
 throat ; he is seized with pains in the back, perhaps hemiplegia,
 and suddenly becomes unconscious; the  pulse will be irregular,
 a mumbling delirium may be present.  On examining the heart
 it will be found to have a tumbling motion and extensive valvular
 lesion; under these circumstances  examine the posterior nares,
 when you wiU be certain to find a small mucous patch of exuda-
 tion, which will confirm your diagnosis.

                        PROGNOSIS.
   Depends upon whether  there is an epidemic  raging, and also
 upon the stage of the epidemic; the fatality being worse in the
 early stage.  It is apt to demolish a whole township of children.
 Age is an important element of prognosis; for, the younger the
 the child, the worse the  prognosis, as death seems to result from
 obstruction in the  pharynx (and consequently from an inability
 to feed the child),  and further, from the excess  of poison in the
 constitution.  When  it attacks  the adult, the prognosis is more
 favorable.  The character of the exudation is an aid in the prog-
 nosis;  for, the darker,  and thicker,  and  more  extensive the
 exudation, the worse the  prognosis.  If it attack the posterior
 nares, and extend upward, if the glands become enlarged, and the
 constitutional symptoms are severe, the  prognosis is grave; but,
 so long as the exudation confines itself to the fauces and anterior
 pfilars of the pharynx, and spreads, but is not thick, even though
 other symptoms be severe, the prognosis is favorable.  Should the
 exudation  extend  downward into the  larynx  and respiratory
 tract; or into the oesophagus,  it will then  be unfavorable.
   If the exhalations from the throat be  offensive,  and, following
 the shock, there be evidences of septic poisoning, the prognosis is
 bad.  Should pharyngeal paralysis  occur before the exudation
 has disappeared, recovery is hardly possible, as deglutition be-
comes involved, and death resulting from inanition.  The paraly-
sis which comes on after the disappearance of the exudation is 
352
DISEASES OF THE BLOOD.
usually recovered from, yet there is one form of paralysis which
destroys life, and that is  when the intercostal muscles are para-
lyzed, accompanying paralysis of the diaphragm (since the patient
then dies from inability to respire).
  Should the slow pulse  come on after a fast pulse, it may be re-
covered from; hut, if in  addition to the slow pulse it becomes in-
termittent, the prognosis is bad.
                        TREATMENT.
  May be divided under four headings:
                   1. Hygienic.
                   2.  External local.
                   3.  Internal local.
                   4.  Constitutional.
  Hygienic.—The patient should be placed in a large, well-venti-
lated room, the temperature of which should range from 68° to
72°.  Great care should be exercised in regard  to  cleanliness, for
there is no disease in which cleanliness is so important.   The bed
and body-linen should be carefully cleansed; the patient should
be quarantined, and all other children removed from the house,
or kept away from the apartment.  It is best to place the patient
in an upper sunny room,  provided, if possible, with an  open fire-
place;  everything which  can be  dispensed with,  such  as books,
clothing, carpets, window curtains, etc., should be removed, be-
cause  when  once the  patient has entered the room, nothing can
with safety be removed until disinfected or fumigated.  One or two
adults  should take the entire charge of the patient, under no cir-
cumstances coming in contact with other persons, especially  chil-
dren.   Great care should be observed not to inhale the breath of
the patient, and parents should be  prevented from kissing the
child.   All soiled linen, and also  every article used in the room,
should  be thoroughly disinfected before it leaves; this can  be
easily accomplished by obtaining one pound  of sidphate of zinc;
place eight tablespoonfuls of this, with four of common salt,  in
an ordinary water pail, and, to them  add one gallon of boiling
water.   This disinfectant solution must be kept in the sick-room,
and into it should be placed, and kept for  one hour, every article 
DIPHTHERIA.
353
 of soiled  clothing, bedding, etc.;  when  they are removed  from
 this they  must be put  into  boiling water before being washed.
 The dishes and spoons used by the patient should be put into
 boiling water before  they are  permitted to  leave the room.   It
 must be borne in mind that every article which is in the room can
 convey the disease, and that nothing should go from it until the
 poison, which they might carry, has been destroyed.
  Be very careful when making an examination that the breath is
 not inhaled, nor the sputa gain entrance into your mouth.  Avoid,
 as much as possible, manipulation and inspection of the throat,
 as it produces irritation, and will necessarily increase the exuda-
 tion ; examination should always be made with the utmost  care,
 and not too frequently.   One of the principal features  in the treat-
 ment of this disease is absolute rest in the recumbent position, and
 the  patient should not be allowed to move  about or walk.  The
 diet should consist simply of milk, and given in small quantities.
 The body should  be  carefully sponged,  and the nasal passages
 syringed out once  a  day, with a half per cent solution of carbolic
 acid, but care should be taken not to exhaust the patient.  The
 windows  of the sleeping-room should be opened, as long as pos-
 sible, every day, as fresh air is about the best  disinfectant; but
 draughts  and chilling the patient should be carefully avoided,
 and  see that  a fire is kept burning in the room, day and night,
 during cold weather.
  External local.—This consists of
    (1) Blood-letting—by the application of leeches to the angle of
       the jaw.
    (2) Cold—by means of the ice-bag.
    (3) Counter irritation—in the  form of blisters, etc
    (4) Hot applications and hot poultices.
  Of these, the preference must be given to  the  hot application
(which should be covered over with oiled-silk when applied) and
hot poultices, because, so long  as  there is a granular exudation
into the membranes, and it can be converted into a serous, the
sooner it will cease. These hasten suppuration, and should, there-
fore, be applied regularly and carefully at the seat of exudation. 
354
DISEASES OF THE BLOOD.
  Internal local.
                   1. Mechanical.
                   2. Escharotics.
                   3. Astringent.
                   4. Antiseptic.
  With regard to the first three methods, it is hardly necessary to
assert that they are only detrimental, as they tend  to aggravate
the part and cause the exudation to infiltrate the deeper tissues,
and produce gangrene and  sloughing   The exudation  should
never be removed, unless you find a  part that has sloughed and is
pendant; it should then  be  drawn forward  and cut off.  The
question naturally arises; you require to start a suppurative pro-
cess under the  exudation.  What is to be done ?  What shall be
used ?   Steam should  be  used, as it is the most  grateful course
that can be pursued for the patient, because it tends to produce
suppuration; therefore, apply hot poultices externally, and cause
steam to be inhaled; and, so soon as  the removal of the exudation
is observed, you know your patient  has had a local affection.
  What is to be done with the septic poison ?  Use antiseptics by
means of the spray,  with a weak  solution of carbolic acid or
chlorine water, and a  very weak solution of the muriate tincture
of iron; or give the patient muriate tincture of iron, gtt. v., with
glycerin; or chlorate of potash, gr.  v., with glycerin, and let him
swallow it, as it acts in the same way as the spray when that plan
cannot be resorted to.
  Constitutional.—From the onset there are evidences of failure
of vital power  and loss of all symptoms of vitality, the patient
dying, as they do in all infectious diseases, from the direct effect of
the over-charging of the poison. The disease must, therefore, be
treated in all ways, as the other infectious diseases.  Muriate tinc-
ture of iron should be  given from the commencement.  As stimu-
lants, alcohol or brandy stand first,  but should not be used unless
the system is very much disturbed constitutionally, as they are not
required; but, so soon  as you find the patient becoming apathetic,
the pulse feeble, and more frequent, and perhaps becoming irreg-
ular, the tongue dry, and  the exudation dark and offensive, then
crowd your stimulants, the first few doses of which should be 
RELAPSING FEVER.                     355
 carefully watched, and it may even be necessary to give as much
 as a tablespoonful every hour to a young child.  Milk should be
 the diet  upon which the patient should be fed ; if it cannot be
 swaUowed, it  must be given by the rectum.  Should there be
 restlessness and  jactitations, opium  may be given in moderate
 doses, but not sufficient to produce narcotism.
   In the laryngeal or pharyngeal complications malt liquors should
 be given and as much as the patient will take, all other methods of
 treatment being of no avail.
   In cardiac diseases opium judiciously administered will have a
 beneficial effect, but in children the only preparations which should
 be given are Pulv. Doveri. and tinct. opii campli.
   When kidney complications occur they must be treated in the
 same manner as acute parenchymatous nephritis.


                  RELAPSING FEVER.

                         SYNONYM.
   Famine fever.
                        DEFINITION.
   Is an epidemic fever, characterised by a sudden invasion and
 persistent high febrile symptoms without remisssion; temperature
 rising to 107°-108%  There is a rapid subsidence within a week and
 then a relapse, usually, within seven days after the first attack.
 The temperature  in this fever rises higher than in typhoid.   It is
 claimed that the disease is due to spirilloe within the blood.

                    MORBID ANATOMY.
  The lesions occurring in this disease will be found in the spleen,
 hver, kidneys, intestines, mucous membranes and the blood.
  Spleen—may be increased in size ; its capsule thickened, smooth
 tense and  shghtly cloudy ; its trabeculoe increased in size ; and
 the Malpighian tufts more prominent than normal, or it may be
 enlarged, soft and flabby.
  Liver—may  be enlarged ; the structural changes will be the
same as those in  the spleen.   The gall-bladder may be distended
with bile of a dark yellow color. 
356
DISEASES OF THE BLOOD.
   Kidneys—increased in size which  is due to congestion of the
 cortical substance and a granular infiltration of the epithehum of
 the uriniferous tubules.
   Intestines—glandular  follicles will be enlarged.  The solitary
 glands are principally affected and Peyer's patches may have the
 shaven-beard appearance.  The mesenteric glands may resemble
 those of typhus or typhoid fever.
   Mucous membranes.—Those of the  stomach and intestines are
 principally affected having small spots of blood-extravasation up-
 on their surfaces, but these extravasations may also  occur on the
 mucous membranes of the bronchial tubes.
 Blood—coagulates imperfectly.  Some  authorities  claim  that
    spirillae are always present in the blood  of patients afflicted
    with this fever.
                         ETIOLOGY.
   It is said to oe due to spirillae in the blood having the power  of
 developing the fever. It seems to be  developed  by squalor, poor
 quality of food, and bad hygienic surroundings.  It may be traced
 to direct contagion.
                        SYMPTOMS.
 Advent is sudden.
 Chill—distinct.
 Fronted headache (which increases with the fever).
 Pain in the muscles and joints—(which increases  with the fever).
 Nausea.
 Vomiting—at  first, contents  of the stomach, then a yellowish
    material, and subsequently of  a  dark color resembling the
    black vomit of yellow fever.
 Temperature—rises rapidly especially during the first twenty-four
    hours; may reach 104° or  even 109° and  may last for two  or
    three days.
Pulse—may  reach 140 to 160 during  the first twenty-four hours
    and is small and compressible.
Respiration—hurried and irregular.
Great prostration and emaciation.
Weight  and uneasiness in the abdomen, especially in the right
    hypochondrium 
RELAPSING FEVER.
357
Liver—enlarged and tender.
Spleen—enlarged and tender.
Muscular pains—Severe and increased by  motion and pressure
    and is of a piercing and lancinating character, and patient lies
    perfectly quiet and sleepless in consequence.
Delirium—may occur and be active in form.
Pupils—may be irregular.
Photophobia—may occur.
Jaundice—may occur with vomiting and diarrhoea.
Eruption—may occur, resembling roseola.
Perspiration—profuse about the seventh or eighth day of the fever
    when the temperature falls and the symptoms abate.
Hemorrhage—from the nose, bowels, or intestines may occur.
Relapse—may occur from the third to the seventh day after the
    symptoms abate which last about four days.
CEdema of the feet—may occur during convalescence, due to great
    anaemia.
                    CAUSES OF DEATH.
  Deaths usually occur from complications  and not from the dis-
ease as from diarrhoea and dysentery during convalescence * from
pachymeningitis; from hemorrhage from some of the mucous sur-
faces ; from syncope during relapse ; from bronchitis, pneumonia
or pulmonary complication; from suppression of urine producing
uraemia.
                     COMPLICATIONS.
  Pneumonia which  is often double ; sudden collapse ; post feb-
rile ophthalmia attacking most frequently the right eye ; diarrhoea
and dysentery.
               DIFFERENTIAL  DIAGNOSIS.
  Is not difficult.  It may be confounded with typhus fever; ty-
phoid fever ; remittent fever ; yellow fever ; dengue fever; small
pox (before the eruption); and measles.  It  differs from them all
in the suddenness of its invasion ; short duration of its primary
fever ; high temperature and-pulse ; termination in  a crisis ; the
occurrence of a relapse between the third and fifth days and con-
stant muscular and arthritic pains. 
358
DISEASES OF THE BLOOD.
                        PROGNOSIS.
  Is always good unless complications exist, the rate of mortality
being lower than in measles.

                        TREATMENT.
  This disease has been experimented upon by almost every drug
in order to control the fever ; the decision now arrived at is that
these patientc progress  more  favorably when placed under the
best hygienic surroundings with free ventilation, a mild diet and
no medication whatever.  During the  primary fever the patient
should be kept in bed and great care should be taken to guard
against syncope,  Should heart failure occur digitalis and stimu-
lants must be administered.
  Test to discover Spirilloz in the  blood (by  Albrechs,  of St.
Petersburg).
  1st. Dry a drop of blood on a slide.
  2d. Put a drop of acetic acid on the slide which eats away the
fibrin and blood-corpuscles.
  3d. Wash off the slide with care so as to get rid of the dissolved
fibrin and blood-corpuscles.
  4th.  Dry the  specimen and examine under the  microscope,
when the spirillae will be  observed, if present 
DISEASES OF THE URINARY
          ORGANS. 
 
RENAL   CONGESTION.
                        SYNONYM.
  Hyperaemia of the kidney.
                    MORBID ANATOMY.
  In active hyperozmia, the kidneys may be found very much in-
creased in size, in both the cortical or medullary portion,  and this
increase will be most marked at  the  base of the pyramids.   The
kidneys will be unnaturally dark in color.  The capsules will be
non-adherent, the surfaces  smooth,  and the organs  softer and
more moist than normal.
  On section, dark spots will be seen corresponding to  the Mal-
pighian tufts.  A fluid will exude on section of the organ (half blood
and half eerum), due  to oedema associated with congestion of
the vessels. The congestion occurs in the arteries and Malpighian
tufts before the veins are involved.  The  changes in the organ
are confined to engorgement of the blood-vessels, and an infiltra-
tion of serum into the intertubular  structure in the cortical
portion.
  In passive or mechanical hyperozmia (especially  when occur-
ring in chronic cardiac disease), the kidneys are not much increased
in size, but are of a stony-hard character and smooth.  The cap-
sules are non-adherent;  their surface is smooth; and  they are of
an uniform red color.
  On section, the medullary is darker than the cortical  portion.
The Malpighian tufts are not prominent, but  are  simply  filled
with blood.  The veins are dilated and  hard; the hardness is due
to a constant dilated condition of the efferent capillaries.  There
are not, necessarily, inflammatory changes in this form of kidney,
but they may be accompanied by inflammation of the uriniferous
tubes.  There may be more or less change in the tubules,  char-
acteristic of simple catarrh of  their lining structures.
                        ETIOLOGY.
  Active congestion is produced by exposure to sudden  changes; 
360
DISEASES OF THE URINARY ORGANS.
to blood-poisons, such  as  scarlatina,  diphtheria, typhus  fever,
malaria; and to irritation of the urinary passages by cantharides,
turpentine, nitre, copaiba. It may result also from diabetes, chohv-
mia, morbid  formations in the organ, traumatism, disease of the
pelvis of the kidney, and cardiac hypertrophy (on account of an
accelerated, or too forcible heart's action).
  Passive congestion is produced by diseases of the heart or lungs;
mechanical obstruction in the thorax or abdomen; venous ob-
struction to the right auricle, such as pressure on the vena cava
above the renal vein, or on the renal vein; arterial obstruction
from the left ventricle; valvular lesions (especially mitral regurgi-
tation, or tricuspid insufficiency); structural diseases of the cardiac
walls; obstruction to the pulmonary circulation, as occurs in em-
physema, pleuritic effusions, pneumo-thorax, fluid in the pleural
cavity; pressure on the inferior vena cava, as occurs in pregnancy
and abdominal tumors;  mediastinal tumors pressing on  the pul-
monary artery or vein;  weak heart, from exhaustion and old age;
surgical operations on the urethra (from nervous causes); calculi
in the kidney; extension of inflammation  from the  urethra and
bladder; and pressure on the heart from pericardial effusions.
                        SYMPTOMS.
Decrease in the quantity of urine.
Increase in the specific gravity.
Albumen and traces of  blood. (If albumen alone, it  usually indi-
    cates inflammation.)
Blood-casts of the uriniferous tubes (rare).
                        PROGNOSIS.
  Is bad, if it occur in  connection with cardiac disease, and also
in the congestive malarial fever of hot climates.  Renal conges-
tion may be followed by inflammation of  the  uriniferous tubes
and development of Bright's disease.
                        TREATMENT.
  For active hyperozmia.—The patient  must be kept  in bed, with
the temperature of the room about 75°. A dozen dry or wet cups
should be applied over  the  lumbar region.  Diluent drinks may 
RENAL HEMORRHAGE.
361
be freely indulged in.  Administer one or two drastic purgatives,
and avoid stimulants.  Induce moderate diaphoresis.
  For passive hyperozmia.—Mild counter-irritants, such as three
or four cups, and no  blisters,  may be used.   A brisk cathartic
may occasionally be  given, or a dose of calomel, in combination
with  some other purgative.  Should there be great renal disturb-
ance, digitalis may be given freely.  If in connection with preg-
nancy, cupping will be found serviceable.


                RENAL  HEMORRHAGE.
                    MORBID ANATOMY'.
  The changes are much the same as those of renal congestion.
The  hemorrhage is  most frequently due  to  embolism and
infarction,  traumatism, new-growths,  or renal calculi.   Con-
gestion always  takes  places in the vessels which surround an
infarction.   Little  masses, like ecchymotic  spots, may often
be  observed in  the cortical  substance;  and these are due  to
an  effusion of blood into  the uriniferous tubules, or interstitial
tissue.  On section, blood often flows freely from the uriniferous
tubules.   The seat of the hemorrhage is usually marked  by the
development of hard uniform masses in the cortical portion; these
infarctions are wedge-shaped, with their apex  toward the hilum
of the kidney, and their base  toward the  surface; they may  be
capillary, and very  small  in  size.  At first  they are dark-red,
gradually becoming  lighter in  color.   In the centre they may
have  a cheesy appearance.  Changes often  take  place  in the
uriniferous tubes in the region of these capillaries, thus causing
congestion and  the  production of lymphoid  cells, which may
undergo  rapid  purulent  transformation,  producing abscesses.
The infarctions may increase in size, and  become necrotic, pro-
ducing gangrene.  Capillary thrombi are sometimes formed, and
may become numerous; this is due  to the slowness of the capillary
circulation.
                        ETIOLOGY.
  Intense active  congestion, resulting in an engorgement of the
kidneys with blood, and rupture of the capillaries (occurring  in 
362
DISEASES OF THE URINARY ORGANS.
scarlet,  typhus, and malaria  fevers ; injuries, wounds, or con-
fusions  of the  kidney; cancerous  development: renal calculi in
the pelvis of the kidney; purpura; scurvy; cardiac diseases (pro-
ducing  passive obstructive  congestion); infarction (due  to renal
embolism or capillary thrombosis).
                        SYMPTOMS.
Urine.—This is the only means of ascertaining a renal hemor-
    rhage, as the blood will be effused into the uriniferous tubules
    or hilum of the kidney, and discharged into the bladder.
If it occur from renal calculi—hemorrhage is liable to take place
    at every violent exertion.
If it occur from cancer or tumor—it is usually profuse in quantity
    and persistent.
If it  occur  from infectious diseases—it is  slight, and perhaps
    only recognized by the microscope.
If it occur from malaria—it is profuse and periodic.
If it occur from infarction—there are chills (as it is usually due to
    pyaemia).
                        PROGNOSIS.
  If it occur from renal  calculi or  cancer, the prognosis will be
bad; if  from infectious diseases, it is merely an indication of in-
tense hyperaemia; and, if from infarction, it is always  attended
with danger.
                       TREATMENT.
  The patient should be kept absolutely  at rest when hemorrnage
occurs.   Ice-bags should be applied  to the lumbar  region, and
styptics, such  as tannic acid, be given internally, as it is expelled
through the kidneys in the form of gallic acid, if the hemorrhage
be profuse, and there  be danger of  exhaustion.   In some cases
ergot may be  given  in  large doses.   If it be due  to malarial
poisoning, large doses of quinine are indicated.


                         UR.EMIA.
  In this disease, the symptoms are divided into two classes.
  1st. Urozmic convulsions—consisting  of twitching and epilepti- 
UREMIA.
363
form convulsions of the voluntary muscles, ushered  in  by head-
ache, nausea, and vomiting.
  2d.  Urozmic coma—which is a state of insensibility, ushered in
by headache, drowsiness, or convulsions.
  Both of these conditions are  due to  failure of the kidney to
eliminate urea, and hence accumulation of poisonous matter in
the blood.  This may occur in almost any disease.

                         ETIOLOGY.
  It may be due to a complete or partial arrest of  the  urinary
secretions, or to the retention of the united  products of all the
nitrogenized effete matter, usually eliminated by the kidneys; or
to urea, which, when  in excess, is an irritant poison, acting pri-
marily on the cerebro-spinal centres, and through them  interfer-
ing more or less with the functions of organic life.

                        SYMPTOMS.
In acute urozmia.
    CEdema—in various parts of the body.
    Restlessness.
    Impaired vision.
    Headache.
    Nausea.
    Vomiting.
    Drowsiness.
    Countenance—pale, waxy, dingy appearance.
    Urine—scanty, high-colored, and bloody;  it contains  albumen
        and casts.
    Violent convulsions—from excess of urea in  the circulation,
        when the
           Face—becomes livid.
           Eyes—glassy.
           Pupils—contracted or dilated.
           Frothy or bloody  mucus around the mouth.
           Perspiration—is of an urinous odor.
           Temperature—elevated (it may reach 107%\
           Pulse—accelerated.
    Coma—comes on gradually; resembles an attack of cerebral 
364
DISEASES OF THE URINARY ORGANS.
       apoplexy; it may be extremely profound, or the patient
       may be  easily aroused, or  even return suddenly to con-
       sciousness. Attempts to speak and swallow fluids are per-
       formed with difficulty.
    Respiration—is  slow  labored, and  stertorous  during the
      coma.
    Pupils—regularly  dilated.
    Pulse— rapid and weak.
    Temperature—rises, and gradually falls below normal.
In chronic urozmia.
    Headache—a prominent symptom.
    Insomnia.
    Lassitude.
    Countenance—peculiar pallor, waxy, etc.
    Skin—dry or moist, and has an urinous odor.
    Muscae volitantes—due often to oedema of the retina.
    Nausea.
    Vomiting—sometimes.
    Restlessness.
    Impaired digestion.
    CEdema—first about the eyes, then the ankles, and extending
        upward.
    CEdema of the lungs.
    General anasarca.
    Changes in the urine—which depend upon the type of kidney
        disease present.
    Convulsions.
    Serous inflammation—especially endocarditis and meningitis
        in the later stages.

                DIFFERENTIAL DIAGNOSIS.
  From epileptic seizure; cerebral apoplexy;  ammonaemia; hys-
terical convulsions; opium poisoning; and cholaemic convulsions.
Epileptic seizure.
    One side convulsed  more than the other.
    Loss of consciousness.   Reflex sensibility and no rise in tem-
        perature.
    Deep sleep follows the seizure. 
                          UREMIA.                       365
Uraemic convulsions.
    Both sides equally convulsed.
    No loss of consciousness.
    Rise in temperature.
    Deep coma follows the seizure.
Cerebral apoplexy.
    Coma precedes the convulsions.
    Paralysis (hemiplegia) can usually be detected.
    Clonic spasms of the affected  side.
    Urinary symptoms of uraemia absent.
Urozmic convulsions.
    Convulsions precede the coma.
    No paralysis.
    Spasms of both sides equally.
    Urine will decide the case.
Ammonozmia.
    Urine, breath, and perspiration are all ammomacal.
    Mucous membrane of the mouth is dry and shining.
    Sallow complexion.
    Frequent chills.
    No dropsy.
    Vomiting—rare.
    Convulsions—rare.
    Coma precedes death.
Urozmia.
    Perspiration—has an urinous odor.
    Countenance—pale,  and of a waxy appearance.
    Chills -possible.
    Dropsy.
    Vomiting.
    Convulsions.
Hysterical convulsions.
    Patient falls (often with a scream) into a convulsive
       or cataleptic condition
    Pupils—normal and constant blinking of eyelids.
    Temperature—normal.
    Pulse—normal.
tetanic, 
366           DISEASES OF THE URINARY ORGANS.
    Limbs—jerked irregularly.
    No lividity of the countenance.
    Breathing—spasmodic, and a choking sensation is often com-
       plained of.
    Discharge of large quantity of pale urine after the attack.
Urozmic convulsions.
    Convulsions are preceded by headache, etc.
    Pupils—regularly dilated, or contracted.
    Temperature -accelerated.
    Pulse —accelerated.
    Jerking is regular.
    Countenance—livid.
    Respiration—labored, slow, and stertorous.
    Urine—will decide the case.
Opium poisoning.
    Temperature—usually below normal.
    Respiration—slow and regular.
    Pupils—uniformly contracted  (pin-point pupils).
Urozmic coma.
    Temperature—elevated 100%
    Respiration—slow, labored, and stertorous.
    Pupils—uniformly dilated.
Cholozmic convulsions.
    Produced from overcharge of  bile in the blood.
    The convulsions are preceded or accompanied by jaundice.

                   CAUSES OF DEATH.
  Death results from the action of urea on, and overwhelming of,
the nerve-centres, producing changes  in the blood, which inter-
fere and arrest oxygenation; there are  then structural changes
taking place in the tissues, rendering them incapable of support-
ing life.

                        PROGNOSIS.
  Depends upon the amount of urea in the blood, and the time it
has been accumulating. 
BRIGHT'S DISEASE.
367
                         TREATMENT.
   The patient should have absolute rest and free elimination, pro-
 cured either by the skin or bowels, or both.  Diaphoresis may be
' accomplished with hot-air baths.  Drastic purgatives, as elate-
 rium, scammony, or croton oil, may  be  administered.  Digitalis
 is the best diuretic that can be given;  it strengthens the heart's
 action and the eliminating power of the kidneys, since the blood-
 pressure is increased.  Inf. of English  leaves, dose 3 cs., may be
 taken every three hours for the first  twenty-four hours, or  until
 the specific effect of the drug is produced.  For uraemic convul-
 sions, morphine should be administered hypodermically; v\ x. at
 first, and if that does not arrest them, give Tfi, xx. every two hours,
 to  control the convulsions.  It arrests  the muscular spasm by
 counter-acting the effect of the uraemic poison on the nerve-
 centres, and establishes diaphoresis, and it further facilitates the
 diuretic action of digitalis.

                   BRIGHT'S  DISEASE.
  The three distinct elements which are  primarily or  secondarily
 involved in the morbid changes of the kidney are (1) the urinifer-
 ous tubules; (2) the blood-vessels/in the  walls); and (3) the inter-
 tubular connective-tissue.
  The various forms of Bright's disease  may be classified under
 three heads (from a pathological basis), as follows:
  1. Those which are inflammatory in   their nature,  and com-
 mence in the urmiferous tubules, designated as "parenchymatous
 nephritis."
  2. Those which are non-inflammatory in their nature, and com-
 mence in the walls of the blood-vessels,  designated as  the " amy-
 loid variety,"
  3. Where the  changes commence  in  the intertubular tissue,
designated as the " cirrhotic type."

          PARENCHYMATOUS  NEPHRITIS.
  This is the  most common form, and  is of an inflammatory
nature.   It may be of either short or long duration, and may, 
368
DISEASES OF THE URINARY ORGANS.
therefore, be subdivided into the acute and chronic form.  It has
three stages.
                          STAGES.
  1st Stage.  Active  inflammation — called "acute desquamative
tubular nephritis," or " acute parenchymatous nephritis."
  2d Stage. Degeneration—which may be either fatty or granular,
and is  called by some authors the "fatty" or " large white kid-
ney."
  3d Stage. Atrophy of the organ.
                    MORBID ANATOMY'.
  First stage  (inflammation).—This may be either catarrhal,
croupous, or desquamative in type.  The kidneys are increased in
size; their capsules  are non-adherent; their surfaces  are smooth
or mottled; they are usually of a dark and purplish color, dotted
with spots of ecchymosis, and are firm on pressure.
  On longitudinal section of the organ.—The cortical portion is
seen to be increased in volume and dotted over with dark or red
spots, which correspond to the congested Malpighian tufts.  The
cortical substance between the tufts may be  paler than  normal.
There will usually be engorgement, well-marked at the base of the
pyramids (at the junction of the cortical and  medullary portion);
the medullary  portion will be darker than  normal, with alter-
nating red and white lines (the light lines denote  changes in the
uriniferous tubes).  The lining  membrane of the pelvis is some-
what congested.  The well-marked engorgement at the base of
the pyramids exists, on account of the venous arcades being situ-
ated over the base of each pyramid.
  On microscopical examination, the  tubules will be  found to
be the  seat of a simple catarrhal process.  The epithelial lining
may be partially or completely lifted, and may have disappeared,
while the tubules may be more or less filled with cells correspond-
ing to new cell-formation (a simple catarrhal  inflammation).   The
centre of the tubes may also contain a hyaline material (which is
coagulated fibrin), or this hyaline material may be surrounded by
epithelium and blood-globules.  (It is an inflammatory exudation,
resembling  that  of  croupous inflammation  elsewhere.) These 
PARENCHYMATOUS NEPHRITIS.
369
changes usually commence in  the epithelial  cells of the tubes;
the cells become cloudy; their nuclei  disappear; they become
distended and granular; and, finally  these changes are followed
by desquamation.  The tubes may thus be filled with broken-
down epithelium and fatty matter (the latter condition indicating
chronic desquamative nephritis).  In the first stage of the inflam-
matory variety you may have one or all of these conditions pres-
ent in the uriniferous tubules, and also new cell-formation in the
in the intertubular tissue.
  Second stage (fatty or granular kidney).—This is described by
some authors as a special type  of  kidney.  The kidneys are en-
larged;  the capsules non-adherent;  the  surfaces smooth; the
organ paler in color and softer than normal (when fatty degener-
ation is going on), and presenting a yellow or mottled appearance.
The enlargement is due to an increase in volume of the cortical
substance (as shown on section of the kidney), which is of a pale
yellowish-white color.   Under  the microscope, the organ shows
more or less fat in the  tubes, and a diminished vascularity of the
kidney.  The changes  occur chiefly in  the  convoluted tubes of
the cortical substance adjoining  the Malpighian bodies.   The
tubules are distended with  oil-globules, and large hyaline casts
may  be found  in them.  Atrophy, or granular degeneration of
the kidney follows  (if  the circulation and  nutrition  of the
organ be interfered with) since this stage is associated with, or the
result of long-continued active or passive renal congestion.
  Third stage.—After the transformation (fatty) of the epithelial
elements in the  second stage, cellular elements are developed in
the walls of the tubes and intertubular tissue.   Organization and
contraction of this new connective-tissue occurs, compressing the
blood-vessels.  The tubules thicken, and atrophy of the kidney
substance, together with fatty and granular degeneration  of the
contents of the tubules and the epithelium, is developed.
  The microscope in this stage shows excessive  development of
the new connective-tissue and constriction of the tubules, causing
development of cysts.  The kidneys are uneven and nodular, and
smaller and harder than normal; the capsule is thickened and
adherent, and, when removed, tears off part of the kidney.  The 
870           DISEASES OF THE URINARY ORGANS.

cortical substance will be seen to be decreased, and sometimes to
have almost disappeared; the tubes have collapsed, and cysts are
found to have developed.  The principal changes  are thickening
of the walls of the blood-vessels; more or less obliteration of  the
uriniferous tubules, and disappearance of the epithelial lining;
evidences  of a previous fatty and granular degeneration, and a
marked increase in the walls of the tubules and the capsules of
the Malpighian tufts.
  In summary, the following changes  may thus be said to take
place in the several stages of this form of  nephritis (the  inflam-
matory form):
  1.  There may  be  more or less  intense  congestion, with very-
active proliferation and desquamation  of the epithelium, which
lines the tubules (causing  the  tubes  to be blocked up and dis-
tended).
  2.  This excessive engorgement may produce  a  rupture of  the
capillary vessels and an escape of blood-globules into the tubes,
and an effusion of fibrin from the interrupted circulation.  This
latter exudation coagulates in the tubes, and mixes with  the epi-
thelial cells and blood-globules (hyaline material).
  3.  The contents of the tubules (epithelial  cells) become the seat
of a fatty degenerative process.   Their nuclei soon disappear,
and the tubules become distended and  filled with a mass consist-
ing of broken-down epithelium matter  and fat.

                         ETIOLOGY.
                    PREDISPOSING CAUSES.
  From exposure to sudden changes;  from  alcohol, "going on a
spree," and sitting in a draught; from irritation and inflammation
of the uriniferous tubules, produced through excessive labor of the
kidneys to throw off the accumulated excrementitious material (the
power of elimination being arrested through the defective action of
the skin); from inflammation due to reflex influence of the nervous
system; from additional work and some peculiar shock through
the sympathetic; from renal hyperaemia, and  its various causes;
from inflammation of other organs. 
PARENCHYMATOUS NEPHRITIS.
371
                       EXCITING CAUSES.
  (1) Blood-poisoning (as evidenced in the renal hyperaemia follow-
ing fevers, scarlatina, typhus, diphtheria, measles, pyaemia, rheu-
matism; and in the direct irritation of the tubuli uriniferi, fol-
lowing the use  of copaiba, turpentine,  cantharides, etc.); (2)
mechanical interference with  the circulation of the kidney, as
occurs in pregnancy and cardiac diseases; (3) senile decay, pneu-
monia, extension of inflammation from adjacent structures, etc.
                         SYMPTOMS.
In the mild form, or simple catarrh of the uriniferous tubides.
    CEdema of the face.
    OMema of  the  feet and  ankles (occurs early if heart lesions
        exist).
    Restlessness.
    Headache—constant and increasing (due to  irritating effects
        of the accumulated urea).
    Urine—scanty,  high-colored, and of high specific gravity.
    Frequent micturition (if  the bladder experiences irritation).

        . .'  y evidences of  the poisonous effects of urea.
    Vomiting, j
    Perspiration—has an urinous odor (if the poisoning by urea be
        rapid).
    Pain—in the back and loins.
    Drowsiness.
    Dry skin.
    Pulse—accelerated and irritable—firm and hard.
    Rise in temperature (denoting fever).
As a severe type develops from a mild form.
    QMema—all over the body.
    Pulmonary congestion.
    Expectoration—watery, streaked with blood.
    Dyspnoea—(from pulmonary oedema, or uraemia affecting the
        respiratory  centres).
    Countenance—pale and waxy.
   Water-logged condition (the dropsy accumulating gradually
        as the case goes on). 
372
DISEASES OF THE URINARY ORGANS.
    OMema of the scrotum and penis—(from blood-poisoning).
    Great restlessness—(from blood-poisoning of nerve-centres).
    Muscular twitchings—(from blood-poison of motor centres).
    Convulsions—from the blood-poison, creating irritation of the
       cortex, or from pressure of oedema.
    Coma—from the blood-poison acting upon the nerve-centres
       to a marked extent.
    Death—from  the blood-poison, creating  oedema of  lungs,
       heart complications, meningeal inflammation, etc.
In the chronic  variety.
  If commencing with an acute type, the following symptoms
may be developed:
    General anasarca.
    Pulmonary oedema.
    Countenance—pale and waxy (like cancer).
    Urine—passed in large quantities.
    Appetite returns,          "] as the symptoms of acute urozmia
    Nausea—disappears,       I subside, and the disease assumes
    Restlessness—disappears,  | a  less active  form of blood-poi-
    Sleep becomes refreshing,  J soning.
    The patient is thus passing on to the third stage, and becomes
       a more or less confirmed invalid.
    (Edema of the feet is always present (to a greater or less de-
       gree).
    Cardiac hypertrophy develops (on account of changes in the
       capillary vessels, and  from poor nutrition  to the heart,
        which necessitates an increase of size  to insure the nor*
        mal power of that organ).
In very acute cases—uraemia may be ushered in by
    Chills.
    Temperature—markedly elevated, 106°.
    Pain—well marked along the back and ureters.
    Marked oedema of the face.
    Urine—completely suppressed or greatly diminished in quan-
        tity, or even bloody.
    Nervous system—disturbed to a marked degree. 
PARENCHYMATOUS NEPHRITIS.
373
    Testicles—retracted (if the kidneys be  excessively irritated,
        even if a calculus be not present).
    Delirium.
    Coma—will probably develop rapidly.
    Death may result in two or three days.
   The main cause to which  most of  these symptoms may be at-
 tributed is urea, in abnormal quantities in  the  blood (producing
 the phenomena which attend the development  of the different
 forms).
   The principal symptoms that always present themselves for
 consideration are those in connection with the changes in the
 urine, the development of dropsy, and the  nervous phenomena.
 These may be thus hastily summarized:

                            Urine.
                      In the First Stage.
 (Stage of congestion and exudation in the uriniferous tubules).
    Scanty and high-colored.
    High specific gravity (1.030).
    Albumen (usually about one-half of the specimen examined).
    Casts—epithelial, small hyaline, blood-casts, and blood-glob-
        ules.
                     In the  Second Stage.
 (Stage of exudation and fatty degeneration).
    More abundant.
    Not so highly colored.
    Lower specific gravity (1.005).
    Albumen (usually about one-third of the specimen examined).
    Casts—oil-globules and fatty, in addition to those in the first
        stage.
                      In the  Third Stage.
(Stage of degeneration and atrophy).
    Greatly increased, and becomes pale.
    Specific gravity usually about 1.010.
    Albumen—(very slight  quantity, if any).
    Casts—fine granular and large hyaline. 
374
DISEASES OF THE URINARY ORGANS.
may be developed if the poisoning be gradual.
                          Dropsy.
  Is caused by the excess of urea acting upon the capillaries and
composition of  blood.  It can thus be explained'
  (1) by hydraemia, and
  (2) by imperfect nutrition of the heart (when there is first hy-
pertrophy, and then softening).
                    Nervous Phenomena.
  Are caused by the urea inducing toxic symptoms.
  Headache, if  constant, is a dangerous symptom, and of great
importance, as it is apt to indicate the possibility of convulsions.
    Drowsiness,
    Stupor,
    Nausea,
    Vomiting,
    Fever,
    Convulsions,
    Coma,
  Death results  from the effects of urea upon the nervous system,
or from some of the complications of uraemic poisoning.
                  Theories for  Convidsions.
  1.  Urea in excess in the blood (which poisons the nerve-centres
directly).
  2. CEdema of the medulla (causing pressure upon it).
  3. Urea becomes an active  poison by being changed into am-
monium carbonate (which causes irritation to the nerve-centres).
  Urozmic convulsions usually come on in  the  manner herein in-
dicated.  Great nervous prostration will probably have previously
existed, as well  as headache and muscae volitantes; sudden stiffen-
ing of the muscles; eyes, rolled up and fixed; head, turned to one
side;  teeth, tightly  clenched; countenance, becomes livid;  in-
spirations, long  and deep;  muscular twitchings; profound sleep;
tongue, may be bitten, or, fall back on the epiglottis, closing  the
larynx, and  thus produce death.
 To determine the quantity of solid matter excreted daily.
  Multiply the two last figures of the specific gravity of the urine by
 the number of ounces passed by the patient during the twenty-four
 hours, and the result will be the quantity of sohd matter excreted 
PARENCHYMATOUS nephritis.
375
in the urine (in grains).  Five hundred grains of urea being the
normal quantity excreted daily in health.
  It is estimated that from six hundred to one thousand and
twenty grains of solid matter are excreted daily by a healthy in-
dividual ; and 25 to 80 fluid ounces of urine passed daily.
                    CAUSES OF DEATH.
  Death may be due to uraemia; meningitis; peri-and endo-carditis;
or pneumonia.
                     COMPLICATIONS.
Cardiac hypertrophy may occur in the chronic form of Bright's
    disease, and is due to interference with the systemic circula-
    tion from long-continued excess of urea.
In the lungs and bronchi.
    Pulmonary oedema—may develop in the first stage, or is one
       of  the results of a general dropsy.
    Pneumonia—if developing in connection  with  pulmonary
       oedema, and if albumen and casts be found in the urine,
       offers an unfavorable prognosis.
    Bronchitis—This  may occur as  a complication of Bright's,
       with or without pulmonary oedema.
    Fluid in the pleura,  in the latter stages of Bright's disease,
       may occur as an evidence of serous inflammation, or of
       general anasarca.
    Endocarditis—(from  the irritating  influence of  poison) may
       exist as one of the serious complications of  Bright's dis-
       ease.
    Meningitis—(as another serious complication) may be devel-
       oped as a result of uraemic poisoning.
    Subacute inflammation of  the  mucous membrane of  the
       stomach (structural  changes).
    Amaurosis or neuro-retinitis (loss of sight).
    Erysipelas—from  poisoning of the nerve-centres, or from a
       defective nutrition of  the tissues.
    Gangrene —from pressure on the vessels  by the oedema (cut-
       ting off  the nutrition);  from changes in the capillaries
       (which interfere with  the circulation of the part); from 
376
DISEASES OF THE URINARY ORGANS.
       defective heart-power (causing poor nutrition); and from
       the direct effects of the poisoned condition of the blood.
                DIFFERENTIAL DIAGNOSIS.
  From typhus fever and the amyloid and cirrhotic forms of kid-
ney disease.
                       PROGNOSIS.
  Is  bad as .regards complete recovery.  In the first stage, the
prognosis varies with the character and intensity of the inflamma-
tory process.   In nearly every instance, the catarrhal or croupous
forms  may be recovered from.  If with the croupous variety de-
generation and desquamation go  on slowly complete recovery  is
rare.
  In the  second stage (fatty) the chances for a complete  recovery
are very  doubtful, if this stage has been reached by epithelial de-
generation, and evidences of extensive obstruction in the tubules
exist, the stage of granular degeneration and atrophy are  sure
to f ollow.
                       TREATMENT.
In the First or Inflammatory Stage.
  1.  Eliminate the urea.
  2.  Remove the inflammatory products in the uriniferous tubules.
  3.  Counteract  the effect of the urea on the nervous system.
  First, remove the exudation in the tubules (which develops de-
generative inflammation).  Digitalis must be given, as it  increases
the secretions, and does not stimulate the kidneys; it also increases
the power of  the heart's action, and overcomes the obstruction in
the renal circulation, causing an increased flow through the Mal-
pighian tufts in the upper portion of the uriniferous tubules.  It
should be given in large doses.  Inf. dig., I ss. every two hours for
twenty-four hours, and wait twelve  hours,  and watch it, then
give smaller doses ( 3 i.), and stop as soon as you have good diure-
sis.  Dry cups should be applied over the region of the kidney, in
conjunction with  digitalis; it draws  the blood to the surface,
but does not cause extravasation.  Then apply  warm  poultices
made of digitalis leaves.  Temporary hot  bath and hydragogue
cathartic may be resoited to if the uraemic  symptoms are urgent. 
AMYLOID KIDNEY.
377
 Oleum  tiglii,  (oleum crotoni)  (but  not  after free diuresis has
 been obtained).  In case of the following symptoms occurring, as
 headache, vertigo, restlessness, convulsions, and coma, the treat-
 ment for acute uraemia  should be followed (see page 367).  Then
 actual cautery may be applied over the lumbar region; it acts on
 the sympathetic nerves, and causes contraction of the renal blood-
 vessels.  Depletion should only  be used  in  the first stage  of
 Bright's, and the form which follows  pregnancy, surgery on
 genito-urinary tract, and exposure.
 In the Second or Degenerative Stage.
   Administer digitalis  in moderate doses, and thus remove the
 fatty accumulations from the tubules.  Iron should be given with
 a most nutritious diet.  The patient  should be fed on about half
 a pint to a pint of milk at a time, consuming about three to four
 quarts in the  twenty-four hours.  Moderate stimulants, such  as
 wines, may be given. The patient must have the best hygienic
 surroundings, be kept in a weU-ventilated department, with an
 uniform temperature, and the body be covered with flannel. Re-
 covery may take place in about six weeks, if no tubular degenera-
 tive process commences.
 In the Tliird or Atrophic Stage.
   Diuretics  are not required;  a supporting plan of treatment is
 indicated.  Food should be given in small quantities, and often,
 and let them have cod-liver oil and iron.  Wines should be ad-
 ministered in moderation.  Cover the body with flannel, and do
 not  expose  it to sudden  changes in temperature; or send the
 patient to a warm climate.  Should the urine become scanty, give
 two or three  full doses of digitalis, to prevent acute  tubular
 nephritic inflammation.



                  AMYLOID  KIDNEY.
                       DEFINITION.
  Is a non-inflammatory condition  of the kidney, which com*
mences as a  deposit of amyloid material in the walls of the bloom* 
378
DISEASES OF THE URINARY ORGANS.
vessels.  It is always chronic in its course, and  usually invades
several organs at the same time.

                    MORBID  ANATOMY.
  The minute arteries are first affected; then changes occur in the
secreting tubes, or cells;  and, finally, atrophy of the organ itself
tches place.  It has three stages.
  1st Stage.  Degeneration of the walls of the blood-vessels.
  2d Stage.  Changes in the blood-vessels and the uriniferous tubes.
  3d Stage.  Atrophy of the organ.
  In the First Stage.—(Degeneration of the walls  of the blood-
vessels).  The  kidney is slightly increased in size  and firmer than
normal.  The  capsule is readily  removed,  and the  surface  is
smooth and  paler than normal.
  On section.—If Lugol's solution  of iodine be  applied, with a
clean camel's-hair brush, over the suspected portion, in a few
seconds, if amyloid material be present, the affected part rapidly
absorbs the  iodine, and results in  a dark-brown tint  which  is
easily  distinguished from the yellow stain of the non diseased
tissue. There are glistening streaks  along the course of the blood-
vessels, and  especially in dots  corresponding to  the Malpighian
tufts.  These glistening portions of the organ  give the blue re-
action to the iodine and the  sulphuric acid tests.
  Microscope.—Shows the changes to be most marked in the Mal-
pighian tufts,  and that the middle coat of the small arteries has
undergone more or less alteration from a deposit of amyloid ma-
terial,  and are irregular  in  outline. This irregularity of outline
is due  to the amyloid deposit in the coats of the blood-vessels.
  In the second stage.  The kidney is very much increased in size ,
the capsule is adherent;  and the surface pale and smooth and pre-
sents a stellate vascularity,
  On section.—The increase in the size of the organ is seen to be
due to an increased development in the cortical  substance.  The
blood-vessels have undergone a waxy change, and the whole kid-
ney has a waxy appearance.
  The  microscope shows the entire surface to have a shining, waxy
appearance.  The tubules  in  the  medullary substance are dis- 
AMYLOID KIDNEY.                   379
 tended with a substance similar to that found in the coats of the
 blood-vessels (but does not respond to the iodine test).  This sub-
 stance  may  be  broken-down epithelium and  fatty granules, or
 fibrinous material, like hyaline casts.  The Malpighian capillaries
 are thickened, opaque, and glistening, and there is degeneration
 of the  larger blood-vessels.  The casts are chiefly in  the  large
 tubes of the pyramids.
   In the Third Stage.—(Atrophy.)
   On section.—The size of the kidney is diminished;  the capsule
 adherent;  the  surface  uneven, pale,  and waxy.   There is  a
diminution in the  size of the kidney (due  to a decrease of both
the meduUary and cortical substance).  The Malpighian tufts are
large and prominent. The small arteries are enlarged; their walls
are impervious;  and their circulation obstructed.
  The microscope shows  the tubules to be more or less atrophied,
and their walls  collapsed. The bloodvessels  are  thickened and
irregular in outline.  The iodine  test decides  the nature of the
change.
                         ETIOLOGY.
  Tertiary syphilis; prolonged suppuration (especially in diseases
of the bone); suppurative diseases of the lungs (empyema, phthi-
sis).
                         SYMPTOMS.
General emaciation (from some wasting disease).
Impaired mental faculties, and, possibly, insomnia.
CEdema of  the feet at night.
Dyspnoea—on exertion (probably due to anaemia).
Complexion—pale and waxy (often with pigment in the eyehds).
A sense of  fullness and weight in the abdomen.
Urine—increased; patient rises two or three times in the night to
    micturate.
General anasarca—may occur.
Perspiration—has an urinous odor.
Dyspepsia.
Nausea.
Vomiting. 
380
DISEASES OF THE URINARY ORGANS.
Spleen—enlarged.
Liver—enlarged, with  smooth, sharp  edges (due to  amyloid
    changes).
Cachexia.
                    CAUSES OF DEATH.
  Death may occur from exhaustion (more frequently from amy-
loid degeneration of other organs); from diarrhoea (due to amyloid
degeneration of the  mucous membrane of  the  intestines); and
from ascites (due to changes in the liver).
  If dyspeptic symptoms do not yield to treatment, and you have
also enlarged liver and spleen and diarrhoea,  it is beyond a doubt
that amyloid degeneration of the intestines has caused death.
  The principal symptoms that have to be borne in mind are those
in connection with the urine, the development of slight dropsy,
and the absence of marked nervous phenomena.
                           Urine,           •
Increased in quantity—may reach one hundred ounces in twenty-
    four hours. Forty ounces in twenty-four hours  is a small
    quantity.   It is of a light color, like clear water, or shghtly
    amber.  Low specific gravity (2.005).
Albumen—not  large in quantity (only a trace may often be de-
    tected);  if large in quantity, it shows that tubular inflamma-
    mation has occurred in a degenerated kidney.
Casts—large hyaline or granular, or both, but not abundant; epi-
    thelial or fatty casts may also be detected (showing inflam-
    matory  process of the tubules).
                           Dropsy.
Is never very marked.
CEdema—of the feet at night, probably due to changes in the liver.
                    Nervous Phenomena.
Rarely headache, convulsions, or coma.
                DIFFERENTIAL  DIAGNOSIS.
  Is easy; for, if from the commencement  of the disease there
has been a copious secretion of urine, of low  specific gravity, con-
taining little albumen, and the symptoms  of the disease  have
come on gradually in one who is suffering  from an exhaustive 
CIRRHOTIC KIDNEY.                  381
disease, you may expect to find amyloid kidneys.  The probabili-
ties are that the kidneys will be increased in size, if the liver and
spleen are found to be enlarged.

                        PROGNOSIS.
  The duration  of life is  uncertain.  It usually takes years to
establish the disease, but, when once established, is fatal.

                       TREATMENT.
  If possible, remove the cause, as it occurs in the diseases of the
bone, suppuration, etc.; therefore, remove  the purulent accumu-
lations.  If occurring from tertiary  syphilis, use  antisyphilitic
remedies, as iodide of potassium  and mercury.  Mercury should
be given in small doses, and often (but do not produce ptyalism);
but when debility  exists, give iodide  of potassium and cod-liver
oil.  Iodide of iron may be given in the form of Blanchard's
pills; give one three times a day when taking food.   Hydragogue
cathartics and diuretics are of no service, excepting when the in-
flammatory form exist, then resort to dry cups,  etc.



                  CIRRHOTIC  KIDNEY.
                        SYNONY'MS.
  "Gin-drinkers' kidney;"  granular kidney; contracted, or "hob-
nailed" kidney.
                       DEFINITION.
  Is due to an  increase  in the  intertubular structure, and an
atrophy of ah the  other structures.

                          STAGES.
  1st Stage. Enlargement—due to an increase in the intertubular
tissue (from connective-tissue cell-growth).
  2d Stage. Organization of this new tissue.
  3d Stage. Atrophy—due  to contraction of this new tissue (pro-
ducing degeneration, on account of pressure on  the blood-vessels
of the organ). 
382           DISEASES OF THE URINARY ORGANS.
                    MORBID ANATOMY.
  As the process progresses, there is shrinking of the kidney tis-
sues.  The kidney is diminished in size, the capsule thickened and
adherent, and there is a prolongation of the connective-tissue into
the cortical substance, causing removal of the structure when the
capsule is torn off. Dilated veins may often  be seen on the sur-
face.  The diminution in the size of the organ is due to a decrease
in the cortical  substance.  The medullary substance retains the
same appearance as normal, and is not diminished.  There may
be cysts near the surface  on the cortical substance (if  the tubes
be obliterated, and the tufts of Malpighi  continue to secrete).
  In the first stage.—The microscope shows an increase  in the
connective-tissue  between the  Malpighian tufts and  the  urin-
iferous tubules.  The kidney is shghtly increased at  first,  and
then shrinks; the Malpighian tufts are diminished; the urinifer-
ous tubules are obliterated by contraction of  the new connective-
tissue; the capsule is thickened, firm, and fibrous.  The arteries
are hypertrophied and irregular; the tufts are brought  nearer to-
gether by the increase in the connective-tissue, and are sometimes
obliterated by cysts.  The tubules may contain coagulated fibrin.
which is indicated by hyaline casts in the urine.  The changes are
due to hyperaemia.  Some say the inflammation is due  to alcohol
or gouty diathesis; if due to the latter, there is, in addition to the
intertubular changes, a deposit of urates of  soda in  the cortical
substance and apices of the cones.
  The inflammatory process is the only cause of the anatomical
changes in the organ.

                        ETIOLOGY.
  The two most common causes are rheumatism and gout, pro-
ducing gouty kidney (due to a change in the blood from these
diseases);  lead-poisoning, cancerous  diathesis,  and alcoholism,
may produce, at the  same time, cirrhosis, both of the hver and
kidney.
                        SYMPTOMS.
Are obscure, and  its approach is insidious.
Frequent micturition is usually present. 
CIRRHOTIC KIDNEY.
383
Urine—may not contain albumen nor casts.
Dropsy—may not occur.
Nervous symptoms may be the only well-defined ones.
The usual symptoms are
    Debility.
    Emaciation.
    Dyspepsia.
    Great thirst.
    Urine—is very large in quantity.
    Complexion—is of a dingy hue.
    CEdema—slight, and usually confined  to the lower extremi-
       ties, after standing or walking.  It is more marked at
       night than on rising in the mcming.
    Expression—care-worn.  The patient often becomes fretful.
    Nervousness.
    Restlessness.
    Insomnia (a prominent symptom in some cases).
    Convulsions.
    Coma—(for twenty-four hours or more before death).
    Death.
  The principal symptoms that have to be borne in mind are those
In connection with the urine, the  dropsy, and the nervous phe-
nomena.
                           Urine.
Increased in quantity.
Low specific gravity (1.010).
Albumen—sometimes present, but inconstant.
Casts—usually large  hyaline.  They are often difficult  to  find,
    and may not be observed until three or four examinations
    have been made.
                           Dropsy.
CEdema—slight, and usually confined to the feet, after exercise or
    standing; but, if it become chronic in the feet, it is  asso-
    ciated with general symptoms.
Ascites-may occur from changes in the liver. 
384           DISEASES OF THE URINARY ORGANS.
                    Nervous Phenomena.
 Headache—most prominent if associated with gout and rheuma-
    matism.
 Vertigo. —  High arterial pressure marked at radial pulse.
 Temporal}' inability to speak may exist in some instances.
 Amaurosis.
 Deafness.
 Numbness.
 Neuralgic pains.
 Cramps.
 Delirium or insanity.
 Insomnia—(great, and extending over a long period of time).
 Paralysis—(temporary, and partial in the arm  or leg).
 Convulsions— (usually developed after some mental or physical
    exertion).
 Coma—which may follow a condition of drowsiness, or delirium.
 Tongue—dark-brown.
 Pupils—dilated (if coma exist).
 Death.
                   CAUSES OF DEATH.
  Death usually takes place from convulsions, preceded by head-
 ache, and terminating in  coma.

                     COMPLICATIONS.
  Cardiac hypertrophy of the left venincle—usually occurs from
disease, atheroma, or calcareous degeneration  of the walls of the
large arteries.
  If cardiac hypertrophy of the left ventricle exist, and the urine
be abundant, of  low specific gravity, and containing or'y a trace
of albumen, it is sufficient to establish the diagnosis of cirrhotic
kidney.
  Mucous inflammations, especially bronchitis  (of the chronic
type), alternating with renal and gouty symptoms.
  Amaurosis (of uraemic origin), called neuro-retinitis (first of one
eye, then of the other).
  Hemorrhage from serous and mucous surfaces, as well as in the
substance of the organs.  Cerebral hemorrhage is especiaUy liable 
PYELITIS.
385
 to occur (cerebral apoplexy) from degeneration of the cerebral
 arteries, and an increased force of blood from an hypertrophied
 left ventricle (thus causing rupture of the capiUaries).
                 DIFFERENTIAL DIAGNOSIS.
   (1) From  typhus fever, on  account of the uremic stupor and
 dry tongue.  In typhus fever, however, there will be  the  erup-
 tion, and the quantity of urine passed may serve as a guide in the
 diagnosis.
   (2) From gouty and  rheumatic diathesis.  In this there will be
 the history. The low specific  gravity and profuse quantity of
 urine (which may contain albumen and casts) is sufficient  to es-
 tablish a diagnosis of cirrhotic kidney.
                         PROGNOSIS.
   Is bad as regards recovery.

                        TREATMENT.
   Hydragogue  cathartics should be given when the disease  is de-
 veloped, in connection with cirrhosis of the liver.  Resulting, as
 this disease usually does, from rheumatism or  gout, and the
 patient suffering from headache, restlessness, nervous and trem-
 ulous affections, it is advisable to send this class of patients to
 the  alkaline springs, as  you  would in cases of rheumatism or
 gout, and administer bicarbonate of soda  and  potash in  large
 doses.  Iron is not desirable,  as it has too great an effect on the
 nervous system.  Strychnia is preferable to iron, and should be
 given in minute doses for a long period.  In many cases cod-liver
 oil should be combined with the hypophosphate of soda.  These
 patients should reside permanently in a warm climate,  all exciting
 causes of cirrhotic development should  be avoided, and hygienic
 rules must be carefully observed.  Ncrer give digitalis or iron.


                        PYELITIS.
                        DEFINITION.
  Is an inflammation of the mucous membrane of the pelvis and
calices of the kidney.  It may be acute or chronic in its course. 
386
DISEASES OF THE URINARY ORGANS.
                    MORBID ANATOMY.
  In the acute variety.—The mucous membrane of  the pelvis is
more or  less congested.  The surface  is dotted with red  spots
(ecchymosis).  The  epithelial covering is  more or less removed
(may be entirely destroyed, or absent in patches).   There is usu-
aUy a muco-purulent secretion covering the surface of the mucous
membrane.  There may be a diphtheritic membranous exudation
on the surface of the mucous membrane, which is due to a gene-
ral diphtheria.
  In the chronic variety.—The mucous membrane of the pelvis
of the kidney is not only much thickened,  but  changed in color.
It may be  grayish-white  or slate-colored, and traversed with
dUated veins.  The pelvis and infundibula  are dilated.   Pus is
abundantly  formed, and, if  not obstructed, flows  off with the
urine; but, if there  be obstruction, it accumulates and produces
pyonephrosis.  The accumulation of pus  causes  the papiUae to
become flattened and obliterated.   Then the pyramids are com-
pressed, and, lastly, the cortical substance, both of which may
eventuaUy disappear on account of  pressure.  The sac so formed
contains pus, broken-down material,  or  calcareous matter.   If
pyelitis be caused by obstruction from renal calculi,  there may be
ulceration of the mucous  membrane, causing  perforation of the
pelvis and extravasation of urine into  the adjacent tissues.  The
ureters may be the seat of disease, from an extension of pyelitis,
and  may be  obstructed by pus, blood, and urinous material, pro-
ducing  a sac, like  an abscess, which  may  be evacuated by  an
opening into the adjacent tissues.   Inflammation  may be estab-
lished, and the pus may be discharged externally (by ulceration),
or into the  intestines.  The accumulation may occasionally un-
dergo absorption, transforming the ureters into a tendinous cord;
in this case,  the other kidney has to do  double work.

                         ETIOLOGY.
  Calculi, or any foreign body or  substance in the  pelvis of the
kidney, may create it; and irritation (by decomposition of urine
in the pelvis of the kidney) may prove an exciting cause.  Ure-
thral stricture or enlarged prostate (by causing retention, after- 
PYELITIS.
387
ward cystitis, and inflammation of the mucous membrane, ex-
tending  to the ureters) may create it.  The lining of the ureters
thus becomes thickened, and their calibre diminished, obstructing
the flow from the kidney.  The retention of urine in the bladder
and the pelvis of the kidney causes a decomposition of urea into
ammonium carbonate and water.   The  ammonium carbonate
produces irritation, which induces inflammation  of the lining
membrane of the bladder and  kidney (cystitis and pyelitis), or
ammonaemia (from absorption of ammonia).   Finally,  blood-
poisoning (of all forms); acute  parenchymatous nephritis, with
bloody urine; and overdoses of turpentine,  cantharides, and other
stimulating diuretics, may be mentioned as causes of  pyelitis. It
may be secondary to morbid processes, or to mechanical irrita-
tion, and occasionaUy follows exposure to cold or dampness.

                         SYrMPTOMS.
  Are modified by the causes which produce it, such as renal cal-
culi, bladder diseases, etc., etc.
Acute Pyelitis.
    Pain—in the back, always over one  or both lumbar regions.
        It  is usually aching in character,  shooting down the
        course of the ureters.  It occurs with micturition, and is
        incessant  if micturition be excessive.   It is also aggra-
        vated by exertion or change of position.
    Urine—is usually acid, and contains blood mixed with mucus
        and epitheUal-cells, pus-cells,  and blood-globules (the epi-
        thelial-cells  are  of the type which  normally exist in the
        pelvis and infundibula).  Epithelial-cells denote an early
        stage of the disease.   Specific gravity 1.025 to 1.030.
    Is ammoniacal in the advanced  stages, and often contains
        albumen.
    If there be obstruction, the urine from the other kidney is
        normal.  If the  obstruction be removed, the  urine may
        suddenly become purulent, and continue to be so.
Chronic  Pyelitis.
    Tumor—in the lumbar region.
    Bulging between the crest of the ilium and the false ribs. 
388
DISEASES OF THE URINARY ORGANS.
    Ureters—completely obstructed.
    Accumulation of fluid in the pelvis of the kidney.
    Palpation—shows  deep-seated  fluctuation.   The tumor is
        painful and tender on pressure.
    Percussion— elicits a dullness whose limits depend on the out-
        line of  the tumor.

               DIFFERENTIAL  DIAGNOSIS.
  From cystitis and peri-nephritic abscess.
  In pyelitis, associated with chronic cystitis, or enlarged prostate,
or stricture (should the pus be large in quantity, the urine slightly
cid, the loin painful, and constant febrile movement and emaci-
ation exist), it indicates chronic pyelitis.
In acute Pyelitis.
    Urine—is acid, and contains epithelial cells of the pelvis and
        infundibula; also blood-globules and mucus.
    If there be epithelial-cells and pus, it indicates an  advanced
        stage.
In Pyo-nephrosis.
    Urine—is acid, and contains pus in large quantities.
    Pain—exists in the lumbar region.
    Tumor—may be detected at the seat of the pain, which grad-
        ually increases.  It  may suddenly disappear, when copi-
        ous flow of pus ensues, which affords great relief to the
        patient.
    This tumor may be mistaken for  hydro-nephrosis, hydatid
        cyst, and peri-nephritic abscess.
Pyelitis.
    Is an inflammation of the pelvis and calices of the kidney.
    Produced by stone in the pelvis of the kidney, or inflamma-
        tion extending upward from the bladder, or  the  use of
        irritant drugs.
    Urine—is acid, and contains blood, pus, and epithehum of the
        pelvis and infundibula.
    No  tumor exists.
    Chills and high temperature may be developed.
    No  pain on motion is present.
    Aspiration—gives negative results. 
PYELITIS.
389
  feri-nephritic Abscess.
     Is a suppuration of the  connective-tissue surrounding the
         kidney.
     A traumatic origin can usually be discovered.
     Urinary  symptoms —are negative (unless perforation take
         place).
     Tumor—may occur and point externaUy.
     Temperature—not so high as in pyelitis.
     Pain—can be  detected on motion of the leg and thigh upon
         the trunk.
     Aspiration—by aspirating at the extremity of the last floating
         rib, pus may be drawn off.

                         PROGNOSIS.
   1* it be the  simple uncomplicated catarrhal form, the prognosis
 is n, t unfavorable.  If both kidneys be affected  and there  be
 purulent discharge, the prognosis is bad.   If it be secondary to an
 enlarged prostate or to an extension of a chronic cystitis, urethral
 stricture, or  cancer, the prognosis  is hopeless.  If it occur with
 calcuh or hydatids, the prognosis is  grave.   If there should be
 pyo-nephrosis and the pus escape externally or into the intestines,
 recovery is possible; but if there should be pyo-nephrosis and the
 pelvis  bursts  into  the peritoneal or thoracic  cavities, the result
 is usually fatal.
                        TREATMENT.
  If of an acute type and the fever be considerable, pain in the
 lumbar region severe, and bloody urine, wet cups should be freely
 applied to the loins, followed by hot baths and a sufficiently large
 hypodermic of morphine to relieve all pain.  The patient should
 be kept in bed and drink freely of alkaline fluids.
  In chronic pyelitis.—Astringents  (tannic acid) should be given
 if pus be abundant. Cod-liver oil and quinine should  be admin-
 istered with a nutritious but not stimulating diet, and  prolonged
 use of  alkaline beverages.  Aspiration should be  resorted to, if
the tumor be  near the surface, and, should the case require it, a
free permanent opening should be left. 
B90
DISEASES OF THE URINARY ORGANS.
                  HYDRO-NEPHROSIS.
                        SYNONYMS.
  Dropsy of the kidney; renal dilatation.
                        DEFINITION.
  Is a non-inflammatory affection, due to a collection of urine in
the pelvis and infundibula of the kidney from obstruction;  com-
pressing and causing an atrophy of the renal substance and con-
verting the kidney into  a sac or pouch.   This dilatation  may
affect the ureter and pelvis, or only the pelvis.
                   MORBID  ANATOMY.
  The  papillae become flattened,  hardened, shrunken, and disap-
pear.  The renal  substance  gradually diminishes from pressure,
becomes tough and resistant, and, in extreme  cases, the kidney
becomes a multilocular cyst, sometimes as large as a chUd's head,
and the ureters the size of the small intestine, with thickened and
convoluted  waUs.  The  contents of  these  cysts  is variable.
Urine, which is usually  more watery than normal, containing
more or less urinary salts and also  blood, pus, epithehum, and
albumen, is generally found.
                        ETIOLOGY.
  From closure of the ureter by an external tumor, cancer, im-
paction of calculi or mucus, or by inflammation causing adhesion
of the walls of the ureters; from stricture of the ureters; from a
congenital valve at the upper end of the ureters; from an abnor-
mal course of the renal artery, w nich may be wound round the
ureter like a cord; from dilatation of the ureter; from an imped-
ing discharge Which may completely close the papiUae and pro-
duce entire suppression of the urinary secretion.

                        SYMPTOMS.
Tumor—detected in the lumbar region, which is of slow develop-
    ment, painless, and fluctuant.  In occasional instances, there 
HYDRO-NEPHROSIS.
391
    is a rapid subsidence of the tumor and a large discharge of
    fluid from the urethra and bladder (diagnostic).
Rupture of these cysts  is uncommon on account of hypertrophy
    of the tunics; the cysts may be of small size, or occasionally
    large enough to contain gallons of fluid.

               DIFFERENTIAL  DIAGNOSIS.
  From ovarian cyst; ascites; hydatids;  and pyo-nephrosis.
  Between hydro-nephrosis and ovarian cysts:
  In hydro-nephrosis—there is the presence of the colon in front
of the sweUing, and an absence of tympanitic percussion in the
lumbar region.
  Between hydro-nephrosis and ascites:
  In hydro-nephrosis—there is no dullness in the lumbar regions,
neither is the line of dullness affected by change in the position
of the patient.  No evidence of portal obstruction can be detected.
  Between hydro-nephrosis and hydatids:
  Unless hydatids be found in the urine it is impossible to make
a diagnosis.
  Between hydro-nephrosis and pyo-nephrosis:
  In hydro-nephrosis—the urine is non-purulent and there is no
suppuration.  The constitutional symptoms are  not so severe as
in pyo-nephrosis.
                        PROGNOSIS.
  When one kidney is affected, the prognosis is favorable, as spon-
taneous evacuations may occur;  but  when  both  kidneys are
affected,  the prognosis is bad, as uraemic symptoms whT develop
and death ensue.
                       TREATMENT.
  Evacuate the tumor by careful manipulation, or by aspiration
at the extremity of the last floating rib.   Medical treatment is of
no avail. 
392
DISEASES OF THE URINARY ORGANS.
                    RENAL  CALCULI.
   These may be formed in the tubes of the pyramids, in the cor-
 tical substance, or in the pelvis.  They may occur at any age;
 from the new-born infant to very old age, or even in the foetus.

                    MORBID  ANATOMY.
   In the aged, the formation of calculi is always associated with
 a gouty diathesis  (as deposits of urate of soda in the kidneys, in
 the  pyramids, and cortical oubstance).  They may also occur in
 connection with diseases of the bone (as carbonate and phosphate
 of lime in the tubes and pyramids).   Cysts may be developed from
 permanent impaction, or  the calculi may be  washed  down  the
 tubes by the urine, and lodged in the pelvis.  They may obstruct
 the  ureters and may also  tend to excite pyelitis, abscess, paren-
 chymatous nephritis,  pyo-nephrosis, or hydro-nephrosis.  The
 nuclei of the calculus may be pus, blood,  epithelium, grains of
 pigment, etc.
                         ETIOLOGY.
   In children, they are usually of the uric acid variety.   In adults,
 they are generally composed of lime and triple phosphates (with
 some nuclei, as above mentioned, for a starting-point).

                         SYMPTOMS.
 These are aggravated by violent exercise and jolting, as in riding,
     horse-back riding, etc. They may last from  a few  hours to a
     few days, or the calculi may pass into the bladder and remain
     there, or they may become  encysted and cease to irritate. . A
tj    large  portion of  the kidney may be sometimes destroyed or
     atrophied as the result of a calculus.
 Renal colic—due  to the passage of calculus along the ureters; it
     is accompanied by the following symptoms:
 Pain—sudden and intense in the region of the kidney of the af-
     fected side, radiating to the  bladder, testis,  inside of  the 
                NEW-GROWTHS OF THE KIDNEY.             393

    thighs, and to the end of the penis.  It is so intense that the
    patient often shrieks violently and rolls about.
Vomiting—violent and frequent.
Testicle—retracted on the affected side.
Countenance—pale,  and covered with profuse perspiration; great
    anxiety is manifested in the face.
Pulse—smaU.                                                i
Extremities—cool.
Fever—may occur, but is not usually present.
Urine—may be  suppressed or  scanty in amount, high-colored,
    bloody, and discharged in drops.  It often causes a painful
    burning sensation during  micturition,  and may contain pus,
    blood, or epithelium.
                DIFFERENTIAL  DIAGNOSIS.
  Renal colic may be  confounded with neuralgia of the lower in-
tercostal and  abdominal nerves, but  the urine  containing pus,
blood,  and epithehum  decides the question of the presence of
renal calculi.  It may be mistaken for blood-clots, or hydatids in
the ureters; for spasm of the ureters; and confounded with hepa-
tic colic (especiaUy if the right kidney be attacked).
                        PROGNOSIS.
  Is good, unless there be impaction and obstruction to the escape
of urine or of the calculus itself.
                       TREATMENT.
  Is the  same as in  pyelitis and  pyo-nephritis.  The paroxysm
maybe relieved by the free administration of opium, warm baths,
and hot poultices to the loins and abdomen.  If  the pain be in-
tense and the vomiting constant, inhalations of chloroform wiU
frequently give speedy and permanent relief.  Change of position
and manipulation along the ureters and drinking something con-
taining carbonic acid  wiU often aid in dislodging the calculus.


        NEW-GROWTHS   OF THE   KIDNEY.
  These comprise (1)  cancer, which is the only one that is of any
clinical importance;  (2) tumors in the intertubular  tissue; (3) 
394          DISEASES OF THE URINARY ORGANS.
syphilitic  gummata; (4) fibroma  in  the  pyramids; (5)  lipoma,
which are sometimes developed around the capsule of the kidney,
and in the pelvis of an atrophied kidney, or in the cortical sub-
stance beneath the capsule, and (6) tubercles (small miliary, gray,
or cheesy), which  are met with only in connection with general
tuberculosis.

                   RENAL  CANCER.
  May be a primary or secondary affection and may occur in both
kidneys.
                   MORBID ANATOMY.
  These deposits are usually of the medullary variety, developing
in the form of  circumscribed nodules in  the cortical substances.
They may become  so large as to fill the whole abdominal cavity.
They are often associated with cancer of the testicle.
                        ETIOLOGY.
  Depends upon either hereditary taint or some type of local in-
fection.
                        SYMPTOMS.
                         Rational.
Emaciation—gradual.
Pain—probably none (confined to the lumbar regions, if present).
Urine—probably no change, but there may be haematuria and
    albumen; when haematuria is present,  it is constant.
Complexion—a peculiar waxy appearance  may often be detected.
                         Physical.
Palpation.—When it attains a large size it can be felt through
    the  abdominal waUs.  Its form and immobility prove it not
    to be an enlargement of the liver or spleen.
                   CAUSES OF DEATH.
  Death may result from exhaustion; hemorrhage; acute paren-
chymatous nephritis; or from invasion from other organs.
                       PROGNOSIS.
  Is bad. 
ADDISON'S DISEASE.                  395
                       TREATMENT.
  Is palliative, and all that can be done is to relieve the symptoms
and sustain the patient as much as possible.



                 ADDISON'S  DISEASE.
                       DEFINITION.
  Is a chronic caseous degeneration of the supra-renal capsules,
attended by a pecuhar dark bronzed appearance of the skin and
atrophy of the neighboring plexus of nerves.
                   MORBID ANATOMY.
  The capsule is swollen,  thickened, dark in color, and studded
with extravasations of blood.  It is firm in consistence, and  its
surface is irregular.   It presents a grayish-white or whitish homo-
geneous substance, with caseous  collections, and calcareous de-
posits.  These caseous masses are composed of debris and cellular
elements in a state of decay or degeneration; or crystals of choles-
terin  may often  be  found.   The pigmentary deposit is in the
lower layer of the rete Malpighi (seen by the microscope).
                         ETIOLOGY
  Is unknown.  It forms one of the symptoms of general tuber-
culosis, cancer, and amyloid and fatty degeneration.
                        SYMPTOMS.
Skin—becomes gradually dark.
Roots of the nails remain white.
Palms of the hands and soles of the feet are spotted.
Sclerotic of the eye—is of a pearly hue.
Black spots appear on the  mouth and lips.
Extreme debihty and dementia are often present.
Pain—in the back and epigastrium usually exists.
Dyspepsia.
Vom%irg.
Diarrhoea—obstinate in character.
Epileptic convulsions—may occur in some cases. 
396
DISEASES OF THE URINARY ORGANS.
Temperature—usually normal.
Heart-beat and pulse—at  first accelerated, but, toward the end,
    become weak and feeble.
Death.
                       TREATMENT.
  Good nourishment and care is all that can be suggested, as it
usually terminates in death in about four years at the most.


                  SURGICAL  KIDNEY.
  Is that type of kidney which is liable to be a sequel to opera-
tions on the genito-urinary tract, especiaUy following the treat-
ment of deep-seated stricture and operation for stone.
  It is sometimes called " acute interstitial nephritis," because, in
extreme cases, suppuration of the  intertubular structure takes
place, forming scattered abscesses throughout the kidney, which
vary in size from a pin's head upward.
  In the majority of instances, intense renal engorgement is  the
only lesion detected unless evidences of previous diseases exist.
  Its chief symptom is suppression  of urine ; and, in fatal cases,
both kidneys are affected.   It is ushered in by a marked chiU or
rigors, within the first two days after the operation.
                       TREATMENT.
  Is both preventive and curative.
  Preventive.—Before the operation the patient should be confined
to his bed for several days; he should have  hot hip-baths;  and be
made to drink freely of diluent beverages.  Quinine should be
given in large doses and (Long's treatment) Fleming's tincture of
aconite, gtt. ij. doses both before and after the operation.
  Curative.—Inf. digitalis and citrate of potash; hot apphcations;
wet cupping; blisters and actual cautery over the lumbar region;
hot-air bath;  hydragogue cathartics; morphia hypodermically. 
CHOREA 
 
399
                         CHOREA.

                       SYNONYMS.
   St. Vitus'  Dance.   St. Guy's Dance.   It has been termed
 " insanity of the muscles."

                        DEFINITION.
  Is a disease of a purely motor neurosis, and characterized by
 irregular clonic spasms of groups of muscles under the influence
 of the wiU, usuaUy occurring on one side of the body, but which
 may become general.

                    MORBID ANATOMY.
  The pathology, notwithstanding the numerous  autopsies that
 have been made in connection with this disease, is admitted to be
 obscure, for it has never been discovered where the  seat of the
 disease occurs in  the central nervous organs, nor what are the
 morbid processes in the parts affected.  On account of its unilat-
 eral origin and unilateral tendency, the disease  is supposed to
 have commenced either in the crus cerebri, or in the correspond-
 ing corpus striatum and optic thalamus or, in the cerebral hemis-
 phere.  The majority of authors are totally averse to such opin-
 ions, in consequence of other parts which are supplied by these
 centers being frequently very little, if at all, affected during the
 course of this disease, and, furthermore, its occurring as a sequela
 to other diseases,  as wUl be seen in its etiology.
  Dr.  Dickinson, from his results of careful autopsies  of several
 fatal cases of this disease, in a  valuable paper read  before the
 Medico-Chirurgical Society,  has come to the conclusion that
 chorea depends "ona widely-spread hyperoemia of the nervous
 centers, not due to any mechanical mischance, but produced by
 causes mainly of two kinds—one being the rheumatic  condition,
 the other comprising  various forms of irritation, mental and
reflex, belonging especially to the nervous system, and in conse-
quence of the vascular changes, sclerosis is induced in the tissuef, 
400
DISEASES OF THE NERVOUS SYSTEM.
which surround the vessels, thereby explaining the rigidity of
the limbs, permanent paralysis,  and wasting  of the  muscles,
which complicate or supervene upon this disease."

                        ETIOLOGY".
  It occurs principaUy in female children at the  period of second
dentition and puberty.  It rarely occurs before the sixth or after
the fifteenth year of life. It may be hereditary.  It may even be
brought on through children mimicking others who have the dis-
ease (this  frequently  occurring in large boarding schools).   It
may be due to an irritation of peripheral portions of  the nervous
system. From  blows ;  falls;  wounding a nerve;  uterine dis-
orders ; painful menstruation ; pregnancy (rarely before the end
of the second month); gastric  or intestinal affections (by acting
as the exciting cause of perverted muscular  movements); strong
mental emotions (fright, fear); over-fatigue ; over-study ; scarlet
fever; rheumatism ;  bad hygienic surroundings ; anaemia and
hydroemia seem to augment the tendency to this -disease ; it may
occur in cardiac complications (rare) or spasmodic action of the
papillary muscles ; worms ;  onanism ; hysteria.

                        SYMPTOMS.
Usually come  on insiduously.   The  child  becomes mopish,
    avoids its companions, takes no interest in games or pleasure,
    cannot commit lessons to memory, or recoUect readily.
Real or apparent mental deficiency.
Fretfulness or capriciousness.
Suspicion  or timidity.
Impairment of  mental function.
Restlessness or fidgetiness.
Clumsy movements.
Inability to hold things steadily in the hand,  and  inability  to
    write or work.
Choreic Movements upon one side (usuaUy) either in the face, eye,
    tongue, head and neck, hitching of the shoulders, hand, arm
    (or both hand and arm), sometimes in the leg, may extend to
    the whole side of  the body, and may become very character-
    istic, consisting in sudden impulsive movements following 
CHOREA.
401
    each other at irregular intervals, involving first one group of
    muscles, then another, then one part of the body, and may
    ultimately involve  the  whole muscular system.   These
    symptoms become greatly aggravated whenever the patient
    endeavors to accomplish  any voluntary movement  (as in
    drinking a glass of water), or when anything occurs to excite
    him, or when he knows he is being watched.
 Difficulty of speech (due to convulsive action of the hps and
    tongue, or a spasmodic affection  of  the larynx and  the
    respiratory muscles).
 The lower limbs are dragged in walking.
 Mastication and deglutition may be affected.
 Pupils of the eye may be greatly dilated, and  the sclerotic coat
    whiter than normal.
 Respiration may be irregular, jerky and noisy in consequence of
    the diaphragm being affected.
 Indigestion (may occur).
 Sphincters of the rectum and bladder may be affected (in severe
    cases)
 Constipation (may occur).
 Impairment of menstrual functions.
 Locomotion or use of the hands may become impossible (in severe
    cases).
 Impairment of muscular strength.
 Paresis (may occur when unilateral).
 Hemiplegia or paraplegia may replace  the  convulsive move-
    ments.
 Impairment of sensation.
 Eyesight may fail.
 Appetite may be bad, capricious, or even fail.
 Cardiac palpitation (may occur), or even a murmur may be heard,
    which is attributed by Sir William Jenner  "to an irregular
    action of the muscular apparatus of the mitral valve, and
    sometimes to  an irregular contraction of  the heart itself,"
    but more probably as the result of anaemia.
InteUect develops slowly  and  is enfeebled as long  as the disease
    lasts. 
402           DISEASES OF THE NERVOUS SYSTEM.
 Sleep is disturbed, or insomnia (may occur in severe cases after
     assuming the form of nightmare).
■ Urine contains an excess of phosphates.

                        PROGNOSIS.
   Is rarely fatal, but is not of short duration, for although being
 of a very acute nature, usually lasts from one to several months
 (due to successive relapses),  the  patient  remaining subject to
 nervous  disorders,  and  may in after years  be followed by
 epilepsy, insanity, or muscular atrophy.  When fatal (in severe
 cases), death  is usuaUy due  to asthenia,  erysipelas, to cardiac
 complications; or, it may result  from extreme agitation ; ner-
 vous exhaustion produced by excessive jactitations, exaggerated
 by sleeplessness, or cerebral rheumatism.
   Complications—Endocarditis and pericarditis, which usually
 precede the disease (being due to rheumatism)—mental  derange-
 ments.

                DIFFERENTIAL  DIAGNOSIS.
   From spasms of acute  cerebral diseases ; from epilepsy ; from
 tetanus ;  from paralysis  agitans ;  from convulsive tremor ; from
 mercurial tremor ; from facial spasm ; from writers' cramp ; from
 salaam convulsions ; from locomotor ataxia.

                        TREATMENT.
   Cold baths  have been advocated, as also river and sea-bathing,
 but on account of their great tendency to produce rheumatism
 in children, they have been abandoned by their greatest advo-
 cates.  These methods have been replaced by dipping the patient
 in baths (two or three times at first), at a temperature about 75°
 F., gradually lowering the temperature every day.
   Sulphur baths have been also recommended, prepared in the
 following manner, from % to 1% ounces  of sulphuret  of potas-
 sium  is dissolved in 12 gallons of water, at  a temperature of
 86° F.  These baths must be repeated daily with the greatest reg-
 ularity, in which the patient is to  spend about one hour at a
 time, but where rheumatism threatens this treatment must not
 be resorted to. 
CHOREA.
403
  Tonics and the preparations of iron are indicated when the dis-
ease is due to chlorosis.
  Arsenic (especially  Fowler's solution) is largely prescribed, in
consequence of its possessing the property of  causing general
excitation, and especiaUy, increased vigor  of the lower extrem-
ities.  I have seen very excellent results by combining the citrate
of quinine and iron  with this drug.   R  Lig. pot. arsen :  3 i-ii
Ferri et quin. cit 3 i-ii. Glycerinoe et aquae aa § i.- 3 i t. i. d. after
meals—gradually increasing the doses of the arsenic  every week.
Should the disease be due to struma, iodine and iodide of potassium
are indicated.
  Tartar Emetic in large doses, in consequence of  its sedative
action on the  nervous system, had its  advocates, but was like
many other remedies abandoned.   Dr. Roger, in an article pub-
lished in tha " Union Medicale," July, 1858, gives  the  following
rules for its administration :  "On the first day,  doses of 4 to 5
grains in the 24 hours, which is doubled on the second day, and
trebled on the third day, and then a period of rest for 3 to 5 days.
If the disease persist, or the convulsive movements merely di-
minish in violence, the drug is again  administered for another
three days, beginning with the same dose as on the first day, plus
an additional grain, then an additional rest. If, after this period,
the disease recur, the same plan is adopted.  So that, if the first
dose, given on the first day of the first series, be 4 grains, that on
the first day of the second series 5 grains,  and on the first day of
the third series 6 grains, and on the third day  of the third series
18 grains."  Antispasmodics and  narcotics such as  assafoetida,
camphor, musk, valerian,  etc., have  been recommended, put
aside, and tried again.
  Cannabis Indica has  been greatly praised by Dr.  Corrigan, of
London, who commences the  treatment by giving  5 minims of
the tincture three times a day for a week  or ten days, then
graduaUy increasing the dose to 25  min. three times a  day.
This drug possessing,  as it does, an alterative action on the ner-
vous system, should be used in obstinate  cases, especially where
narcotics are indicated, in order to prevent dangerous  complica-
tions.
  Opium finds a strong advocate in Trousseau, where the disease 
404
DISEASES OF THE NERVOUS SYSTEM.
is  comphcated  by insomnia,  which  gradually exhausts  the
patient's strength, the sulphate of morphia being preferred, giving
it in grain doses every four hours.  He increased the dose until
30 grains had been administered in the twenty-four hours, when
he obtained complete recovery.  In very severe cases,  when the
movements become beyond control, chloroform should be admin-
istered.
  Sulphate of Zinc, from 2 to 3 grains three  times a day, dis-
solved in a sufficient quantity of water to prevent gastric irrita-
tion, was at one time used by Dr. Hammond, of this city, but he
now prefers the bromide, beginning with ten drops, three times  a
day, increasing  the dose till the symptoms begin to disappear,
and theu decreasing the dose accordingly.
  Gymnastic Exercises  have their advocates among many prac-
titioners, which, when  properly carried out have many  advan.
tages.  Whenever the vertebrae are sensitive to pressure, leeches
and cupping have  been applied to the side of the spine, foUowed
by  counter-irritants.
  Hygienic Measures, as they occupy a prominent part,  should
not be forgotten in this disease.  The patient  should sleep in  a
well-ventilated room ; nutritious and tonic food  should be taken
at regular intervals; cod liver oil, if there be great debility ; open
air  exercise, without producing fatigue, in order to facilitate the
organic movements of  repair, thus preventing recurrence of the
disease ; the bowels should be properly regulated ; cold bathing
and swimming  may be indulged in in moderation.   When the
disease  assumes the severe type it is advisable  to separate the
patient from others, on account of the annoyance, and because
the affection is apt to extend from one to the other from  sympa-
thetic irritation. 
PRESCRIPTIONS 
 
PRESCRIPTIONS.
 ALKALINE MIXTURE For Nursing
              Children.
  IJ Pot. carb.................gr. ij.
    01. cajuput.............Til i.
    Aq. anethi..............3 ij.
  M.   Sig. three or four times a day

            ASCARIDES.
  IJ Quassiae..............  3 ij.
    Ac. salicyl..............gr. x.
    Aquae ..................O.i.
  M.  Sig. to be used as an enema.

              ASTHMA.
  ]J El. ext. ergotae,
    Tr. hyos................aa \ i.
    Hoff. anodyne............  3 ij-
  M.  Sig. 3 i. every half-hour till  re-
lieved, then every 2 hours for the next
24 hours;  then give
  IJ Mist, glycyrrh..........5 iij.
   Tr. opii camph..........\ i.
   Ammon.  mur...........gr. Ix.
  M.  Sig. 3 i. t. i. d.
  If it become severe, paint the chest
with
  IJ Canth. collod. sol. over a space 3
inches by  8 inches and give
  IJ Hyd. chlor. mit.........gr. x.
   Pulv. Jalapse............gr. xv.
Or,
  IJ Pot. iodidi,
   Tr. bella...............aa  3i.
   Liq. pot.  arsen.........HI xl.
   Spts. ether, co............5 iss.
   Elixir simplicis...........1 i j.
   Aq. cinnamon............ivi.
  M.  Sig.  3 iv. t. L d. after meals.
          ASTHMA (Hay).
  IJ Pot. iodidi................. 5 i.
    Liq. pot. arsen...........  3 i.
    Aquas................— Jiv.
  M  Sig. 3 i. every 4 hours.
 Or,
  IJ Liq. pot. arsen...........3 iij.
    Tr. bella...............3 ix.
  M.  Sig. gtt. xij. after meals, and in-
 crease in 3  days to xvi., and after 19
 days to gtt.  xx.          *

      ASTHMA (In Pregnancy).
  IJ Pot. brom................3 iij.
    Chioral hydrat.............3 ss.
    Aqua......................1 i.
  M.  Sig. 3 j. to be used as required.
 Or,
  IJ Pot iodidi................3i.
    Iodini.....................gr. i
    Tr. gent, co..............5 i.
    Aquas...................| ij.
  M.  Sig. 3 i. t. i. d.

       ASTHMA (Spasmodic).
  IJ Pot. iodidi .......gr. xv.-xxx.
  Every 2 or 3 hours.

      ASTHMA (In a Child).
  First, for sneezing, keep the bowels
open with a Gregory's powder, ant"
give
    Pulv. Dov.,
    Quin. sulph......  ..aagr. viij.
Also,
    Spts. nit. dulc,
    Tr. Scillae,
    Tr. opii camph.....6a \ i.
  Sig.  3 i. every hour till relieved. 
408
PRESCRIPTIONS.
  ASTHMA (With Emphysema and
       Chronic Bronchitis).
 R Syr. prun. virg..-   ... 5 iv.
    Hoff. anodyne........I ss.
    Pot.-'  -li/M............3ij.
    Tr. beua...............3 ij.-iv.
  M.  Sig.   3i.  t. i. d. and  send the
patient to a warm climate.

      AN.EMIA (In Children).
 IJ Ferri cit.................3 ij.
    Aq. aurant...............| vss.
    Syr. simplic__".........5 ss.
  M.  Sig. from a  teaspoonful  to a
tablespoonful before or  after each
meal.
             ANAEMIA.
 R Tr. ferri perchlor.,
    Acid. acet. dil........aa HI xx.
    Syrupi ..................3 ij.
    Liq. ammon. acet___.... 3 vi.
  M.  Sig. 3 ij.-iv. every three  hours.

               ACNE.
 R Tr. sap. vir...............§ iij.
    Ac. carbol................3 ss.
    Sp. vini rect..........ad Jiv.
  M.  Sig. to be used at night.   In the
morning the parts should be washed
with  warm water and  then  rubbed
down with
    Ungt. hydrarg, ammon.,
    Zinci oxidi.............iia §ss.

            ANEURISM.
 R Pot. iodidi........gr. xv.- 3 ss.
  Sig. take this amount t. i. d.

            APERIENT.
 RF1. ext. rhei.............Hi xl.
    Fl. ext. ipecac...........ill iij.
    Sodii bicarb___..........sij.
    Aq. menth. pip........ad?ij.
         AMENORRHCEA.
 R Ferri. arsen.  .............gr. ▼.
   Ergotinas (aq. ext.).......3 ss.
  M. et ft. pil. xxx.
  Sig. One night and morning.
Or            ^Tonic).
 R Sulph. strych............gr. L
   Ferri. pyrophos.,
  * Quin. sulph............aa 3 i.
   Ac. phos. dil.,
   Syr zingiber...........aajij.
  M. Sig. 3 i. t. i. d.

       ANGINA PECTORIS.
  IJ Ammon. valer........gr. v.-x
   Chlor.  ammon.........gr. xxx.
  Sig. take immediately.
Or,
  R Tr. rhei et sennae.........? iss.
   Syr. zingib........  .  ...3 iij.
   Tr. opii...................I i.
  M. Sig.  3 i. in hot water immedi-
ately.
        ANUS (Itching of).
  R Pot. brom.,
   Chlor. hydrat.....aa gr. x.-xv.
   Aquae. ............. 1 i.
  M. Sig. To be taken at bed-time.
Also,
  R Sodii bibor.............3 ij.
   Morph. mur...........gr. xvi.
   Ac. hydrocyan. dil___  5 ss.
   GlycerinaB..............5 ij.
   Aquae.............ad 5 viij.
  M. Sig. to be applied to the affected
part.
Or,
  R Chloroformi..............3 ij.
   Glycerinae.................5 ss.
    Cerat. simp...............5 iss.
  M. et ft. ungt.  Apply locally.

  (* Tr. hydrast. may be substituted.) 
PRESCRIPTIONS.
409
      ARTHRITIS (Chronic).
 R Lithii brom...............3 iij.
   Syr. zingiber..............5 ss.
   Aquas....................5 iss.
  M.   Sig. 3 i. t. i. d.

Or,

 R Lithii carbonat............3j.
   Ac. citrici.................3 ij.
   Aquas.....................|ij.
  M.   Sig. 3i. t. i. d.
           ARTHRITIS.
 R 01. sassafras..............3 ij.
    Aq. ammon..............3 iv.
    Lin. sap. camph..........5 iij.
  M. ft. liniment (for ext. application).

     APHTHA OF PHTHISIS.
 R Quin. sulph..............gr. i.
    Olei piperis nig......... .gtt. i.
    Aquae...................§i.
 Sig. apply with a brush or rinse out
the mouth. 
410
PRESCRIPTIONS.
      BLADDER (Inflam. of).
 RTr. bella................  3i.
    Fl. ext. buchu............5 i.
    Liq. pot. arsen...........3 ss.
    Syr. simp.................? iss
    Tr. opii camph............3 vi.
    Aquas..................ad ? vi.
  M.  Sig. 3 i. every 3 hours.  (Tr. opii
camph. should not be included when
Olood exists in the urine.)
Or,
 R Pot. brom................3 iij.
    Chloral hydrat...........3 iss.
    Syr. rub. idaei,
    Aquas................. aa 5 i.
  M.  Sig. 3 i. every half-hour till re-
lieved (and apply hot fomentations).
     BLADDER (Irritation of).
 R Pulv. opii................gr- ij-
    01. theobro..............q. s.
  M. ft. suppos. 1.
Or,
 R Acid, benzoic..............3 ij.
    Aq. cinnam...............5 vi.
  M.  Sig. a tablespoonful t. i. d.
         BREAST LOTION.
 R Ext. bella...............3 i.-ij.
    Pulv. camph............3 i.
    Glycerinae..............5 ij.
    Chloroformi............3 sa
    01. menth. pip..........Ji.
  M.  Sig. apply locally.

        BILIARY CALCULI.
 R Phos. sodae.................3i.
 Sig. take this t. i. d.
Or,
 R Bismuthi,
    Inf. calumb.............aa 3 ij.
    Hydrat chloral...........  J ss.
    Syr. rub. idaei,
    Aquae...................aa5ij.
 M. Sig. 3 i. t. i. d.
           BRONCHITIS.
 R Pot. nit....................3 ij.
    Pulv. sacch. albi...........3 ij.
  M. et ft. chart, xij.
  Sig. one every two or three hours.

      BRONCHITIS (Acute).
 R Vini ipecac................3 ij.
    Liq. pot. cit...............5 iv.
    Tr. opii camph.,
    Syr. acacias.............aaji.
  M.  Sig.  3 ij. t. i. d.
Or,
 R Ant. et pot. tart.,
    Morph. acet........... aa gr. i.
    Aquae destil..............?iv.
  M.  Sig. 3 i.  every hour.

BRONCHITIS  (After  Loosening  of
              Cough).
 R Syr. scillae................I iij.
    Tr. opii camph..........5i.
 M.  Sig. 3 i.  t. i. d. or 3 ij. at night.

      BRONCHITIS (Chronic).
 R Ammon. chlor............3 ij.
    Mist, glycyrrh. co........J iij.
 M.  Sig. dessertspoonful t. i. d.
Or,
 R Ext. eucalypt............  %L
    Ammon..mur.,
    Ext. glycyrrh..........aa 3 ij.
    Syr. tolu..................5 iij.
 M.  Sig. 3 i-  every two hours.
Or,
 R Ammon. chlor............3 iij.
    Muc. acacias............fl. 5 iv.
 M.  Sig. a tablespoonful four times a
a day.

 BRONCHITIS (With Dry Cough).
 R Antimon. tart............gr. i.
    Syr. scillae...............5 iv.
 M.  Sig.  a  tablespoonful  every 3
hours. 
PRESCRIPTIONS.
411
BRONCHITIS (Chronic) (With Asth-
        ma and Emphysema).
 R Syr. prun. virg.........5 iv.
   Spt. oether. comp. (Hoff.). 5 ss.
   Pot. iodidi.............3 ij.
   Tr. bella...............3 ij.-iv.
  M.  Sig. 3 i. t. i. d. and send the pa-
tient to a warm climate.
 BRONCHITIS (Acute in Children).
 R Tr. ver. vir...............itlij.
   Syr. scillae comp.........  3 ij.
   Syr. balsam, tolu........3 xiv.
  M.   Sig. 3 i. every 2 or 3 hours to a
child 5 years old, in first stage of the
disease.
     BRONCHITIS (In Infants).
 R Syr. senegas..............3 i.
    Syr. tolu.................I ij.
    Ammon. mur...........gr. x.
  M. Sig. 3 i. (small) every 3 hours.

     BRONCHITIS (2d Stage).
 R Sulph. morph.............gr. i.
    Syr. bals. tolu.,
    Syr. prun. virg........aa Ji.
  M.  Sig. 3  i. t. i. d., and if there be
night-sweats add morphine gr. 1-60.
Or,
 R Sulph. morph.............gr. i.
    Vin. antimon.............3 ij.
    Syr. tolu..................? iss.
    Aquas....................5 iij.
  M.  Sig. 3  i. t. i. d. 
412
PRESCRIPTIONS.
        CALCULI (Biliary).
 R Bismuthi,
   Inf. calumb.............aa 3 ij.
   Hydrat chloral.............5ss.
   Syr. rub. idasi,
   Aquas...................a a 1 i j.

CARDIAC HYPERTROPHY (With-
       out Valvular Lesion).
 R Fl. ext. ergotas.....".....I hiss.
   Tr. digit.................Iss.
  M.  Sig. 3 i. t. i. d.

      CATAMENIA  (Stopped).
 R Pot. brom...............3iv.
   Aquae......................5 U-
  M.  Sig. 3 i. t. i. d.
            CHANCRE.
 R Hyd. chlor. mit..........3 i.
   Liq. calcis................ 5 iv.
  M. et ft. lotio.  Sig. apply on lint.
Or,
 R Hyd. chlor. corr......gr. xvi.
   Liq. calcis..............5 viij.
  M. et ft. lotio.  Sig. apply on lint.

              CLAP.
 R Tinct. hydras............3 ij.
    Aquae..........  ........3viij.
  M. ft. lotio, inject 3 or 4 times daily.
Or,
  R Fl. ext. hydras.,
    Glycerinae...............aa 3 ij.
  M. et ft. lotio for injection, t. i. d.
And,
  RTinct. gelsemii.............3i.
    Aquas...........  .........5 "J-
  M.  Sig. 3 i. every 4 hours.
Or,
  R 01. santalis flavae.........3 ij.
    01. cinnamomi............fltfj.
  M.  Sig. Take gtt. x-xv.  on a piece
 of sugar  t.  i. d. (and as much milk as
possible, but no spirits).
              CRABS.
 R Tr. delphini.................?1.
  Sig. Put on sponge and sponge the
parts.
           CATHARTIC.
 R Strych sulph......... .gr. i.
    Res. podoph............gr. x.
    Ext. col. co.............gr. xl.
    Pulv. capsici............gr. xx.
 M. etft. pil. xl. sig. One or  two when
required.
     CEREBRAL CONGESTION.
 R Sodii brom................?i.
    Fl. ext. ergot. (Squibb's).. ?iv.
  M.  Sig. Tablespoonful t. i. d.
Or,
 R Sodii brom................Si-
    Pep, sacch.,
    Lig. carb. pulv.........aa 3 iij.
    Fl. ext. ergot.,
    Aquas...................fialij.
  M. Sig.  3 i. t. i. d. for one month.
Then give as a tonic:
 R Quin. sulph..............gr. iv.
    Ac. hydrobrom..........5 iv.
  M.  Sig. 3 i. t. i. d. after meals.

            CHILBLAINS.
  R Plumb, acet...............5 ss.
    Aquas....................O.i.
  M.  Sig. Apply as a lotion to the af-
 fected parts.
 Or,
  R Acid, carbol...............3i.
    Tr. iodini..................3 ij.
    Acid, tannici..............3 ij.
    Cerat. simp...............1 iv.
   M.  Sig. Ungt.

               COLIC.
  R Sodii bicarb.,
    Spt. oether comp. (Hoff.),
     Morph. sol.,
     Syr. zingiber...........aa 3 ss.
     Aq. camph., ad ..........?ij.
   M.  Sig. 31. repeat till relieved. 
PRESCRIPTIONS.
413
             COLLYRIA.
  R Atrop. sulph.............gr. iv.
     Aq. dest.................fl. 1 i.
 Or,
  R Duboisiae sulph.........gr. 3£.
     Aq. dest.................fl. I i.
 Or,
  R Eserinas.................gr. ij.
     Aq. dest..................fl. 5i.
 Or,
  R Zinci sulph..............gr. iv.
     Aq. dest...............fl. 5i.
 Or,
  R Aluminis.................gr. ij.
     Aq. dest..................fl. 5L
 Or,
  R Acidi gallici..............3 ij.
     Glycerinae................fl. 1L


          CONSTIPATION.
  R Tr. nuc. vom.,
     Tr. bella.,
     Tr. physost.............aa 3 ij.
  M.  Sig. gtt. xxx. in water morning
 and evening.
 Or,
  R Ext. physostig.,
    Ext. bella.,
    Ext. nuc. vom.........aagr. v.
  Ft. pil. x.  Sig. one pill at bed-time.
 Or,
  R Aloes soc.,
    Sap. Castil............aa 3 i.
    Ext. hyos................gr. x.
    Pulv. ipec................gr. v.
  M. et ft. pil. xx. Sig. take one night
 and morning.
 Or,
  R Ext. bella................gr. v.
    Ext. nuc. vom..........  gr.x.
    Ext. col. co..............3 i.
    Sodii carb. exsiccat......gr. xl.
  M. et ft. pil.  xl. Sig. take 2 at bed-
time.
          CONSTIPATION.
 Or        (In Children).
  R Podoph...................gr. i.
    Sacch. lactis..............3 i.
  M.  et ft. chart,  xx. Sig.  take one
 every morning or night.
 Or,
  R Pulv. rhei................gr. iij.
    Sodii bicarb.............gr. x.
    Pulv. zingib............gr. ij.
  M. et ft. chart, i.
 Or,
  R Ext. colyc. co...........gr. ij.
    Ext. bella...............gr.  %.
    Ext. gent...............gr. i.
    01.  carui................gtt. ss.
  M. et ft. pil. i.
 Or,
  R Resin, podoph...........gr. 1-6.
    Pulv. rhei...............gr. ij.
    Ext. bella...............gr. )£
    01. carui................gtt. ss.
  M. et ft. pil. i.
 Or,
  R Rheirad.,
    Sapon. Castil ..........aa 3 ss.
    01. anis.................gtt. iv.
  M. ft. pil. xx. Take one or two as
 required.
 Or, when obstinate,
  RRhei................... 3ij.
    Aloes ...................3 i.
    Ext. nuc. vom...........gr.  iv.
  M. et ft. pil. xl. One  or two as re-
 quired.
 Or      (Chronic in Women).
  R Ext. bella................gr. v.
   Ext. nuc. vom............gr. x.
   Ext. colocynth.  co.......3 i.
  M. ft. pil. xx.  Take  one at  night.
 Should griping occur, add sodii bicarb.
and make pil. xl. Take 2 at bed-time. 
414
PRESCRIPTIONS.
          CONSTIPATION.
Or     (During Pregnancy).
 R Ext. aloes...............gr. iv.
   Nuc.  vom................gr. i.
   Ext. hyos................gr. iv.
   (Or, ext. bella............gr. i.)
  M.  et ft. pil. iv. Sig. take one every
morning.
Or         (In Infants).
 R Resin. podoph...........gr. i.
   Syr. rhei................3 i.
   01. fosnic.................gtt. i.
  M.   Sig. gtt. x.- 3 i.
Or         (In Women).
 R Ext. col. co..............gr. iij.
   Ext. bella...............gr. %.
   Saponis.................gr. i.
  M.  et ft. pil. 1. Take one every night.

             COUGH.
 R Morph. sulph.............gr. ij.
   Ac. hydrocyan. dil.......3 ss.
   Syr. scillas,
   Syr. tolu..............aa, 5 ij.
  M.  Sig. 3 i. every 2 hours till relieved.
Or,
 R Ammon. chlor..........3 ij.
   Morph. sulph...........gr. ij.
   Tr. aeon,  rad...........HI xvi.
   Fl. ext. bella............ni v.
   Fl. ext. glycyrrh.,
   Syr. simp.............55 I i.
   Aquas.............    ad?iv.
  M.  Sig.  3 i. every 2 hours.
Or    (Reflex of Pregnancy).
 R Pot. brom..............gr. xx.
   Chloral hydrat..........gr. v.
  M. Sig. this amount to be taken at
bed-time for  2 or 3 weeks.
Or (When Violent and Trouble-
               some).
 R Ac. hydrocy. dil.......gtt. xvi.
   Syr. prunis virg.......fl. 5 i.
  M. Sig.  3 i. every 2 or 3 hours.
              COUGH.
Or        (Troublesome).
 R Syr. scillae................1 iss.
   Spt. cetVr comp. (Hoff).... 5 i.
   Morph. sulph.............gr. i.
   Aq. camph.,
   Muc. acacias...........551 i.
  M. Sig. 3 i.-iv. t. i. d.

    COUGH MIXTURE (Adult).
 .R Syr. senega,
   Syr. prun. virg.,
   Syr. tolu..............5a I i.
   Tr. opii camph.,
   Sp. nit. dulc............55 ? ss.
   Ammon. mur.............3 ss.
  M. Sig.  3 i. t. i. d.
          COUGH SYRUP.
 R Morph. acet...........gr. #.  "
   Tr. hyos.................3 iss.
   Syr. tolut................3 iiss.
   Aq  ...................  I ss.
  M.  Sig. 3 ij. every three hours.

             CHOREA.
 R Liq. pot. arsen.............5 •■
   Sig. gtt. ij. t. i. d. and increase gtt.
i. every week.
Or,
 R Elixir phos................5 i j.
  Sig. 3 i. t. i. d.
Or,
 R Zinci valer................3ij.
   Cinchoniae sulph..........3 i.
  M. ft. pil. xx.  Sig. one pill t. i. d.
Or,
 R Zinci brom.................3 i.
   Syr. simp.......... ........5 i>
  M.  Sig. gtt. x. t. i. d. and increased
so soon as the stomach can bear it.
Or,
 R Strych. sulph............gr. ij.
   Aquae...................5L
  Sig. gtt. v. t. i. d. to a child from 10
to 15 years old. 
PRESCRIPTIONS.                          41")
       CHOLERA INFANTUM.
  R Tr. opii comp. (Squibb's)... 5 i.
   Sig.  gtt. x. every J£ hour in water till
 relieved.

 Or,

  R Cup. sulph.............gr. i.
    Tr. opii deodor.......gtt. viij.
    Aq. destil..............I iv.
   M. Sig. 3 i. every 2, 3, or 4 hours till
 relieved.
 Or,
  R Tr. zingib.,
    Tr. menth. pip.........5a3i.
    Tr. opii camph............3 ij.
    Aq. menth. pip.........ad 5 ij.
   M. Sig. 3 i. every hour.

 Or,
  R Mist, creta............1 ij.
    Tr. catechu,
    Lactopeptin,
    Bismuth, subnit.. . .5a3i.
    Tr. opii...............gtt. xij.
   M. Sig. 3 i. every hour in water till
 relieved.

 Or     (With  Vomiting, etc.).
  R Pepsin (Boudault's)___3 ss.
    Bismuth, subnit........3 i.
    Ingluvin...............3ss.
    Tr. opii camph.........gtt. xvi.
    Aq. anisas...............1 ij.
  M. Sig.  3 i. every three hours.
Or    (In  a Child 6 Months Old).
 R Sodii bicarb..............gr. vj.
    Pepsin...................gr. xx.
    Ingluvin.................gr. xv.
    Pulv. opii................gr. ss.
  M. et ft. chart, vij.
       CHOLERA MORBUS.
  R Plumbi acet.,
    Pulv. camph..........55 gr. vi.
    Pulv. opii...............gr. i.
    Ext. gent................q.s.
  M. ft. pulv. vi.  Sig. One every three
hours  till  relieved,  and  if  vomiting
very bad give,
  R Plumb, acet...........gr. viij.
    Morphias acet...........gr. i.
    Aq. camph.............1 ij.
  M. Sig.  3 i. every hour.
             CHORDEE.
  R Camphorae,
    Lactucarii...............55 3 i.
  M. et ft.  pil. xxx.  Sig. take 1, 2, or
more as necessary.
Or,
  R Vin. colchici............Tl xxx.
  Sig. to be taken every night.
            CHLOROSIS
  R Tr. ferri perchlor.,
    Ac. acet. dil.........55 Tq, xx.
    Syrupi...................3 ij-
    Liq. ammon. acet.......3 vij.
  M.  Sig.  2 to 4  teaspoonfuls every 3
hours.

              CROUP.
  R Hyd. sulph. flav.......gr. xij.
    Pulv. eacch. albi........gr. xxx.
  M. et ft., chart, vi.   Sig.  give one
every J^ hour till vomiting be produced.

     CEREBRAL CONGESTION.
   (For a Child 6 Years of  Age).
 R Potass,  brom...............3 iv.
   Potass,  iodidi..............3 ss.
   Fl. ext.  ergotas (Squibbs)___3 ij.
   Syr. rub. idoei,
   Aquas....................aa 1 j.
  M. Sig. 3 i. every three hours. 
416
PRESCRIPTIONS.
   DEAFNESS (With Discharge).
  R Hydrarg. perchlor......gr. v.
    Liq. opii..................3 ss.
    Glycerinae................5 i-
    Aquae..................ad? iij.
  M.  Sig.  Fill the ear morning and
evening with equal parts of hot water
and the above preparation.

  DEBILITY (With Nervousness.
  RPot. brom.................li-
    Ferri sulph. exsicc........3 ss.
    Calumbas,
    Zingiberis...............55 3iv.
  M. et ft. chart, xxiv.   One at bed
time.
       DELIRIUM TREMENS.
  R  Tr. capsici................3 vi.
    Tr. nuc. vom.............3 ij.
  M.  Sig. gtt.  xx.  in water every 4
hours.
Or,
  R  Morph. sulph. sol.,
    Fl. ext. valerian.......55 fl. J i.
  M.  Sig. 3 i-ij. as required.
Or,
  R  Pot. brom..............3iv.
    Chloral hydrat.............3 iij.
    Aq.........................?ij.
  M.   Sig.   3 i- every % hour till re-
lieved.
Or,
  R Chloral hydrat..........gr. xxx.
  Every kg hour.

       DEPRESSED SPIRITS.
  R Ac. nit. mur................5 ss.
  Sig. gtt. x. t. i. d. in water.

         DYSMENORRHCEA.
  R Pulv. Opii.................gr. ij.
    01 theobro.................q.s.
  M. ft. suppos. 1'.
        DYSMENORRHCEA.
Or        (From Anemia).
 R Sulph. strych.............gr. i.
    Ferri pyrophos.,
    * Quin. sulph...........55 3 i.
    Ac. phos. dil.,
    Syr. zingiber...........5a 5 ij.
  M.  Sig. 3 i. t. i. d.

  DYSENTERY (With Tenesmus).
 R Iodoformi,
    Pulv. opii............55 gr. viij.
  M. ft. pil. viij.  Sig. One every S
hours unless allayed.
Or            (Acute).
 R Cup. sulph...............gr. ss.
    Mag. sulph...............I i.
    Ac. sulph. dil............3 i.
    Aq....................___I iv.
  M.  Sig. a tablespoonful  every four
hours.
Or         (Asthenic).
 R Aq. camph.............|iv.
    Acidi nitr..............Tt\, xxx.
    Tr. opii.................nixxx.
  M.  Sig. A tablespoonful every 2 or
3 hours.
Or           (Chronic).
 R Liq. pot.  arsen..........gtt. ij.
    Tr. opii...............gr. v.
  M.  Sig. Take this before each meal
Or          (Chronic).
  R Cup. sulph.,
    Morph. sulph.....55 gr. i.
    Quinias sulph..........gr. xxiv.
  M. et ft. pil. xij. Sig. One t. i. d.
Or          (Chronic).
  R Fl ext. ergot. (Squibb's). 5 iiiss.
    Tr. opii deodor .........? ss.
  M.  Sig. 3 i. t. i. d.
* Tr. hydrastis may be substituted. 
PRESCRIPTIONS
417
             DYSENTERY.
  Or  (In a Child 5 Years of Age).
   R  Iodoformi..............gr. xv.
      Mucil. acac..............Ji,
      Acidi tannici............gr. xl.
   M. Sig. put 3 i. in some thin boiled
  Starch and inject per rectum.

  Or  (In a Child 5 Years of Age).
   R Plumb, acet...........gr. xx.
     Pulv. opii..............gr. i.
     Ergotin.................gr. iv.
     Glycyrrhiz..............q.s.
   M. et ft. chart, x.  Sig.  One every 2
  hours.

             DYSPEPSIA.
   R Sodii bicarb.............gr. xx.
    Acid carbol............gtt. ij.
    Acac,
    Saccharialbi.........aaq.s.
    Spts. lavand. co........3 i j.
    Aq......................3 vi.
   M.   Sig. 3 i.  two hours  after each
 meal.
 Or,
  R Pulv. pepsin.,
    Bismuth. subcarb....55gr. xx.
   M. et ft. chart, x.  Sig. take one t. i. d.
 Or,
  R Tr. gent, co.,
    Tr. rhei___............. 55§ ij.
  M.  Sig.  3 i. before each meal.
 Or        (And Vomiting).
  R Bismuth, subcarb.......gr. x.
    Sodii bicarb..............gr. iij.
  M. et ft. chart, i.

Or          (Chronic).
  R Arg. oxidi,
   Ext.  hyos............5agr. v.
  M. et ft. pil. x.  One  t.  i.  d. before
meals.
             DYSPEPSIA.
 Or (Sour Risings after Meals).
   R Inf. calumb............  Itv.
     Liq. potass...............3ss.
   M.  Sig.  3 ij. t. i.  d.  half an hour
 before each meal.

 Or (When Hands and Feet Cold).
   R Asafcetidas..........gr. iij.-ix.
     Sodii bicarb..........gr. ij.
     Paradise semen......gr. i.
   M. put the above pill in capsule (one
 should be taken t. i. d.).

 DYSPEPTIC TONIC (After Fevers,
                ETC.).
  R Ammon. carb.............3iv.
    Ferri ammon. cit ........3 i.
    Tr. nuc. vom.............3 ij.
    Tr. quassias,
    Tr. gent, co.............Safiv.
    Elixir simp...............§ iij.
    Aq. camph ..  -........ad O.i.
   M.  Sig. 3 ij.-iv. t. i. d. before or
 after meals.

            DIARRHOEA.
  R Morph. sulph............gr. ss.
    01. theobrom............q. s.
  Ft. suppos. No. 1.
 Or,
 R Iodoformi................gr. v.
    01. theobrom.............q. s.
  Ft. suppos. No. 1.
 Or,
 R Morph. sulph...........gr. ss.
    Ext. bella........  ......gr. iss.
    01. theobrom............q. s.
  Ft. suppos. 1.
Or,
 R Morph. sulph............gr. ss.
   Ext. bella  ............gr. iss.
   Ac. tannici.............gr. v.
   01. theobrom............q. s.
 Ft. suppos.  1. 
418
PRESCRIPTIONS.
            DIARRHCEA.
Or,
 R Ac. tannici....... ......gr. v.
   01. theobrom.............q. s.
  Ft. suppos. No. 1.
Or,
 R Aq. camph.............I iv.
   Acidinit...............nixxx.
   Tr. opii.................Til xx.
  M.   Sig. A tablespoonful every 2 or
3 hours.
Or,
 R Pulv. opii...............gr. j.
   Plumb, acet.............gr. ij.
  M.  et ft. pil. i.
Or,
 R Pulv. opii...............gr. j.
   Acid, tann..............gr. iij.
  M. et ft. pil. i.
Or,
 R Spts. lavan. co...........1 i.
   Spts. camphor............3i.
   Tr. opii.................  3 ss. ■
   Sacch. albi,
   Muc. acac..............55 3 iss.
   Aq. cinnam............ad 1 vi.
  M.  Sig.   A tablespoonful  every 3
hours.
Or,
 R Tr. opii................gtt. xx.
   Bismuth, subnit........3 ij.
   Syr. simp...............I i.
   Mist, cretas.............I iij.
  M.  Sig. 3 i. every 3 hours.
Or,
 R Mist, cretae................5 ij.
   Lactopeptin...............3 i.
   Tr. catechu................5 i.
  M.  Sig.  3 i. every 2 hours.
Or,
 R Ol. ricini............3 i.
   Tr. zingib...........gtt. xx.
   Tr. opii.............gtt. x.-xx.
    Vin. gallici.........li.
  M.  Sig.  Take at once.
           DIARRHCEA.
Or,
 R Bismuth, subnit..........3 ij.
   Morph. sulph.............gr. i.
  M. et ft. pulv. vi.  Sig. 3 i. t. i. d. in
milk.
Or,
 R Ac. sulph. arom..........nixl.
   Ext. hasmatoxyli.........3 i.
   Tr. opii camph............3 iv.
   Syr. zingiberis............3 iv.
  M. Sig. 2 teaspoonfulsevery 3hours.
Or,
 R Mist, cretas...............3 v.
   Tr. catechu,
   Tr. opii camph........ .aii3 iss.
  M.  Sig.  Dose one teaspoonful every
3 hours.
Or,
 R Tr. calumb...............3 xv.
    Tr. opii deodor...........3 i.
  M.  Sig.  3i. in wine-glass of  water
before meals.
Or          (Chronic).
  R Liq. pot. arsen..........gtt. ij.
    Tr. opii..................gtt. v.
  M.  Sig. Take this before each meal.
Or          (Chronic) .
  R Cup. sulph.,
    Morph. sulph......aa gr. i.
    Quiniae sulph.........gr. xxiv.
  M. et ft.  pil. xij.  Sig. one t. i. d.
Or          (Chronic).
  R Fl. ext. ergot. (Squibb's). I iiiss.
    Tr. opii deodor..........\ ss.
  M.  Sig. 3 i. t. i. d.
Or (In Child 6 to 9 Months, with
           Green Stools).
  R Pepsin.................3 ss.
    Bismuth, subnit........3 i.
    Tr. opii................gtt. xx
    Aq. menth. pip.,
    Aquas lauro cerasi___aa | i.
  M.  Sig. 3 i. every 3 hours. 
PRESCRIPTIONS.
419
            DIARRHCEA.
Or      (In Typhoid Fever).
 R Bismuth. subcarb..gr. xxx.-lx.
  Sig. Take this t. i. d. in milk.

    DIARRHCEA OF PHTHISIS.
 R Resin, terebin..........gr. iij.
   Argent, nitrat.,
   Pnlv. opii.............aagr. }£.
  Sig. One pill when needed.
       DIARRHCEA (Summer).
 R Mag. sulph................I i,
   Ac. sulph. dil..............3 ij.
   Morph. sulph.............gr. i.
   Aq........................I iv.
  M.   Sig.  3 ij. every 3 or 4 hours.
Or      (Summer, in Adults).
 R Mag. sulph..............3vi.
   Tr. rhei,
   Tr. zingiberis .........aa 1 iss.
   Aq. menth. pip........ad Jvi.
 M.  Sig. 3 iv. t. i. d.
Or (Summer, for Children 1 Year
            and Under).
 R Mag. sulph................3i.
   Tr. rhei..................3 ij.
   Syr. zingiber.............3 iv.
   Aq. menth. pip  .......ad f iss.
 M   Sig. 3 i. every 3 hours.
           DIPHTHERIA.
 R Tr. ferri mur............3 iss.
    Sat. sol. chlor. pot........I ij.
  M.  Sig. 3 i. every 2 hours.
Or,
 R Tr. ferri persulph.........5 ss.
  M.  Sig,  Put 3 i. in a tumblerful of
water and gargle the throat.
Or,
 R Hydrarg. prot. iodidi,
    Pot. bichrom..........aa 3 iv.
  M.  Sig.  Put sufficient in a tumbler
of water to make it a deep yellow and
take a teaspoonful every hour.
Or,
 R Pot. chlor..................5ss.
    Aq.......................I vi.
  M.  Sig. Tablespoonful t. i. d.
             DROPSY.

 R Vin. colch. sem.........\ ss.
    Sol. ammon. acet........5 iiss.
    Inf. petroselin..........1 v.
  M.  Sig. A tablespoonful  every four
hours. 
420
PRESCRIPTIONS.
            EAR-ACHE.
 R Chloroform i............3 i.
   Vini opii,
   Glycerin...............aa 3 ij.
   01. amygdal..............3 iij.
  M.   Sig. gtt. i. or ij.  to be dropped
in the ear night and morning.
             ECZEMA.
 R Ung. zinc, ox.,
   Ung. hydrarg. nit.,
   Ung. plumb, subacet...aa J ss.
  M.  et  ft.  ungt.  Apply to parts  af-
fected.
Or,
 R Acid. nit. dil..............3 ss.
   Plumb, acet..............gr. v.
   Aq...................... Ivi.
  Sig.  Lotion.
Or,
 R Liq. plumbi subacet. ... 5 i.
   Glycerinas..............5 ss.
   Aq.  lauro cerasi.......5 iiiss.
  Sig.   Lotion.
Or,
  R Ac.  salycil.,
    Pulv. boracis.........55 gr. x.
    Aq.................___O.i.
  M.  Sig.  Apply to parts affected.
            EMETIC.
R Ipecac.................gr.:
  EMPHYSEMA (With Asthma and
        Chronic Bronchitis).
  R Syr. prun. virg........5 iv.
    Spr.eethercomp. (Hoff.).. 3 ss.
    Pot. iodidi..............3 ij.
    Tr. bella...............3 ij.-iv.
  M.  Sig. 3 i-1. i. d. and send the pa-
tient to a warm climate.
Or,
  R Pot. chlor................3 iss.
    Tr. bella..................5 iss.
    Fl. ext. prun. virg.,
    Tr. cinchon. co.........55 \ ij.
  M.  Sig.  A dessertspoonful 4  times
a day.
            ENTERITIS.
 R Pulv. opii...............gr. i.
    Plumb, acet.............gr. ij.
  M. et ft. pulv. i.

           ERYSIPELAS.
  R Vin. ipecac..............fl. 5ss.
  Sig. gtt. xx.  every  2 or 3 hours in
water.
Or           (Facial).
  R Quin. sulph.............3 ss.
    Ext. bella.,............gr. iij.
  M. ft. pil. x.  Sig.  One  every four
hours.

       EPILEPSY (Idiopathic).
  R Pot. iodidi,
    Pot. brom..............553J.
    Ammon. brom............3 ss.
    Pot. bicarb................3ij.
    Inf. calumb...............5 vi.
  M.  Sig.  3 i. before each meal and 3
tablespoonfuls at bed-time with water.

          ERYSIPSLAS.
R Tr. ferri perchlor.,
    Glycerinae................aaij.
  Sig.  3 ij. every 2 hours. 
PRESCRIPTIONS.
421
       FACIAL  NEURALGIA.
  R Ammon. val...........gr. v.-x.
    Chi. ammon..........gr. xxx.
  M.  et ft. pulv.  Sig. Take  immedi-
ate,y-          FEVER.
  R Lig. ammon. acetat.........5 ij.
    Sp. nit. dulc.
    Syr. ipecac...............aa | i.
  M.  Sig. 3 i. every 2 hours.
Or         (Malarial).
  R Quin. sulph..............3ij.
    Fer. sulph. exsic..........3 i.
    Ac. arseniosi..............gr. i.
  M. et ft. pil. xx.  Sig. One t. i. d.
   FJECAL ACCUMULATION..
R Tr. aloes et myrrh........3 vi.
  Tr. nucis vom.............3 ij.
 M.   Sig. gtt. xv.-xxx. t. i. d.

   FAECES (Incontinence  of).
RTr. bella...................3 v.
  Fl. ext. ergotas,
  Aq......................55 5ij.
 M.   Sig. 3 i. t. i. d. 
422
PRESCRIPTIONS.
        GASTRITIS (Chronic).
  R Argent, nitratis........gr. v.
    Pulv. opii..............gr. iiss.
  M. et ft. pil. xx.  One t. i. d.

    GLEET (In Anemic Persons).
  R Tr. fer. perchlor...........3 vi.
    Tr. cantharides...........3 ij.
  M.   Sig. gtt. xv. in water t. i. d.

           GONORRHCEA.
  R Sol.  plumb,  subacet.
      (Goulard's)...........3 ss.-i.
    Aq......................jiv.
  M.  et ft. injectio.  Sig.  Use  once
 daily.
 Or,
  R Copaibas,
    Pulv. cubebae.........55 5 ij.
    P ulv. alum...............5 i.
    Pulv. opii.................gr. v.
  M.  Sig.  3 i.—ij. night and morning.
Or,
  R Ol. copaibas,
    01. cubebas,
    01. santal. flav..........55 3 i.
    Magnesias..................3 ij,
  M. et ft. pil. Ix. Sig. Take two pills
every 4 hours.
Or,
  R Vin. colch. sem..........^ss.
   Sol. pot. cit.............1 viss.
   Tr. opii deodor..........3 ij.
  M.  One tablespoonful t. i. d.
Or,
  R Liq. plumb, subacet. dil. 5 iv.
   Zinci sulph......  ......gr. viij.
  M. et ft. injectio.
Or,
  RCad. sulph................gr. i.
   Aq........................3jiv,
  M. et ft. injectio.
Or,
  R Bals. copaibas,
    Sp. nit. dulc.........55 3 i.
    Liq. potas...............3 ij.
    Fl. ext. glycyrrh.......3 ss.
  Misce et adde:
    01. gaulther...........gtt. xv.
    Syr. acac.............ad 5 vi.
  M.   Sig. 3  i. t. i. d.


    GONORRHCEA AND  GLEET.

  R Fl. ext. hydrastis..........3 i.
    Mucil. acac...............5 iv.
  M. et ft.  injectio.  Sig.  Use 5 ss. as
an injection.
Or,
  R Fl. ext. hydras.............| ss.
    A1........................5ij.
  M. et ft. injectio.


               GOUT.

  R Pil. hydrarg............. gr. vi.
    Carb. sodii..............gr. v.
    Ext. col. co............gr. vi.
  M. et ft. pil. i.  Sig.  Take at bed
time.
Or,
  R Pulv. ipecac,
    Hydrarg, chlor. mite.,
    Ext. mellon,
    Ext. colch. acet......55 gr. i.
    Ext. nuc. vom...........gr. %.
  M.  Sig.  One pill every 4  hours; it
attack be very bad,  1 in every 2 hours.
In severe cases, with pain, give gtt. S.
Magendie's solution.
Or,
 R  Vin. colch. rad...........3 i.
    Pot. bicarb.,
    Pot. et sod. tart.......55 3 iiss.
    Aq. menth. pip..........jjy.
  M.  Sig.  3 iv. t. i. d. 
PRESCRIPTIONS.
423:
Or,           GOUT.
 R Pot. carb.,
   Pot. nit................55 3 iiss.
   Aq.....................I viij.
  M.   Sig. Tablespoonful t. i. d.
Or,
 RTr. colch.seminis........fllxx.
   Pot. bicarb...............gr. x.
   Aq. piment...............1 i.
  M.   Sig. A draught.
Or,           GOUT.
 R Tr. colch. sem.........til xv.
   Mag. carb.............gr. vi.
   Mag. sulph.......  ....gr. xx
   Aq. menth. pip.....ad 5 i.
  M.   Sig. A draught. 
424
PRESCRIPTIONS
          HAY ASTHMA.
 R Pot. iodidi................5i.
    Liq. pot. arsen............3 i-
    Aq.........................?iv.
  M.  Sig. 3 i. every 4 hours.
Or,
 R Liq. pot. arsen............3 iij.
    Tr. bella..................3ix.
  M.  Sig. gtt. xij. after meals and in-
crease in 3 days to xvi. and after 10
days to gtt. xx.

  HAEMATEMESIS  (From Low Con-
              dition).
 R Ol. terebinth..............3 iij.
    Fl. ext. dig...............3i.
    Mucil. acac...............1 ss.
    Aq. menth. pip...........5 i.
  M.  Sig. 3 i. every 3 hours.

          HAEMOPTYSIS.
 R Plumbi acet.,
    Pulv. digit.............553i.
    Pulv. opii..............gr. x.
  M. ft. pil. xx.  Sig.  One every  four
hours.
Or,
  R Fl. ext. ergot...........5 iij.
    Fl. ext. ipec,
    Tr. opii deodor.........aa 5 ss
  M.  Sig. 3>i. every hour.

            HEADACHE.
  R Fl. ext. guaran............f i.
    Hoff. anodyne............3 ij.
    Tr. lavand. co.............5 vi.
  M.  Sig.  3i.  every X hour till  re-
lieved.
Or           (Reflex).
  R Pot. cyanid..... .....  gr. x.-3i.
    Aq. lauro cerasi.....5 iv.
  M.  Sig.  Poison.  A compress moist.
ened  with the solution to be applied to
the seat of pain.
           HEADACHE.
Or      (Severe Continuous).
 R Givehydrarg.chlor.mite.gr. 1-30.
  Every 15 minutes.
Or,
 R Pot. brom.................Ji.
   Pot. iodidi.................3 ij.
   Glycerinae,
   Syr. rub.  idaei...........55 5 i.
  M.  Sig. 3 i. every 3 hours.
Or             (Sick).
 R Ext. gent.,
   Pulv. rhei..........aa 3 ss.
   Pil. hydrarg..............gr. iv.
   01. caryophyl..........gtt. iv.
  M. et ft. pil. xx.

HEART  COMPLICATIONS (In Rheu-
              matism).
 R Pot. bicarb................3 iss.
    Pot. acet..................3 ss.
    Pot. nitratis..............3 i.
    Spts. cether. comp.........51.      .
    Ac. citrici................3 i.
    Aq.......................5i.
  M.  Sig.  Take  half this mixture
every hour (making 2 doses).

     HEART (Hypertrophy of).
  R Plumb, acet..............3 ss.
    Pulv. opii.................gr. v.
    Confect.  ros............q. s.
  M. et ft. pil. xx.   One t. i. d.

HEART LESIONS (with Dilatation).
  R Brom. potas..............3 iij.
    Chloral hydrat............. 3 i,
    Syr. rub. idaei,
    Aq ...................aa ? i j.
   M. Sig. 3 i. every hour till relieved.
   HEMIPLEGIA (Due to Syphilis).
  R Pot. iodidi...........3 i. (dose).
   Give t. i. d. in half a tumbler of infu-
 sion of  hops,  and increase the  pot.
 iodide till 5 i. t. i. d. be reached. 
PRESCRIPTIONS.
425
    HEMORRHAGE (Puxmonary).
  R Piumb. acet................3 ss.
  M. etft. pulv. vj.  Sig.  One  every 3
 hours.
    HEMORRHAGIC DIATHESIS.
  R Ac. gall...................3SS.
    Ac. sulph. dil.,
    Tr. opii deodor......... aa 3 i.
    Inf. ros. co...............jiv.
  M.   Sig. A tablespoonful  every 3
 hours.

          HEMORRHOIDS.
  R Pulv.  hydras............3 iij.
    Vaseline.................31.
    Paraffin...................q. s.
  M. et ft. ungt.   Sig. Apply night and
 morning.
 Or,
  RPulv.  gall...............  3i.
    Pulv.  opii................gr. x.
    Ung. plumb, subacet___3ij.
    Ung. simpl...............31.
  Sig.  To be used as directed night
 and morning.
 Or,
  R Pulv. opii................gr. ij.
    01. theobro..............q. s.
  M. ft. suppos. 1.

         HEPATIC COLIC.
  R Sodii phos.........___3i.- 3 i.
  Sig.  Take this amount  before each
meal.

           HYSTERIA.
  RChloral hydrat.............3iss.
    Pot. brom.................3 iij.
    Syr. rub. idaei............I i.
   Aq. aurant. flav..........5 iij.
  M. Sig  3 i.  t. i. d.

        HOOPING COUGH.
 R Zinci oxidi................3 i.
   Ext. bella.................gr. v.
  M. et ft.  pil. xxi.  Sig. One t. i. d.
         HOOPING COUGH.
  R Syr. ipecac..............3iiss.
     Syr.scillae................3 iij.
     Mist, assafcet.........ad I ij.
   M.  Sig. 3 i.-ij. every 3 hours.
 Or,
  R Pot. brom.................3 ij.
     Hydrat. chlor.............3 ss.
     Ext. bella.................3 i,
     Syr. tolu.................1 ij.
  M.  Sig. 3 i. every half-hour till re-
 lieved.
 Or,
  R Camph. monobrom.....gr. v.
    Syr. tolu................| i.
    Mucil. acacias.............q. s.
  M.  Sig.  3 i. as required.
 Or,
  R Ac. nit. dil................3 iij.
    Tr. cardamom, co........5 i.
    Syr. simp................5 iij.
    Syr. cinnamon............1 vi.
  M.   Sig.  3 ij.  every three hours and
let them drink freely of
  R Ac. phos. dil...............3 i,
    Aq ........................O.i.
Or          (If Severe).
  R Fl. ext. hyos..............3 ss.
    Aq. aurant................| iv.
  M.  Sig.  3 i.-iv. every three hours.

            HORRORS.
  R Pot. brom.,
    Aq........................5a 5 i.
  M.  Sig.  3 ij.  every 4 hours.

         HYDROPHOBIA.
  R Inf. xanthis spinosi.....gr. ss.
  M.  Sig. Take this amount t. i. d. for
6 weeks (for adults); for children under
12 years of age, give % this dose. 
426
PRESCRIPTIONS.
  INFLAMMATION OF BLADDER.
  RTr. bella .................3 i.
    Fl. ext. buchu............|i.
    Liq. pot. arsen............3 ss.
    Tr. opii camph...........3 vi.
    Syr. simp.............._.. ? iss.
    Aq..................... ad 3 vi.
  M.  Sig. 3 i. every 3 hours (tr. opii
camph. should not be included  when
blood exists in the urine).
Or,
  R Pot. brom................3 iij.
    Chloral hydrat.............3 iss.
    Syr. rub. idaei,
    Aq......................55 ?i.
  M.  Sig.  3 i. every half-hour till re-
lieved (and apply hot fomentations).

  INFLAMMATION OF  BOWELS.
  R Pulv. opii...............gr. i.
    Plumb, acet.............gr. ij.
  M. ft. pulv. i.

          INDIGESTION.
  R Cinchon. sulph..........gr. ij.
    Ext. glycyrrh...........gr. iij.
    Sacchari albi...........gr. v.
  M. et ft. chart, i.
Or,
  R Sodii bicarb.,
    Pulv. zingib.,
    Pulv. calumb....... aa gr. iiss.
  M. et ft. chart, i.
Or,
  R Bismuth, subnit........gr. xv,
  Ft. chart, i.
              IRITIS.
  R Morph. sulph............gr. iv.
   Zinci sulph..............gr. iij.
   Atrop. sulph...........gr. ij.
   Aq. destil..............5 i.
  M. Sig. lotio.
      ITCHING (Obstinate).
  R Ac. hydrochlor.......gtt. xx.
   Aq.....................5iv.
  M. Sig. Apply to parts.
            IMPOTENCE.
  R Ferri arsen..............gr  v
    Ergotine (aq. ext.).....3 ss.
  M. ft. pil. xxx. Sig. Take one night
and morning.

    INCONTINENCE OF  URINE.
  R Acid benzoic..............3 ij.
    Aq. cinnam...............5 vl.
  M. Sig. A tablespoonful t. i. d.

  INCONTINENCE OF URINE AND
              FAECES.
  RTr. bella...................3v.
    Fl. ext. ergot.,
    Aq  .....................55Iij.
  M.  Sig.  3 i. t. i. d.

     INSOMNIA (From Worry).
  R Pot. brom.................3 vi.
    Aq.......................   $iij.
  M.  Sig.  3i. before each meal end
take 3 ij. at bed-time.

            INFLUENZA.
  R Vin. ipecac..............in xvi.
    Tr. opii................mxiij.
    Spt. aether, nit.........3 i.
  M.  To be taken, in water,  at bed-
time.
Or       (Of Old People).
  R Ammon. carb.............3 i.
    Muc. acac...............fl. ?iv.
    Aq. menth. pip..........  5 i j.
  M.  Sig. 3 i.-ij. every hour.
Or  (After Loosening of  Cough).
  R Syr. scillas.................5 iij.
    Tr. opii camph............5 i.
  M.  Sig. 3 i. t.  i. d. or 3 ij. at night.

               ITCH.
  R Sulph. iodidi...............3i.
    Adipis......................51.
  M.  Apply to the part.
Or,
  R Sulphuris.................jj,
    Adipis.....................j«
  M. et ft. ungt. 
PRESCRIPTIONS.                         427
            JAUNDICE.
 R Pot. bitart...............51.
    Ext. tarax...............3 ss.
    Decoct, tarax............3 viij.
  M.  Sig. Half a wine-glassful t. i. d.
Or,
 R Sodii phos.......dose 3 i.-1 i.
    For children.....  " gr. x.-3i.
Or         (Catarrhal).
 R Spt. oether. comp. (Hoff.).. 3 L
    Sodii bicarb...............gr. x.
 Sig.  Take this dose t. i. d.
       JOINTS (Swollen).
R Pot. iodidi............., 3 i.
  Glycerin...............3 i.
  Tr. sap. camph.........$ iij,
  Ol. limonis..............gtt. iv.
M. et ft. liniment. 
428
PRESCRIPTIONS.
LABOR (WEARINESS 0R Over-exer-
             tion IN).
R Hydrat chloral..........gtt. viij.
  Liq. morph. sulph. (Ma-
    gendie)...............gtt. iij.
    Aq. camph —  .......3 i.
  M.   Sig. 3 i.  every hour till sleep is
 produced.
            LARYNGITIS.
  R Zinci sulph.............gr. viij.
    Acidi tannic............gr. xx.
    Aq .....................3iv.
  M. et ft. gargle.
             LAXATIVE.
  R Mag. carb.,
    Mag. sulph.,
    Sulphuris loti.,
    Sacch. alb...............aa 3 iv.
    Pulv. anis.................3 ij.
  M. et ft. chart, i.
 Or           (Cooling).
  R Pulv. ipecac...........gr. 1-6.
    Pulv. rhei...............gr- ij.
    Sodii bicarb.,
    Pulv. cubeb..........aagr. iv.
  M. et ft. chart, i.

           LEUCORRHCEA.
  R Alum....................3 ij.
    Aq.......................3 viij.
  M.   Sig. Inject into vagina bis die

         LICE (To Destroy).
  R Hyd. chlor. cor............3i.
    Aq.........................? iv.
  M.   Sig. Use as a wash.

              LOTION.
  R Liq. plumb., subacetat.......| j.
    Aqua.......................Oj.
  M.  Sig.  External application.
             LINIMENT.
 R Veratrias...............gr. iv.
   Chlorof ormi.............3 i.
   Tr, aeon. (Fleming's).....3 ij.
   Tr. capsici............,---3 ss.
   Tr. menth. pip..........3 iss.
   01. menth. pip...........3 ss.
  M.  et ft. lotio.  Sig. Poison.
Or,
 R Fl. ext. aeon, rad.,
   Chlorof ormi............55 3 i.
   Spt. camph................3 ss.
   Lin. sap..............q. s. 3 ij.
  M.

        LIVER (Enlarged).
 R Quinias sulph. .  .........gr. x.
   Pulv. capsici.............gr. i.
   Pulv. camph...........gr. ss.
  M.   Sig.  Take this dose t. i. d.  (in
capsule).
Or,
 R Granules of arsenious
     acid..................gr. 1-16.
  T. i. d.
Or,
 R Warburg's tinct...........3 ij.
  T. i. d. for an adult.
   Warburg's tinct...........3 i.
  T. i. d. for children.

          LOTION (Red).
 R Zincsuph.................gr. ij.
   Tr. lavand co............. fllxv.
   Aq........................Ji. 
PRESCRIPTIONS.
429
        MALARIAL FEVER.
  First give an emetic, then:
 R Quin. sulph...............3 ij.
   Ferri sulph. exsic.........3 i.
   Ac. arsen...............gr. i.
  M.  et ft. pil. xx.  Sig. One t. i. d.
Or   (With Cerebral Symptoms).
 R Quin. sulph...........gr. v.-x.
   Pot. brom.............3 ij.-iv.
   Syr. rub. idaei,
   Aq................5a 3i.
  M.  Sig.  3 i.  every hour.
Or (In Child  IS Months of Age).
 R Quin. sulph.............gr. xij.
   Lactopeptin............gr. xv.
    Hydrarg. submur......gr. i.
  M. et ft. chart, vi.  Sig.  One t. i. d.
Or        (In Pregnancy).
 R Ol. eucalypt. glob.......gtt. Ix.
  M.  (Put into 12 capsules). Sig. One
every 3 hours.
Or        (With Vomiting).
 R Quin. sulph............gr. xx.
   Bismuth, subnit.......3 iss.
   (Vel oxalatis cerii .....gr. viij.)
   Morph. sulph...........gr. ss.
  31. et ft. chart, iv.  Sig. One t. i. d.


           MARASMUS.
 R Pepsin..............gr. xxiv.
   M. et ft. pulv. viij. Sig. One t. i. d.


         MASTURBATION.
 R Pot. brom................3 iv.
   Tr. cinchonas,
   Aq ....................aa 3 iss.
  M.  Sig. 3 i. t. i. d.
          MENORRHAGIA.
 R Ferri arsen...............gr. v.
    Ergotinas (aq. ext.).......3 ss.
  M. et ft. pil. xxx.  Sig.  One night
and morning.

      MENSES (Stoppage of).
 R Pot. brom.................3 iv.
    Aq.....................5 ij-
  M.  Sig. 3 i. t. i. d.

     MERCURIAL POISONING.
 R Pot. iodidi................gr. x.
  Give t. i. d.

          MILK FEVER.
 R Tr. aeon, rad...........gtt. xx.
    Ant. et pot. tart.......gr. ij.
    Sp. etheris nit.,
    Syr. simp............aa 3 i.
    Aq. aurantii flor......5 ij-
  Sig. 3 i.  in a wineglassful of water
(with sugar) every 2 hours.

     MITRAL REGURITATION.
 R Ferri redact.,
    Quin. sulph...........aa 3i.
    Pulv. dig.,
    Pulv. scillas............aa gr. x.
  M. et ft. pil. xx.  Sig.  One t. i. d.

     MOUTH (Ulceration of).
 R Pot. chlor.................3 ss.
    Aq.........................3 vi.
  M.  Sig. Tablespoonful t. i. d.

          KOUTH  WASH.
 RSodiibor.................3 ij-     (
    Pulv. myrrh .............3 i.
    Aq.........................ivi.
  M. ft. wash or gargle. 
430
PRESCRIPTIONS.
 NERVOUSNESS (With Debility).
 R Pot. brom.................5 !•
   Ferri sulph. exsic.........3 ss.
   Calumbas,
   Pulv. zingiberis.........55 3 iv.
 M. et ft. chart, i.
           NEURALGIA.
 R Aconitin................gr. i.
   Strychnias  .............gr. iij.
   Hydrarg. iod...........gr. vi.
   Adipis..................  3 ij.
   Vermilion.     .........q. s.
 M. et ft. ungt.  Rub the affected part
well  with  a very small  piece of the
ointment.
Or,
 R Tr. aeon, rad.,
   Chlorof ormi............55 3 ss.
   Lin.  sap...................3 i-
 M.   Sig.  Apply to the seat of pain.
Or,
 R Aconitiae................gr. iv.
   Veratrias...............gr. xv.
   Glycerin................3 ij.
   Cerati  ..................3 vi.
 M.   Sig.  To be rubbed over the part.
Take care there is no abrasion.
Or,        NEURALGIA.
 R Ext. hyos.,
   Ext. lupuli..........55 gr. x.
   Morph. sulph...........gr. iss.
  M. ft  pil. vi.  Sig.  One night and
morning.
Or            (Facial).
 R Ammon. val.........gr. v.-x.
   Chi. ammon..........gr. xxx.
  Sig.  Take immediately.
Or           (Sacral).
 ROl. crotonis................3i.
   01. amygd. dulc.........3 ix.
  M. et ft. embrocatio.
  NOCTURNAL INCONTINCE  OF
      URINE IN CHILDREN.
 R Strych..................gr. i.
   Pulv. canthar..........gr. ij.
   Morph.  sulph..........gr. iss.
   Ferri pulv.............3i.  ■
  M.  ft.  pil. xl.   Sig.  One t. i. d. to a
child 10 years of age.
    OINTMENT (For Sores).
R Zinci oxidi..............gr. x:
  Cerati simp.,
  Vaseline..............aa 3 ss.
 M. et ft. ungt. 
PRESCRIPTIONS.
431
       PAINS (After Labor).
 R Sol. morph. sulph (U. S. P.). 3 j.
  M.  Sig.  3i. every  2 hours till  re-
lieved.

           PERIOSTITIS.
  Givejpot. iodidi gr. v. to commence
with,  and increase  gradually to  gr.
        PERITONITIS (Local).
  R Morphias.............gr. i.
     Camphorae............gr. xij.
     Pulv. sacch. alb......gr. xxiv.
  M. et ft. chart, vi.  Sig.  One every
 3 hours till relieved, and apply flaxseed
 poultice.

 PERITONEUM,    INFLAMMATION
  OF, AND OTHER INFAMMATORY
  CONDITIONS.
  R Tr. aeon, rad......  .....3 i.
    Adipis...................3 iij.
    Chlorof ormi............3 i.
    Morph.  mur.............gr. vi.
  M. ft. linctus.  Sig.  Apply on cotton
 wadding to a small surface only.

        PLEURISY (Acute).
  R Hydrarg. chlor. mit.gr. vi.
    Pulv, opii...........gr. iij.-vi
    Antimon. tart......gr. iss.
  M. et ft. pulv. xij.  Sig.   Take one
every 3 hours in water.
Or          (Subacute).
  R Pot. acet.,
    Inf. digital...........aa 3 ij.-iv.
  Sig. This amount each day.
Or,
  R  Pulv. dig.,
    Pulv. scillae mer.,
    Hyd  chlor. mit.......aa gr. x.
  M. et ft. pil. x.  Sig. One pill t. i. d.
             PLEURISY.
 Or             (Pain).
  R Tr. aeon, rad............3i.
     Adipis....................3 iij.
     Chloroformi.............3i.
     Morph.  mur.............gr. vi.
   M. ft. linctus. Sig. Apply on cotton
 wadding to a small surface only.

       PNEUMONIA (Caseous).
  RInf.dig....................3iv.
     Plumbi  acet...............3 i.
     Tr. opii...................3i.
  Sig. A tablespoonful bis die.
 Or          (Typhoid).
  R Ammon. carb..........3i.
     Muc. acac...............fl. 3iv.
    Aq. menth. pip............3 ij.
  M.  Sig. 3 i.-ij. every hour.

    PREGNANCY (Vomiting of).
  R Bismuth, subnit.......3 iij.
    Ac. carbol............gr. ij.-iv.
    Muc. acac..........3 i.
    Aq. menth. pip______3 iij.
  M.  Sig. 3 ij. t. i. d.
 Or        (Vomiting of).
  R Cerii oxalat.,
   Pulv. ipecac...........35 gr. i.
   Creasoti..................gtt. ij.
  M.  et ft.  pulv.  Sig.  To  be  taken
every hour.
Or       (Sick Stomach of).
 R Rad. calumbo,
   Rad. zingiber...........55 3 ss.
   Fol. sennas................3 i.
   Aq. bullient...............O.i.
  M.   Infus.  Sig.  A wineglassful be-
fore  each meal.

    PILES OR  HEMORRHOIDS.
 R Pulv. opii................gr. ij.
   01. theobrom.............q. s.
  M.  et ft. suppos. 1. 
432
PRESCRIPTIONS.
             PHTHISIS.
  ROl. morrh................3i.
    Tr. iodinii co............HI viij.
  M.  Sig.  3 i.-iv. every 3 hours.
Or,
  R Mist. ol. morrh..........3i.
    JEtheris..................fllxvi.
Or,
  R Ac. carbol.............3 iij.
    01. gaulther..........gtt. xx.
    Glycerin...............3 i-
    Spts. alcohol...........3 ss.
    Aq................. .ad 3 viij.
  M.  Sig.  Put one tablespoonful in
O.ss. water and inhale the vapor.
Or,
  R Sulph. morph...........gr. i.
    Syr. bals. tolu,
    Syr. prun. Virg....... 55 3 i.
  M. Sig. 3 i. t.  i. d.  If there be night-
sweat j add:
    Morphine.............gr. 1-60.
Or,
  R Sulph. morph............gr. i.
    Vini antimon.............3 ij.
    Syr. tolu..................3 iss.
    Aq........................3"j-
  M.  Sig. 3 i. every 3 hours.
Or         (Aphth.e of).
  R Quin. sulph..............gr. i.
    Olei piperis nig.........gtt. i.
    Aq.......................3i-
  Sig. Apply with a brush or rinse out
the mouth.
Or           (Fibroid).
  R Fl. ext. ergotas,
    Tr. hyos................55 3 iv.
  M.  Sig. gtt. xx. t. i. d.
Also,
  R Protagon..................31.
    Glycerin..................5 ij.
  M.  Sig. 3 ss. after each meal.
             PHTHISIS.
Or     (Troublesome Cough).
 R Syr. prunis Virg.,
    Syr. lactucarii...........5a 3 ij.
  M.  Sig.  One or two dessertspoon-
fuls at night or 3 ij. during the day
Or   (When Temperature Ris«s
            Above 100°;.
 R Fl. ext.gelsemii,
    Tr. ver. vir............. 55 3 i.
    Tr. aeon,  rad..............3 ij.
    Tr. digitalis............3 hj.
  M.  Sig. gtt. vij. t. i. d.  If irregular
ity of pulse exist, omit the digitalis.

     PROSTRATION IGeneral).
 R  Ammon. carb.............3 i.
    Muc. acac..............fl. 3 iv.
    Aq. menth. pip...........3 ij-
  M.  Sig. 3 i.-ij.  every nour.

   PUERPERAL CONVULSIONS.
 R  Chloral hydrat............3 iij.
    Syr. rub.  idasi............5 i-
  M.  Sig. 3 i. every 20 minutes.

              PURGE.
 R  Pil. hydrarg..............gr. vi.
    Sodii bicarb........__gr. v.
    Ext. coloc. co...........gr. vi.
  M.  Sig.  To be taken at bed-time.

            PRURITUS.
 R  Ac. carbol...............3 i.-ij.
    Glycerin................3 i.
    Aq...................ad 3 viij.
  M.  Sig. Use as a lotion.

          PRURITUS ANI.
 R  Pot. brom.,
    Chi. hydrat.......aa gr. x.-xv.
    Aq................ad 31".
  M.  Sig.  To be taken at bed-time. 
PRESCRIPTIONS.
433
Also,      PURITIS ANI.
  R Sodii bibor.............3 ij.
    Morph. mur............gr. xvi.
    Ac. hydrocyan. dil.....3 ss.
    Glycerin...............3 ij.
    Aq..................ad 3 viij.
  M. Sig.  To be applied to the affected
part.

    PROSTITIS WITH CYSTITIS.
 R Tr. hyoscyam..............3;.
    Potass, bicarb.............3 iij.
    Aquas......................3 iij.
  Mi  Sig.  3 iv. t. i. d.
Or,      PRURITIS ANI.
 R Chloroformi..............3 ij.
   Glycerin..................3SS.
   Cerat. simp..............3iSs.
 M. et ft. ungt.  Apply locally. 
434                         PRESCRIPTIONS.
      RHEUMATISM (Acute).
 R Ac. salicyl................3 iij.
   Sodii bicarb..............3 9-
   Glycerinae,
   Aq......................aa 5 ij.
  M.  Sig. A tablespoonful every two
hours.
Or          (Chronic).
 RTr. guaiac.................5ij.
  Sig. 3 L t. i. d. in water.
      RHEUMATIC  PAINS.
R Lin. aeon.,
  Lin. bella...............55 3 ij.
  Glycerinae...............ad 3 ij.
Sig. Apply locally over seat of pain.

        RUM STOMACH.
R Tr. nuc. vom.........gr. v.-xv.
  Tr. gent, co.,
  Tr. calumbas co.. .55 3 i.
Sig.  Take before meals. 
PRESCRIPTIONS.
435
 SMALL-POX (To  Prevent Pitting).
   R Pulv. carb. lig............3 ss.
     01. picis,
     Cerati simp.............aa 3 ij.
     Syracena purpura........3 ss.
   M. et ft. ungt.  Sig.  Rub over all
 parts that are exposed.


              SPRAIN.

  R Liq. plumb, subacet. dil. 3 iss.
     Morph. acet..............3 i.
     Aq......................3 viij.
   M. et ft. lotio.  Sig.  For external
 application.
 Or,
  R Lin. sapon___  ...........3 iv.
     Aquas ammon..............3 ss.
   31. et ft. embrocatio.
 Or,
  R Chlorof ormi............fl. 3 i j.
     Tr. aeon, rad.,
     Aq. ammon..........5a fl. 3 ss.
     01.  olivae................fl. 3 v.
   M. Sig. Liniment for external ap-
 plication.

 Or        (Of Ligaments).
  First place the limb for five minutes
 in a hot salt and  water bath, then  ap-
 ply:
  R Chloroformi,
    Tr. aconiti,
    Tr. opii.................55 3 iij.
    Lin. sap...................3 iv.
  M. et ft. lotio.   Sig.  To be used as
directed.

            SEDATIVE.
 B Pot. brom.,
    Sp. ammon. arom......55 3 ij.
    Syr. scillas................. 3i.
    Aq........................3 iij.
M.
        SPERMATORRHOEA.
  R Ferri arseniat.......___gr. v.
    Ergotinas (aq. ext.)......3 ss.
   M.  et ft.  pil. xxx.  Sig.  One night
 and morning.
 Or       (With Impotence).
  R Tr. canthar........gtt. vi.
    Tr. ferri perchlor ..gtt. xv.-xx.
  Sig. t. i. d. in water.

        SPLEEN (Enlarged).
  (See liver enlarged.)

      SWELLING OF JOINTS.
  R 01. sassafras  ............  3 ij.
    Aq. ammon..............3 iv.
    Lin. sap. camph..........3 iij.
  M. ft. liniment (for external applica-
 tion).

 SICK  HEADACHE  (Due to Gastri-
                tis).
  R Pulv- calumbas,
    Bismuth, subnit......55 gr. x.
  M.   Sig.   Take this t.  i.  d. after
 meals.
 And,
  R Inf. cinchon......  ...   5 ss.-ij.
  Take this before meals t. i. d.

     SICKNESS OF STOMACH.
  R Bismuth, subcarb.....gr. xxx.
    Ingluvin.....  .........gr. xx.
  M. et ft. pulv. v. (for adult).  Sig. 1
t. i. d.

          SKIN DISEASES.
  R Liq. pot. arsen............5 ss.
  Sig. gtt. v. t. i. d.
Or  (Due  to Syphilitic Origin).
  R Liq. arsen. et hyd. iodidi.. 3 ss.
  Give m ij.-v. t. i. d.

        SKIN ERUPTIONS.
  R Ungt.  hyd. nit. mit........3 ss.
  Sig.  For external application. 
436
PRESCRIPTIONS.
             SYPHILIS.
 R Hyd. protiodidi........ .gr. xij.
    Rosae confect...........3 i.
  M. et ft. pil. xij.   Sig.  Take one bis
die.
Or        (Constitutional).
 R Pot. iodidi.................3 ss.
    Aq. cinnamomi............3 >■
  M.  Sig. 3 i. t. i.  d.
Or,
 R Pot. iodidi..............gr. xx.
    Hyd. chlor. cor___.___gr. 1-6.
    Aq. cinnam.............3 i-
  31.  Sig. 3 ij.-iv. every 3 or 4 hours.
Or,
 R Hyd. chlor. cor.......gr. H.
    Pot. iodidi............gr. lxxx.
    Aq. menth. pip.......3 i.
  M.  Sig. 3 i.-ij. every 3 or 4 hours.

Or          (Secondary).
 R Liq. arsen. et hydrarg iodid. 3 iss.
  Sig. gtt. iij.-v. t. i. d.

Or       (2d and 3d Stages).
 R Hydr. bichlor............gr. ij.
    Pot. iodidi..............3 ss.
    Pot. chlor................31.
    Tr. gent, co.,
    Aq....................55 3iv.
 M.  Sig.  3 i. t. i. d. after meals.
Also,
 R Pil. hyd. prot............gr. ss.
  In the middle of the day.

Or          (Infantile).
 R Hydrarg. bichlor.........gr. i.
    Pot. iodidi................3 iv.
    Syr. aurant.,
    Aq......................55 3ij.
  M.  Sig. gtt. v. for child  about one
month old and  increase  to xv.-xx. if
the disease does not yield.
            SCROFULA.
 R Iodini...................3 vi.
    Pot. iodidi........(troy) 3 iss.
    Aq. destil............... O.i.
  31.  Sig. gtt. v.-vi. bis die, in water.
Or,
 R Syr. fer. iodidi..........fl. 3ss.
  Sig. gtt. x.-xx. in water t. i. d.

          SORE NIPPLES.
 R Plumbi nit...........gr. x.-xx.
    Glycerin.............3i.
  Sig.  Rub on the affected part.
Or,
 R Aquas rosae.............3 iiiss.
    Liq. plumb, subacet. dil. 3 ss.
    Ext. opii aq.............3 i.
  Sig.  Lotion.   First  apply a  bread
and milk poultice  to the parts, and
after removal, apply a piece of linen
of two thicknesses, after being wetted
with the lotion.

            SORES (Bad).
 R Ac. carb.................gr. ij.
    Aq.......................O.i.
  M. et ft. lotio.
Or             (Red).
 R Alum.....................3SS.
    Tr. camph................3 ij.
  Add the white of four eggs.  M. Sig.
Apply to the parts affected.

            STOMACHIC.
 R Ac. nitro-mur. dil........nixl.
    Inf. gent, co..............3 i.
  31.  Sig.  3 ij. every 3 or 4 hours.
Or,
 R Liq. pot. arsen...........3 ss.
    Tr. quassiae..............3 ij.
    Syrupi...................3vsg
  M.  Sig.   3i.  (diluted)  immediately-
after meals. 
PRESCRIPTIONS.
437
          SUNSTROKE.
R Hydr. bichlor..........gr. i.
  Pot. iodidi.............gr. viij.
  Aq.....................3 iiss.
M.   Sig.  3 i. t. i. d.
     STRYCHNIA POISONING.
 R Nicotinas................gr. ss.
   Aq. dest.................3 ij.
  M.   Sig.  Give ill x. as occasion re-
quires. 
438
PRESCRIPTIONS.
          TAPE WORM.
  R Insert a tube down the oesophagus
to the stomach and pour down it from
200 to 400 centigrammes of a very con-
centrated decoction of pomegranate
root, and let the patient fast for  24
hours.
Or,
  Let him drink soda water ad lib.

              TONIC.
 R Sulph. strych...........  .gr. i.
   Ferri pyrophos.,
   Quin. sulph............55 3 i.
   Ac. phos. dil.,
   Syr. zingiber...........55 5 ij.
  M.  Sig. 3 i. t. i. d.
Or,
 R Ferri sulph..............gr. ij.
   Mag. sulph...............3 iss.
   Ac. sulph. dil............Tlxv.
   Inf. quassias.............3 i.
  M.  Sig.  Tablespoonful every three
hours.
Or,
 R Vin. ferri................3 iij.
   Liq. pot. arsen..........3 ss.
   Syrupi...................3 iss.
   Aq.......................3 iij.
  M.   Sig.  A tablespoonful diluted,
after meals.
Or,
 R Ferri et quin. cit..........3 ss.
   Syr. simp.................3 ij.
   Aq........................Jvi.
  M.  Sig. 3 i. t. i. d.
Or,
 R Quin. sulph..............gr. x.
   Ac. sulph. dil............q.s.
   Glycerin.................3 ij.
   Aq.......... .........ad3L
  M.  Sig. 3 i. t. i. d.
Cr            TONIC.
 R Cinch, sulph.............3i.
   Tr. ferri chlor............3 iv.
   Tr. quas.................  3 i.
   Aq...................ad3iv.
  M.  Sig. 3 i. t. i. d.
Or,
 R Liq. pot. arsen............3 ij.
   Vini ferri...............ad 3 iv.
  M.  Sig. 3 i. t. i. d. in a wineglass of
water after meals.
Or         (Chalybeate).
 R Ferri phos___..............3i.
  Divide in chart, xij. Sig.  Take one,
in water t. i. d.

    TONIC AND ALTERATIVE.
 R 01. phosphor............nixvi.
    Ol. gaulther..........fliviij.
    Muc. acac...............3 i.
  M.  Sig. 3 i.-ij. every 3 hours.
Or,
 R Pot. chlor................3 ss.
    Tr. ferri chlor...........3 i.
    Aq  ......................3vij.
  M.  Sig. 3 i. every 3 hours.

     TONIC AND  SOOTHING.
 R Ext. nuc. vom..........gr. iv.
    Ext. hyos...............gr. xv.
    Pulv.  aloes,
    Quin.  sulph.,
    Ferri sulph.......__553i.
  M. et ft.  pil. xx.  Sig.  Take one
twice a day.

           TONSILLITIS.
 R Vin. ipecac.............fl. 3 ss.
  Sig. gtt. xx. every 2 or 3 hours in
water.
Or,
 R Quin.  sulph.........gr. x.-xx.
  Give twice a day. 
PRESCRIPTIONS.
439
Or        TONSILLITIS.
 R Tr. guaiac................  3ij,
   Yolk of egg.
  M.  Sig. 3 ss. every 4 hours.
Or,
 R Pot. chlor.,
   Alum...................5a3ij.
   Ext.  bella.................3iv.
   Glycerin.,
   Aq. rosas...............aa  3 ij.
  31. et ft. garg. Sig.  Use four times
daily.
     TORPOR  OF INTESTINES.
 R Ext.  physos.,
   Resin, podoph.......aa gr. iij.
  31. et ft. pil.  vi.   Sig.  Take one at
bed-time.
Or,
 R Tr. physost.,
   Tr. nuc. vom.,
   Tr. bella................5a3ij.
  M.  Sig. gtt. xxx. in water night and
morning.
     THROAT (Ulceration of).
 R Pot. chlor.................5 ss.
   Aq......................3vi.
  M.  Sig.  Tablespoonful t. i. d.

            TYPHLITIS.
 R Pulv. opii,
   Pulv. ipec ...........5a gr. vi.
  M. etft. pil.  xij.  One every three
hours.

     TYPHOID PNEUMONIA.
 R Ammon. carb.............3 i.
   Muc. acac..............fl. 3 iv.
   Aq.  menth. pip...........3 ij.
  M.  Sig. 3 i.-ij. every hour.

     URINE (Incontinence of).
 RTr. bella  ..................3v.
   Fl. ext. ergot.,
   Aq......................aa3ij.
  M.  Sig. 3 i. t. i. d.
         URETHRITIS.
R Copaibas..................3 i-
  Pulv. acac................3 iij.
 Mix well and add
  Liquor potass.............3 iiss.
  Glycerinas,
  Spts. nit. dulc..........aa  Jiss.
 Sig.  3 iv. t. i. d. 
440
PRESCRIPTIONS.
            VAGINITIS.
 R Ac. carbol.................3 ss.
   Glycerinae.................
   Cerati simp..............aa 3 i.
  31.  et ft. ungt.
Or,
 R Ac. carbol..................3i.
   Ung. zinci ox...............3 i-
Or,
 R Ac. tannici............gr. xxx.
   Adipis................3 i-
Or,
 R Camph.,
   Chloral hydrat...........55 3 ij.
   Aq. rosas....... ..........3 iv.
   31. et ft. lotio.

        VARICOSE VEINS.
 R Iodini ...................gr. i.
   Pot. iodidi...............3 iiss.
   Tr. aurant. co.,
   Tr. cinch, co..........55 3 i.
   Aq..................ad3ij.
  M.  Sig. 3i. t. i. d.

             VOMITING.
 R Sodii bicarb...... ......3iv.
   Spt. oether comp. (Hoff.).. 3 i.
   Morph. Sulph..........gr. iiss.
   Aq. cinnamom........ad 3 iv.
  M.  Sig. Take one or two teaspoon-
fuls at once.
Or,
 R Oxalat. cerii.........gr. xxxv.
   Lactopeptin.........gr. xxx.
  M.  et ft. chart, vi.  Sig.  One every
2 hours till relieved.
            VOMITING.
Or        (Of Pregnancy).
 R Ingluvin...............gr. xx.
   Oxalat. cerii..........gr. xxv.
  M. et ft. chart, vi.  Sig.  One  every
4 hours.
Or        (Of Pregnancy).
 R Cup. sulph...............gr.  ij.
   Aq. destil..............3ss.
  31.  Sig. gtt. vi. t. i. d.
Or        (Of Pregnancy).
 R Bismuth, subnit......3 iij.
   Ac. carbol............gr. ij.-iv.
   Muc. acac...........3i-
   Aq. menth. pip.......3 iij.
  31.  Sig. 3ij. t. i. d.

Or       (Of Pregnancy).
 R Cerii oxalat.............gr. i.
    Ipecac...................gr. i.
    Creasoti.................gtt. ij.
  Sig.  To be taken every hour.

Or        (Of Teething).
  R Bismuth, subnit......3 iij.
    Ac. carbol............gr. ij.-iv.
    Muc. acac...........3 i-
    Aq. menth. pip ......5 "j.
    M.  Sig.  3 i. (small, for a child) t.
i. d.

Or        (Of  Teething)
 R Bismuth, subcarb........3 ij.
   Morph. sulph............gr. ss.
  M. et ft. chart, vi.  Sig.  One t. i. d.
in milk. 
PRESCRIPTIONS.
441
  WAKEFULNESS (From Worry).
 R Pot. brom................; vi.
    Aq........................5 iij.
  31.  Sig. 3 i.  before each meal, and
take  3 ij.  at bed-time.


              SVOR3IS.
 R Santonini................gr. i.-iij.
    Sacchari albi............gr. ij.
  Ft.  chart, i.

Or  (Round and Ascaris Vermicu-
               laris).
 R Fl. ext. spigelias,
    Fl. ext. sennas  ........55 3 ss.
  31.  Sig. 3 i. to a child 3 or 5 years of
age.
Or,
 R Fl. ext. spigelias,
    Fl. ext. sennas.......55 3 ss.
    Santonini............. • gr. viij.
  31. Sig.  3 i. to a child 5 years of age.
Or
 R Hyd. chlor. mit.......gr. xxx.
    Santonin  .............gr. xij.
  M. et ft. pulv. vi.  Sig.  One t. i. d.
Or,
 R  Pulv. santon............gr. x.
    Hyd. chlor. mit.........gr. iij.
    Res. jalapas.............gr. i.
    Sacch. lactis......... •  gr. xx.
 M. et ft. chart, vi.  Sig. Onet. i. d.
        WHOOPING COUGH.
  R Syr. ipecac.............3 iiss.
    Syr. scillas ..  ............3 iij.
    Jlist. assafcet..........ad 3 ij.
  31.  Sig. 3 i.-ij. every 3 hours.
Or,
  R Zinci oxidi...............3 i.
    Ext. bella..............gr. v.
  31. et ft. pil. xxi.   Sig.  One t. i. d.
Or,
  R Ac. nit. dil................3 iij,
    Tr.  cardamom, co........3 i.
    Syr. simp.................3 iij.
    Syr. cinnam..............3 vi.
  31.  Sig.  3 ij- every 3 hours, and  let
them drink freely of:
  R Phos. acid..................3 i.
    Aq........................O.i
Or,
  R Pot. brom...............3 ij.
    Hydrat. chloral...........3 ss.
    Ext. bella.................3 i.
    Syr. tolu.................5 ij.
  M.  Sig.  3 i. every half-hour  till re-
lieved.
Or,
  R Camph. monobrom......gr. v.
    Syr. tolu.................3 i.
    Mucild. acac.............q.  s.
  31.  Sig.  3 i. as required.
Or           (If Severe).
  R Fl. ext. hyos..............3 ss.
    Aq. aurant................3 iv.
  31.  Sig. 3 i.-iv. every 3 hours. 
DISINFECTANTS.
For Privies:—
    Dissolve a pound of sulphate of iron in a gallon of water; or
    mix thoroughly in water the same quantity of chloride of
    lime.
For Water-closets, Bed-pans, etc. :—
    Use Labarraque's solution of chlorinated soda, a fluid ounce
    to a quart of water; or permanganate of potassium (the crude
    permanganate is much cheaper than the crystallized and will
    answer equally as well), ten grains to a quart; or carbolic
    acid, twenty grains to the pint or quart.  Tar is a very  good
    disinfectant.
For Drinking-water:—
    After filtering, add  sufficient permanganate of potassium to
    make it of a pinkish color in a strong light.
For Articles of Clothing, etc.:—
    If much soiled from the discharges of patients, they should be
    burned or boiled thoroughly.  Use a solution of permanganate
    of potassium, one ounce to  three gallons of water.  Expose
    for  several hours to a dry heat of from 200° to 250° F., all
    woollen articles and bedding  which cannot be washed.
For Occupied  Rooms and Houses:—
    Ventilate freely and diffuse by spray through the  air Ledoyen's
    liquid solution  of nitrate of lead; or  solid chloride of lime
    may be placed in shallow vessels, or sprinkle  one-per-cent
    solution of  carbolic acid. Whitewash the cellars.   Charcoal
    and quicklime, especially charcoal, absorb gas, and  thus aid
    in purifying the air.
For Hospital Wards:—
    Disinfect, ventilate, and  cleanse well with  Ledoyen's  liquid,
    or with chloride of lime, or  bromine may be left exposed to
    the air in shallow vessels, or iodine moderately heated
For Heaps  of Filth, Solid or  Semi-liquid:—
    Cover with charcoal two or three inches  deep, or with dry
    earth.
For Drains, Ditches, and Sewers:—
    Disinfect with sulphate of iron, coal-tar, or chloride of lime.
    A pound of good chloride of lime will be sufficient for a 1,000
    gallons of running sewage. 
POISONS AND  THEIK ANTIDOTES.
NEUROTIC POISONS.
    Poisons.
Aconite.
Alcohol.
Atropia and Bella-
  donna.
Calabar Bean (physos-
  tigma.)
Cannabis Indica.


Chloral.


Conium.
Digitalis.
Dulcamarra.
           Antidotes.
 After thoroughly emptying the stomachy
   diffusible stimuli  must  be used both
   inwardly and outwardly  (especially
   alcohol).
 Stomach-pump ; emetics ; cold affusions;
   counter irritants ;  strong coffee; artifi-
   cial  respiration ;  electro-magnetism ;
   hypodermic injections of  atropia.  It
   is better to administer ammonia as it is
   the physiological antidote.
 Stomach-pump ; emetics (especially sul-
   phate of copper in  ten grain  doses);
   cathartics ; cold affusions ; hypodermic
   injections of a morphia salt; magnet-
   ism; stimulants.
 Stomach-pump ; emetics ; cold affusions;
   counter irritation  ; strong  coffee; hy-
   podermic injections of atropia; arti-
  ficial respiration ;  magnetism.
Stomach-pump; strychnia (hypodermic-
   ally) ; vegetable acids ; vinegar; hot-
   spirits and water.
Same as Calabar Bean.  Do not use arti-
  ficial respiration.  Physiological anti-
  dote is strychnia.
Same as Aconite.
Same as Aconite.
Same as Belladonna, 
444          POISONS
Hydrocyanic Acid
  and Cyanides
Hyoscyamus.
Lobelia.
Oil of Bitter Almonds.
Opium or Morphia.
Stramonium,
Strychnia.
Tobacco.
Veratria.
Veratrum Viride
AND THEIR ANTIDOTES.
  Ammonia;   chlorine;  cold  affusions;
    fresh air and artificial respiration.
  Same as Belladonna.
  Same as Aconite.
  Same as Hydrocyanic Acid.
  Same as Calabar Bean.
  Same as Belladonna.
  Tannic  acid ; opium ; conium ;  extract
   of  hemp ;  camphor;  chloral; calabai
   bean ; bromide of potassium ; inhala-
   tions of ether or chloroform; atropia.
  Same as Aconite.
  Same as Strychnia,
  Same as Aconite.
    Poisons.
Acids (mineral  and
  vegetable).

Alkalies.
Alum.
Arsenious Acid.
CORROSIVE POISONS
             Antidotes.
   Magnesia ; chalk ;   alkaline solutions ;
fixed oils ; carbonate of soda.
use emetics.
Do not
Citric acid ; lemon juice ; vinegar ; oils.
Carbonates of ammonium or sodium.
Hydrated magnesia ;  hydrated  sesqui-
  oxide of iron (31 doses).
Sulphates of magnesium,  sodium,  or
  potassium.
Alkaline carbonates ; soap ; magnesia.
Baryta and its soluble
  salts.
Bichromate of Potas-
  sium.
Chromium compounds.  Chalk or magnesia compounds ; emetic* 
POISONS AND THEIR ANTIDOTES.
445
Corrosive  sublimate
  and  soluble mer-
  curial salts.
Cream of Tartar.
Nitrate of Silver.
Salt of Sorrel.
Soluble Arsenites.
Soluble Cupric Salts.

Soluble Lead Salts.
Soluble Zinc Salts
White of egg ; milk ; flour ;—for cuprio
  salts also ferrocyanide of potassium.

Sodium carbonates in solution.
Chloride of sodium.
Salts of calcium.
Ferric subacetate.
Same  as   Corrosive,  Sublimate   and
  Soluble Mercurial Salts.
Alkaline or soluble earthly  sulphates;
  diluted sulphuric acid;emetics (for after
  treatment milk and  opium should be
  given).
Albumen ; magnesia -.sodium carbonates;
  emetics ; demulcents (warm).
Sulphates and Chloride  Alkaline carbonates.
  of Iron.
Tartar Emetic.
    Poisons,
Arsenic.
Arsenic (in solution)

Asphyxiating Gases.

Bromine.
   Tannic acid ; catechu  or any vegetable
      acids.
IRRITANT POISONS.
                  Antidotes .
   Salts of iron (dyalized  iron); magnesia ;
      lime and astringents ; artificial replica-
      tion ; ammonia : charcoal; cold  affu-
      ions.
   Freshly precipitated hydrated sesqui-ox-
      ide of iron.
   Cold  affusions;  artificial  respiration •
        magnetism.
    Ammonia. 
446           POISONS

Cantharides.


Carbolic Acid.

Chlorine Gas.
Chlorine Water and
solutions of Chlorin-
  ated lime.
Chloroform.

Colchicum,


Creosote.
Croton Oil,
Drastic Cathartics.
Iodine.

Paris Green
  (arseniate of copper).
Phosphorus.
AND THEIR ANTIDOTES.

  Emetics; opiates  (which may be given
    either  by  mouth  or  rectum)  and
    demulcents.
  Substances of an albuminous, mucilagi-
    nous or oleaginous nature.
  Cautious inhalation of ammonia.
  Albumen  given freely  in  the form  of
    milk, eggs, flour, etc.

  Artificial  respiration;  cold  affusions;
    galvanism.
  Tannic   acid;  emetics;   demulcents.
    Should symptoms of coma come on ad-
    minister ammonia, brandy, coffee.
  Same as Carbolic Acid.
  Sulphate of  copper (in gr. x.  doses),  to
    produce emesis, which  should be fol-
    lowed by  mucilaginous  drinks  con-
    taining opium.  •
  Demulcents ; opiates ; stimulants.
  Starch  or   flour-water;  demulcents;
    emetics.
  Same as Arsenic
Magnesia;   oil   of  turpentine  (old);
  emetics; purgatives. 
INDEX.
 Abdominal pain, causes of, 20.
            typhus fever, 261.
 Abnormal  state  of  the blood
   classified, 16.
 Abscess, retro-pharyngeal, 165.
 Acclimative fever, 296.
 Addison's disease, 395.
 African fever, 280, 296.
 Albuminous urine, causes, of 33.
 Alcohol poisoning, 260.
 Amyloid kidney, 377.
          liver, 218.
 Anaemia of the brain, 227.
 Angina Ludovici, 164.
         pectoris, 145.
 Aortic obstruction, 116.
        regurgitation, 118.
 Apex-beat of heart,  causes of
  displacement of, 20.
 Aphonia, causes of, 28.
 Aphthae, 152.
 Apoplexy, 229, 259.
          cerebral, 229, 856.
          heat, 255.
          pulmonary, 69.
 Ardent fever, 280.
 Arthritis, 343.
 Ascaris lumbricoides, 197.
Ascites, 212.
        causes of, 26.
Asiatic cholera, 192.
 Asphyxia, 259.
 Asthma, 56.
 Ataxia,  locomotor, 251.
 Autumnal fever, 261.

 Basedow's disease, 147.
 Basilar,  meningitis, 238.
 Bilious fever, 296.
        remittent fever, 298.
 Bladder, diseases of the, classi-
  fied, 15.
 Blood, abnormal states of the,
         classified, 16.
       in urine, causes of, 30.
 Bloody-flux, 189.
 Bothriocephalus latus, 197.
 Brain, anaemia of the, 227.
       dropsy of the, 238.
 Break-bone fever, 285.
 Bright's  disease, 367.
 Bronchi, diseases of the, classi-
  fied, 13.
 Bronchial hemorrhage, 71.
Bronchitis, 47.
           acute capillary, 50.
           acute catarrhal, 48.
           chronic  catarrhal,
             52.
           croupous, 55.
           plastic, 55.
Broncho-pneumonia, 80. 
U8
INDEX.
Buccal cavity, diseases of the,
  classified, 10.

Calculi, renal, 392.
Calenture, 255.
Camp fever, 291.
Cancer of the liver, 216
       of the lungs, 74.
       of the pericardium, 110.
       renal, 394.
Cancrum oris, 153.
Caput Medusae, 211.
Carcinoma of  the  intestines,
              193.
            of the stomach, 173.
Cardiac dilatation, 135.
        hypertrophy,  132.
        murmurs, 130.
        thrombosis, 143.
Catalepsy, 259.
Causes of abdominal pain, 20.
       of aphonia, 28.
       of albuminous urine, 33.
       of ascites, 26.
       of blood in urine, 30.
       of cerebral hyperaemia,
         225.
       of chill, 23.
       of chylous urine, 34.
       of coma, 26.
       of displacement of apex-
         beat of heart, 20.
       of dyspnoea,  24.
       of epigastric pulsation,
         19.
       of haemoptysis, 27.
       of headache, 23.
       of Hepatic abscess, 34.
Causes of hemiplegia, 29.
       of hemorrhage from the
         digestive tract, 27.
       of instantaneous death,
         31.
       of jaundice, 25.
       of pain in the thorax, 2\
       of paraplegia, 29.
       of pus in urine,  31.
       of retention of urine, W
       of suppression of urine,
         30.
       of vomiting, 22.
Cerebral apoplexy, 229.
         compression, 258.
         concussion, 258.
         hyperaemia, 225.
         softening, 248.
         typhus fever, 291.
Cerebro  spinal   meningitis,
           242.
Chill, causes of, 23.
Chylous urine, causes of, 3»,
Cholera, Asiatic, 192.
         morbus,  184.
Cirrhosis of the liver, 210.
          pulmonary, 82.
Cirrhotic kidney,  381.
Classification of abnormal states
  of the blood,  16.
Clergyman's sore throat, 40.
Climatic fever,  280.
Colic, flatulent, 200.
      hepatic, 219.
      intestinal, 199.
      lead, 200.
Chorea.  397. 
INDEX.
449
 Coma, causes of, 26.
        its principal causes and
          differential diagnosis,
          258.
 Congestion, renal, 359.
 Congestive fever, 280.
 Continued fever, 291, 296.
 Coup de soleil, 255.
 Cranial cavit}r, diseases within
   the, classified,  9.
 Croup, pharyngeal, 164.
        p s e u d o -membranous,
          345.

 Dandy fever, 285.
 Dengue fever, 285.
 Diabetes, 336.
          insipidus, 338.
          mellitus, 336.
 Diarrhoea, types of, 33.
 Digestion, organs of,  classified,
  10.
 Diphtheria, 345.
 Diphtheritis, 345.
 Disease, Addison's, 395.
         physical signs of, 4.
         rational signs of, 3.
Diseased condition of the body,
  9.
Diseases of the bladder, classi-
          fied, 15.
         of the bronchi, classi-
          fied,  13.
         of the buccal  cavity,
          classified, 10.
         of the digestive tract,
          151
 Diseases of the heart and peri-
            cardium,  classified,
            14.
           of the intestinal canal,
            classified, 12.
          of the intestines. 181.
          of the kidney,  classi-
            fied, 15.
          of the larynx, 37.
          of the larynx,  classi-
            fied,  13.
          of the liver, 210.
          of the liver, classified,
            12.             [14.
          of the lungs, classified.
          of the mouth, 151.
          of the nervous system r
            classified, 9.
          of the oesophagus, 166-
         of  the  oesophagus,
            classified, 11.
         of  the  pericardium,.
            103.
         of the pharynx, 164.
         of the pharynx, classi-
           fied, 10.
         of the  pleura,  classi-
           fied, 14.
         of the stomach, 169.
         of the stomach,Jclassi-
           fied, 11.
         within   the   cranial
           cavity, classified, 9.
         within the spinal cord,
           classified,  9.
Dothenenteria fever,  261.
Dysentery,  189. 
450
INDEX.
Dyspepsia, 176.
Dyspnoea, causes of, 24.

Embolism, cerebral, 259.
Emphysema,  60.
Empyema, 89.
Endocarditis,  acute, 110.
              chronic, 114.
              ulcerative, 113.
Enteralgia, 199.
Enteric fever, 261.
Enteritis, catarrhal, 181.
Epigastric pulsation, causes of,
Epilepsy, 245, 259.          [19.
Erysipelas, 329.
Exanthematous fever, 291.
Exophthalmic goitre, 147.
Expectoration, types of, 32.

Falling sickness, 245.
Famine fever, 355.
Fatty  degeneration  of heart,
         141.
       liver, 215.
Fever, abdominal typhus, 261
       acclimative, 296.
       African, 280,  296.
       ardent, 280.
       autumnal,  261.
       bilious, 296.
       bilious remittent, 298
       break-bone, 285.
       camp,  291.
       cerebral-typhus, 291.
       climatic. 280.
       congestive, 280,
       continued, 291, 296.
Fever, dandy, 285.
       dengue. 285.
       dothenenteria, 261.
       enteric, 261.
       etiological  division  of,
         261.
       exanthematous, 291.
       famine, 355.
       forty-day, 261.
       fourteen days', 291.
       gastric. 261.
       gastro-enteric, 261.
       heat, 255.
       hospital, 291.
       ileo-typhus, 261.
       jail, 201.
       malarial, 277.
       pernicious,  280.
       petechiel, 291.
       putrid, 291.
       relapsing, 355.
       remittent, 296.
       scarlet, 306.
       ship, 291.
       simple intermittent, 277.
       southern, 296.
       spotted, 242.
       sun, 255.
       thermic, 255.
       tropical typhoid, 280.
       typho-malarial, 287.
       typhoid, 261.
       typhoid  affection,   of
         Louis, 261.
       typhus, 291.
       western, 296.
       yellow, 272. 
INDEX.
451
 Fevers, tables  of differential
   diagnosis of the five principal
   eruptive, 316.
 Flatulent colic, 200.
 Forty-day fever, 261.
 Fourteen  days' fever, 291.

 Gall-stones, 219.
 Gangrenous sore-mouth,  155.
 Gastric catarrh, acute, 169.
        catarrh, chronic,  171.
        fever, 261.
 Gastro-enteric fever, 261.
 Glossitis,  161.
 Glycosuria, 336.
 Gout, 343.
       flying, 332.
 Grand mal, 245.
 Grave's disease, 147.

 Haematemesis,  27, 177.
 Haemo-pericardium, 109.
 Haemoptysis, causes of, 27.
 Haut mal, 245.
 Headache, causes of, 23.
 Heart and  pericardium,  dis-
         eases of the, classified,
         14.
       dilatation of, 135.
       fatty  degeneration  of,
         141.
       hypertrophy of, 132.
       murmurs, classified, 131.
       sounds, 130.
Heat apoplexy, 255.
      fever, 255.
      stroke, 255.
Hepatic abscess, causes of 34.
 Hemiplegia, causes of, 29.
 Hemorrhage from the digestive
               tract, causes of.
               27,
             renal, 361.
 Hepatic colic, 219.
 Hooping cough, 58,
 Hospital fever, 291.
 Hydatids of the liver, 221.
 Hydrocephalus, acute, 238.
                chronic, 241.
 Hydro-nephrosis,  390.
 Hydro-pericardium, 108.
 Hydro-pneumo-thorax, 91.
 Hydro-thorax, 93.
 Hysteria, 259.

 Hio-typhus fever, 261.
 Infarction, pulmonary, 69.
 Infarctions, 324.
 Insolation, 255.
Instantaneous  death, causes of,
  31.
 Intermittent fever, simple,  277.
 Intestinal canal, diseases of the,
             classified, 12.
          colic, 199.
          hemorrhage, 194.
          obstruction, 195.
 Intestines,  carcinoma of  the,
             193.
            diseases of the,  181.

Jail fever, 291.
Jaundice, 213.
          black, 223.
          causes of, 25. 
452
INDEX.
Kidney, amyloid, 377.
        cirrhotic, 381.
        contracted, 381.
        diseases of the, classi-
          fied, 15.
        dropsy of the, 390.
        gin-drinkers', 381.
        granular, 381.
        hob-nailed, 381.
        hyperaemia of the, 359.
        new growths of the,
          393.
        surgical, 396.

Lardaceous liver, 218.
Laryngeal phthisis, 40.
Laryngitis,  acute catarrhal, 37.
            acute croupous, 44.
            chronic  catarrhal,
              40.
Larynx, diseases of the, 37.
        diseases of  the, classi-
          fied, 13.
Lead colic,  199.
Liver, amyloid, 218.
       cancer of the, 216.
       cirrhosis of the. 210.
       diseases of the, 210.
       diseases of the, classified,
         12.
       fatty, 215.
       hydatids of the, 221.
       lardaceous, 218.
       yellow atrophy of the,
         223.
       waxy, 218.
Lobar pneumonia, 76.
Lobular pneumonia, 80.
Locomotor ataxia, 251.
Lungs, cancer of the, 74.
       diseases of the, classi-
         fied, 14.

Malarial fevers, 277
Marasmus, 183.
Measles, 312.
Meningitis, acute, 232.
           basilar, 238.
           cerebro-spinal, 242.
           chronic,  236.
           pachy-, 236.
           simple, of the  con-
              vexity, 232.
           subacute, 235.
           tubercular, 238.
Milleturia, 336.
Mitral obstruction, 121.
       regurgitation, 123.
Morbus  maculosus  Werlhofii,
           341.
         sacer, 245.
Mouth, catarrh of, 151.
        diseases of the, 151.
        gangrenous sore, 155.
        syphilitic affections  of
           the, 15C.
        ulcers T>f the, 157.
Myelitis, 249.
Myocarditis, 139.
Muguet, 154.
Mumps, 159.

Nephritis,  parenchym a t o u s>
   367. 
INDEX.
453
 Nervous  cardiac  palpitation,
             144.
           cardialgia, 175.
           system,  diseases   of
             the, classified, 9.
 Noma, 155.
 CEdema glottidis, 42.
 (Egyytian starstroke,  255.
 (Esophagus, dilatation of, 167.
             diseases of the, 166.
             diseases  of  the,
               classified, 11.
             nervous affections
               of, 169.
             perforation   and
               rupture of,  168.
             stricture  of  the,
               166.
 Opium poisoning, 260.
 Organs of digestion, classified,
          10.
        of  respiration,  classi-
          fied, 13.
        the urinary, classified,
          15.
 Oxyuris vermicularis,  198.

 Pain in the thorax, causes of, 21.
 Paraplegia, causes of, 29.
 Parenchymatous nephritis,
  acute, 367.
 Parotitis, 159.
Perforating duodenal ulcer, 186.
Pericarditis, acute, 103.
            chronic, 107.
Pericardium, cancer of the, 110.
             diseases  of  the,
               103.
 Pericardium, haemo-, 109.
              hydro-, 108.
              pneumo-, 109.
              tuberculosis  o f
                109.
 Peri-proctitis,  188.
 Peritonitis, 201.
            acute primary, 201.
            chronic, 208.
            .infectious, 206.
 Perityphlitis, 186.
 Pernicious fever, 280.
 Pertussis, 58.
 Petechial fever, 291.
 Petit mal, 245.
 Pharyngeal croup, 164.
 Pharynx, diseases of the, 164.
           diseases of the, classi-
            fied, 10.
 Phthisis, 94.
          catarrhal, 94.
          fibrous, 94.
          laryngeal, 40.
          tubercular, 94.
Physical signs of disease, 4.
Pleura, diseases of the, classi-
  fied, 14.
Pleurisy, 84.
          acute, 84.
          chronic, 89.
          sero-fibrous, 86.
          subacute, 86.
Pneumonia, 76.
            brcncho-, 80.
            catarrhal, 80.
            chronic catarrhal,
               94.
            croupou  , 76. 
454
INDEX.
Pneumon ia, fibrous, 82.
             interstitial, 82.
             lobar, 76.
             lobular, 80.
Pneumo-pericardium, 109.
Podagra, 343.
Polymorpha, 159.
Polyuria, 338.
Progressive muscular atrophy,
  254.
Pseudo-membranous angina,
                       345.
                     croup,
                       345.
Ptyalism, 158.
Pulmonary apoplexy, 69.
           cirrhosis, 82.
           congestion, 65.
           gangrene, 73.
           infarction, 69.
           oedema, 63.
Pulmonic obstruction,  127.
          regurgitation, 127
          stenosis, 127.
          valves, 127.
Pulse,  varieties of, 19.
Purpura, 341.
         hemorrhagica, 341.
Pus in urine, causes of, 31.
Putrid fever, 291.
       sore throat, 345.
Pyaemia, 320.
Pyelitis, 385.

Quinsy, 162.

Rales, varieties of, 6.
St. Guy's Dance, 397.
 Rational signs of disease, 8.
 Relapsing fever, 355.
 Remittent fever, 296.
 Renal calculi, 392.
       cancer, 394.
       congestion, 359.
       dilatation. 390.
       hemorrhage.  361.
 Respiration, organs of,  classi-
               fied, 13.
             varieties of, 5.
 Retention  of urine, causes of,
  30.
 Retro-pharyngeal abscess, 165.
 Rheumatism, 332.
              acute   articular,
                332.
              chronic articular,
                334.
              muscular, 336.
 Rotheln. 315.

 Salivation, 158,
 Scarlet fever, 306.
 Scorbutus, 339.
 Scurvy, 339.
 Septicaemia, 324.
 Stomatitis, croupous, 152.
            diphtheretic, 153.
 Sun fever,  255.
 Sun stroke, 25 5.
 Suppression of urine, causes of
  30.
 Surgical kidney, 396.
 Syncope, 258.
 Ship fever, 291.
8mall-pox, 299.
 St. Vitus' Dance, 397. 
INDEX.
'  455
 Soor, 154.
 Sore mouth, gangrenous, 155.
     throat, clergyman's, 40.
             putrid, 345.
 Southern fever, 296.
 Spinal cord, diseases within the
   classified, 9.
 Spotted fever, 242.
 Sprue,  154.
 Starstroke, aegyptian, 255.
 Stomach, carcinoma of the, 173.
          chronic ulcer of the,
            179.
          diseases of, 169.
          diseases of the, classi-
             fied, 11.
          hemorrhage from the,
            177.

 Tabes dorsualis, 251.
 Table of differential diagnosis
  of the five principal eruptive
  fevers,  316.
 Taenia mcdiocanellata, 197.
       solium, 197.
 Thermic  fever, 255.
 Thrombosis, cardiac, 143.
 Thrush, 154.
 Tonsillitis. 162.
 Trichocephalus dispar, 198.
 Tricuspid regurgitation, 128.
 Tropical typhoid fever, 280.
Tubercular meningitis, 239.
Tuberculosis, acute miliary, 94.
Tuberculosis  of  the  pericar-
                dium, 109.
Types of diarrhoea, 33.
      of expectoration,  32.
Typhlitis, 183.
Typhoid affection of Louis, 26L
         fever, 261.
Typho-malarial fever, 287.
Typhus fever, 291.

Ulcerative endocarditis, 113.
Ulcer of the stomach, chronic,
  179.
Ulcers of the mouth, 157.
Uraemia, 260, 362.
Urinary organs, diseases of the,
  classified,  15.
Valvular diseases of right heart,
           127.
         lesions, 116.
Varieties of pulse, 19.
         of rales, 6.
         of respiration, 5.
Variola, 299.
Varioloid,  299.
Vomiting,  causes of, 22.

Water-canker, 155.
Waxy  liver, 218.
Western fever, 296.
Whooping cough, 58.
Worms, 197.

Yellow fever, 272.
        atrophy of liver, 333. 
NLM001059473