m h:-1 >^\ 3NIDI03W jo Aavaan ivnoiivn 3Ni3iaaw jn b gSbSOTOO WIN ................n I III 11 lllltiu NLM001059589 \K/t Aavaan ivnoiivn JOI1VN NATIONAL II I / BNiDiasw jo Aavasn ivnoiivn 3Nioia3w jo Aavaan ivnoiivn 3NiDia3w jo a*v c f ^ *L LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRAR /6~Z Scale of Urinary Colors, according to Vogel. PALE YELLOW. n. LIGHT YELLOW. in. YELLOW. REDDISH YELLOW. YELLOWISH RED. VI. RED. VII. BROWNISH RED. VIII. REDDISH BROWN. BROWNISH BLACK. SAUNDERS' QUESTION-COMPENDS, Nos. 8 & 9. ESSENTIALS OF PRACTICE OF MEDICINE. ARRANGED IN THE FORM OF QUESTIONS AND ANSWERS. PREPARED ESPECIALLY FOR STUDENTS OF MEDICINE. BY HENRY MORRIS, M.D., LATE DEMONSTBATOR JEFFERSON MEDICAL COLLEGE, PHILADELPHIA; VISITING PHYSICIAN TO ST. JOSEPH'S HOSPITAL; FELLOW COLLEGE OF PHYSICIANS, PHILADEL- PHIA; CO-EDITOR BIDDLE'S MATERIA MEDICA, AUTHOR OF ESSENTIALS OF MATERIA MEDICA, ETC., ETC. WITH A VERY COMPLETE APPENDIX, OX THE EXAMIXATION OF URINE, BY LAWRENCE WOLFF, M.D., DEMONSTRATOR OF CHEMISTRY, JEFFERSON MEDICAL COLLEGE. PHILADELPHIA: W. B. SAUNDERS, 913 Walnut Street. MS T fee. Entered, according to Act of Congress, in the year 1890, by W. B. SAUNDERS, In the Office of the Librarian of Congress, at Washington, D. C. Press of Wm. F. Fell & Co., 1220-24 SANSON! ST., PHILADELPHIA. PREFACE. This little volume is intended as an aid to the advanced student of medicine who is preparing for his degree, or to the young prac- titioner in diagnosing affections or selecting the remedy for them. The author has endeavored to place in as concise language as possible the essentials of the principles and practice of medicine, and in order to do this in few words has been obliged in some instances to make slight sacrifices of grammar at the altar of brevity. He hopes it will be distinctly understood by the student that this book is not intended to, nor can it, replace the larger text-books in general use. He dedicates it to the many students who have honored him with their attention during the past fifteen years, and acknowl- edges his indebtedness to most of the recent works on the Practice of Medicine, and especially on Neurology; and also to his friend, Dr. John M. Eager, recently of Baltimore, who has kindly under- taken the index for him. In conclusion he would thank the medical critics for the kindness which they have shown him in the past, and invite any suggestions which they or other of his readers may feel disposed to make. ':. THE AUTHOR. 313 S. Sixteenth St., Philadelphia, September, 1890. vii CONTENTS. PAGES Introduction,.................... 17 Definitions,.................... 17-20 General Symptomatology,............. 20-25 Pain,..................... 20 Physiognomy of Disease,............ 21 Pulse,.................... 21-22 Tongue, ................... 22-23 Temperature,................. 23-25 General Diseases.—A. (Exanthematous and Zymotic Dis- eases), ....................... 25-97 Fever,...................... 25-26 The Essential Fevers, ............... 26-85 Continued Fevers,................. 27-47 Simple Continued Fever,........... 27-28 Catarrhal Fever,................ 28-30 Typhoid Fever,................ 30-39 Typhus Fever, ................ 39-42 Relapsing Fever,................ 42-43 Cerebro-spinal Fever.............. 43-47 Periodical Fevers,................. 47-63 Intermittent Fever,.............. 48-50 Remittent Fever,............... 50-53 Hemorrhagic Malarial Fever,.......... 53-55 Congestive Malarial Fevers,........... 55-58 Malarial Cachexia,.............. 58-59 Yellow Fever,................. 59_63 Eruptive Fevers,.................. 63-85 Scarlatina,.................. 63-69 Measles,................... 69~72 Rubella,................... 72_73 ix X CONTENTS. PACES Smallpox.................... 73-78 Inoculation and Vaccination,........ . 78-79 Varicella,.................. 80 Erysipelas,............... . 81-83 Dengue,................... 84-85 Diphtheria,.................... 85-89 Parotitis,..................... 89-90 Pertussis,..................... 90-92 Cholera, ........... ......... 92-97 General Diseases.—B. (Diathetic Diseases),...... 97-121 Acute Rheumatism,................ 97-101 Muscular Rheumatism,...............101-101 Chronic Rheumatism,............... 102 Rheumatoid Arthritis,...............103-104 Acute Gout,....................104-106 Chronic Gout,.....,............. 106 Lithsemia,.................... 107 Diabetes,.....................107-110 Polyuria,................... . 110-111 Diseases of the Blood, ... ...........111-121 Anaemia,...................111-113 Essential Anaemia,...............113-114 Leukaemia,..................114-116 Pseudo-leukaemia,...............116-117 Addison's Disease,...............117-118 Scorbutus,..................118-120 Purpura,...................120-121 Diseases of Special Organs,............121-362 Diseases of the Digestive Organs,.........121-186 Diseases of the Mouth, Fauces and Pharynx,.....121-128 Stomatitis,..................121-122 Muguet,................... 123 Glossitis,...................123-124 Acute Tonsillitis,....... .......124-126 Chronic Tonsillitis, .............. 126 Angina and Pharyngitis,............126-128 Diseases of the CEsophagus,.............128-131 Oesophagitis,.................128-129 contents. xi PAGES Stricture of the CEsophagus, ..........129-131 Diseases of the Stomach,..............131-144 Acute Gastritis,................131-132 Acute Gastric Catarrh,.............132-133 Chronic Gastritis,...............133-135 Gastric Ulcer,.................135-136 Gastric Cancer,................136-138 Haematemesis,.................138-140 Dilated Stomach,...............140-141 Gastralgia,..................141-142 Dyspepsia,..................142-144 Diseases of the Intestinal Tract,...........144-167 Colic,.....................144-146 Constipation,.................146-147 Cholera Morbus,................147-149 Acute Diarrhoea,................149-150 Chronic Diarrhoea,............... 150 Duodenitis,..................150-151 Catarrhal Enteritis,.............. 152 Membranous (Croupous) Enteritis,........152-154 Enteritis,...................154-155 Colitis,.................... 155 Acute Dysentery,...............155-159 Chronic Dysentery, ..............159-160 Typhlitis and Perityphlitis,...........161-163 Proctitis,...................163-164 Intestinal Obstruction,.............164-167 Diseases of the Peritoneum, ............167-171 Acute Peritonitis,...............167-170 Chronic Peritonitis,.............. 170 Diseases of the Liver,...............171-186 Icterus,....................171-172 Hepatic Hyperaemia, Acute, .......... 172 Chronic,................. 173 Acute Hepatitis,................173-174 Chronic Hepatitis,............... 174 Acute Catarrh of the Bile Ducts,........174-175 Passage of Gall-stones,.............176-177 Hepatic Abscess, ...............177-178 xii contents. PAGES Interstitial Hepatitis..............179-180 Acute Yellow Atrophy, ............ 181 Fatty Liver,..................181-182 Albuminoid Liver,...............182-183 Cancer of the Liver,..............183-185 Hydatid Cyst of the Liver,........... 185 Functional Disease of the Liver,......... 186 Diseases of the Kidneys,..............187-205 Renal Hyperaemia, Acute and Chronic,......187-188 Acute Parenchymatous Nephritis,........188-190 Chronic Parenchymatous Nephritis,.......190-193 Chronic Interstitial Nephritis, .........193-194 Albuminoid Kidney,..............194-195 Cystic Degeneration of the Kidney,.......195-196 Passage of Renal Calculi,............196-197 Formation of Renal Calculi, ..........197-199 Pyelitis,...................199-200 Haematuria,..................200-202 Tubercular Disease of the Kidney,........ 202 Cancer of the Kidney,............. 203 Perinephritis, . . ...............203-204 Floating Kidney,...............204-205 Diseases of the Pancreas,..............205-207 Pancreatitis, .................205-206 Cysts of the Pancreas,............. 206 Cancer of the Pancreas,.............206-207 Diseases of the Spleen,...............207-209 Acute Affections of the Spleen,.........207-208 Splenic Hyperaemia,..............207-208 Acute Splenitis,................ 208 Splenic Abscess,................ 208 Chronic Diseases of the Spleen,.........208-209 Diseases of the Chest,...............209-301 Physical Diagnosis,................209-219 Inspection,..................209-210 Palpation, .................. 210 Mensuration,................. 210 Percussion,..................211-212 Respiratory Percussion,.............212-213 contents. xiii PAOES Auscultation,.................213-218 Combination of Physical Signs (Table),..... 218 Diseases of The Respiratory Organs,.......219-268 Diseases of the Larynx, ..............219-225 Acute Laryngitis,...............219-221 Chronic Laryngitis,..............221-222 Croup, .................... 222-225 Diseases of the Bronchial Tubes,..........225-233 Acute Catarrhal Bronchitis,...........225-227 Acute Plastic Bronchitis,............227-228 Capillary Bronchitis,..............228-230 Chronic Bronchitis,..............230-231 Asthma,...................231-233 Diseases of the Lung Tissue,............233-261 Emphysema,.................233-235 Pulmonary Hyperaemia,............235-237 Pulmonary CEdema,.............. 237 Haemoptysis,.................237-240 Acute Lobar Pneumonia,............240-246 Broncho-Pneumonia,..............246-248 Chronic Pneumonia,.............. 248 Pulmonary Gangrene,............. 249 Tuberculosis,.................250-260 Acute Tuberculosis,............251-253 Chronic Tuberculosis,...........253-260 Pneumonic Phthisis,.............. 260 Fibroid Phthisis,............... 261 Diseases of the Pleura,..............262-268 Acute Pleurisy,................262-265 Chronic Pleurisy and Empyema,........265-267 Pneumothorax,................267-268 Diseases of the Circulatory System, .......269-301 Physical Examination of Heart,...........269-272 Inspection and Palpation, ........... 269 Percussion,..................269-270 Auscultation,.................269-270 Heart Sounds (Table),............. 270 Endocardial Murmurs,.............270-271 Pericardial Murmurs,.............271-272 XIV contents. PAGES Diseases of the Heart,...............272-293 Cardiac Hypertrophy,.............272-277 Cardiac Dilatation, ..............275-278 Fatty Heart,.................278-280 Endocarditis,.................281-289 Acute Endocarditis,............281-284 Chronic Endocarditis and Valvular Disease, . . 284-289 Angina Pectoris,................289-290 Exophthalmos,................290-291 Cardiac Palpitation,..............292-293 Diseases of the Pericardium,............293-297 Pericarditis,..................293-297 Diseases of the Vessels,...............298-301 Thoracic Aneurism,..............298-301 Diseases of the Nervous System,..........301-362 Diseases of the Brain,...............301-326 Cerebral Hyperaemia, .............301-302 Cerebral Anaemia,...............302-303 Meningitis,..................303-305 Tubercular Meningitis,............305-306 Apoplexy, ..................307-310 Cerebral Embolism and Thrombosis,.......310-311 Aphasia,...................311-312 Acute Cerebral Softening,............313-314 Chronic Cerebral Softening,........... 314 Abscess of the Brain,.............. 315 Cerebral Tumors,...............316-317 Cerebral Syphilis,...............317-318 Acute Hydrocephalus,.............318-319 Insolation,..................320-323 Delirium Tremens,.............323-325 Chronic Alcoholism,..............325-326 Diseases of the Spinal Cord,.............326-353 Spinal Hyperaemia,..............326-327 Spinal Meningitis,...............327-328 Pachymeningitis,...............329-330 Myelitis,............„......330-331 Spinal Hemorrhage,..............331-332 Acute Poliomyelitis,.............. 332-334 CONTENTS. XV PAGES Chronic Poliomyelitis,..... .......334-336 Spinal Sclerosis,................336-338 Antero-lateral Sclerosis, ..........336-337 Posterior Sclerosis,.............337-338 Disseminated Sclerosis,..........337-338 Paralysis Agitans,............... 339 Bulbar Paralysis,...............339-340 Varieties of Tremor,..............340-341 Writer's Cramp,................341-343 Convulsions, .................343-344 Paralysis,...................345-348 Tabular View of Paralysis,.........345-346 Facial Paralysis,.............. 347 Syphilitic Paralysis,............ 348 Neurasthenia,.................348-349 The Neuroses,.................350-353 Chorea,..................350-351 Epilepsy,.................351-353 Diseases of the Nerves,..............353-362 Neuralgia,....................353-359 Cerebral Neuralgia,............ 355 Neuralgia of the Fifth Pair, ........355-356 Cervico-occipital Neuralgia,......... 356 Cervico-brachial Neuralgia,.........357-357 Dorso-intercostal Neuralgia,......... 357 Intercostal Neuralgia,...........357-358 Lumbo-abdominal Neuralgia,........ 358 Sciatica,...................358-359 Neuritis,.....................359-360 Multiple Neuritis,.................360-362 Index,........................363-368 THE ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. INTRODUCTION. What is meant by the principles and practice of medicine ? By this term is meant all the knowledge which has been acquired of the cause, pathology, symptoms and cure of disease. What is pathology ? Pathology relates to the study of disease, or diseased action dur- ing life, and is divided into general and special pathology. What is meant by these terms ? By general pathology is meant the study of groups of disease processes, e. g., the pathology of fever. By special pathology is meant the disease process occurring in one affection, as the pathology of typhoid fever. What is pathological anatomy ? Pathological anatomy is the study of diseased processes as they are found after death. What is pathological chemistry ? This is the study of the changes produced by disease in the excretions, secretions or tissues of the body. What is disease ? Disease is a deviation from the normal standard of healthy func- tions, or from the standard tissue changes. Afunctional disease is one in which the tissues do not properly perform their function, but 2 17 18 essentials of practice of medicine. in which there is no structural alteration to be found. An organic disease is one in which the functions are not properly performed, owing to structural lesion of the tissues at fault. Every disease has a local anatomical beginning. What is meant by the incubation period ? The incubation period is that time elapsing between exposure to a disease and the manifestation of the first symptoms. The time during which the disease may be said to lie latent in the system. What is the prodromic period? This is the stage of early development of disease, the time elaps- ing between the incubation period and the full manifestation of diseased action. What are symptoms ? Symptoms are the language of diseased nature, and may be either objective or subjective. Objective symptoms are such as are evident to the senses of the observer. Subjective symptoms are such as are felt and complained of by the patient. How do diseases terminate ? All diseases terminate in health or in death. They may end by (1) Lysis, a gradual withdrawal of diseased action ; (2) by Crisis, a sudden change for better or worse; or (3) by Metastasis, a sudden shifting of the disease. The first process is most common ; the last is rarely seen. What is death? Death is a complete cessation of the bodily functions and of recon- structive tissue change. Death always comes through one of three channels, the heart, the brain or the lungs. It may be due to asthenia, or increasing debility with depression of the vital function, to ancemia, or an insufficient quantity or quality of the blood, to apncea, or non-aeration of the blood, and consequently of the tissues or to coma, an abolition of the function of the brain. What is meant by aetiology ? This is the study of the causes producing disease. How may the causes of diseases be divided ? They may be divided into predisposing and exciting causes. Pre- introduction. 19 disposing causes may be inherited, or acquired by debilitating influences. Our habits, age, sex, occupation, race and previous dis- eases all act as predisposing causes. Exciting causes may be food (too little or too much, or of unhealthy quality), drink (impure water or milk, or other beverages), heat, cold, noxious substances in the atmosphere (such as chemical poisons or disease germs), barometric changes, different electrical conditions, absence of light, or substances or individuals with whom we come in contact produc- ing infectious or contagious diseases. What is an infectious disease ? An Infectious Disease is one which is due to a disease-germ introduced into the body from without, but not capable of being reproduced in the body, hence, not capable of being communicated from one individual to another {e.g., influenza, malaria, tubercle). What is a contagious disease ? This is a disease due to a specific cause, capable of being repro- duced in the economy, and of being transmitted from the sick to the well (e. g., typhus fever, smallpox). How does contagion spread? Contagion spreads principally by absolute contact with the poison, and to a slight extent, also, by atmospheric diffusion. The atmos- phere, however, dilutes and weakens the poison. What is meant by a sporadic disease ? A Sporadic Disease is one which occurs in isolated cases (e. g., rheumatism). What is meant by an endemic disease ? A disease is endemic when a number of cases occur in a limited locality, due to the same cause (e. g., typhoid fever in a limited locality, from drinking water of a contaminated well). What is an epidemic disease ? When a disease is widely spread over a community it is said to be epidemic (e. g., cholera or smallpox). Epidemics are usually con- tagious or infectious. What is diagnosis ? Diagnosis is the discovery of disease by means of its symptoms. 20 essentials of practice of medicine. What is differential diagnosis ? Differential Diagnosis is the art of discovering the disease which is present by a careful comparison of its symptoms with those of other diseases which may closely simulate it. What is prognosis ? Prognosis is the art of foretelling the issue of any disease (it may be general, as the general prognosis of typhoid fever, or special, as the special prognosis of any given case). What is meant by treatment ? Treatment is the art of preventing disease, or of taking care of the sick, and alleviating their sufferings, or of aiding and hastening their cure. It may be Prophylactic when the aim is to prevent the spread of disease ; Abortive, where the disease is cut short and prevented from running its regular course ; Palliative, where it tends to allay suffering ; Expectant, where the disease is allowed to run its course, the symptoms being treated as they require it; Restorative, where it aims to build up the constitution, and restore to the system such materials as may be wanting in the economy (e. g., iron in ansemia, or the phosphates in rickets); or Radical, where a rapid impression is made upon the system and the course of a disease cut short. GENERAL SYMPTOMATOLOGY. What is meant by general symptomatology ? By general symptomatology is meant the study of such symptoms as pain, the expression of the face, the pulse, the tongue and the temperature, not in connection with any special disease, but with diseased processes generally. Describe the varieties of pain. (1) Pain may be sharp, acute and lanceolating (usually intermit- tent). This kind of pain is seen in peripheral nervous affections, as neuralgia ; also in the inflammations of serous membranes. (2) It may be dull, gnawing and more or less continuous. This kind of pain is found in chronic tissue changes generally (e. g. in hepatic or splenic affections and in inflammation of the mucous membranes or of bone). general symptomatology. 21 Exception.—In malignant diseases (cancer), even when character ized by chronic tissue changes, the pain is sharp. The character of the pain will vary also according to the tissue involved (e. g., in inflammations of the skin it is burning and itching, in the bone, dull and boring, in mucous membranes, aching, etc.). Describe the physiognomy of disease. Various diseases have their own characteristic physiognomies, which cannot be described accurately, and a knowledge of which can only be acquired by experience (e. g., malaria, cancer, scrofula, tubercle, respiratory and cardiac diseases, and various fevers). Describe the pulse of disease. The normal pulse in adults varies from 65 to 75 per minute; in infants, from 112 to 120 ; in old age, about 60, rising in extreme old age until it approaches that of the infant. It is more rapid in females, more rapid during waking, more rapid in the erect posture, and more rapid during digestion. The pulse of disease should be studied with regard to its frequency (rapid or slow), its volume or strength (full or small), its resistance or tension (hard and incom- pressible, soft and compressible), and its rhythm. A moderately rapid pulse is found in acute sthenic diseases. A very rapid pulse, in marked anaemia, or in low fevers with great debility, therefore it shows great weakness. The pulse is very slow in brain effusions, in disintegration of the cardiac muscle, as the result of great cold, in jaundice and in shock. It is full in health, in states of high arterial tension from any cause (e. g., powerful ventricular contractions). A hard pulse is usually associated with a full pulse, and is found in the early stages of acute diseases. Exceptions.—(1) The receding pulse of certain cardiac diseases is full but not hard. (2) In atheroma of the vessels, the pulse is hard because the vessels are rigid, but is not full. A small pulse is usually soft and compressible and is seen in debility. Exception.—In peritonitis and other inflammations below the diaphragm, the pulse is small but hard and wiry. Rhythm.—The rhythm is altered in certain brain diseases, as tuber- cular meningitis ; in organic diseases of the cardiac muscles, in func- '1'1 essentials of practice of medicine. tional disturbance from perverted innervation of the heart (as from indigestion), from the abuse of tobacco, tea or alcohol, or from uterine disorders. In children the rhythm may be disturbed from the changes occurring at puberty, or from certain medicines, as quinine. Describe the appearance of the tongue in disease. The tongue in health is small, smooth, and often slightly coated, particularly in the morning. These characters may be altered by disease of the organ itself or by disturbances of the system at large. It is red, swollen and superficially ulcerated in acute glossitis, and may be characteristically altered by other local disease, as ulcer., can- cer, syphilis, etc. When the tongue is heavily coated (due to the accumulation of epithelium) it shows that a similar condition exists in the alimentary canal, especially the stomach and the upper part of the small intestines. This is seen in all acute catarrhs of the alimentary tract. The coating is usually white. It may be yellow in hepatic disorders or it may be artificially colored from food. It may be denuded of epithelium, and studded with prominent papillae, as in scarlet fever, dysentery, and sometimes in pneu- monia. When the tongue is very moist it indicates an increased secretion of the mouth, and generally a similar condition of the upper part of the alimentary tract. It is often swollen and indented by the teeth. This condition may result from ptyalism, or as a part of a general hyper-secretion of all the glands. It is not a very common condition. The tongue is dry in persons who sleep habitually with their mouths open, as when the nares are obstructed It is also seen when the secretions generally are arrested, which in acute disease shows a condition of lowered vitality, hence a condition of danger. According to Dickinson the tongue is usually diy just before death. In coma, no matter what the cause, the tongue will be found dry. If in the course of a chronic disease the tongue should be dry, sugar will probably be found in the urine. A livid tongue is seen when the circulation is much interfered with. It is extremely red in great irritation of the stomach and bowels, GENERAL SYMPTOMATOLOGY. 23 but may be red only at the tip and edges, the remainder of the tongue being concealed by heavy coating. A glazed tongue, smooth and glossy, with prominent papillce, discolored, often brownish, and frequently cracked or fissured, is only seen in cases of great prostration. The glazed appearance is due to fungi developed between and on the papilla. A fissured tongue, if neither glazed nor brown, indicates nothing of importance, frequently being seen in perfectly healthy indi- viduals. How is the temperature of the body ascertained? The temperature is taken by a clinical thermometer, placed either in the mouth, axilla or rectum, the mouth being the most convenient, the axilla the most accurate. A self-registering thermometer is used, and should be gently waved to and fro by swinging the arm, in order to set the index. It is then placed in the axilla carefully, in such a manner that it is in contact with the skin on all sides, and is allowed to remain for at least six minutes, when it is removed and the temperature read. It should be taken at least twice daily. What is the normal temperature of the body? The average temperature is 98.6°. There may be a normal varia- tion of from .5° above to .5° below the average, which is compatible with perfect health. These variations are even greater in children. The temperature of the mouth is about .5° lower, that of the rectum 1.° higher, than the axillary temperature. There is a certain rela- tion between the temperature and the pulse, the latter increasing about ten beats per minute for every 1° rise in temperature above the normal. Are greater variations than the above compatible with life ? The temperature in fever may rise to 107° with recovery (rare). A temperature of 111° has been observed in cerebral rheumatism, the patient recovering (very rare). INIr. Teale has reported a case of injury to the nervous system which recovered, in which the tem- perature rose to 117°. Another case has been reported, of 120° (?), with recovery. When the temperature is very high the thermome- ter is usually inaccurate, or the patient is playing some trick with the instrument (malingering cases). In hysterical patients under 24 ESSENTIALS OF PRACTICE OF MEDICINE. great excitement the temperature may be very high for a short time. The temperature is depressed in debility (97°). After severe cholera morbus, or in collapse cholera, it may even be as low as 92°. In the insane it sometimes falls to 80°, or even below it. What temperature indicates a fever ? A temperature of over 100° is a febrile temperature. From 100° to 101° is a slight fever ; 101° to 103° a decided fever ; 103° to 105° a high fever ; when over 105° it indicates great danger. What is meant by the period of defervescence ? The decline of the fever is thus spoken of. The temperature then often falls below the normal. Do special diseases have characteristic temperatures ? Certain diseases have peculiar temperature records which are characteristic of them, e.g., typhoid fever, measles, etc. In can- cerous affections the temperature is below the normal. In all cases where the tubercular process is active the temperature is above the normal. Is the temperature of any prognostic value ? In fevers a steady or falling temperature is a favorable sign, while a rising temperature indicates danger. If it remains high when it should fall it is a bad sign. In acute tuberculosis when the fever subsides the active process is arrested. What therapeutic indications may be deduced from the study of the temperature ? A high temperature calls for antipyretics. A low demands stimulants and tonics. Is the thermometer ever used to take the local temperature of individual parts of the body ? As increased tissue change is accompanied by elevation of tem- perature, which will be higher in the neighborhood where it is produced, the thermometer over an inflamed part will indicate a greater elevation of temperature than over other parts of the body. For the purpose of taking the surface temperature, thermometers are used the bulbs of which are arranged in a flattened coil. The EXANTHEJIATOUS AND ZYMOTIC DISEASES. 25 surface temperature is always several degrees lower than that of the axilla, due to evaporation and the radiation of heat. The tempera- ture of the head and abdomen is nearly 3° lower, and that of the chest 2° lower than that of the axilla. GENERAL DISEASES.—A. (EXANTHEMATOUS AND ZYMOTIC DISEASES.) Fever. What are the characteristics of a fever ? Fevers are characterized by (1) an elevation of temperature; (2) Increased rapidity of tissue change; (3) As a rule increased rapidity of the circulation, and (4) Alteration in the secretiom, which are usually diminished. What are the general indications for their treatment ? (1) Reduce the temperature by cold sponging, cold baths, quinine (gr. xx), or if the temperature is very high, by antipyretics, as antipyrine. (2) Give easily digested food in small amounts frequently re- peated, to counterbalance the waste of the tissue. (3) Regidate the circulation by alcohol, ammonia, or perhaps digitalis, if the pulse is small, weak and rapid, or by aconite, vera- trum viride, or antimony, if the pulse is full and strong. (4) Keep up the secretions by diuretics, diaphoretics or purgatives, as the case may require. Mention some of the general laws governing fevers. (1) They are all due to special poisons. (2) They are mostly contagious or infectious. (3) They are mostly self-limited diseases, I e., they run a definite course and terminate spontaneously. (4) One attach usually protects the individual from a recurrence of the disease. (5) With few exceptions there are no specifics. (6) With few exceptions fevers have no characteristic pathological lesions. 26 ESSENTIALS OF PRACTICE OF MEDICINE. What is meant by fever diet ? Fever diet consists in giving the patient plenty of milk, arrowroot or broth, therefore a light, easily digested, fluid diet every two or three hours, day and night. If milk alone is used the patient can take from three to five pints in twenty-four hours. What is meant by fever treatment? Fever treatment consists in sponging off the body of the patient under the bed-clothes with cool water, three or four times a day, keeping him lightly covered, the room well ventilated, and its tem- perature from 68° to 70°. He should be given plenty of cooling drinks, in small quantities, from fear of overloading his stomach, but frequently repeated, and he should be coaxed to take them. The secretions must be kept up by diuretics, diaphoretics or purgatives, as indicated. The Essential Fevers. Have the essential fevers definite periods of incubation ? The average period of incubation is less than a week in catarrhal fever, cerebrospinal fever, dengue, diphtheria, erysipelas, scarlatina and relapsing fever. It is two weeks in smallpox. Two to three weeks in typhoid fever. One to four weeks in malarial fever. Twelve hours to twelve days in typhus fever. Twenty-four hours to twenty-four days in yellow fever. Eight to twenty-eight days in measles. What are the days on which the eruptions of the essential fevers appear? The eruptions appear on the second day in scarlet fever and varicella. During the third day in smallpox and rotheln. On the fourth day in varioloid and measles. On the fifth day in typhus fever. From the fifth to the seventh day in dengue. From the seventh to the ninth day in typhoid fever, and is early or uncertain in cerebrospinal fever. CONTINUED FEVERS—SIMPLE CONTINUED FEVER. 27 How are the essential fevers classified ? They are divided, according to their chief characteristics, into the continued, the periodical, and the eruptive fevers. CONTINUED FEVERS. What are continued fevers ? Fevers of the continued type are those of which the chief charac- teristic is a temperature more or less continuous during the duration of the disease. They are simple continued fever, influenza, typhoid fever, typhus fever, relapsing fever, and cerebrospinal fever. Simple Continued Fever. What is simple continued fever ? It is a short febrile disease without any very obvious cause, and having no constant pathological lesion. What are the synonyms of simple continued fever ? It is called essential fever, ephemeral fever, irritative fever, febricula, ardent fever, synocha, etc. What is its duration ? It lasts from four to seven days, and frequently terminates by a crisis. What is its cause ? It is often due to fatigue, especially in children ; to mental strain or anxiety in adults, or to exposure to heat. What are its symptoms ? It begins with a chill, followed by fever and gastric disorder, last- ing for a few days, and ending by a critical perspiration or diarrhoea. In adults, after mental anxiety or exposure to heat, there is often severe headache and even delirium. How is this disease diagnosed ? The diagnosis is made by the cause, by the symptoms, the dura- tion and the termination. 28 ESSENTIALS OF PRACTICE OF MEDICINE. (1) From cerebral softening it is known by the cause and duration. (2) From typhoid fever, by the absence of sufficient intestinal symptoms, by the absence of the eruption, and by the duration. What is the prognosis ? The prognosis is favorable, the disease always ending in recovery. How should it be treated ? It should be treated by rest in bed ; fever treatment and diet; acting on the skin with diaphoretics, and giving quinine and tonics as convalescence approaches. Catarrhal Fever. What is catarrhal fever ? It is an acute epidemic disease, characterized by fever with catarrh, severe pains and great nervous depression. What are the synonyms of this disease ? It is called epidemic catarrhal fever, epidemic contagious catarrh, influenza, dandy fever, la grippe, la coquette, la folette, etc. Is this a new disease ? It is not. Epidemics of influenza were reported in the fifteenth century, and perhaps even prior to this period. It occurs in marked epidemics, sweeping rapidly over continents, about every twenty- five or thirty years, with numerous minor epidemics, more or less limited in extent, occurring in the intervals. What is its cause ? It is due to a special atmospheric poison, probably a germ, and is infectious rather than contagious. If contagious it is but feebly so. What are the symptoms of this disease ? It begins suddenly with chilly sensations, rapidly developed, with general hyperaesthesia of the surface, and severe shooting neuralgic pains all over the body, but particularly in the back and limbs. There is fever (100° to 103°), with catarrh of the nose, eyes, fauces, pharynx, larynx, and sometimes of the bronchial tubes; a strange, irritative, laryngeal cough, worse at night, and singular nervous depression, out of .proportion to the local symptoms. It sometimes CONTINUED FEVERS—CATARRHAL FEVER. 29 ends abruptly by a critical discharge from the bowels or skin, and often leaves the patient much debilitated, with a feeble heart, with laryngeal cough, or with a fingering catarrh of the mucous passages. What is the duration of influenza ? It lasts from three to ten days, often followed by a tedious con- valescence. What are its complications ? (1) Pneumonia occurs in about four per cent, of the cases. It is more frequent in some epidemics than in others, and may be either catarrhal or (not so commonly) croupous. It is the most fre- quent complication. (2) Gastro-intestinal Catarrh.—In some epidemics the alimentary canal bears the brunt of the disease. This complication is seen in a small number of cases in any epidemic, and is occasionally very severe. (3) A cerebral complication, resembling meningitis, characterized by severe headache, photophobia and violent delirium, lasting four or five days, is occasionally seen, but is not a common complication. It would appear to be due rather to an irritation of the brain result- ing from the poison in the blood than from any definite lesion. (4) Stiffness of the joints, without inflammation, lasting four or five days, is occasionally met with. How may this disease be diagnosed ? It is recognized by being epidemic, by the fever with catarrh, by the hyperaesthesia and the pains, by the great nervous depression, and by the complications. What is the prognosis of influenza ? It is one of the least fatal of diseases in itself, but owing to the great depression it induces the death-rate is frightfully increased during its prevalence, for, when it attacks old persons, or people debilitated from any cause whatsoever (as teething children, or those affected by chronic cardiac diseases, or chronic bronchial or pulmonary dis- eases), it proves fatal. How should this disease be treated ? The patient should be confined to bed and ordinary fever treat- ment and diet administered. Diaphoretics (as neutral mixture and 30 ESSENTIALS OF PRACTICE OF MEDICINE. sweet spirits of nitre) should be freely given, and the bowels regu- lated. He should take quinine in tonic doses, from the commence- ment of the disease far into convalescence. Under no circumstances should the treatment ever be of a depressant nature. If any com- plication is present, or if there is much exhaustion, stimulants should be freely used; and, during convalescence, iron, quinine and other tonics must be administered. How should special symptoms be treated ? If the cough is severe small doses of Dover's powder (gr. iij-v) may be given at night and repeated as necessary, or inhalations of compound tincture of benzoin in hot water may be used at bedtime, or paregoric or minute doses of morphine administered. If the stomach is irritable, small doses of calomel with sodium bicarbonate or cocaine may be taken ; or minute doses of morphine injected hypodermically. If the neuralgic pains are very severe, antipyrine with quinine may be administered in capsules or solution. For the nasal catarrh, a solution of cocaine may be sprayed or inserted on cotton into the nostrils, or the tincture of iodine inhaled from a wide-mouthed bottle. Should delirium, sleeplessness, etc., be present and opium seem to aggravate rather than relieve it, urethan, chloral or the bromides may be given instead of Dover's powder. Bronchitis and pneumonia should be treated as if no other disease were present, great care being taken not to depress the patient. Should the cardiac action be weak, rest should be enjoined far into convalescence, and digitalis, strophantus or strychnine conjoined with the tonic treatment. Typhoid Fever. What is typhoid fever ? It is an acute infectious fever, due to a special poison characterized by an insidious beginning, a characteristic temperature record, char- acteristic eruption, peculiar intestinal symptoms with diarrhoea, and having characteristic post-mortem appearances. CONTINUED FEVERS—TYPHOID FEVER. 31 What are its synonyms ? It is called enteric fever, gastro-intestinal fever, infantile remittent fever, slow nervous fever, autumnal fever, abdominal typhus, etc. etc. What are the causes of typhoid fever ? It is due to a specific poison, probably never generated de novo, but favored in its development by decomposing animal matter, par- ticularly the alvine dejections, as may occur in foul drains. The poison may be propagated by drinking water, or milk contaminated with it. It attacks persons in the prime of life. What are the incubation period and duration ? The incubation period is about two weeks, sometimes three weeks or longer. The duration is three and a half weeks, followed by a tedious convalescence. What are the symptoms of this disease ? (1) Prodromic Period.—It comes on gradually, with chilly sensa- tions, malaise, perhaps some diarrhoea, the patient being feverish toward night, and in about half of the cases having irregular attacks of epistaxis ; all this lasting from three days to a week. (2) The First Week of the Disease.—The fever then becomes continuous, with evening exacerbations and morning remissions. Diarrhoea, if not present before, now comes on. There is great lassitude, headache, a soft, frequent pulse, and often nocturnal de- lirium. (3) Second Week.—These symptoms all increase, an eruption appears, the patient is often in a condition of stupor, alternating with hallucinations, the tongue is dry, and the fever more continuous. (4) Third Week.—If the case is doing well the symptoms now begin to abate. There is not so much delirium or headache, and there are marked variations in the fever, the temperature being much lower in the morning, but high at night. If the case is not doing well the stupor deepens, the diarrhoea in- creases, there is picking at the bed-clothes, subsultus tendinum, the patient has a tendency to sink down in the bed, and he dies from exhaustion, or from some of the complications which may occur at this time. 32 ESSENTIALS OF PRACTICE OF MEDICINE. (5) Fourth Week. —About the middle of the fourth week the fever ceases, the evening temperature being normal, and he enters upon a tedious convalescence, some irritability of the bowels remaining. Special Symptoms. Fever Symptoms.—Temperature is characteristic. Commencing at 99° the first night it gradually ascends, being about 1° higher each evening than on the preceding evening, but declining nearly a degree in the morning from the temperature of the preceding night. This continues until the evening of the fifth to seventh day of the dis- ease, when the temperature has reached 103°-104°. It then remains stationaiy, with a slight remission and evening exacerbation, until the thirteenth or fourteenth day, when it begins to decline, coming down every morning 1°, H° or even 2°, but going up again in the evening nearly as high as the night before. This continues until from the twenty-first to the twenty-fifth day, the evening tempera- ture being normal. It occasionally happens (very rarely) in persons who have been subjected to great exhaustion and extreme nervous depression before they contracted the disease, that typhoid fever will run its course without any elevation of temperature whatever. The pulse is small, soft, and compressible. It is frequent rather than rapid. Should it be very rapid it would indicate great debility. The heart muscle is very weak, from granular degeneration. The first sound of the heart is consequently indistinct, and in bad cases may be entirely absent. Intestinal Symptoms. Diarrhoea, if not present from the first, generally comes on by the end of the first week. There are three, four, or often many more large, fluid and very offensive stools, yellowish or brownish in color, resembling pea soup in consistence. In some epidemics the diarrhoea is not present, or only to a slight extent. Persons suffering from hernia frequently pass through the disease without diarrhoea. Tympanites.—This comes on in the second week usually, and is often excessive. Gurgling on pressure over the right iliac fossa is usually present in the second week, but is a symptom of little importance. The spleen is found by palpation to be enlarged, softened, and tender, on touch. CONTINUED FEVERS—TYPHOID FEVER. 33 The tongue is covered with a light yellow fur at first, becoming dry, devoid of epithelium, and glazed in the second week. Its tips and edges first lose the coating, giving rise to a peculiar V-shaped redness on the otherwise heavily coated tongue. If the tongue cracks, bleeds, and becomes covered with a dull varnish, it is a bad sign. Sordes appear on the teeth, gums, lips and roof of mouth, and consist of collections of dried mucus, epithelium, bacteria, and some- times blood. Eruption.—This is only absent in about 12 per cent, of the cases. When present it is the most strongly diagnostic symptom. It appears from the seventh to the ninth day, in the form of a few rose-colored, slightly elevated spots, like flea-bites, generally on the abdomen chest or back, sometimes on the limbs, but never on the face. They disappear on pressure, and during convalescence, but reappear if a relapse takes place. They.come in crops of four or five in number, lasting three or four days. They are not present after death. The face is flushed, having a dull, stupid expression, and the eyes are heavy and listlesss. There is pain in the right iliac fossa, griping in character, with tenderness on pressure in the same region. The urine is deficient in chlorides, and, in bad cases, contains albumin, which is not necessarily indicative of renal disease. Rales are heard over the chest, especially posteriorly, and are due to hypostatic congestion of the lungs, and effusion into the bronchi. Ridges are found on the nails during convalescence, and if a relapse takes place it will be indicated by a second ridge. Nervous Symptoms. The headache is very intense, being replaced by stupor in the second week. Delirium is generally present in the second week, if not earlier. It is usually of a low muttering type. Occasionally fierce delirium is seen, in which patients usually manifest a great desire to jump out of the window. The special senses often suffer, hearing being generally obtunded, and vision perverted. 3 34 ESSENTIALS OF PRACTICE of .medicine. Muscular System.—There is great muscular weakness, from granular degeneration. What is the pathology of this disease ? Peyers patches and the solitary glands become infiltrated by poison, and swell during the first ten days or thereabouts. Inflammation ensues, and from the tenth day ulceration occurs, and perforation of one or more of the coats of the bowels may result. The ulceration continues from the eighteenth to the twenty-fifth day, after which cicatrization takes place, and the ulcers are generally healed in six weeks. Cicatrization may occupy a longer time. What is the pathological anatomy of typhoid fever ? Intestines.—Infiltration, inflammation and ulceration (the ulcers being in the longitudinal axis of the bowels) of the solitary glands and Peyers patches; often more or less complete perforation, and partial cicatrization is found after death. The mesenteric glands are enlarged and swollen, but do not ulcerate. The spleen is always large and soft. The lungs are congested, especially at the lower part, but pneu- monia is rare. The heart and other muscles have undergone granular degenera- tion. What are the complications!? (1) Hypostatic congestion of the lungs is often present, to a greater or less degree, but pneumonia is rare. (2) Intestinal hemorrhage from ulceration of a vessel of the bowel. If in the second week the temperature suddenly falls to or below the normal, it will indicate a hemorrhage from the bowel, even before the appearance of the blood in the stool. (3) Perforation with peritonitis is generally fatal. The symptoms of this complication are sudden, severe pain in the right iliac fossa, rapidly followed by symptoms of peritonitis and collapse. What are the sequelae of typhoid fever ? (1) Ancemia, from an impoverished condition of the blood. (2) Dropsy, usually from blood changes, but which may result from renal disease. (3) Phlegmasia dolens {milk-leg).—This is due to phlebitis of continued fevers—TYPHOID fever. 35 one of the larger veins, and is a tedious, but not dangerous com- plication. (4) Paralysis, usually of the lower extremities, and probably due to spinal anaemia. The electro-muscular reactions are impaired. It is tedious, but not dangerous, and may be foretold by a tremor occurring during convalescence in the part about to be affected. (5) Dysentery.—If in the third week the diarrhoea passes into dysentery, the large bowel has become ulcerated, and the prognosis is not so favorable. (6) Periostitis. (7) Formation of abscesses, and various other sequelae indicating a lowered vitality and an impoverished condition of the blood. Describe the period of convalescence. Convalescence is always slow. The patient is always greatly emaciated, and the bowels remain irritable. If there is any latent disease in the system, as phthisis, cancer or scrofula, it may develop during this period. Relapses are not uncommon, and are probably due to a further absorption of the poison which has remained dormant in the bowels. During a relapse all the symptoms, as eruption, fever, etc., return. The disease, however, runs a more rapid course, and usually ends favorably. What is meant by abortive, and by walking typhoid? Cases of abortive typhoid are usually, but not necessarily, mild. The eruption appears earlier, the disease runs a more rapid course, and ends in about two weeks. Walking typhoid is usually milder in the beginning, but as the patient continues to attend to his usual business, and takes no care of himself, they are generally serious cases, and often terminate fatally. How is typhoid fever diagnosed ? The diagnosis is formed from the history of the gradual beginning, from the characteristic temperature record, from the characteristic eruption, and from the peculiar intestinal symptoms, and nervous phenomena. Differential Diagnosis. From (1) Simple Continued Fever.—This disease ends about the 36 ESSENTIALS OF PRACTICE OF MEDICINE. time the typhoid fever is beginning. There are no intestinal symp- toms, no eruption, and no characteristic temperature record. (2) The Typhoid Condition in Other Diseases—In these cases the history, the absence of the eruption, of the characteristic intestinal symptoms, and of characteristic temperature, should render the diagnosis plain. (3) General Debility.—The same remarks apply to this as to the preceding condition. (4) Acute Tuberculosis.—Here we have an irregular fever, absence of eruption, presence of bacillus in the sputum, and the physical signs of the disease. (5) Cerebrospinal fever can only be mistaken for typhoid when the acute stage of the former disease is passed, and the patient has entered into a low asthenic state. But the history, the difference of the eruption, the absence of intestinal symptoms, and the presence of rigidity or stiffness of the muscles of the neck, would indicate the nature of the attack. (6) Typhus.—This disease is differentiated by the sudden begin- ning, the difference in the temperature and eruptions, the constipa- tion, and the greater prominence of the nervous system. (7) Meningitis.—Cases of typhoid fever with severe headache and active delirium may simulate meningitis; but in the latter disease the pulse is hard, full and tense; there is no eruption, no diarrhoea, but causeless vomiting, with a clean tongue. What is the mortality and prognosis in typhoid fever ? In hospital practice the mortality is about 18 per cent.; in private practice 10 to 12 per cent. The earlier it is treated the better the prognosis. When a case runs a typical course the prognosis is favorable. All complications increase the danger. Unfavorable prognostic symptoms are a very high temperature, a pulse over 120, subsultus tendinum, picking at the bed-clothes (carpologia), and sinking down in the bed. What is the treatment of typhoid fever ? (1) Prophylactic Treatment. Disinfect the stools, water closets, etc., most thoroughly with corrosive sublimate or other germicide. continued fevers—'typhoid fever. 37 (2) General Treatment. Give fever treatment and diet, with special attention to the liquid diet. Good hygiene (cleanliness, cool air, thorough ventilation); good nursing; diluted nitro-hydrochloric or other mineral acids (gtt. x-xx, freely diluted, every two to four hours), or carbolic acid with tincture of iodine; stimulants generally in the second week, and treating any symptoms that may require it. (3) Treatment of Special Symptoms. (a) If the fever is very high antipyrine or large doses of quinine may be given, or cold baths or a wet pack employed if there is no tendency to intestinal hemorrhage. , (b) Profuse Diarrhoea.—If there are more than three or four stools a day, and the patient's strength is failing, opium should be given conjoined with bismuth (gr. x-xx), alone or combined with carbolic acid (gtt. j); or the sulphate of copper, nitrate of silver, acetate of lead, or other mineral astringent may be used with the opium. (c) If there be excessive tympanites, turpentine injections (gtt. x ; tr. opii deodor., gtt. j-v ; in gum water every three hours), or tur- pentine stupes and turpentine internally, or injections of vinegar and water, should be employed. Nux vomica or strychnine, given internally, are often of service. (d) If there be much gastric disorder, which is sometimes seen early in the case, especially in malarial districts, calomel (gr. v-x) will often give relief. (e) Should there be great oppression in breathing, turpentine stupes and turpentine internally, with frequent change in the patient's position, and, in severe cases, dry cups to the chest, should be used. (/) If the heart is very weak the patient should be stimulated with alcohol, strychnine, strophantus and quinine. During the height of the fever digitalis is not efficient as a cardiac stimulant. It is better to reserve it until convalescence. (g) For restlessness and sleeplessness urethan (gr. xx repeated once), opium (gr. j of the extract in suppository), or morphine (gr. J to i, hypodermically) should be given at night, and repeated if necessary. Musk is also good in these cases. Chloral, if used, should be given with care, because of the cardiac depression. 38 ESSENTIALS OF PRACTICE OF MEDICINE. (h) If the delirium is excessive, the same treatment may be employed, but should be given during the day as well as night. Great delirium calls for an increased amount of stimulants. If it is associated with high temperature and all else fail, cold baths may be tried. (i) The headache usually passes away without treatment. If it should continue and be excessive, the head may be shaved and ice applied to the scalp. Occasionally, if the circulation is languid, hot water bags give a better result. Should this treatment produce no result, morphine (gr. £) may be used hypodermically, or a blister applied to the scalp. (j) For stupor and coma free stimulation must be employed, and caffeine or cocaine given. (k) Great debility or exhaustion, which generally occurs in the second week, calls for the use of stimulants, the amount being regulated by its effect on the pulse and on the first sounds of the heart. As long as the pulse becomes steadier and less frequent, and the first sound of the heart more distinct, the amount of alcohol is not in excess of the requirements of the system. Usually not more than half a pint of brandy per day is required. Stimulate especially in the early morning hours, and nourish the patient well. Caffeine or cocaine (gr. £ every two hours) may be used as heart stimulants. (I) Subsultus tendinum calls for chloral and opium ; or better still, if there is much restlessness, camphor, asafoetida, musk, or spirits of chloroform, may be used. (4) Treatment of Complications. (a) For hypostatic congestion of the lungs. Frequent change of position, turpentine internally, turpentine stupes, and diy cups are the best means of combating this complication. (b) For intestinal hemorrhage give less food, and, if possible, less stimulant; keep the bowels absolutely at rest by opium, and give ergot hypodermically and internally every half hour to an hour, until the blood disappears from the stools; or the oil of erigeron, or Monsel's solution well diluted, may be alternated with the ergot, or acetate of lead may be given. In some instances ice applied to the abdomen, or bandaging the abdomen as tightly as possible, appears to exert a favorable influence. CONTINUED FEVERS—TYPHUS FEVER. 39 (c) For perforation with peritonitis give as little food as possible. The amount of stimulants must be regulated by the amount of collapse. The patient must be kept continually under the influence of large doses of opium, a great tolerance for which drug is present in these cases. (d) All other complications should be treated on general principles. Typhus Fever. What is typhus fever ? It is an acute contagious disease due to a special poison, character- ized by a sudden beginning with peculiar temperature record, a characteristic eruption, and constipation. No constant lesion is found after death. Synonyms. Jail fever, camp fever, ship fever, hospital fever, brain fever, or spotted fever. Cause. It is due to a specific poison, originating in or cultivated by filth or overcrowding. It occur in epidemics, and is very contagious. Incubation Period. Twelve hours to twelve days. Duration. About two weeks. What are the symptoms of the disease ? It begins suddenly with a chill, high fever from the start (the temperature rising, however, until the eruption appears, then re- maining stationary until the tenth day, when a slight remission occurs), grave nervous symptoms, a flushed, dull and muddy looking face, and costive bowels. It ends by a crisis about the fourteenth day. Special Symptoms. (1) Fever Symptoms.—There is a chill, followed by fever, the temperature being high immediately, but continuing to rise until the second or third day, when it has reached 104°. It continues at 40 essentials of practice of medicine. this height, with slight morning remissions, and evening exacerba- tions, until the tenth day, when there is a more marked remission ; but it soon rises again, and continues high until the fourteenth day, when it falls rapidly to the normal, or even below it. (2) Eruption.—The eruption appears on the fifth day of the disease, and covers the entire body except the face. It is scarcely influenced by pressure, and consists of coarse measly blotches, which soon become darker and purplish, and often petechial. It remains after death, but fades during convalescence. (3) Nervous Symptoms.—These are like those of typhoid fever, but there is more headache, more marked delirium, often fierce in character in the early part of the disease, and more stupor. What are the complications of typhus fever ? (1) Pneumonia, much more frequent than in typhoid. (2) Albuminuria.—Renal complications are more frequent than in typhoid fever, and may result in uraemia. (3) Diarrhoea. (4) Dysentery. (5) Erysipelas. (6) Parotitis.—This is a dangerous complication, death frequently occurring from pressure of the enlarged glands on the jugular vein. Therefore, suppuration should be encouraged, and the pus evacuated as early as possible. (7) PJdegmasia dolens, and other complications (not intestinal), such as occur in typhoid and other low fevers. Describe the morbid anatomy in typhus fever. The blood is dark and diffluent, and the spleen enlarged. No constant lesion is found. How is this disease diagnosed ? It is known by its beginning suddenly with a high temperature record, a characteristic eruption, absence of intestinal symptoms, and grave nervous phenomena. Differential Diagnosis. (1) From typhoid fever by the sudden beginning, the temperature, the eruption, the constipation, and the duration. (2) From measles; there is no eruption on the face, no catarrhal CONTINUED FEVERS—TYPHUS FEVER. 41 symptoms, a different temperature record, and more marked nervous symptoms. (3) From meningitis (sometimes, also, called brain fever), by the history the eruption, the rapid, compressible pulse, the coated tongue, and the absence of vomiting as a prominent symptom. (4) From relapsing fever, by the eruption, the different tem- perature record, the different history, and the absence of spirillae in the blood. What is the prognosis and mortality of this disease ? The mortality is twenty-five per cent. The older the patient the more unfavorable the case. When an epidemic attacks armies it is very fatal. Unfavorable symptoms are a pulse above 120°, very profuse eruption ; contracted pupils; sleeplessness, and very high temperature. When the pulse remains very rapid during conva- lescence it indicates the development of tubercle in the lungs. What is the treatment of typhus fever? (1) Prophylactic Treatment. Thorough disinfection, ventilation and isolation. (2) General Treatment. Fever treatment and diet, with less attention, however, to a fluid diet than in typhoid fever. Regulate the bowels with calomel, podophyllin and safines. Give mineral acids, as in typhoid fever. (3) Treatment of Special Symptoms. Headache.—Leeches, and warm or cold applications to the head. Opium may be given if the pupil is not contracted, or bromides and chloral may be resorted to. Sleeplessness.—For this symptom anti-spasmodics, as musk and camphor, are of service. Opium may be given, but not too fre- quently. Urethan, bromides and chloral are also of use. For stupor and coma, stimulants, caffeine and cocaine are usually indicated. (4) Treatment of Complications. Every complication should be treated as if it were the only disease present. Pay special attention to the bladder, and be sure that retention of urine does not occur. 42 essentials of practice of medicine. Pneumonia.— Stimulants and quinine are here indicated ; and for the oppression in breathing the free use of turpentine internally and externally affords most relief. Relapsing Fever. What is relapsing fever? It is an acute epidemic disease, usually limited to the seaboard towns in this country, characterized by a sudden begiuning, with chills, fever, headache, muscular pains, vomiting and jaundice, ending suddenly in a week, and having a great tendency to recur. Synonyms. Februs recurrens, mild yellow fever, bilious relapsing fever, famine fever, seven days fever, etc. Cause. It is a contagious disease, occurring in epidemics due to the presence of a peculiar spiro-bacterium (the spirochsete of Ehren- berg) in the blood. These organisms are rarely absent during an attack, and are in constant motion at this time. The disease spreads more rapidly under bad hygienic conditions and in times of famine. What are the symptoms of this disease ? It begins suddenly with a chill, followed by fever, violent head- ache and great muscular pains. After a few days vomiting and epigastric tenderness occur, and are prominent symptoms. Soon jaundice takes place, with hepatic and splenic tenderness, the fever increases and the pains in the limbs become more severe. This lasts for five to seven days, when suddenly the fever terminates, and all the symptoms pass away as rapidly as they came on. The patient is now apparently well, and remains so for a week, but generally on the fourteenth day from the commencement of the fever the pains and other symptoms recur, and the patient suffers a relapse as severe as the primary attack, but of shorter duration. After three or four days the disease again terminates, and the patient remains well for one or two weeks, when another relapse may occur. Prognosis and Mortality. The prognosis is favorable. The mortality in private practice is about 20 per cent. CONTINUED FEVERS—CEREBRO-SPINAL FEVER. 43 Morbid Anatomy. The spleen is found invariably enlarged, and the white blood cor- puscles are increased in number, and spirochete are found in the blood. Complications. Pleurisy and pneumonia are the most frequent complications. Diagnosis. The disease is known by the presence of an epidemic, by the sud- den high fever, the jaundice and other hepatic symptoms, the short duration, abrupt termination, the relapse and the presence of spirochaete in the blood. How is this disease treated? (1) Prophylactic Treatment. Thorough ventilation, disinfection and isolation. (2) General Treatment. Fever treatment and diet, rest in bed during the attacks and between them, if possible. Keep the bowels open with calomel and salines. Give diuretics, diaphoretics, and quinine, as a tonic. (3) Treatment of Complications. Treat every complication as if it were the only disease present. Nourish the patient well. Cerebro-spinal Fever. What is cerebro-spinal fever ? It is an acute infectious fever, due to a special poison characterized by a sudden beginning, with intense headache and delirium, contrac- tion of the muscles of the back, moderate fever, irregular pulse, frequently a petechial eruption, usually followed by grave sequelae and having characteristic post-mortem appearances. What are the synonyms of this disease ? It is also called cerebro-spinal meningitis, cerebro-spinal typhus, and spotted fever. What is its causation ? It is due to a specific poison which is said to be most malignant 44 ESSENTIALS OF PRACTICE OF MEDICINE. during wars, and to be found following the route of armies. It is rarely seen in summer—occurs in epidemics, and is not contagious. What is its incubation period and duration? The period of incubation is about one week. It lasts about a week, but the convalescence may be protracted for many months. Describe this disease. It begins suddenly with a chill, followed by intense vertigo and violent headache, vomiting, fever, petechiae, irregular pulse, hyper- aesthesia of the skin, and rigidity with spasmodic contractions of the muscles of the back. Delirium, stupor, and in bad cases intense restlessness, coma and death. Deviations of Type (all of which may be followed by the same sequelae):— (1) The Fulminating Form.—These cases occur in the beginning of the epidemic. They run a rapid and violent course, death occur- ring usually in twenty-four hours, from the intensity of the poison acting on the nervous system. (2) The Abortive Form.—These are mild cases where the patient is not confined to bed, but suffers from obstinate rigidity of the muscles of the back of the neck, with intense headache and inability to apply the mind to any of his ordinaiy occupations which require thought. (3) The Hysterical Form.—In this variety the delirium is of an emotional kind, resembling hysteria. Partial paralysis may take place, with stiffness of the muscles of the neck. Special Symptoms :— (1) Premonitory Symptoms.—A sense of weight in the back of the head and neck, with pain on pressure in the same region. (2) The eruption is not characteristic. It may come early (a bad sign) or irregularly, and is found all over the body and, later in the disease, on the face also. It is not influenced by pressure and con- sists in petechial spots of extravasated blood, like purpura. It is absent in about half the cases. (3) The temperature is usually not over 102°, except in the ful- minating form, when it may be very high. It is apt to intermit or remit. CONTINUED fevers—cerebro-spinal fever. 45 (4) The pulse is very irregular, and often does not correspond to the apex beat. It varies very much in twenty-four hours. (5) Vertigo is often one of the first symptoms. It is very severe, but grows gradually less as the disease progresses. (6) The headache is fearful, the patient complaining of it as long as he is conscious. (7) The delirium is generally fierce and active, and is rarely absent. The restlessness is so great that the patient constantly wants to get out of bed and leave the house. Sometimes the delirium simulates hysteria. (8) Spinal Symptoms.—There is shooting pain along the spine, and retraction of the muscles, as in tetanus. Clonic and tonic con- tractions occur, and hyperaesthesia of the surface is present. (9) Convalescence.—If the patient is about to recover, about the ninth or tenth day the delirium ceases ; there is less difficulty in swallowing ; the stiffness lessens, and the patient slowly enters upon a tedious convalescence, passing into a low typhoid condition, which lasts many months. During convalescence the sequelae usually appears. What are the complications and sequelae ? (1) Pneumonia. —The lung symptoms maybe so severe as to mask those of the disease, should the fever be mild in character. (2) Joint affections are sometimes seen, resembling acute articular rheumatism. The Sequela-: are :— (1) Blindness in one or both eyes. (2) Deafness. (3) Idiocy. (4) Epilepsy. (5) Local or general paralysis. The first three are usually incurable. Epilepsy occasionally im- proves under treatment. Paralysis gives a more favorable prognosis. What is the morbid anatomy of this fever ? There is an inflammation and exudation of plastic lymph on the meninges of the brain and spinal cord, the pia mater and arachnoid being especially affected. The exudation occurs into the ventricles, but particularly at the base of the brain, in the subarachnoid spaces, 46 essentials of practice of medicine. hence the sequelae. The pia mater is congested and adherent to the cord. The lungs are engorged, and spots of catarrhal pneumonia are usually present. How is cerebro-spinal fever diagnosed ? This disease is known by the presence of an epidemic, by the sudden onset, by the violent vertigo, the retraction of the head, the delirium, eruption, irregular pulse and temperature, and the various sequelae. (1) From congestive fever it is differentiated by the spinal symp- toms, eruption, and absence of remission. (2) From spinal meningitis, by the cerebral symptoms and erup- tion. (3) From typhus fever, by the spinal symptoms, the difference in eruption, which is sometimes absent, and which appears on the face. (4) From tubercular meningitis, by the sudden onset without prodromes, and by affecting adults as well as children. (5) From typhoid fever; no mistake is possible until the acute symptoms have subsided and the patient passes into a low typhoid condition. In these cases the history, the rigidity of the muscles of the neck, the absence of kitestinal symptoms, the difference in erup- tion, and the sequelae would indicate the nature of the disease. What is the prognosis and mortality ? The mortality is very high, varying with the epidemic from twenty to seventy-five per cent. It is greatest in the early part of the epidemic. The disease is not so fatal among children. The least fatal age is from two to five years, the most fatal from eighteen to twenty-five. How is this disease treated ? Give the patient fever treatment and diet. Keep the head cool and the body warm. Act on the skin with small doses of pilocarpine, and keep the bowels open with calomel, podophyllin and salines. In the early stages give large doses of opium—enough to keep the patient under its influence—either alone or alternating with potas- periodical fevers. 47 sium bromide. (The latter acts well in children when used alone.) Chloral may also be given with the same object in view (i. e., to depress the reflex centres and diminish the amount of blood in the brain). Ergot may be used to contract the blood-vessels. Locally, local depletion by cup or leeches may be employed if the patient is young and robust, followed by ice to his head and spine. In the latter stages combine potassium iodide with the other treatment, apply warmth to the head, and blisters to the back of the neck and spine, to cause absorption of the exudate. During convalescence give quinine in tonic doses, feed the patient well, and stimulate if the heart is weak. The complications and sequela; should be treated on general principles. PERIODICAL FEVERS. Name the periodical fevers. The fevers of this group are intermittent, remittent, hemorrhagic malarial, congestive, typho-malarial, and yellow fevers. All except the last are due to malaria. What is malaria ? Malaria is a poison which is generated by heat and moisture. It is most likely due to microscopic germs of either vegetable (bacillus malariae) or animal (plasmodium malariae) origin. There can be no malaria without heat and moisture. It is gener- ated in marshes where vegetable decomposition is going on. Or, in newly turned up earth, where the land has long lain fallow. It is said that it may be developed from the decomposition of rock. It accumidatcs in low moist districts and at the bases of mountains. It drifts in the direction of prevailing winds. It would appear to be a heavy poison, for it rarely rises higher than five hundred feet above the sea level, and trees growing in the vicinity of swamps appear to arrest its spread. Certain trees, as the eucalyptus, absorb and destroy the poison. Water also absorbs it, and salt water prob- ably destroys it. Persons drinking fresh water impregnated with the poison are apt to become infected and suffer from malarial dysentery. It disappears under good drainage and the cultivation of the soil. 48 essentials of practice of medicine. It enters our bodies with our food and drink, or through the aii». Poisoning is most apt to take place in the early morning hours or at night. The poison is more readily absorbed during fasting than during digestion. Malarial poison is the same all over the world, and manifests itself by its periodicity. The period of incubation is very uncertain, usually from three to four weeks; although in some instances but a few hours have elapsed between the exposure and the development of the sickness. Intermittent Fever. What is intermittent fever ? Intermittent fever is a fever due to malaria, characterized by attacks of distinct febrile paroxysms, recurring periodically, with complete intervening intermission. Each paroxysm consists of three stages—a cold stage, a hot stage, and a sweating stage. The length of the interval between paroxysms (called the apyrexia) gives the name to the type of the disease. What are the types of intermittent fever ? Intermittent fever is of a quotidian type when the apyrexia lasts twenty-four hours, the attack recurring each day. It is tertian when the apyrexia last forty-eight hours, the attack recurring every other day. It is quartan when apyrexia lasts seventy-two hours, the attack recurring every third day. A double tertian is really a quotidian, but every other day the attacks are more severe. When two attacks occur in one day it is spoken of as a duplicated quotidian. Quotidian and tertian intermittents are the most common varieties in this part of the country. What is the duration of this fever ? If not treated after ten or twelve paroxysms, the type may undergo a change, the fever becoming more continuous and gradually sub- siding, to recur in a few weeks or months. What are its symptoms ? (1) Premonitory Symptoms.—Preceding an attack, the patient periodical fevers—INTERMITTENT fever. 49 often complains of pain in the back and limbs, increased salivary secretion and a frequent tendency to yawn. (2) The symptoms of the cold stage are, a chill, with blue nails, pale skin (the so-called goose-flesh), frequent urination, shivering and intense thirst. During this time a thermometer in the axilla will show that the internal temperature of the body is from 104° to 106°. This stage lasts from half an hour to two hours, and is followed by the hot stage. (3) The symptoms of the hot stage are subjective and objective heat of surface. There is a full bounding pulse, flushed face, severe headache, nausea and vomiting. The axillary temperature rises to 105° or 108°. This stage may last up to four hours, and is followed by the sweating stage. (4) Sweating stage; perspiration now breaks out, first on the brow and face, then over the whole body. The secretions are re- established. The headache disappears, the nausea subsides, the pulse falls, and the temperature goes down 1° or 2° every five or ten minutes, until it is below the normal, when the attack is over and the patient is well until the next paroxysm. The urine is acid during the paroxysms, is often alkaline during the intermission, and may contain albumen. How is this disease diagnosed ? This disease is recognized by the history of malarial exposure, by the stages, the high temperature, the complete intermission, and the recurring paroxysms. (1) From hysteria it is differentiated by the characteristic tempera- ture, the stages, the complete intermission, and the recurrence of the paroxysms. During an hysterical chill the temperature is sometimes very high, but only for a short time, with great and irregular oscillations. (2) From hectic fever it is diagnosed by a physical examination, which shows the absence of cause for the hectic. In the latter disease, also, the pulse remains high in the intermission, and the chills usually occur in the afternoon. (3) From urethral or syphilitic fever by the absence of the neces- sary history, and the fact that the temperature is much higher than in the latter diseases. 4 50 ESSENTIALS OF PRACTICE OF MEDICINE. What is the treatment of intermittent fever ? (1) If a chill is impending and there is not time for the actioi >f quinine, it may be warded off by a hypodermic injection of mor- phine (gr. \), or of pilocarpine (gr. J). (2) Treatment of the Cold Stage.—Keep the patient as warm as possible by hot drinks, by hot applications externally, and by warm covering. (3) Of the Hot Stage.—Fever treatment, cold drinks and ice, cobl sponging to the surface, and a fever mixture with a little aconite if the fever run high, are indicated. Antipyrine will reduce the temperature, but does not shorten the disease. (4) Of the Sweating Stage.—During this stage do nothing except when it is prolonged and exhaustive, in which case the body may be sponged with alum or tannin in solution ; and a few drops of chlo- roform in mucilage and water, or a minute dose of atropine may be given. (5) Of the Intermission.—Purge the patient with calomel, followed by a saline to unload the portal circulation, if there is time. After this administer quinine (gr. xx-xxiv in 24 hours, in solution or freshly made pills, which should not be sugar coated) in two decided doses, the last from four to six hours before the expected paroxysm. If for any reason quinine cannot be given, cinchonidine or some other alkaloid of cinchona, may bei substituted. Should these not be available, arsenious acid or Fowler's solution may be substituted. In obstinate cases Fowler's solution, with strychnine and iron, or small doses of quinine with whiskey early in the morning, may be successful. Vapor baths also are very valuable in these cases. Remittent Fever. What is remittent fever ? It is a fever due to malaria, characterized by periodical exacerba- tions and remissions, the patient never being free from fever until the attack terminates. It is found all over the United States, par- ticularly in the South and Southwest, in Africa and parts of Europe, as Italy, Hungary, etc. It attacks men more frequently than PERIODICAL FEVERS—REMITTENT FEVER. 51 women, and children but rarely suffer from it. The black race is nearly exempt. Each exacerbation at first consists of three stages {vide intermit- tent fever), but later on, the cold stage disappears. It may be quotidian, tertian or quartan, but is usually quo- tidian. What are the synonyms of this disease ? It is called bilious fever, bilious remittent fever, marsh fever, jungle fever, Roman fever, etc. What are its symptoms ? There is a chill, at first recurring daily with the exacerbations, followed by quickened pulse and respiration, flushed face, intense headache, pains in the back and limbs, like yellow fever and small- pox, great gastric disturbance, a temperature of 105° to 107°, sometimes delirium, and frequently jaundice. All this lasts from 10 to 18 hours, when the sweating stage takes place, during which the temperature is rapidly lowered some 3° or 4° (but not to the normal); and a remission occurs in which the patient feels well, but the fever, although less, still continues. After a time the exacerbation sets in again, and the symptoms of the first paroxysm are repeated. After three or four paroxysms the chill disappears, and the fever becomes more continuous, with morning remissions (as a rule) and evening exacerbations. If the disease is not treated and the patient is about to recover, the fever gradually passes away in two or three weeks, or may end as an intermittent fever, or the patient may pass into a low typhoid condition known as typho-malaria. The puke is full, bounding, rapid and a little tense during the paroxysms. The tongue is coated with a heavy yellowish fur. Nausea and vomiting, or at all events gastric irritability, are usually present, and are sometimes very severe. The bowels are generally constipated, sometimes stubborn diar- rhoea is seen, and in rare cases the stools are dark and offensive. Toward the end of the attack there are black, tarry passages from the bowels, due to altered bile. Jaundice is a frequent symptom. 52 ESSENTIALS OF PRACTICE OF MEDICINE. The headache is usually severe, generally disappearing in the remission, but may be a prominent symptom throughout the attack. Delirium is often present. What are the sequelae and morbid anatomy of remittent fever ? Sequels. (1) Persistent headache. (2) Dropsy, and persistent arnxmia. (3) Malarial cachexia. Morbid Anatomy. The heart is softened and granular. The blood contains pigment, and the corpuscles of Lavcran are usually present. The mucous membrane of the stomach is softened and congested. Brunei's glands are enlarged and of a dark slaty color, due to the deposition of pigment. The liver is olive-colored or bronze. The spleen is enlarged and slate-colored. What is the diagnosis and prognosis of this disease ? Diagnosis. This disease is known by the history of malarial exposure, the paroxysms of fever, the constipation, remission, black, tarry stools, the frequent jaundice, and the recurrence of the paroxysms. (1) From intermittent fever it is known by remitting, but never intermitting; (2) From jaundice by the high fever and rapid pulse; (3) From meningitis by the remissions, highly - coated tongue, pulse, high temperature, and jaundice ; and (4) From typhoid fever by the more marked remissions, the jaun- dice, constipation and absence of eruption. Prognosis. Formerly this was a very fatal disease, and even now, under appropriate treatment, two per cent. die. What is the treatment of remittent fever? (1) General Treatment. Fever treatment and diet (light, easily digested food, fluid in character) are called for, and, as a rule, stimulation must be avoided. periodical fevers—hemorrhagic malarial fever. 53 Quinine (gr. xx-xxx per diem) may be given at any time, or in any stage, without waiting for the remission ; although, if of a quotidian type, the bulk of the remedy is preferably administered during this time. It is best to precede the administration of quinine by a mercurial purge, if there is time enough for it to act; otherwise do not wait for the purge before giving the quinine. If the fever is not broken after six or seven days, reduce the amount of quinine one-half and continue the laxatives, treating the symptoms as they arise. (2) Treatment for Special Symptoms. For irritable stomach give calomel (gr. ij-v, with sodium bicarbo- nate), followed by a saline, as Rochelle salts. If this does not check it, give smaller doses of calomel (gr. \-\), with minute doses of mor- phine. Let the patient swallow small pieces of ice, or drink efferves- cent mineral waters; or employ small doses of cocaine hypodermically. As a last resort a blister may be applied to the epigastrium. If the fever is high, with a bounding pulse, intense headache, etc., add tincture of aconite (gtt. j) to the fever mixture, every two or three hours. Apply cold to the head, use mustard foot baths, and mustard plasters to the nape of the neck, or give antipyrine. If the head symptoms are very severe, and are not benefited by other means, local blood-letting may be employed. Hemorrhagic Malarial Fever. What is hemorrhagic malarial fever ? It is a remittent fever, of peculiar type, characterized by sudden jaundice and bloody urine, occurring just before the remission, and depending on the intensity of the malarial poison, which probably acts on the solar plexus of the sympathetic nervous system. It is found especially in the South and Southwest, It is becoming a more common disease, and appears to be spreading over larger areas of territory. It is occasionally seen on the eastern shores of Maryland also. Svnonym. It is sometimes called Yellow Disease. 54 essentials of practice of medicink. Describe this disease. It begins Jike an ordinary remittent fever, but the symptoms are more marked from the onset—more severe. (1) There is a chill, which may be repeated in the second or third paroxysms, and is much more severe than in ordinary remit- tent fever. (2) There is high fever, with severe pains, vomiting, headache, delirium, etc., as in ordinary remittent fever, but much more severe. (3) This is followed by a sweating stage, at the beginning of which the patient suddenly becomes deeply jaundiced, and hemorrhages occur from the gums, fauces, lungs, stomach (rare), bowels (also rare), but especially from the kidneys, and continue until the remis- sion, during which they disappear until the succeeding paroxysm. As the paroxysms continue to recur the renal hemorrhage becomes continuous, and does not intermit as at first. The urine under the microscope is seen to contain blood corpuscles (many of which are altered in form), haematoglobin (from decomposition of blood cor- puscles) and blood casts. The urine is of a uniform black color. The blood is not coagulated, and no more albumen is found than can be accounted for by the presence of the blood. After from six to twenty-four hours the remission occurs and lasts a variable time, depending upon whether the disease is of the quotidian, tertian or quartan type. The disease may end fatally, the patient dying of exhaustion, or from anaemia due to the hemorrhages. More fre- quently, however, death results from uraemia, caused by the renal congestion. What is the prognosis and mortality ? Although a very dangerous disease, it is very amenable to treat- ment. If not treated about two-thirds die. If not treated early half the cases die. If treated from the beginning not more than 10 or 15 per cent. die. What is found on post-mortem examination ? The liver, spleen and kidneys are congested, the latter containing blood casts. The blood itself is dark and diffluent. How is hemorrhagic malaria recognized? This disease is known by its occurring in malarial districts, by periodical fevers—congestive malarial fever. 55 beginning as a severe remittent fever, by the early jaundice, the hemorrhage, the remission, and the return of the paroxysm. (1) From yellow fever it is differentiated by the malarial exposure, by the high temperature, by the abrupt jaundice and bloody urine (rare in yellow fever) at the end of the paroxysm, by the recurrence and by the presence of no more albumen than can be readily accounted for by the blood. (2) From intermittent hcematuria; this disease is rare in this country, and consists of occasional haematuria without fever. How should it be treated ? The treatment does not differ materially from that of remittent fever, except in— (1) The earlier, freer and more determined use of quinine (giving gr. xxx-xl per day, not waiting for the stage of remission, but ad- ministering the remedy as soon as the patient is seized with the dis- ease). (2) Keeping up the secretion of urine during the disease and follow- ing convalescence (by washing out the kidneys with mild diuretic mineral waters, as Vichy, etc., or flaxseed tea and plenty of water. It should always be remembered that acute Bright's disease may supervene). (3) By treating the hemorrhage with diluted sulphuric acid (gtt. v-x eveiy hour, continued during the remission until the urine loses its smoky appearance. Ergot may be used for the same purpose, or tincture of the chloride of iron (not so good). Gallic acid, gr. x-xxx, repeated at short intervals, is much used in Louisiana). (4) By giving, during convalescence, a long-continued course of mineral acids, with tincture of ferric chloride (or Basham's mixture), and quinine in tonic doses, given steadily and kept up for some time. Congestive Malarial Fever. What is this disease ? It is a fever due to a profound affection of the nerve centres by a concentrated malarial poison, and is characterized by symptoms of internal congestion. It is also called Pernicious Malarial Fever. 56 essentials of practice of medicink. What are the varieties of this disease? The principal varieties found in this country are the cerebral, the pulmonary or thoracic, and the gastro-intestinal forms, depending on the seat of the congestion. Another variety, the sweating form, is occasionally met with, but occurs especially in Italy. Any of the varieties may be of the quotidian, tertian, or quartan type. They are all characterized by the hot, cold, and sweating stages, as are the other forms of malaria. What are the symptoms of this fever ? It is never congested from the beginning, but starts as an ordinary remittent or intermittent fever, the symptoms, however, being much more severe than usual. In the second, third or fourth paroxysm, usually in the cold stage, it becomes congestive. In all the varieties there is marked prolonged chill, the surface being cold, but the internal temperature 106° to 108°. There is intense longing for fresh air, and great anxiety. This lasts for several hours, is followed by reaction and increased fever, followed in its turn by sweating, and a remission or intermission; or the cold stage or the hot stage may be followed by exhaustion, perhaps by death. The symptoms of internal congestion come on usually in the cold stage, last through the hot stage, and pass away in the sweating stage, to recur with the next paroxysm. In the cerebral form, in addition to the common symptoms, there is violent headache, fierce, active delirium, and coma. In the pulmonary form there is gasping for breath, cough, and sputa tinged with blood. On percussion the resonance is impaired ; on auscultation the vesicular murmur is almost suppressed, and rales are heard over both sides of the chest, with other symptoms and signs indicative of congestion of the lungs. In the gastro-intestinal form there is violent vomiting and purging, often rice-water stools, and collapse with a cold surface, like Asiatic cholera. In the sweating form the sweat is so severe and protracted that the patient appears to be wasting away before the eyes. After an intermission or remission all the symptoms return, with increased severity, and this is repeated until the patient dies or the attack is broken up. PERIODICAL FEVERS—CONGESTIVE MALARIAL FEVER. 57 What is the diagnosis and prognosis ? The diagnosis is easy ; the disease begins as an ordinary intermit- tent fever, symptoms of internal congestion being superadded to the third paroxysm. Prognosis. The first paroxysm is not very dangerous. In the second, death usually occurs in the cold stage. A third almost always terminates fatally. If treated from the beginning the prognosis is favorable ; if not, it is bad. How should it be treated ? (1) To Prevent a Threatening Paroxysm.—If the patient has had a severe chill and another is impending, morphine should be admin- istered hypodermically at once, followed by pilocarpine. This will lessen the severity, if it does not arrest the approaching chill. (2) If not seen until the chill, endeavor to bring on the reaction by frictions with hot turpentine, cayenne pepper, or hot brandy. Fric- tion should be applied to the whole surface, but particularly to the spine. In the cerebral form dry or wet cups may be applied to the nape of the neck, or even general blood-letting resorted to. In the pulmonary variety wet cups or dry cups followed by hot turpentine fomentation should be applied to the chest. In the gastro-intestinal variety dry or wet cups, or leeches should be used externally, and opium should be given internally, combined with blue mass, or with acetate of lead, camphor and capsicum. (3) When reaction takes place and the fever is high, the tempera- ture should be reduced by antipyrine and cold sponging, and the circulation regulated by aconite. In the sweating variety atropine should be administered, and the surface sponged with whiskey and alum or other astringents. (4) To prevent recurrence quinine should be given as soon as the patient is seen, preferably in solution and by the mouth, if not contraindicated, giving at least gr. xl before the next paroxysm. If there is much gastric irritability it may be given in suppositories by the rectum in double the dose ; or if the bowels are also irritable, the tartrate, lactate or hydrobromate of quinine, or the muriate of 58 ESSENTIALS OF PRACTICE OF MEDICINE. quinine and urea, may be injected hypodermically, the dose being half as large as when given by the mouth. In children the oleate of quinine may be applied with friction to the skin of the abdo- men, thighs and axilla. The quinine should be continued for several weeks in small doses, the amount being increased at the septenary periods. Malarial Cachexia. Describe this condition and its treatment. This occurs— (1) After repeated attacks of any kind of malarial fever, or— (2) After a long residence in a malarial district, in persons who have not suffered from an attack of fever, but who have gradually absorbed the poison. Symptoms. Malaise, listlessness, attacks of dyspepsia, more or less acute, and sometimes slight jaundice, high-colored urine, malarial anaemia, and sometimes albuminuria (which may even prove fatal), sleepless or restless nights, and although there is no actual outbreak of fever, yet there is a certain periodicity manifested by the symptoms, as shown by their liability to recur at stated times. All this may last for months, and is particularly apt to recur in the Spring and Fall. The spleen is often much enlarged, and the patient presents a cachectic appearance difficult to describe, but easy of recognition. Post-mortem Examination. The liver and spleen are pigmented, the latter being sometimes enormously enlarged (so-called ague cake), glistens on section, and later undergoes waxy degeneration. The blood is deteriorated and contains pigment. Treatment. Change of climate, or at least change of scene for a time (moun- tains or seashore), is very essential. When this cannot be done, or as an adjunct, the secretions should be regulated by occasional saline laxatives, light diuretics, as Vichy or Poland waters, and the secre- tion of the skin kept up by systematic exercise and Turkish baths. Antiperiodics.—The system is generally saturated with quinine, but small doses of it (gr. ij-iv) may be given on rising in the PERIODICAL FEVERS—YELLOW FEVER. 59 morning, conjoined with Fowler's solution (gtt. ij-iv t. i. d.), after meals. Iron and strychnine are also of use. For the ague cake, ergot should be administered hypodermically (in doses of n\, xx, every second day), or internally (especially in children). This is better than the treatment by iodine. Yellow Fever. What is yellow fever ? It is an acute, infectious epidemic disease, due to a special poison, consisting of one paroxysm of three stages, characterized by an abrupt beginning, with severe pains, albumen in the urine, remission and jaundice, black vomit and collapse. It is found in hot, low climates, as the West Indies, South America, the southern parts of the United States, Gibraltar, the Mediterra- nean, Siam, etc. It is also called the Yellow Jack, El vomito, Typhus icterodes, Mediterranean Fever, etc. What is its cause ? It is caused by a specific poison, not malarial in nature, but prob- ably a vegetable germ. It is epidemic, is very feebly contagious from the bodies of the sick, but spreads with great rapidity through merchandise, clothes, hair, etc. It does not seem to spread through infected stools, or water. It attacks strangers especially, and is self- protective. It is spread, not caused, by bad hygiene ; is destroyed by frost, or by heat exceeding 225°. What is the incubation period and duration ? The incubation period is from twenty-four hours to twenty-four days. The duration is from three to nine days, the average being seven. Describe a case of yellow fever. It consists of three stages: first, the fever stage, lasting from a few hours to three days ; second, the remission or lull, from twenty-four to thirty-six hours ; third, the stage of collapse and exhaustion. (1) Febrile stage; begins abruptly, with a chill, usually at night. There is headache, fever, brilliant eye, severe supraorbital pains, 60 ESSENTIALS OF PRACTICE OF MEDICINE. and pains in the sockets of the eyes, back and joints. Nausea, great thirst, and albumen in the urine. The muscular strength is well preserved, and the mind remains clear. Sometimes the patient is very restless, which is a bad symp- tom. After lasting from a few hours to a few days these symptoms all subside, and are followed by— (2) The stage of remission or lull, during which the patient is per- fectly well, except for a little gastric irritability and for the jaundice which now appears. The disease may end here, or pass into the third stage after twenty-four to thirty-six hours, never longer. (3) The stage of exhaustion or collapse; the tongue and skin become dry ; there is high fever ; irregular respiration; constant vomiting, often of blood (the black vomit) ; hemorrhages from the nose, and sometimes from the bowels ; occasionally petechial spots on the skin ; the jaundice deepens ; and, though recovery may take place, collapse and speedy death generally follow. Deviations of Type. (1) Inflammatory cases are those marked by high fever and severe symptoms in the first stage. (2) Congestive cases are those in which there is congestion of the internal organs, with early and grave prostration. (3) Walking cases are those in which the patient does not feel sufficiently ill to go to bed, but continues about his ordinary occupa- tions, thus overtaxing a heart which is weakened by granular and fatty degeneration, and which usually speedily gives out. Special Symptoms. The pulse is rarely above 100, irregular, and often below the nor- mal in the remission ; it usually rises in the stage of collapse, although it may be either slow or rapid. It is very small and weak in bad cases. The temperature in the first stage is usually from 100° to 102°, but may be as high as 105° or 106°, especially in inflammatory cases. It falls during the remission, but rises in the stage of collapse. Black Vomit— This consists of blood altered by the abnormal secretions of the stomach. It is found also in the intestines, and sometimes in the cavity of the pericardium. It generally appears in the third stage, after the skin becomes dry. It lasts until death PERIODICAL FEVERS—YELLOW FEVER. 61 supervenes, although it is not invariably a fatal symptom. The vomited matters come up without effort. Bleeding may occur from any mucous surface or may take place under the skin, therefore there is a hemorrhagic tendency. Black vomit is sometimes seen in other diseases, as in typhus fever, the plague, etc. Jaundice.—The skin is of a peculiar orange color. This is not true jaundice, but is due to disintegrated blood, as well as to bile in the circulation. It may be absent, and when present appears slowly at the end of the first and during the second stage. The urine contains albumen, even in the first stage. This may account for the coma and convulsions which are sometimes seen. Post-mortem Examination. The heart is granular. The stomach and upper part of the intestines are congested, their mucous membranes are softened, and ecchymotic spots of extrava- sated blood are formed on their surfaces. The liver is yellow, having undergone acute fatty degeneration. The kidneys are congested and granular. Disintegrated blood is found in the alimentary canal, pericardium, under the skin, and sometimes in other cavities of the body. How may this disease be diagnosed? Yellow fever is known by being epidemic, by consisting of one paroxysm of three stages, by beginning suddenly, with severe pains, albuminuria, remission, jaundice, black vomit and collapse. Differential Diagnosis. (1) From intermittent fever it is known by being epidemic, by the albuminuria, by the different temperature records, and by its consist- ing of one paroxysm. (2) From remittent fever, by its being epidemic, of shorter dura- tion and consisting of one paroxysm. By the presence of albumin- uria from the beginning, by the severe pains, by the absence of muscular prostration and by the black vomit. (3) From hemorrhagic malarial fever, by its being epidemic ; by the difference in the temperature record ; by the slow supervention of jaundice at the end of the first stage ; by the early albuminuria ; by the black vomit and the absence of hemorrhage from the kidneys, and by the fact that the paroxysm does not recur. 62 essentials of practice of medicine. (4) From typhoid fever; a mistake is only possible should the patient pass into the typhoid state during convalescence. The history of an abrupt beginning without intestinal symptoms or eruption; a knowledge of the epidemic, and the difference in the temperature record, should render the diagnosis clear. What is the prognosis and mortality of yellow fever ? In hospital practice the mortality is high, being from 30 to 50 per cent., while in private practice only 10 to 12 per cent. die. Walking cases are very dangerous. A very high temperature in- dicates a bad case. How should this disease be treated ? (1) Preventive Treatment. As this disease spreads by human intercourse, merchandise, clothes, etc., care should be taken, first, to destroy all clothing which comes in contact with the disease, or, if it cannot be destroyed, to disinfect it thoroughly and afterward to boil it. This is better than quarantine. Second, to disinfect the bodies of the sick, as it appears to be contagious from bodily contact; and third, to subject all vessels coming from an infected port to the action of superheated steam, as heat above 225° destroys the poison. (2) General Treatment. The patient should have plenty of fresh air and cooling drinks. Absolute repose in the recumbent position should be insisted upon, on account of the granular degeneration of the heart. Diet.—During the first stage he should be given as little food as possible, and that little should be very bland. During the second stage the diet should still be somewhat restricted in very small amounts, and very easily digested. In the stage of collapse he should be fed frequently, and if the stomach is too irritable to retain the food, it should be given per rectum. Stimulants are often necessary in this stage. Laxatives.—These should be given in the early stages, and con- tinued in small doses throughout the disease. Diaphoretics, as neutral mixture, with small doses of morphine, should be freely administered during the first stage. The latest treatment consists in giving small doses of corrosive ERUPTIVE FEVERS—SCARLATINA. 63 sublimate with bicarbonate of sodium, in large quantities of water, frequently repeated. (3) Treatment for Special Symptoms. If the temperature is very high in the early stages, sponging with ice water, or other cold applications to the surface, is indicated. If there is much nausea or vomiting in the early stages, carbon- ated waters, ice, cocaine, or a few drops of chloroform in iced gum-water, with mustard plasters to the epigastrium, is the best treatment. For the black vomit tincture of ferric chloride (gtt. v-x on shaven ice every third hour), or Monsel's solution, or cocaine, do good. As the kidneys are congested, plenty of cooling drinks, as cream of tartar lemonade, should be given throughout the disease, to pre- vent urinary suppression. ERUPTIVE FEVERS. Name the eruptive fevers. The eruptive fevers are scarlatina, measles, rubella, smallpox, varicella, erysipelas and dengue. Eruptive Fevers are all characterized by— (1) Having an eruption. (2) By being self-limited ; by running a definite course. (3) By being self-exhaustive and self-protective. (4) By being contagious, and— (5) By attacking children especially, with the exceptions of small- pox, erysipelas and dengue. Scarlatina. What is scarlatina ? Scarlatina is an acute fever, due to a special poison, characterized by a high temperature, a rapid pulse, a peculiar eruption, and a tendency to involve the throat. It is found all over the world, independent of climate, although most prevalent in the cold and temperate regions. It appears in 64 ESSENTIALS OF PRACTICE OF MEDICINE. epidemics, but is always present in cold climates, especially in winter. The first epidemic is described about the middle of the sixth century. Synonym. Scarlet feveri What is the cause of this disease ? It is due to a specific poison, which is highly contagious, and which resides partly in the breath, partly in the secretions, but more especially in the skin of the patient. The desquamated scales are highly contagious, and, clinging to the walls of rooms or to clothing, spread the disease. The disease is also inoculable by the blood or serum of the sick to the well. No special bacterium has been found. What are its symptoms and varieties ? Scarlet fever begins suddenly with vomiting (sometimes with a chill, sometimes with convulsions). The pulse is very rapid from the start, ranging from 130 to 180, and the fever very high. At the end of twenty-four hours an eruption appears on the face and neck, sometimes on the breast, and spreads all over the body in twenty-four hours more. The vomiting now lessens and stops, and sore throat (if not present earlier in the disease) now appears and becomes a prominent symptom. Nocturnal delirium is also present. The disease remains at its height for about one week, when the eruption begins to fade and desquamation occurs. The fever now subsides, but does not entirely disappear before the third week. The other symptoms, however, abate, and the patient is convalescent. Varieties. (1) Scarlatina Simplex.—This is the variety just described. (2) Scarlatina Anginosa.—In this variety the symptoms are similar to those of scarlatina simplex, but the throat symptoms appear earlier and are more marked. The tonsils and cervical glands are swollen, a grayish-white membrane is found on the throat, the mucous membrane of which is ulcerated, the breath is offensive, and frequently the thyroid gland is enlarged. (3) Scarlatina Maligna is the gravest form of the disease, the ERUPTIVE FEVERS—SCARLATINA. 65 nervous symptoms predominating. There is delirium and recurrent convulsions, very high fever (even as high as 115°); the throat symptoms are generally, but not necessarily, severe ; the eruption is irregular, often late in appearing, is livid, uninfluenced by pressure, and often interspersed with petechial spots. (4) Scarlatina Latens is a variety with no marked symptoms; the eruption may or may not be present, and the sore throat, of which the patient generally complains, may be very slight. It is, however, liable to the same complications and sequelae as are the most severe cases. Special Symptoms. (1) The eruption comes out at the end of the first twenty-four hours, and appears first on the face and neck, sometimes on the breast, as a bright scarlet rash. Appearing at first in minute dots, it soon becomes confluent, and spreads all over the body in twenty- four hours after its first appearance. It is most marked around the joints, and on close examination in these situations, minute spots are seen a little raised above the surface, and more vividly red than the surrounding skin. It disappears on pressure, except in malignant cases, when it is of a dusky or livid hue. It is associated with swelling of the skin, and is due primarily to congestion of the cutaneous capillaries. The superficial layers of the skin, when examined under the microscope, are seen to be infiltrated with embryonic cells, and superficial hemorrhages are found in the glandular structure of the mucous membranes. The eruption re- mains at its height for from three to five days, and then gradually fades in the order of its appearance. (2) Desquamation comes on when the eruption fades, and occurs first on the face, afterward on the body, in large flakes. It may continue for weeks. As long as it lasts so long is there danger of contagion from the patient. (3) Throat Symptoms.—These have already been described when speaking of the anginose varieties. (4) Fever Symptoms.— The pulse is very rapid. This is so early a symptom that causeless vomiting, and a pulse of 130 to 160 per minute, in a child, should lead to the suspicion of this disease, even before the eruption appears. The pulse remains frequent during convalescence. 5 G6 ESSENTIALS OF PRACTICE OF MEDICINE. The temperature rises to a great height early in the case, and remains high even after the eruption appears. It falls when the eruption fades, but while the morning temperature may be normal in the second week, the evening temperature will remain high, and it is not until the third week that it reaches the normal. What are the sequelae of this disease ? (1) Inflammation of the glands of the neck. (2) Enlarged tonsils and chronic sore throat. (3) Post-nasal catarrh. (These three sequela) are hard to cure.) (4) Chorea. (5) Scarlatinal rheumatism. (6) Valvular disease of the heart. (These three sequelae may appear long after the disease has subsided.) (7) Otorrhoea, and deafness, from extension of the inflammation from the throat into the ear. It may give rise to pyaemia from absorption of pus, or to inflammation and abscess of the brain. (8) Ulceration of the cornea. (9) Chronic diarrhoea. (Pcyer's patches, and the solitary glands are often enlarged.) (10) Scrofulous throat affection. (11) Persistent antemia, with glandular enlargement. (12) Inflammation of any of the serous membranes. (13) Tuberculosis. (14) Acute Bright's disease. This comes on as the disease dis- appears, about the tenth or twelfth day, rarely after the third week. Albumen is found in the urine in small amounts during desquama- tion in any bad case, but if inflammation of the kidneys supervenes, a large amount of albumen is found, and the urine will be scanty, high colored, and of a smoky appearance, from the blood which it contains. Under the microscope an abundance of red blood cor- puscles and tube casts containing blood and desquamated epithelium are found. As the acute stage subsides, the secretion of urine be- comes freer, the amount of blood diminishes, and then dropsy, which is rare in scarlet fever from any other cause, may come on, and rapidly increase to an enormous extent. How is scarlet fever recognized ? It is recognized by the eruption appearing at the end of twenty- ERUPTIVE FEVERS—SCARLATINA. 67 four hours, and preceded by vomiting, high fever, and very rapid pulse. Should the patient not be seen until later, the course, des- quamation and the marked sequelae, would aid the diagnosis. (]) From roseola it is diagnosed by the fever, the sore throat, and the eruption, which does not come and go as in the latter disease. (2) From dengue, by being contagious and occurring in epidemics, by rarely affecting adults, by the absence of pain in the joints, and by the eruption, which does not come and go as in the latter. What is the prognosis ? The prognosis differs in different epidemics and in different indi- viduals. Excluding the epidemics of malignant scarlet fever, in which the mortality ranges from 50 to 60 per cent., it would probably average 13 to 19 per cent. Unfavorable signs are convulsions, a temperature over 105°, and an irregular eruption. Should convulsions occur late in the disease, they are usually referable to uraemia, and give a better prognosis than when they occur early. Should this disease occur after surgical operations, or in pregnant or puerperal women, the prognosis is bad. Prognosis of Complications. When deafness occurs it is usually permanent. The prognosis of kidney complications is unusually favorable, con- sidering the nature of the disease and the gravity of the symptoms. By far the larger majority recover under appropriate treatment. The prognosis of heart complications is as bad regarding the ultimate result as when they follow acute rheumatism. How should this disease be treated ? (1) Prophylactic Treatment. Isolation must be complete and entire, not only of the patient, but of all who come in contact with him. There should be only one nurse, and she must change her clothing before coming in contact with others. Only the necessary furniture should be allowed in the room, which should not be carpeted. The patient must not be allowed to come in contact with others until desquamation has entirely ceased. Disinfection.—The body of the patient, and of all who come in contact with him, must be scrupulously disinfected. The desqua- 68 ESSENTIALS of practice of medicine. mated scales must be collected and burned. Such clothing as cannot be destroyed must be disinfected and boiled, and the room scrubbed with disinfectants, repapered and repainted after the disease is over. (2) General Treatment. Fever treatment and diet; anoint the skin ; keep up the action of the kidneys with plenty of diluents, and, as desquamation begins, give quinine in tonic doses, and infusion of digitalis if albuminuria is present, substituting Basham's mixture for the latter during con- valescence, and keep the patient in the room, or at any rate in the house, for three weeks after all desquamation has ceased, for fear of complications, as well as from fear of spreading the disease. (3) So-called Specific Treatment. Mercuric iodide has been lauded as a specific and to lessen the tendency to complications. Sodium salicylate has been used every three or four hours, inter- nally and by inunction (gr. xx to vaseline 3j). Used in the latter manner, it allays the burning and heat of the surface. Ammonium carbonate is good as a cardiac and nervous stimulant, if it does not produce gastric irritability. Potassium chlorate with tincture of ferric chloride is often used when there is much throat complication. (4) Treatment for Special Symptoms. For high temperature antipyrine, quinine, or digitalis lay be used, conjoined with sponging with tepid water and disinfectants. If cerebral symptoms are present with high temperature, put the patient in a warm bath and pour cold water on his head, thus lessen- ing the temperature of the bath rapidly. For restlessness and nocturnal delirium occurring early in the case, bromide of potassium and chloral may be cautiously given. To allay the irritation and burning and itching of the skin, any oleaginous preparation externally maybe used, especially the sodium salicylate. For the throat complications, keep the throat clean, and disinfected by boric acid in glycerine, potassium permanganate, thymol, or other disinfectant gargles. When the patient is too young to use a gargle spray the throat with an atomizer. Let the patient also have plenty of ice in the mouth. ERUPTIVE FEVERS—MEASLES. 69 In malignant cases reduce the temperature by cold baths, antipy- rine, etc., and stimulate even though the temperature is high. Quinine should be given in decided doses in these eases. During convalescence give quinine as a tonic, with tincture of ferric chloride. (5) Treatment for Complications. For ear complications the utmost cleanliness should be enjoined, and powdered boric acid blown into the auditory meatus. For convulsions, if occurring early in the disease, reduce the temperature by cold water treatment and by antipyrine, and give potassic bromide and a brisk purgative. When occurring later, they are generally of uraemic origin. Large amounts of fluids should be administered internally ; infusions of digitalis and chloral should be given, and cups should be applied over the kidneys. For kidney complications, large amounts of diluents should be administered, and infusion of digitalis, with some alkaline diuretic, given until the blood disappears from the urine ; at the same time dry or wet cups are employed externally. When the acute stage is passed, Basham's mixture should be substituted for the digitalis. A milk diet should be insisted upon until all trace of albumen has dis- appeared. When dropsy is present pilocarpine maybe administered in small doses, frequently repeated, and vapor baths employed. Measles. What is measles ? Measles is an acute, contagious, exanthematous fever, due to a special poison characterized by marked catarrhal symptoms. Synonyms. Morbilli, Rubeola (this name is also applied to Rubella). Causation. It is due to a specific poison, which can be inoculated either by the nasal mucus or the blood. It is very contagious, especially among children. It usually attacks children from five to thirteen years of age, but may occur at any age, and when attacking adults is more severe. A second attack is exceedingly rare. The Incubation Period is from eight to twenty-eight days. 70 essentials of practice of medicine. Describe a case of measles. It begins with chilly sensations, catarrhal symptoms and fever, sometimes convulsions. On the second day the fever declines, but the other symptoms persist. On the fourth day an eruption appears, the temperature again rises, and the catarrhal symptoms increase. After the eruption has lasted for from three to five days it begins to fade, the fever declines and a minute desquamation sets in, the patient convalescing by about the tenth day. Special Symptoms. Eruption.—The eruption appears on the fourth day, first on the face and neck (from which it also first disappears), spreading slowly over the body, and consisting of papules arranged in crescentic patches, alternating with healthy skin. It lasts from three to five days, and gradually fades. Sometimes the eruption is delayed in appearance; in these cases there are apt to be grave nervous symp- toms. Catarrhal Symptoms.—The eyelids are swollen, there is a burn- ing discharge from the nose, sore throat with cough, and laryngeal catarrh. Occasionally the mucous membrane of the alimentary canal suffers from the catarrhal process. Fever Symptoms.—The temperature rises abruptly on the first day to 102° or more. On the morning of the second day a distinct remission occurs, the temperature falling almost to the normal, and then remaining stationary until the eruption appears, when it rises again to 102° or 103°, and continues there until the eruption has faded, when it returns to the normal. Varieties. Malignant or black measles occurs especially in adults, particularly among raw recruits, when it is called camp measles. The eruption is usually delayed, convulsions, delirium, or other nervous symptoms are present, and petechial spots occur under the skin and mucous membranes. It is a very fatal variety. Complications. (1) Pneumonia.—This is usually catarrhal, but in adults it may be croupous, and is a very fatal complication. (2) Pleurisy is occasionally seen. ERUPTIVE FEVERS—MEASLES. 71 Sequels. (1) Chronic cough or chronic sore throat. (2) Otorrhoea and deafness. (3) Enlarged lymphatic glands. (4) Development of the hereditary taints, as scrofula, phthisis, etc. What is the diagnosis and prognosis of measles? Diagnosis. This disease is recognized by the abrupt rise in temperature, the remission, the catarrhal symptoms, the second rise in temperature at the time of the eruption, and the eruption, followed by minute desquamation. Differential Diagnosis. (1) From scarlet fever it is differentiated by the eruption appear- ing later, and in the form of crescentic patches, with intervening healthy skin, by the catarrhal symptoms, by the lower tempera- ture, less rapid pulse, and the absence of pronounced throat symptoms. (2) From Typhus Fever.—A mistake is only possible in malignant cases. Here the presence of an epidemic of either disease, with the catarrhal symptoms and appearance of the eruption on the face in measles, or the marked cerebral symptoms and prostration in typhus, should reveal the nature of the disease. Prognosis. The prognosis is favorable. This disease is only dangerous through its complications and sequelae. It is more dangerous in adults, and especially among troops is it more apt to be malignant, and to have serious complications. What is the treatment of measles ? Give fever treatment and diet, and occasionally a laxative ; act on the skin and kidneys by a fever mixture, and treat the catarrhal symptoms. If the eruption is delayed and nervous symptoms are present, place the patient in a hot bath and pour cold water oh the head, as in scarlet fever ; at the same time administering quinine. Should the fever be high add aconite to the fever mixture, or even give antipyrine. 72 ESSENTIALS OF PRACTICE OF MEDICINE. In malignant eases reduce the temperature, give quinine, and stimulate boldly, to gain time. For itching of the skin sponge with warm vinegar and water, or anoint the surface as in scarlet fever. Should the cough prove troublesome, minute doses of opium or Dover's powder may be administered, or steam may be inhaled. For jiuhnonary complications treat as if they were the only diseases. Rubella. Describe this disease. It is an acute specific exanthem, due to a special poison, charac- terized by the peculiar eruption, somewhat resembling measles, and usually accompanied by very little fever. Synonyms. It is also called German measles, French measles, rubeola sine catarrho, and rbtheln. Symptoms. There is usually very little fever, the eruption appears on the first or second day, generally coming first on the neck or chest, and spreading more or less over the body. It comes and goes. Catarrhal symptoms are usually absent, or but very slight. There is sore throat, swelling of the lymphatic glands of the neck, often sore mouth, with swollen gums, and a variable amount of headache and lassitude. The disease lasts for a week or ten days, and is followed by little, if any, desquamation. Sometimes the hair falls out after this, as after other fevers. The eruption is not uniform. It is usually a coarse, measly rash, with large masses of intervening healthy skin. It is rose-colored, not crescentic, and frequently fades and reappears several times during the course of the disease. Complications. (1) Pneumonia. (2) Desquamative nephritis. Prognosis. It is not a dangerous disease, and the complications are but rarely seen. ERUPTIVE FEVERS—SMALLPOX. 73 Treatment. Fever treatment and diet, light laxatives and diaphoretics are indicated. For the enlarged glands the parts should be kept warm, and the neck rubbed with camphorated oil. For the sore mouth washes of borax and honey should be employed, and even local depletion of the gums may be required if the inflammation is severe. Other symptoms must be treated as in measles, should they require it. Smallpox. What are the varieties of smallpox ? There are two varieties of smallpox. Variola, or smallpox proper, and Varioloid, or modified smallpox. Both are produced by the same poison, and equally capable of transmitting the worst variety of this disease to the unprotected. I. Variola. What is variola ? It is an acute, specific, eminently contagious and infectious fever, characterized by a peculiar eruption consisting of three stages, by a remission of the fever and other symptoms when the eruption first appears, and a secondary fever when the eruption attains its height. What is the cause of this disease ? It is due to a specific poison, which is communicable from the time of the initial fever. It is highly contagious, and may be trans- mitted by the breath or other emanation from the body of the sick. The pus and scabs are most highly contagious. The poison clings to clothing. The black race are very susceptible. This is an old disease, having probably always existed in Asia, and having first been brought to Europe by the Crusaders. What is the incubation period and duration ? The incubation period averages fourteen days. Duration.— Four or more weeks must elapse before danger of contagion is over. 74 ESSENTIALS OF PRACTICE OF MEDICINE. Describe the symptoms of variola. It begins with a chill, moderate fever, intense headache and pain in the back and loins and legs, lasting for three days. Then a char- acteristic eruption appears, and the other symptoms abate or per- haps entirely subside. The eruption is at first papular, changing to vesicular, and finally becoming pustular. On the eighth day after its first appearance, the pus oozes out from the pustules, and a secondary fever occurs. The pus dries and forms scabs, the fever declines and the scabs fall off, leaving little depressed red spots, which heal by pitting. Special Symptoms. (1) The inkial or primary fever is like any other fever, but the headache and pains in the loins and legs are much more intense. It lessens or disappears when the eruption comes out. (2) The eruption comes out on the third day, first in the face, forehead and lips, but soon appears all over the body, and is papu- lar. On the second day of the eruption, the papules change to vesicles. On the third, fourth and fifth days, the vesicles become pustules. On the fifth, sixth and seventh days the pustules increase in size, become indented in the centre (spoken of as l^''umlnlicated,,) and surrounded by a distinct areola. On the eighth day of the erup- tion, usually, the pustules are at their height, and pus oozes from them at their base and forms scabs. This continues until the four- teenth day of the eruption, and is called period of maturation, after which the scabs begin to fall off and continue falling until about the twentieth or the twenty-eighth day. They leave little red or livid spots, which gradually become white indentations called pits. The character of the eruption determines the type of the disease. Variola is said to be discrete when the pustules are scattered; confluent when the pustules coalesce (and the symptoms are more severe), and malignant when extravasations of blood occur into the pustules, and grave symptoms of blood poison are present. (3) The secondary fever usually occurs on the eighth day of the eruption (eleventh day of the disease), when the pustules maturate. It is caused by a slight degree of septicaemia, due to the absorption of pus into the circulation. During this time the face is immensely swollen, there is delirium, dyspnoea, and grave complications are apt ERUPTIVE FEVERS—SMALLPOX. 75 to occur. It is the period of greatest danger. The worse the case, the worse the secondary fever. What are the varieties of variola ? (1) Variola disereta is the variety just described, each pustule being separate and distinct. It is the mildest type of this disease. (2) Variola confluens is characterized by greater severity of symp- toms and by the tendency of the pustules to run together in masses, forming enormous scabs, particularly in the face. (3) Variola maligna or black smallpox is the most severe variety of the disease. The eruption may come out early, or may not appear until after death. Petechial spots occur on the skin, and blood is extravasated into the vesicles and pustules. There is active delirium passing into stupor and coma. The patient usually gets better or dies in the first week. What are the complications of smallpox ? (1) Salivation. (2) Inflammation or ulceration of the cornea. (3) Pulmonary congestion. (4) Pneumonia. (5) Pleurisy. (6) Formation of abscesses. (7) Periostitis. (8) Caries or necrosis, particularly of the lower extremities. (9) And other complications, such as are seen after low fevers generally. Describe the anatomy of the pustules. Each pustule is subdivided into compartments (which do not com- municate with each other), by little septa of connective tissue. The glands of the skin and the hair pass through them. The pus does not apparently differ chemically or microscopically from ordinary pus. Pustules are found not only on the skin, but on the broncho-pul- monary mucous membrane, and perhaps give rise to the laryngeal and pulmonary complication. They are sometimes found on the pleura, but rarely in the peritoneum. It is exceedingly rare to find them in the gastro-intestinal tract, 76 ESSENTLVLS OF PRACTICE OF MEDICINE. Describe the post-mortem appearances of variola. With the exception of the eruption there is nothing characteris- tic. The blood is black and fluid, the heart is sometimes granular, and the kidneys are sometimes congested. How is this disease diagnosed? This disease is recognized (1) By the initial fever, with intense pain in the back. (2) By the eruption appearing on the third day on the face, being at first papular, changing to vesicular and becoming pustular. (3) By the initial fever subsiding and its symptoms abating when the eruption first appears, and (4) By the occurrence of a secondary fever when the pustules maturate. What is the prognosis and mortality of variola ? The prognosis is favorable if the case runs a typical course. It is vnfavondle if the secondary fever is severe ; if the kidneys do not act well; if there is marked salivation ; if buboes and ab- scesses form ; if it is complicated with pneumonia; if there are severe cerebral symptoms ; or if it occurs in pregnant women. The mortality in discrete smallpox is about four per cent., in confluent smallpox about fifty per cent.; in malignant smallpox nearly all die. It is least fatal between the ages of fifteen and thirty years ; it is most fatal before ten and after sixty years of age. Is this a self-protective disease ? As a rule, one attack will protect forever from the disease. Should the patient have a second attack it is generally fatal. From a third, very few, if any, recover. How should it be treated ? (1) Prophylaxis. Most thorough isolation should be practiced. There should be as little furniture in the room as possible, and the patient must be attended by but one nurse, who should be scrupulously isolated, and should never come in contact with any one without having pre- viously changed her clothes and thoroughly disinfected herself. The attending physician should not stand nearer the patient than is neces- ERUPTIVE fevers—SMALLPOX. 77 sary to make a thorough examination, should not prolong his visit unnecessarily, and should never go to visit others to whom he may communicate the disease, without having changed his clothing and disinfected his whole person. The patient should be sponged with disinfectants, and the clothing, bedding, etc., destroyed when the disease is over. The room should be thoroughly disinfected, and ventilated for a long time before it is again occupied The scabs should be collected and burned, and the patient have a thorough dis- infecting bath after all the scabs have fallen from his body, before he is allowed to come in contact with others. (2) General Treatment. Give ordinary fever treatment and diet, and feed liberally, and stimulate toward the period of maturation. Keep the room dark, and have it thoroughly ventilated. Treat such symptoms as require it, on general principles. There is no specific. Xylol may be given. Carbolic acid or the sulphocarbolates have been recommended. Thymol has also been used. (3) Treatment of Special Symptoms. If diarrhoea is present, sulphuric acid with a little morphine may be used. If the throat symptoms prove severe, boric acid and glycerin, or potassium permanganate gargles are useful. For delirium when fierce and active in the initial fever, bromides and chloral, with cold to the head, will generally give relief; when low and muttering {usually in the secondary fever), camphor, opium, given cautiously, free stimulation, and nourishing food at frequent intervals, is the best treatment. During convalescence give tincture of ferric chloride and quinine, as tonics. To prevent pitting keep the patient in a dark room, and apply anything to the exposed surface which will keep out light and air. Corrosive sublimate lotions have lately been much employed. (4) Treatment of Complications. If salivation is profuse, astringent gargles, as a solution of tannic acid, are indicated. 78 ESSENTIALS of practice of medicine. For ulcers of the cornea, touch each ulcer with nitrate of silver in strong solution, or in the form of lunar caustic. Feed the patient well, and stimulate boldly. For other complications, stimulate, nourish and treat as if it were the only disease present. II. Varioloid. What is varioloid ? Varioloid is variola modified by inoculation, vaccination, or occa- sionally by a preceding attack of variola. How does it differ from variola ? It differs from variola, (1) In having an initial fever of less intensity, and .characterized by less violent symptoms. (2) By the eruption appearing one day later. (3) By the eruption running a more rapid course, many of the papules aborting without even reaching the vesicular stage, and the pustules which are present maturating sooner than in the unmodi- fied disease. (4) By the absence of the secondary fever—therefore the period of maturation is not particularly dangerous. (5) Ulceration of the cornea and other severe complications never occur. Means of Preventing Smallpox. What means may be employed to prevent smallpox ? (1) Inoculation, with the virus of smallpox. This usually gives rise to a milder form of the disease, but as occasionally it is followed by the most virulent type of smallpox, and as each inoculated person is a centre from which the disease may spread, it should never be practiced. (2) Vaccination.—This was first performed by Jenner, May 14th, 1796, and consists of introducing into an abrasion on the surface of a healthy person the lymph from an eruption on the udder of a cow affected with cow-pock, or, from the eruption produced in a human subject by lymph thus previously introduced. It affords an almost entire immunity from smallpox,—the few persons who take the ERUPTIVE FEVERS—SMALLPOX. 79 disease after a good vaccination suffering from it in a very modified form (mild varioloid). Re-vaccination should be practiced at the age of puberty, or in the face of a spreading epidemic of smallpox. How to Vaccinate. How is vaccination performed, and what will occur should it be successful ? (1) In vaccinating use human lymph or scab, or the virus taken from the cow affected with true cow-pock, which is much better than that produced by inoculating the cow with human smallpox. (2) Scrape the surface to be vaccinated until it is devoid of epi- thelium, and seram begins to exude from it. Make several slight incisions, and cross incisions, but not deep enough to draw blood. (3) Rub over this surface the matter, previously moistened, and protect it until it is thoroughly dry. (4) Watch the patient carefully, observing the vaccination to see whether it is a good one, or in other words really protective. If The Vaccination Takes— (1) About the fourth day a slight red papule appears. (2) On the fifth, sixth and seventh days this papule becomes a dis- tinct vesicle, and enlarges. (3) On the eighth day the vesicle is at its height, and a distinct regular areola is formed. (4) By the ninth, tenth or eleventh day it becomes a pustule with an enormous areola. (5) By the fourteenth day the areola fades and a crust forms. (6) By the nineteenth or twentieth day the scab comes off. When animal virus is used the course of the eruption may be three or four days later. If a patient is exposed to the contagion of smallpox it is better to vaccinate him immediately, as the vaccinia has almost run its course before the incubation period of smallpox is over, so that he will be at least partially protected from the later disease. SO ESSENTIALS OF PRACTICE OF MEDICINE. Varicella. Describe varicella. Varicella, or chicken pox, is a slight contagious fever, attended with vesicular eruption, which never becomes pustular. Cause. It is due to a specific poison which is not identical with that of smallpox, and from which it does not protect. The Incubation Period is less than a week. The Duration is about a week. Symptoms. There is a chill, slight fever, malaise, a vesicular eruption, ending in about a week by the formation of scabs, which fall off, sometimes leaving pits. The eruption comes out during the first twenty-four hours, and is vascular from the beginning. It is usually most marked on the trunk, and runs a rapid course, scabs forming by the fourth day. It is sometimes seen in the mouth, on the arches of the palate, the uvula and posterior pharyngeal wall, giving rise to sore throat. Complications are rare. The most important is pleurisy. Prognosis. This is favorable. Death is exceedingly rare in this disease, and, when it occurs, it is due to some complication. Treatment. Isolate the patient, giving him fever treatment and diet, and treat any symptoms which may require it. If the bowels are constipated make use of laxatives. If the fever is high give aconite or veratrum viride. To prevent pitting, when the eruption is on the hands or face, make use of the same means as are indicated in smallpox. ERUPTIVE FEVERS—ERYSIPELAS. 81 Erysipelas. Describe erysipelas. Medical erysipelas is an acute eruptive fever, attended with well- marked constitutional symptoms, the eruptions being usually limited to the head and neek. It is also called St. Anthony's Fire. Cause. It is due to a special poison, and is slightly contagious. It may, however, be carried in clothes, or on the person of a physician or nurse, to a puerperal woman, and give rise to puerperal septi- caemia. Incubation period is less than a week, and the duration is about a week. Symptoms. It begins with a chill, fever, eruption, swelling of the skin, gastric disturbance, albuminuria; the glands of the neck are frequently swollen, and cardiac murmurs are often present. Sometimes there is nocturnal delirium. After lasting several days the eruption gradually fades, and desquamation follows. Special Symptoms. The eruption starts as a little red spot on the side of the nose, cheek or ear, and spreads rapidly over one side of the face and head, and sometimes the neck. The color varies from a vivid red to a yellowish-red or dusky hue. Sometimes the entire head and neck is involved. The swelling is great, the parts are oedematous, and pit on pres- sure. The fever is often very high and is preceded by chills of greater or less severity. Varieties. (1) Simple erysipelas is the variety just described. (2) Phlegmonous erysipelas is that variety in which the deeper structures are involved, the swelling being much greater, the parts more dusky in color, and abscesses usually forming in the connective tissues. 6 82 essentials of practice of medicine. (3) Gangrenous erysipelas is rare in this country. In this variety the skin and subjacent struetuies become gangrenous. It may be epidemic, and is especially seen among troops. (4) Erysipelas ambulans or migrans is a form of erysipelas in which various parts of the body are successively involved. Complications. (1) (Edema of the glottis. (2) Bronchitis. (3) Pneumonia. (4) Abscesses. (5) Endocarditis (rare). (6) Cerebral Erysipelas.—In this complication the inflammation extends to the brain, through the communicating branch of the facial to the internal maxillary vein, thence to the pterygoid plexus, and thus to the cavernous sinus. The symptoms are grave nerve disturbance and very high tem- perature. What is the diagnosis and prognosis of this disease ? Erysipelas is recognized by the chills, the fever, the gastric dis- turbance, the eruption usually limited to the head and neck, which are much swollen, the albumen of the urine, and the swelling of the glands of the neck. Differential Diagnosis. (1) From Erythema.—The latter is not confined to the head, as a rule ; it runs an irregular course, and there are no constitutional symptoms. (2) From Roseola.—This disease shows no tendency to spread, and runs an irregular course. Prognosis. This is usually favorable. It is unfavorable— (1) In drunkards. (2) In cases marked by much delirium, stupor, coma or other cerebral symptoms, showing blood poison. (3) In cases with severe internal complications. (4) In protracted cases of erysipelas ambulans, in which the patient may die, worn out by the successive attacks. ERUPTIVE FEVERS—ERYSIPELAS. 83 How should erysipelas be treated ? (1) General Treatment. Isolation, disinfection and cleanliness. Fever treatment and diet and mild purgatives, with diaphoretics, should always be used. It is useless to attempt to limit the spread of the eruption by local applications. (2) Local Treatment, however, gives relief, and should always be resorted to. (a) Moist applications, as corrosive sublimate lotion, lead water and laudanum, or poultices may be used. Or— (b) The surface may be dusted with powdered starch, bismuth, or oxide of zinc. Or—■ (c) Ointments may be applied, as zinc ointment, cold cream, etc. (3) Specific Treatment. When the patient is strong and active, and the disease appears to be spreading rapidly, especially when the temperature is high, hypo- dermic injections of pilocarpine (gr. J) will often abort the attack. Tincture of the chloride of iron (gtt. xx-xxx) every third hour, combined with quinine (gr. xvj per day) is also of great value. (4) Treatment for Special Symptoms and Complications. Should the throat symptoms be severe, cleanliness and disinfecting gargles must he used, and the throat may be painted with Monsel's solution in glycerin. Should oedema of the glottis be present every means must be taken to arrest the inflammation, and if all fail and the patient is in danger of suffocation, scarification of the glottis or tracheotomy should be performed without delay. When phlegmonous abscesses form, the pus should be evacuated by an early incision, and the parts treated antiseptically. Low muttering delirium due to weakness or septicaemia should be treated by quinine and stimulation. If the inflammation extends to the brain, free purgation, arterial sedatives and bromide of potassium, with opium, should constitute the treatment. S4 essentials of practice of medicine. Dengue. What is this disease ? This disease, which is also known as break-bone fever, dandy fever, etc., occurs in epidemics, principally in the East and West Indies and the southern United States, and is characterized by symp- toms resembling both those of scarlatina and those of acute rheuma- tism combined. The Cause is unknown. It is contagious. Symptoms. It begins with stiffness, pains and swelling in some of the smaller joints, with pain in the back and stiffness and aching of various muscles, especially affecting those of the neck. There is fever and headache. These symptoms last for three or four days, and then the fever declines and the other symptoms lessen or pass away. After an interval of two or three days the symptoms return, and in addition there is usually much gastric irritability and a heavily coated tongue. From the fifth to the seventh day of the disease an eruption appears and the other symptoms again subside. The eruption usually resembles that of scarlet fever, but sometimes is in the form of papules and occasionally of wheals or vesicles. It lasts for two or three days and is accompanied by much irrita- tion of the skin. During convalescence there is much depression and muscular weakness, and arthritic pains and stiffness may per- sist for some time. The lymphatic glands are sometimes enlarged. Diagnosis. The disease is recognized by the muscular and arthritic pains, the fever, the lull, the eruption, the termination, and the knowledge of an epidemic. Prognosis. Favorable. Treatment. The patient must be isolated, as the disease is contagious. He should be placed on fever treatment and diet, and confined to bed until convalescence is established. There is no specific. Quinine may be given in tonic doses throughout the disease and, as conva- lescence approaches, combined with iron and strychnine. DIPHTHERIA. 85 A moderate amount of stimulation is serviceable after the primary fever subsides. For the pains, Dover's powder, or even antipyrine or phenacetin may be administered. The joints are treated locally, as in acute rheumatism. For the itching and burning of the skin the treatment is similar to that of scarlatina. Diphtheria. What is diphtheria ? Diphtheria is an acute general disease, characterized by a conta- gious sore throat in which membrane forms on the tonsils, uvula, and back of the fauces especially, but may form on the skin, in the bladder, stomach and intestines, nares, or bronchial mucous mem- brane. Glandular enlargements also occur and there is great general depression, out of proportion to the local symptoms. Synonyms.—It is also called Egyptian sore throat, malignant sore throat, synanche maligna, etc. This disease was known to the ancient Egyptians, but disappeared for centuries, to reappear again in the early part of this century. What is the cause of this disease ? It is due to a special poison, connected probably with bad drain- age. It clings to walls, is frightfully contagious, may be communi- cated by the breath or membrane, and is usually epidemic. It is more intense during cold weather, and may affect any age ; but is most common from two to seven years of age. Describe the membrane. The membrane is diffused on the surface; it consists of fibrin, de- generated epithelium, blood corpuscles, pus, and bacteria. It at first is free on the surface, but soon extends in and through the mucous membrane and into the glands. No peculiar bacteria have been found. As far as has been ascertained, they are not the cause but the consequence of diphtheria. The mucous membrane under- lying the false membrane is usually superficially ulcerated, the cervical glands are swollen and full of bacteria. The membrane remains for a week or ten days, disintegrates, is loosened, and comes 86 ESSENTIALS OF PRACTICE OF MEDICINE. off, leaving the underlying surface normal, or only superficially ulcerated. The membrane has a strong tendency to recur, is con- stantly forming, or spreading to other parts. What are the symptoms of diphtheria ? It begins usually with a chill, vomiting, slight fever, and a sore throat, with difficulty in swallowing from the first; soon the peculiar membrane is seen in the throat, beginning as a grayish exudation which appears in spots on the fauces, palate, roof of the mouth and tonsils, the spots rapidly coalescing ; the glands of the neck become swollen, the voice is muffled and nasal, the breath offensive and there is great general depression. All this lasts for a week or ten days when the membrane begins to disappear by shriveling up, being expectorated or swallowed. Albumen, if not present in the urine before appears about this time ; convalescence is tedious, the patient being very weak, pale and anaemic. The patella tendon reflex is abolished. Relapses may occur, the patient finally dying from exhaustion; or grave symptoms of blood poisoning may supervene and the patient die of septicaemia or pyaemia. What are the complications of diphtheria? (1) Laryngeal diphtheria, where the membrane extends into the larynx, causing cough, muffled voice, oppressed breathing, and symptoms like those of membranous croup intensified. (2) Nasal diphtheria, where the membrane extends into the nose, causing a thin irritating discharge and usually symptoms of blood poisoning. This is the most fatal form of the disease. What is the incubation and duration of diphtheria? The incubation period is about a week, the average duration two weeks. What are the sequelae ? (1) Paralysis of the muscles of deglutition causing difficulty in swal- lowing and regurgitation of fluids into the nose. This may appear two or three months after convalescence. (2) Local or general paralysis of sensation or motion. (3) Paralysis of the bladder, which may appear several months after the disease. DIPHTHERIA. 87 (4) Paresis or weakness of the heart, which may give rise to cardiac failure. This may come on during the disease, and last for a long time after convalescence is established. (5) Perversion of the special senses, as defective eyesight, perverted taste or smell. (6) Persistent anazmia. How is this disease diagnosed? Diphtheria is recognized by the knowledge of an epidemic, the presence of the membrane in the throat, the great nervous depres- sion, the enlargement of the cervical glands, and the presence of albumen in the urine. Differential Diagnosis. (1) From scarlet fever, it is known by the tendency of the mem- brane to spread, by its firmer consistence, by the absence of eruption, and by the difference in the pulse and temperature. (2) From follicular sore throat in children. In these cases the membrane is strictly limited to the follicles of the tonsils, and can be scraped away in masses. It does not tend to return, and there are no sequelae, and no great nervous depression. (3) From stomatitis or thrush occurring in low fevers. In thrush the deposit occurs on the gum and consists of fatty material inter- spersed with a parasitic growth. It is soluble in ether and acids, but not in alkalies, as is the diphtheritic membrane. (4) Laryngeal diphtheria may be diagnosed from membranous croup, by the membrane beginning above, in the pharynx, and spread- ing downward into the larynx in 99 per cent, of cases, by the albumen in the urine, and by the prominence of the constitutional symptoms from the onset. What is the prognosis and mortality ? The prognosis is always grave, but no case should be despaired of. Unfavorable symptoms are, great swelling of the-glands, marked albuminuria, and extension of the membrane into the nose, larynx, and gastro-intestinal canal. The mortality varies greatly in differ- ent epidemics. In a mild epidemic it will average about five per cent., in a grave epidemic about thirty-three per cent. SS ESSENTIALS OF PRACTICE OF .MEDICINE. How should this disease be treated? (1) Prophylactic Treatment. Strict isolation should be enforced, as in the contagious fevers. Thorough ventilation should be practiced, and everything coming from the patient should be scrupulously disinfected. (2) General Treatment. Fever diet must be given, the patient being sustained every two hours, as in typhoid fever. Free stimulation should be resorted to, giving alcohol, for its effect on the strength, pulse and mind of the patient. There is a great toleration for alcohol in this disease. (3) Medical Treatment. Very early in the disease, when the membrane is first forming, the application of a strong solution of sulphate of copper, or of Monsel's solution, with equal parts of water freely applied to the throat, is occasionally serviceable. After the membrane has formed, strong applications are injurious; the throat should then be kept disinfected with potassium perman- ganate, or a solution of salicylic acid (seven per cent), or thymol (gr. iv, in glycerin and water). Internally the mercurials give the best result; corrosive sublimate may be given in doses of gr. ^V every two hours, and increased to the point of tolerance, or calomel may be given in doses of gr. xx three times daily, especially when there is tendency to laryngeal complications. Many prefer to give smaller doses of calomel, fre- quently repeated. Mercurial should always be guarded by a little opium. Tincture of the chloride of iron, with or without chlorate of potassium, is sometimes used in large doses, with a little quinine, as in erysipelas. (4) Treatment of Complications. (a) In laryngeal diphtheria inhalations of the vapor of slaking lime, followed by emetics if the patient is not too weak, are some- times of use. The sufferer must be supported by frequent feeding, and stimulation should be pushed to the verge of tolerance. Saturated solutions of pepsin, trypsin or papain may be sprayed into the throat with the view of dissolving the membrane. Should all else fail, intubation or tracheotomy should be resorted to. general diseases—parotitis. 89 (b) For nasal diphtheria constitutional treatment must be pushed, and the nostrils kept clean with disinfectant solutions employed with a nasal douche or long syringe. (5) Treatment of Sequelae. In the treatment of paralyses time is a great factor,, and good hygiene, iron and quinine administered internally, and strychnine hypodermically, with the use of galvanism, and sea-bathing when possible, are useful adjuncts. For persistent anaemia, cod-liver oil, alterative and nutritive treat- ment and sea-voyages give the best result. For the weak heart, rest, digitalis, strophanthus, strychnine, and a moderate amount of alcohol are to be employed. Parotitis. What is parotitis ? Parotitis, or mumps, is an acute, infectious disease due to a special poison occurring in epidemics and characterized by an acute inflam- matory process affecting one or both of the parotid glands. It is usually a self-protective disease, and attacks children or young adults. What is the period of incubation of this disease ? The period of incubation is two or three weeks. What are its symptoms ? It appears suddenly with a chill, fever, malaise, and headache. The temperature may be as high as 103°, the pulse is quick and irritable. After a day or two there is stiffness of the temporo- maxillary articulation, the parotid gland becomes swollen, the skin is often reddened, oedema of the face takes place, and pain is ex- perienced, which is greatly increased by any movement of the jaws or by taking any acid substance into the mouth. Salivation is often present. One gland is usually involved at a time, followed, as the swelling subsides (in a week or ten days), by a similar attack in the opposite gland. Metastatic involvement of the testicle, ovary, or mammary gland sometimes occurs, and is not unfrequently followed by permanent impairment of their functions. 90 ESSENTIALS OF PRACTICE OF MEDICINE. What is the prognosis of mumps? The prognosis is always favorable. The only danger is that if metastasis occurs, the organs involved may be permanently damaged. What is the treatment of mumps ? The treatment is entirely symptomatic. Pilocarpus has been used with some success as a specific. The patient should be kept warm, and dry or moist heat applied to the face. Pertussis. What is this disease ? Pertussis, or whooping-cough, is an inflammation of the larynx and bronchial mucous membrane, with characteristic nervous phe- nomena, and is eminently contagious. It is a disease of childhood, is epidemic, the epidemics usually following those of measles. It is due to a specific poison. What are the symptoms and complications of whooping- cough ? The disease consists of three stages :— (1) The Catarrhal Stage, in which the symptoms are naso-laryngo- bronchial catarrh, often associated with nocturnal dyspnoea. (2) The Nervous Stage.—During this stage the whoop comes on. The catarrhal trouble continues, but the paroxysms of coughing be- come more severe, and the expiratory efforts keep up until the eyes fill with tears, the face becomes deep red and livid from interference with the aeration of the blood, and the child is thoroughly exhausted. Then follows an inspiratory whoop, after which the expiratory efforts again continue. After a time a thick, tenacious mucus fills the mouth, the child often vomits, and the paroxysm of cough ends. The paroxysm is often produced by hearing others cough and fre- quently by the sight of food. In severe cases, bronchial or conjunc- tival hemorrhages may occur from rupture of small capillaries during the paroxysm; and hernia has resulted from the violence of the cough, in boys with patulous inguinal canals. (3) The Stage of Decline.—The symptoms gradually pass away, the cough becoming less and less frequent. GENERAL DISEASES—PERTUSSIS. 91 Duration. The first stage usually lasts for eight or ten days. The second stage about two weeks ; the whole disease about six weeks, or some- times much longer. Complications and Sequelae. 1. Pneumonia, a dangerous complication. 2. The development of latent taints, as scrofula or tuberculosis. What is the prognosis, diagnosis and treatment ? The Prognosis is favorable, the danger lying in the complica- tions or sequelae. Diagnosis. The disease is recognized by the attacks of dyspnoea, the catarrhal trouble, the whoop, and the knowledge of an epidemic. Physical examination of the chest reveals nothing more than in ordinary bron- chitis. Treatment. Warm baths and diaphoretics are always of service. Try to get the patient to resist the tendency to cough. If the catarrhal symp- toms continue, squill or ammonium chloride is of advantage. If the secretion is excessive, alum should be employed internally. Ouabain has been recently strongly recommended, given in doses of gr- rrnnr every three hours, to a child over a year old. It may be used in any stage of the disease. For the paroxysms of cough, quinine, chloral and bromide of potassium may be given every few hours, or small doses of prussic acid, or antipyrin, acetanilide or phenacetin may be employed, or cocaine may be applied to the parts. Asafoetida, musk and other antispasmodics are sometimes of use. Quinine in large doses is occasionally very serviceable. It should at any rate be used as a tonic, and should be employed in the form of suppositories. After the disease is over cod-liver oil should be given, and, if pos- sible, change of scene and air prescribed. 92 ESSENTIALS OF PRACTICE OF MEDICINE. Cholera. What is cholera ? Cholera is an acute, epidemic, infectious disease, characterized by excessive vomiting, violent serous purging, severe cramps and col- lapse. It is a native of India, where it is always present, and from whence it spreads in epidemic -waves, usually traversing the entire civilized world before it subsides. What is the cause of this disease ? It is due to a special poison, probably to the cholera bacillus of Koch, which is always present in the dejecta of those suffering from the disease. This poison is especially transmitted by running water, in which it multiplies with marvelous rapidity, and to which it finds its way from clothes which may have been washed in a stream, or from cholera stools which have been carelessly thrown away. It may also be transmitted by merchandise. By these means especially does the infection spread. What is the period of incubation ? The period of incubation is very short, the average being about four days. What are the symptoms ? Cholera may commence suddenly, or it may be preceded by an attack of diarrhoea, which is more persistent and more severe than an ordinary diarrhoea, and usually accompanied by nausea, vomiting, pain and depression. The disease consists of three stages :— (1) The incipient stage—that of diarrhoea. (2) The stage of the fully developed disease, and— (3) The stage of collapse, or, if the patient is about to recover, the stage of reaction, followed by the condition known as cholera typhoid. First Stage.— Cholera usually begins with chilliness, a coated tongue, pain in the neighborhood of the umbilicus, thirst, diarrhoea, perhaps vomiting, malaise, and often a morbid dread of the disease. The stools at first are watery, but contain fecal matter; they are voided with considerable force, and rapidly become more serous, GENERAL DISEASES—CHOLERA. 93 losing their fecal characters. After this has lasted for a variable period, usually several days, the disease becomes fully developed. Second Stage.—The diarrhoea now becomes more marked, profuse and watery, and is so continuous that the patient hardly has time to rise from the commode before he is obliged to return to it again. The force with which they are voided increases until they are fairly shot out from the patient's body. The passages now consist of large quantities of grayish fluid, consisting of serum and epithelium, re- sembling rice-water in consistence and appearance (hence the name applied to them). The same matters are vomited, or perhaps the vomited matters may contain bile. There is no particular pain attending the passages, but the patient suffers from intense thirst, due to the escape of the fluids from the body and, consequently, from the tissues generally. Cramps soon come on in the calves of the legs especially, but in all parts of the body as well, which are very severe in character, and the patient becomes too weak to rise from his bed. Third Stage.—The patient very soon passes into the stage of col- lapse, or reaction takes place. The latter condition is sometimes seen even when the patient has been in the stage of relapse. Collapse.-—The rice-water discharges continue to be voided both from the mouth and the rectum, and the cramps continue with undi- minished severity. The loss of fluids is so great that the patient's body seems to shrink visibly under the very eyes of his attendants. His eyes are shrunken, the nose pinched, the cheeks hollow, and the lips and face livid from impeded circulation, the blood having become too thickened to flow freely through capillaries, and otherwise too much damaged to properly perform its oxidizing functions. The surface of the body is cold, the temperature falling sometimes as low as 73°. The breath is icy and seems to have lost its moisture, to have become dry. The vomiting and purging cease for want of expulsive power ; the veins become prominent and turgid with thick black blood, the pulse is feeble and very compressible, but may be either slow or rapid. The mind remains clear, although the sufferers usually be- come apathetic, probably from the accumulation of carbonic anhy- dride in the blood. The urine is scanty and contains albumen. This is the condition known as cholera asphyxia, or the algid state of cholera, from which very few recover, although reaction even from this condition sometimes occurs. 94 ESSENTIALS OF PRACTICE OF MEDICINE. Reaction.—When this comes on, the temperature of the body rises, and a secondary, or reactionary fever sets in, the temperature often going up as high as 103° or 104°. Simultaneously, the pulse also increases in volume and in strength, and the vomiting and purging lessen, and finally cease. The urine increases in amount, but still contains albumen, and the patient either recovers in a week or two, or passes, more generally, into a low typhoid state called cholera typhoid, which protracts his recovery for four or five weeks. What is the duration of an attack of cholera ? Sometimes the disease is very rapid, there being no prodromes at all, but simply severe vomiting and purging coming on very sud- denly, rapidly followed by collapse, death taking place a few hours after the appearance of the first symptoms. Usually, however, the disease lasts several days. When recovery takes place, the convales- cence is generally very tedious, and is often prolonged by the occur- rence of various sequelae. What are the complications and sequelae ? (1) Uramia is of frequent occurrence and may come on in any stage of the disease. (2) Bronchitis. (3) Pneumonia. (4) Parotitis, or, (5) Bedsores, may come on in any stage, but more particularly in the last, and prove to be exceedingly serious complications. The Sequels are— (1) Ancemia, with great debility. (2) Irritability of the bowels, lasting for months. (3) A tendency to the formation of boils and abscesses, and (4) Other sequelae such as are common after any acute debilitating disease. What is found on post-mortem examination? After death from cholera the temperature of the body often rises. Rigor mortis comes on very rapidly, and the resulting muscular con- tractions are so powerful that the limbs are often displaced, or, at all events, the fingers and toes are moved, presenting a very'weird spectacle. The body is shrunken ; the blood thick, deprived of its GENERAL DISEASES—CHOLERA. 95 seram, and slightly acid in reaction. The veins are distended, while the arteries are entirely empty. The mucous membranes are pale and anaemic, except here and there in the intestine where there are spots of intense congestion, even devoid of epithelium. The stomach and intestines contain large quantities of a rice-water-like fluid, mingled with epithelial debris, and, under the microscope it is seen to contain large quantities of the peculiar bacillus of cholera. The kidneys are congested and their tubules choked with desquamated epithelium. The veins of the medulla are enlarged and distended with blood. How is this disease diagnosed ? There is only one disease with which it might be confounded, and that (severe cholera morbus) is more likely to be mistaken for cholera, than cholera for it. The distinctive points are, the knowledge of an epidemic of Asiatic cholera, the greater severity of the symptoms from the onset, the early occurrence of the rice-water discharges, which are almost continuous, and ejected with much violence, the cramps which are much more severe in true cholera, and the presence of the comma-bacillus in the stools. What is the prognosis ? The prognosis is very unfavorable. The cases in which the disease comes on suddenly, are nearly all fatal. Those who were previously debilitated, especially if debilitated by drink or by sexual excesses, usually suffer severely. When it attacks the very young or the very old, the prognosis is not favorable. How is cholera treated? (!) Prophylaxis. (a) If cholera is threatening a community, but is not actually present, everything must be done to insure the best possible hygienic conditions, and to this end old cess-pools must be thoroughly disin- fected, and, if possible, entirely destroyed; the utmost attention must be paid to the drainage, and the water supply must be rigidly inspected and guarded. The people must be made to understand that their safety depends upon the care which they exercise to prevent any of the emanations from cholera patients gaining access to the water which is used for domestic purposes ; that the cholera stools must be 96 ESSENTIALS OF PRACTICE OF MEDICINE. thoroughly disinfected, and when thrown away, they must not be cast where they can possibly infect any running water which that community or any other uses for drinking, cooking or washing. Clothes soiled by the discharges of cholera patients had better be destroyed than washed, or when that is impossible, they should first be thoroughly disinfected, then washed in water remote from any running stream, and this water carefully thrown away. These; pre- cautions, if strictly carried out, are much surer than quarantine, as it is usually practiced, which gives a false idea of security, without absolutely excluding the disease. (b) When the disease is actually present in a community, the sick must be separated from the well, and the latter pay the most scrupulous attention to their hygienic surroundings, to cleanliness of person, to their food, and to their drink. The water used for cooking or drinking must be previously boiled. The diet of those who are not suffering from the disease should be of the kind to which they are accustomed, avoiding, of course, any indigestible food, unripe fruit, or uncooked vegetables. Inoculations with cultures of the "comma-bacillus" have been practiced in Italy and Spain as preventives to cholera. The result is still sub judice. (2) General Treatment. The patient must be placed on fever treatment and diet from the start of the disease, but should be given no water. Small pieces of ice may be dissolved in the mouth, or a little brandy and ice, or small amounts of iced aerated waters may be given. It is of the utmost importance to check the diarrhoea as soon as possible, and no case of diarrhoea, no matter how trifling it may seem, should be neglected during the prevalence of an epidemic of cholera. For this purpose the best remedy is sulphuric acid com- bined with opium or morphine. Acetate of lead (gr. iv) combined with opium (gr. j) repeated in an hour, if the diarrhoea continues, may be used instead of the sulphuric acid. If the disease passes into the second stage in spite of the treatment, with vomiting, purging and cramps, continue the use of the acid or of the lead acetate with opium (gr. ss-j) frequently repeated, and give morphine hypodermically as well, to allay the nausea and vomiting and to relieve the cramps. Do not, however, trust entirely to the morphine hypodermically, as opium, either in the solid form, or as ACUTE RHEUMATISM. 97 the deodorized tincture given by the mouth, produces the best effect in these cases. Chloral has been used hypodermically for the cramps, and may at all events be beneficially employed as an embro- cation dissolved in soap liniment. Stimulating frictions should also be employed, and mustard plasters applied to the surface generally. If this treatment is systematically carried out in the early stages of the disease, and is energetically pushed, the disease may be arrested. If, in spite of the treatment, the disease passes into the third stage, diffusible stimulants, persistent frictions with hot turpentine, and baths as hot as the patient can bear them, give the best results. Caffeine (gr. ss) and ether have been injected hypodermically with good results, and intravenous injections of saline solutions (sodium carbonate 3j, sodium chloride 3iij, with enough water to make the sp. gr. of the solution about 1020), giving about one to two pints of the solution at a time, have been used. Unfortunately, although temporarily of service, its effects are rarely lasting. When reaction takes place, or when the patient survives the stage of collapse, great attention must be paid to the state of the kidneys. Aerated mineral waters must be given in large quantities, both to supply the water to the system which it has lost, to keep the kid- neys acting, and to aid in the elimination from the blood of impuri- ties which would otherwise be retained in the system. GENERAL DISEASES-(B.) DIATHETIC DISEASES. Acute Rheumatism. What is acute rheumatism ? It is an acute constitutional disease, characterized by fever, acid sweats, and a special tendency to inflammation of the larger joints, which, however, are not permanently affected. Synonyms. Rheumatic fever; acute articular rheumatism. 7 98 ESSENTIALS OF PRACTICE OF MEDICINE. What is its cause ? It is predisposed to by the so-called rheumatic diathesis, which is generally hereditary. An excess of lactic acid is found in the blood, shortly before the attack, but whether it is the cause of the disease, or its result, is not definitely determined. Exposure to damp and cold is an exciting cause. What are the duration and symptoms of this disease ? If not treated, the attack will last from three to six weeks, or more. Under the present plan of treatment the duration is from ten days to three weeks. Symptoms. It begins with a severe chill, followed by fever and stiffness in the joints. Soon, however, the stiffness lessens, and the joint becomes red, swollen, painful on motion or to the touch, and hot. Acid sweats occur which do not lessen the pain, nor reduce the fever. The fever is usually not very high, ranging from 102° to 104°. The pulse is full and bounding. The tongue is coated with thick creamy fur. The urine is high-colored, scanty, and contains an abundance of urates. Acid sweats occur often from the beginning to the end of the disease. The Joints.—One joint, or corresponding joints on both sides, may be involved, and as the disease leaves one joint, others become succes- sively affected ; the smaller joints escape. What are the complications of acute rheumatism ? (1) Complications Affecting Serous Membranes. Endocarditis.—Vegetations form on the valves of the heart, and permanently impair their functions. Pericarditis. (2) Complications Affecting the Mucous Membranes are Rare. Bronchitis. (3) General Complications. Rheumatic Hyperpyrexia.—-This is a grave complication, charac- ACUTE RHEUMATISM. 99 terized by restlessness, delirium, albuminuria, and a temperature from 108° to 115. Cerebral Rheumatism.—Very dangerous, but rare. What is the morbid anatomy of this disease ? There is a local inflammation of the joint affected, and effusion takes place into the synovial cavity, but there is no ulceration, and no tendency to the formation of pus ; hence, no serious consequences to the joints. The blood contains lactic acid and an increased amount of fibrin. Heart lesions may or may not be found. How is this disease diagnosed ? The joints are hot, swollen, red and painful, but there is no ten- dency to suppuration. The attack leaves one joint in a few days, and others are apt to be involved, the first being well. The larger joints are affected ; there are acid sweats and a tendency to complica- tions, especially of the heart. Differential Diagnosis. (1) From Pycemia.—The latter disease is known by the history of some suppuration and the fact that the constitutional depression is much greater than in rheumatism. (2) From Gout.—This disease occurs after middle age, involves the smaller joints, and is followed by merely local sweats and des- quamation. A deposit of chalk stones takes place in the joints if the attacks recur, and a similar deposit is also found in the lower part of the cartilage of the ear. (3) From gonorrhosal rheumatism it is differentiated by the cause and history. (4) From Rheumatoid Arthritis.—The latter disease occurs in debilitated subjects, especially women ; is not attended by signs of inflammation or constitutional disturbance, and leaves the joints permanently deformed. Heart complications do not occur. What is the prognosis ? The prognosis is favorable. If the temperature rises to above 107° (hyperpyrexia), it is dan- gerous. Cerebral rheumatism is dangerous, but is rarely seen. 100 essentials of practice of medicine. Cardiac complications give a grave prognosis as to the future, but there is no immediate danger. They occur in about 50 per cent, of the cases. What is the treatment of acute rheumatism ? The patient should be confined to bed, should have easily-digested food as in fevers, and the joints should be wrapped in cotton and kept warm. There are two special plans of treatment. (1) Treatment by Salicylic Acid or the Salicylates.—This consists in giving the patient sodium salicylate, gr. xv-xx every two or three hours until two drachms have been taken in twenty-four hours, when the dose is reduced. Or in giving salicylic acid, gr. x every hour or two until six doses have been given, when the dose should be decreased or the intervals lengthened. Should disagreeable symptoms arise from the administration of these drugs (as nausea, tinnitus aurium, etc.), the medicine must be stopped. If no effect be observed within the thirty-six hours, the medicine should be aban- doned. These drugs must never be given to patients who are weak or anaemic, or where cardiac complications are threatening. The salt is preferred to the acid, as less likely to cause disagreeable effects. (2) The Alkaline Plan of Treatment.—This consists in giving potassium bicarbonate or acetate, gr. xl every two or three hours until one to two ounces have been administered in twenty-four hours, when the amount should be reduced one-half. If the latter plan of treatment is adopted, quinine should be given in tonic doses after the first three days, as it appears to lessen the liability to relapse. If there is much restlessness, ammonium bromide maybe conjoined with the other treatment, or small doses of Dover's powder given at night. The latter is also serviceable when there is much pain. During convalescence tincture of ferric chloride, with quinine, should be administered as tonics. Locally, hot applications may be applied to the joints, as a hot solution of potassium nitrate (gj) with laudanum (gj) in water (Oj). Or, an ointment consisting of cocaine gr. xx in lanolin (gj) may be applied and the part wrapped in raw cotton. If endocarditis occurs, the alkaline plan must be substituted for MUSCULAR RHEUMATISM. 101 the salicylates, or if the latter is being employed, the dose should be doubled. If pericardial effusion occurs, digitalis should be given, and a small blister applied over the heart. For hyperpyrexia, a cold bath or the application of iced cloths, and sponging with ice water, may be used externally, or antipyrine administered internally. For cerebral rheumatism the best treatment is stimulants and the administration of digitalis. If the joints remain stiff and a permanent lesion is feared, small blisters may be applied over them. Muscular Rheumatism. What is muscular rheumatism ? Muscular rheumatism is pain and stiffness in the muscular and fibrous structures due to exposure. The Synonyms vary with the situation. Thus, it is called lum- bago when it affects the muscles of the back ; pleurodynia when it affects the chest; torticollis or wry neck when it affects the sterno- mastoid and trapezius muscles, etc. Causation. It is due to exposure to drafts, especially when heated. There is usually an underlying rheumatic diathesis. The Duration is usually from three to seven days. But it may become chronic and last for months. Symptoms. There is pain, stiffness and sometimes swelling in the affected muscles, without redness, little or no fever, and no cardiac complica- tions. The pain is not continuous, but is produced by motion. Diagnosis. The disease is recognized by the history of exposure to drafts, par- ticularly if the patient is of a rheumatic diathesis. The pain remains in one situation, and is aggravated by motion. 102 essentials of practice of medicine. Differential Diagnosis. (1) Myalgia, or straining of a muscle, and is never accompanied by fever, and the history of strain gives a clue to the diagnosis. (2) Neuralgia.— Here the pain is limited to the course of the affected nerve, and it is not influenced by motion. There are painful points on pressure over the affected nerve. Prognosis. This is very favorable. When chronic it may be obstinate. What is the treatment of muscular rheumatism? In acute cases, rest and warmth usually result in a speedy cure. Dry heat may be employed, as by a hot salt bath, or passing a hot iron over the part, protected by a double blanket. Stimulating ointments or liniments may be used, and diaphoretics and broken doses of Dover's powder and nitre, given internally. If the disease lingers or becomes chronic, iodide of potassium and colchicum, large doses of quinine, or of ammonium chloride (gr. x- xx) may be given. Externally, belladonna plaster or pitch plaster with cantharides may be used. In very obstinate cases atropine (gr. ^y) with mor- phine (gr. ^) may be used hypodermically, two or three times a week. Deep injections of chloroform or of warm water have also been employed with advantage. Chronic Rheumatism. What is chronic rheumatism ? It consists in enlargement of the joints, following repeated attacks of the acute disease, combined with muscular rheumatism, and pro- ducing permanent deformity. Heart lesions are also usually present. How should it be treated ? Everything must be done to improve the nutrition of the patient. He should dress in warm flannel, and should use stimulating lini- ments containing ammonia, or chloral dissolved in soap liniment. Turkish baths or sulphur baths are of value. Internally, he may take alteratives, as potassium iodide, colchicum, sulphur, or cod- liver oil. RHEUMATOID ARTHRITIS. 103 Rheumatoid Arthritis. What is this disease ? It is a chronic disease consisting in a series of attacks of chronic inflammation of the joints, resulting in enlargement, anchylosis, dislocation, or other permanent deformity. What are its synonyms ? Rheumatic gout, arthritis deformans. What are its causes ? It is strongly hereditary. It occurs more frequently in women than in men. Bad hygiene, grief, anxiety, and overwork may favor its development in those who are predisposed to it. What is the duration of this disease ? It lasts for years, only ending with the patient's life. What are its symptoms and pathology ? A joint becomes stiff and swollen without fever or suppuration. The attack passes off, and again recurs in the same joint until it is destroyed, distorted, and generally anchylosed. Other joints are affected, and the patient finally becomes a helpless cripple. All this time there is little or no constitutional disturbance, except debility. The large and small joints are both affected. Morbid Anatomy. The articular cartilages are ulcerated, and become absorbed, or are destroyed. The synovial membrane is also destroyed, and the bones become eburnated by rubbing against each other. Suppura- tion never takes place. On what is the diagnosis of this disease based ? It is recognized by being a chronic disease, affecting the large and small joints alike, without constitutional disturbance, and never being complicated with disease of the heart. Differential Diagnosis. (1) From Gout.—It is diagnosed from this disease by the his- tory, by the absence of uric acid in the blood, by the absence of redness, by affecting the large and small joints, by the absence of 104 essentials of practice of medicine. chalk stones, and the presence of anchylosis or other permanent deformity. (2) From Rheumatism.—-It is hardly likely to be confounded with acute rheumatism, and can be diagnosed from the chronic disease by the absorption of the cartilages, the anchylosis and deformity, the absence of involvement of the muscular system, the slow progress and the absence of disease of the heart. What is its prognosis ? The sooner the treatment is commenced the better is the result obtained. If neglected the prognosis is terrible, the patient becom- ing a helpless cripple, unable even to feed himself. How should it be treated? The patient must have the best possible food, which must be nourishing and even stimulating. His hygienic surroundings should be of the best character, and he should be given alteratives, as cod- liver oil, arsenic, iodides of iron, of potassium, or compound solution of iodine. At the same time the skin should be acted on with Turkish baths. Locally, leeches, iodine and blisters may be applied to the affected joints, and massage and manipulation of the joints should never be neglected. If anchylosis takes place the patient should be etherized and the adhesions broken up. Acute Gout. What is gout ? It is an hereditary disease characterized by severe pain and swelling, occurring in one of the smaller joints, an excess of uric acid in the blood, and the deposit of chalk stones (sodium urate) in the joints and cartilages. Synonyms. When it occurs in the foot (the most frequent seat) it is called podagra; in the hand, chiragra; in the knee, gonagra. It is an old disease, alluded to by the later classics. Causes. It is strongly hereditary, and affects men more frequently than ACUTE gout. 105 women. It occurs particularly in those who lead a sedentary life, and indulge largely in animal food, especially when eaten hurriedly. Wines, particularly sweet wines, and malt liquors in excess, when indulged in habitually, lead to acute attacks. Strong mental emotion, as anger, may excite an attack. In addition to these causes, an ex- cess of uric acid in the blood is a prime factor in the development of the attack. Acute gout is not common in this country, but is met with especially in England and the beer drinking countries of Europe, as Bavaria. What are the symptoms of acute gout ? It begins usually at night with intense pain in the ball of the great toe (the metatarso-phalangeal joint). The pain is aggravated by pressure and by vibrations, as those produced by heavy wagons in the street. The patient is restless and feverish; next morning the pain is lessened, but the joint is red, swollen and glossy, and this redness extends to the other joints. The swelling somewhat relieves the pain, which, however, increases toward night. The small joints of the other foot or of the hand may be also affected. This continues for five or ten days, and slowly disappears, followed by slight desquamation. During the paroxysm the urine is deficient in uric acid, there is an extraordinary irritability of temper, nausea and constipated bowels. After the acute attack passes off the patient is much better than he was before it came on. How is gout diagnosed ? Gout is recognized by the sudden onset with excruciating pains, by affecting the small joints only, by the fever, the deficiency of uric acid in the urine, and the absence of cardiac complications. What is the prognosis of gout ? The prognosis of the attack is favorable; but it is apt to recur at intervals. Occasionally retrocessant gout is seen, which is dangerous. Gout of the brain is rare, but is a dangerous complication. Gen- erally the cerebral symptoms are rather due to the alcohol which the patient has habitually imbibed than to the gout. The same may be said of gout of the stomach. Gout of the heart is character- ized by pain and intermittency. It occurs in old persons and gives a bad prognosis. 106 ESSENTIALS OF PRACTICE OF MEDICINE. How should gout be treated ? An acute attack of gout should be treated by rest, warmth, eleva- tion of the parts, and quiet. Internally, colchicum given in small doses, to avoid purgation (wine of the root, gtt. x-xx), every three or four hours, in neutral mixture, affords most relief. This should be given during the acute attacks, and not in the intermission be- tween them. A little opium in the form of Dover's powder may be given at night, to allay pain and cause sleep. Diaphoretics, mild diuretics and an occasional cathartic are also indicated. Locally, warm applications should be applied to the part. Cold externally often gives quick relief, but is very dangerous, as it frequently pro- duces retrogression of the gout. Chronic Gout. What is chronic gout ? Chronic gout is a condition occurring from repeated attacks of the acute disease, characterized by enormously enlarged and swollen joints, and swellings occurring under the tendons, from deposit of chalk stones, which may give rise to ulceration and abrasion of the skin, leading to their discharge. How is it diagnosed ? It is diagnosed by the history of the preceding acute attack, by the deposit of chalk-stones in the smaller joints and cartilage, par- ticularly the cartilage of the ear. How should it be treated ? The patient should be placed on a vegetable diet, consisting of milk, fish, or oysters, but no meat, no sweet wines, no malt liquors, and no pastry or sweetmeats. If possible, he should avoid all alco- holic beverages, but if he must drink, he should take a little claret, or a little whiskey or brandy with water, at his meals. The action of the skin and liver should be maintained by exercise in the open air (walking, horse-back riding, etc.), Turkish baths, etc. Colchicum does no good in chronic gout, but should be kept for the acute attacks. The alkalies, and especially the lithium preparations and the alkaline mineral waters, as Vichy, Buffalo lithia water, Poland water, etc., should be given. DIABETES. 107 Lithaemia. What is lithaemia ? Lithaemia is a condition of undeveloped gout characterized by an excess of uric acid in the blood, giving rise to various disturbances of the system, but not attended by an acute attack of gout. What are its synonyms ? Uric acid diathesis, lithiasis. What are its causes ? These are the same as those which produce gout. What are the symptoms of this disease ? The symptoms of lithaemia vary according as one or another organ bears the brant of the disease. Usually there is great depression of spirits, numbness in the extremities, with pain and slight enlarge- ment of the smaller joints. High colored, scanty urine, with abun- dant deposit of uric acid, which may contain a small amount of sugar. Impaired digestion, flatulency, irregularity of the bowels, and perhaps symptoms referable to chronic gastric catarrh, chronic hepatic hyperaemia, or even to contracted kidney or interstitial hepatitis. Sometimes there are no joint symptoms; sometimes persistent vertigo or intense headache, or neuralgia, lasting for several days at a time. What is the prognosis of this disease ? If promptly recognized and properly treated, recovery will be the result. The disease is usually, however, of long duration. How should it be treated ? The treatment is the same as that of chronic gout. Diabetes. What is diabetes ? Diabetes, or Glycosuria, is a chronic disease, characterized by the passage of large quantities of urine, which contains glucose as a constant ingredient, and associated with progressive emaciation and loss of strength. 108 ESSENTIALS OF PRACTICE OF MEDICINE. What are the causes of this disease ? It is often hereditary and occurs at all ages, though most fre- quently in early middle-life. The cause of the excessive formation of sugar in the system is not thoroughly understood. It evidently is not formed in the kidneys, but, being excreted by them, sets up an irritation in its passage through those organs which results in the greatly increased amounts of water which they eliminate. It exists in the blood, and in some instances would appear to be due to ex- cessive formation of glycogen by the liver; in other instances the affection seems connected with disease of the pancreas, while in other instances it appears to arise in connection with some disease or irritation in the neighborhood of the floor of the fourth ventricle of the brain. What are the symptoms of diabetes ? The amount of urine passed in twenty-four hours is often enor- mous,—generally about two to three or four quarts,—sometimes very much more, amounting occasionally to several gallons. On the other hand, the quantity of urine is sometimes not increased at all. Among the earlier symptoms are, inordinate thirst; great dryness of the throat; a tendency to the formation of boils, and a great itching of the skin. In women there is intense pruritus vulvae, and in men much pain and itching in the penis is complained of, owing to the development of the penicilium in the few drops of urine which re- main about the parts after urination. Later in the disease, the thirst, which was present as an early symptom, increases and becomes almost unbearable; the urine in- creases in amount, and the quantity of sugar it contains is usually much increased also; the bowels are constipated, because all the water that the system can spare is being excreted as urine ; the skin feels harsh and dry, and cataract develops in one or both eyes; various neuralgiae occur and give rise to much additional suffering; bone diseases, as periostitis, caries or necrosis may take place, and the patient often suffers, in addition, from attacks of gout. There is much emaciation, and the general health and spirits of the patient suffer greatly. Special Symptoms. The urine is clear and pale; it has a sweetish taste and odor, a DIABETES. 109 high specific gravity (102S-1050, the average being about 1030), which will vary with the amount of sugar passed and its degree of dilution. Sugar can be detected if the proper tests are applied to the urine, the best of which, as rough tests, are Boettger's, Moore's or Trommer's. If, however, it is desired to determine accurately the quantity of sugar which is being passed daily, Pavy's or Feh- ling's tests must be used, or Roberts' fermentation test resorted to. The quantity of sugar excreted daily varies very much. Usually it is equal to about thirty per cent, of the urine voided, or one ounce to two pounds or more. The nervous system also suffers. Not only is the patient irritable, but he suffers from nervous debility and loss of nervous tone. He is often vacillating, where prior to the disease he was firm. The respiratory system shares in the general malnutrition. There is a cough from bronchial catarrh, and as the disease progresses, fibroid changes, and finally tubercular deposits take place in the lungs. The circulation is languid, and the first sound of the heart feeble. The temperature is lower than in health. What is the duration of this disease ? The duration varies. Under the improvements which have been made in the treatment, the duration is gradually lengthening. For- merly, according to Prout, the average duration was about two years. How does it terminate ? The majority of the cases terminate fatally, from exhaustion, or from decomposition of the sugar in the blood, which, being converted into acetone, causes either diabetic coma (the patient becoming sopo- rose and finally comatose, with dilated pupils and a cold surface) or delirium and convulsions. What is the prognosis ? Probably the disease never ends in recovery, although much can be done by treatment to retard its progress. Any acute intercurrent affection greatly increases the danger. How is this disease diagnosed ? The symptoms and the presence of sugar persistently in the urine render the disease unmistakable. If a patient with a chronic disease is suffering with great thirst, has a dry mouth and tongue, and intense 110 ESSENTIALS OF PRACTICE OF MEDICINE. itching of the skin, the urine should always be examined for sugar, particularly when there is a tendency to the formation of successive crops of boils. It should always be remembered that the presaice of glucose in the urine, without it is persistent, does not indicate dia- betes. A temporary glycosuria may occur from many causes, as excessive sexual indulgence, and even from eating heartily of certain articles of food, as asparagus, or following the inhalation of chloro- form. What is the treatment of this disease? It is of the utmost importance that all starchy matters and sugars should be excluded from the patient's food. He must scrupulously avoid sugar of all kinds, and such articles as contain starch, as bread, potatoes, peas, and beans, rice, etc., if he wishes to live. Glycerin or saccharin may be used as a substitute for sugar, but it is hard to find a substitute for bread. He must live on an animal diet almost ex- clusively. He should be warmly clad, use warm baths and occasion- ally take a Turkish bath, to keep the skin acting, and render it pliable. Opium seems to exert some effect upon the excretion of sugar, and upon the amount of water passed, but the patient will become a hopeless opium-eater, and the influence of the drug is usually not maintained. Codeine has been highly recommended, and appears to act very favorably upon the disease. Ergot is also useful, and sodium salicylate has been employed with advantage, but the regula- tion of the diet is the most important part of the treatment. Polyuria. What is polyuria ? It is a disease characterized by extreme thirst, emaciation, debility and the passage of immense amounts of pale, limpid urine, free from either albumen or sugar. What are its synonyms ? Chronic diuresis ; diabetes insipidus. What are its causes ? The causes are very obscure. It seems to be produced by some irritation of the nervous system in the region of the floor of the AN.EMIA. Ill fourth ventricle, and may follow sunstroke, exposure to cold, mala- ria, syphilis, etc. What are its symptoms ? There is great thirst and voracious appetite ; the skin is dry and harsh, the bowels constipated, and an enormous quantity of pale urine of low specific gravity (1001-1007) is passed, which does not contain either albumin or sugar. The patient is nervous, irritable, and acquires a curious tendency to inaccuracy in his statements, so that a man who was absolutely truthful before, can hardly be relied upon, after he is afflicted with this disease. There is also inability to concentrate the mind for any period of time upon one object, and severe headache, usually frontal or occipital. Very soon the patient becomes so much weakened, that any acute intercurrent affection is apt to prove fatal. How is this disease treated ? The amount of water taken by the patient should be limited. This is much easier to order than to have carried out, as the patient will drink whenever he has the chance and deny the fact when ques- tioned about it. Patients suffering from this disease have been known to drink their own urine, the thirst is so intense. Ergot and potassic bromide seem to give most relief, except when the patient is suffer- ing from syphilis (which may, perhaps, be a cause of this, as of so many other affections), in which case potassic iodide and mercury are of more avail. Pilocarpine has also been used successfully. Galvanism has been recommended. Tonic treatment must also be employed, no matter what other remedies are given, and the bowels should be properly regulated. DISEASES OF THE BLOOD. Anaemia. What is anaemia ? Anaemia is a disease of the blood characterized by a deficiency of albumen and red corpuscles. 112 ESSENTIALS OF PRACTICE OF MEDICINE. What is its synonym ? Oligaemia. What are the causes of anaemia ? (1) Predisposing Causes. Women are more frequently affected than men. Very young and very old persons are particularly susceptible. Nervous, irritable, and hysterical persons are especially predisposed to it. (2) Exciting Causes. Bad hygiene, poor diet, a want of exercise on the one hand, or ex- cessive exercise, great grief or other depressing emotion, drains on the system as from some chronic discharge, poisons circulating in the blood, as the poison of malaria or the metals, disease of the blood-making organs as the spleen or lymphatic glands, and ex- cessively cold weather, all act as exciting causes. What are its symptoms ? There is great pallor; the tongue, gums, and cartilages of the ears when held against the light, and the conjunctiva are all pal- lid. There is great muscular weakness, a frequent pulse, with a soft blowing systolic murmur heard over the heart; a venous hum in the jugular veins, frequent respiration, with breathlessness on slight exertion, irritability of temper, dizziness, frequent fainting fits, causeless vomiting, and dropsy (a late symptom). In women menorrhagia is frequently present. What are the sequelae of anaemia ? The sequelae of anaemia are degenerations of various viscera, due to want of nutrition, thus fatty heart and ulcer of the stomach are frequently seen ; softening of the brain is among the rarer sequelae of this disease. How is this disease diagnosed? This disease is known by the pallor and pearly hue of the conjunc- tiva, the rapid pulse, the heart murmurs, and the venous hum in the jugular vein. What is the prognosis of anaemia ? The majority of cases recover, but suffer from relapses at critical times, as during pregnancy, or at the menopause. Organic changes due to malnutrition render the prognosis less favorable. ESSENTIAL ANAEMIA. 113 What is the treatment of anaemia ? The patient must be placed upon a good diet, and under the best hygienic conditions. She must have plenty of fresh air and sunlight, cheerful surroundings, and properly regulated exercise. Any obvious cause must be removed if possible, and iron given in rapidly increas- ing doses until the point of tolerance is reached. This is known by the supervention of headache, slight vertigo, coated tongue, nausea and sometimes vomiting, and a slightly elevated temperature. The tincture of the chloride of iron is the best preparation if the digestive organs are in good condition. The potassio-tartratc, lactate or citrate may be used if the digestion is feeble. Cod-liver oil and the extract of malt may be combined with the above treatment if they do not disorder the digestion. If there is much gastric disturbance, the bitter tonics combined with a mineral acid should be administered, and the preparation of iron deferred until the condition of the patient has somewhat im- proved. If there is a tendency toward hemorrhages, a liberal diet, and the use of bitter tonics will give a better result than the treatment by iron. If there is profound ancemia due to loss of blood, transfusion may be resorted to. Essential Anaemia. What is essential anaemia ? It is a profound form of anaemia, pursuing a progressive course in spite of treatment and almost invariably terminating fatally. What are its synonyms and causation ? It is also called idiopathic anaemia and progressive pernicious anaemia. The cause is not well understood ; it may be due to disease of the spleen, lymphatic glands or bone marrow. It is more common in the female than the male, and seems particularly liable to affect pregnant women. What are the symptoms of this disease ? In the early stages the symptoms are those of anaemia much 8 114 ESSENTIALS OF PRACTICE OF MEDICINE. intensified, but the patient does not lose much flesh. Later on internal hemorrhages take place, as intestinal hemorrhage, or hemor- rhage into the retina ; slight albuminuria is also present, and irreg- ular accessions of fever occur. After a time there is almost continual fever, the temperature, however, not rising very high, with slight morning remissions and evening exacerbations. After the fever has continued three or four weeks the difference between the evening and morning temperature becomes more marked. The patient now begins to lose flesh, is extremely weak, dropsy supervenes, and death occurs usually from exhaustion. What is the pathology of this affection ? The corpuscles and albumen of the blood are relatively diminished; the blood is therefore more watery than normal, but the relation between the red and white corpuscles is unaltered. What does a post-mortem examination reveal ? No constant lesion is found; the heart may have undergone fatty degeneration from malnutrition, the spleen is sometimes enlarged and thickened, the lymphatic glands may or may not be normal, the marrow of the bones may have undergone degeneration or may be healthy, the gastric tubules may be diseased. What is the prognosis ? This disease almost invariably terminates in death. How should it be treated ? The patient must be placed on a properly regulated diet, and should have change of scene, and live in the open air. Iron, phosphorus and cod-liver oil may be administered internally, and treatment should be directed to any symptoms which seem to require it. Transfusion does no permanent good. By proper treatment we may prolong the life of the patient, although he cannot be cured. Leukaemia. What is leukaemia ? Leukaemia is a disease of the blood, characterized by an enormous increase of white corpuscles. LEUKAEMIA. 115 What is its synonym ? It is also called leucocythaemia. What is its cause ? It is caused by some disorder of the blood-making organs. Gen- erally there is some disease of the spleen, sometimes of the lym- phatic glands, or lymphoid cells, and sometimes of the bone marrow. What are the symptoms, duration and pathology ? The Symptoms are those of anaemia, with enlargement of the spleen and often of the lymphatic glands. A hemorrhagic diathesis is developed late in the disease, and bleeding occurring from the stomach or bowels, the anaemic symptoms becoming more profound. Anomalous febrile attacks are now seen, bronchial catarrhs and diar- rhoeas often take place, with curious alterations of the special senses, great depression, dropsy, and death from exhaustion. Duration about two years. Pathology. The white blood corpuscles seem to be formed instead of red cor- puscles, or perhaps fail to be transformed into the latter. They are enormously increased in number, and may even be as numerous as the red. Post-mortem. The blood is white in appearance, has a low specific gravity, and forms soft white coagula in the right side of the heart. The lym- phatic glands all over the body are frequently enlarged. Sometimes new glands seem to be formed (lymphadenomata). What is the diagnosis, prognosis and treatment of this dis- ease? Diagnosis. Under the microscope more than twenty white corpuscles are found in each field. In the lymphatic form, the microscope shows in addi- tion numerous free cells and small nuclei. If it is due to disease of the marrow of the bones pain will usually be complained of on pres- sure over the sternum, tibia and other bones. Prognosis. The prognosis is usually favorable as regards immediate danger. 116 essentials of practice of medicine. The patient may live comfortably for a long time, if the white cor- puscles do not exceed one-fifth of the whole number of cells. If they arc in excess of 50 per cent., the prognosis is extremely bad. Treatment. The patient must be well fed, placed under the best hygienic con- ditions, and given iron and quinine as tonics. In the lymphatic form, Lugol's solution or potassium iodide in small doses, long continued, sometimes does good. Sea-bathing and sea-voyages are also employed with advantage. In the splenic variety, if it is seen in the early stages, ergot ad- ministered hypodermically is sometimes of value. In the later stages of the disease the patient's strength should he maintained by all possible means. Pseudo-Leukaemia. What is pseudo-leukaemia ? Pseudo-leukaemia is a blood affection, characterized by a high de- gree of anaemia in connection with disease of the lymphatic and often of the mesentery glands, but without increase of white cor- puscles. What are its synonyms ? It is also called Hodgkin's disease and lympho-sarcoma. What are its causes ? It develops without known cause. It is not hereditary. It is more frequently seen in males than in females, and in young rather than old people. What are the symptoms and duration of this disease ? The symptoms are those of profound anaemia,—extreme pallor, breathlessness, altered nutrition, emaciation and dropsy. In addi- tion, lymphatic tumors are found all over the body, which are not painful on pressure. There is a tendency to hemorrhage and diar- rhoea ; but rarely, if ever, is there an increase of white corpuscles. The duration is about two years. ADDISON'S DISEASE. 117 What is the diagnosis, prognosis and treatment ? Diagnosis. The disease is known by the glandular enlargements with anosmia, but without an increase of white corpuscles. (1) From Leukaemia.—The white corpuscles are not increased. In leukaemia the changes in the blood come before the changes in the glands, in pseudo-leukaemia the changes in the glands precede the changes in the blood. Prognosis. It is more favorable than leukaemia. The disease is not very amenable to treatment, but can frequently be arrested, if not cured. Treatment. Good hygiene, good diet, and plenty of fresh air are indispensable. Internally, cod-liver oil, iodine and iron may be given in combination or alternately. In the latter stages, chloride of gold (gr. -^ - g- in glycerin and water), freely diluted, three times a day, may prove of service. For the enlarged glands, iodine or the iodides produce the best results. Addison's Disease. What is Addison's disease ? Addison's disease is a grave form of anaemia, associated with marked nutritive disturbance, and frequently with degeneration of the suprarenal capsules. What is its cause ? It appears to be most frequent in those subjected to great physical or mental strain. What are the symptoms, duration and pathology of this affection? The Symptoms are those of great anaemia. A peculiar bronzing of the skin frequently occurs, but is not constant. It appears on the face and in the folds of the body, at first in patches, later be- coming more general and gradually almost uniform over the surface. There is pain in the back; gastric and intestinal irritation, more marked than in other blood affections; a tendency to dropsy as the 118 ESSENTIALS OF PRACTICE OF MEDICINE. anaemia increases, and, later, symptoms referable to the cerebro- spinal and sympathetic nervous system, with death from anaemia or malnutrition in about eighteen months. Pathology. In addition to the deficiency of red corpuscles and albumin in the blood, the suprarenal capsules undergo a special strumous degene- ration. It is not every disease of the suprarenal capsules that produces this affection. What is the diagnosis, prognosis and treatment of Addison's disease ? Diagnosis. The disease is recognized by the anaemia, the bronzing of the surface, and the gastro-intestinal disorders. Prognosis. Few persons affected with this disease live longer than eighteen months. Treatment. Good hygiene and good food are as useful in this as in other dis- eases of the blood. A moderate amount of stimulus, especially the light red wines, as claret, with meals are of some service. Tincture of ferric chloride, combined with glycerin, is of use, and phosphorus, strychnine, or the chloride of gold and sodium, may also be em- ployed. Scorbutus. What is scorbutus ? Scorbutus is a disease characterized by anaemia, malnutrition, ecchymoses, a spongy condition of the gums, which bleed readily on the slightest touch, physical and mental lethargy, and which is pro- duced by improper diet. What is its synonym ? It is commonly called scurvy. To what is it due ? It is caused by abstinence from fresh vegetables, especially those which contain large quantities of the salts of potash, as the potato scorbutus. 119 or cabbage. Any depressing influence also acts as an exciting cause in those predisposed to it by improper diet. It has occurred in epidemics, especially on shipboard and among armies. Scurvy was known to the ancients. What are its symptoms, duration and pathology ? The Symptoms come on gradually. At first there are general symptoms of anaemia; the patient is easily fatigued, feels weak ; is breathless on the slightest exertion ; is depressed in spirits ; suffers from rheumatic pains in the back, and is less able to resist exposure to cold. These symptoms last from one week to several months. The gums now become dark-bluish, congested, spongy, protrude between the teeth and bleed readily on the slightest touch. The teeth are loosened; the breath foetid; palpitation occurs on exer- tion ; petechiae and ecchymoses appear on the surface ; hemorrhages occur from the internal organs; old cicatrices and wounds open ; old fractures become disunited, and the spleen enlarges ; albumin appears in the urine, and the urine itself is diminished in amount and its solids are relatively decreased. Duration. This disease is usually protracted, the duration is largely influenced by hygiene, diet and mental emotion, as depression or hope. Pathology. The red corpuscles and solids of the blood are diminished; petechiae and ecchymoses are found in the skin and internal organs ; serous effusions are found in the cavities of the body and connective- tissue spaces; the spleen is enlarged and softened. What is the diagnosis, prognosis and treatment of this affec- tion? The Diagnosis is made from the history, the spongy gums, the ecchymoses, the lassitude and the diet on which the patient has been living. (1) From mercurial poisoning, it is differentiated by the fact that salivation never occurs in scurvy, although the gums are spongy and discolored, and the teeth loosened. Prognosis. The prognosis is favorable if the case is properly treated. 120 essentials of practice of .medicine. Treatment. (1) Prophylaxis.—A diet of fresh vegetables, as potatoes, raw cabbage, sauerkraut, etc., or lemon-juice, will prevent the develop ■ ment of this disease. Lemon or lime-juice should always form part of the rations of sailors who are engaged in long voyages, as in Arc- tic expeditions. (2) Medicinal Treatment.—When the disease is fully devel- oped, the mineral acids, with lemon-juice and tincture of the chloride of iron, must always be administered. Ergot is also employed to arrest the hemorrhages. A change in diet is imperative. Locally, for the spongy condition of the gums, astringent mouth- washes and gargles should be employed. Purpura. What is purpura ? Purpura is an acute disease, characterized by a hemorrhagic tend- ency, which manifests itself by ecchymotic spots occurring under the skin, and sometimes by internal hemorrhages. What is its causation ? It occurs in all seasons of the year and under all conditions of life. It is independent of diet, and is probably due to vasomotor paralysis and a deficiency of the fibrogenous materials of the blood, What are the symptoms, varieties and pathology of this dis- ease? The Symptom is hemorrhage ; it may take place under the skin, forming petechiae, ecchymoses, etc. ; or it may occur from a mucous surface, as the bladder or stomach. There is slight fever, and ma- laise, but no debility except when the loss of blood is great. Varieties. (1) Purpura simplex, where petechiae only occur (2) Purpura hemorrhagica, where there are other hemorrhages also. & Pathology. The blood is altered in structure and in composition, the fibrin- diseases of the mouth—stomatitis. 121 forming elements being diminished. The arteries and capillaries are often diseased, so that the blood more readily leaves them, and, possessing less inherent power of coagulation, a tendency to hemor- rhage is developed. What is the prognosis and treatment of purpura? The Prognosis of purpura simplex is favorable, but relapses are frequent. Purpura hemorrhagica is unfavorable in proportion to the hemorrhage. Treatment. Sustain the patient's strength by good diet and stimulants. For the tendency to hemorrhage, give ergot internally or hypodermically in small doses, frequently repeated, combined with sulphuric acid or Monsel's solution. The oil of turpentine (gtt. x every one or two hours) is an excellent remedy. DISEASES OF THE DIGESTIVE ORGANS. DISEASES OF THE MOUTH. Stomatitis. What is stomatitis ? Stomatitis is an acute inflammation of the mucous membrane of the mouth. It may be either catarrhal, follicular or ulcerative. What are the causes of these affections ? They are caused by the introduction into the mouth of irritating substances ; by disorders of the stomach, want of cleanliness, teeth- ing ; or they may occur as secondary affections, following the acute exanthemata. Ulcerative stomatitis is particularly seen in children where the hygienic surroundings are poor, and is sometimes epi- demic, perhaps even contagious. What is the pathology of these affections ? In catarrhal stomatitis the mucous membrane of the mouth and the tongue is deeply congested; the tongue is usually swollen and 122 essentials of practice of medicine. indented with the teeth, and the secretions of the mouth are at first diminished, afterwards much increased, the parts being covered with a tenacious mucus. In follicular stomatitis, small, white elevations appear on the gums, lips, cheek, tongue or roof of the mouth, surrounded by a distinct zone of inflammation. These may remain separate or coal- esce, but after a few days they rupture and leave a superficial ulcer, which heals slowly. Ulcerative stomatitis consists in the deposit, in patches, of a false membrane on the gums, which are much congested. This substance softens and breaks down, leaving an irregular ulcer, with an un- healthy base, which tends to spread. What are the symptoms of stomatitis ? There is burning pain in the mouth, increased by taking food or talking ; the mouth is hot, and in the two latter varieties salivation occurs; there is some fever, more marked in the severer forms of the disease; the breath is offensive, and diarrhoea, or in the latter variety entero-colitis, is of frequent occurrence. Fever is present, varying with the severity of the case. In ulcerative stomatitis the submaxillary glands are swollen and tender. How is this disease recognized ? If the mouth is carefully examined, it is impossible not to recog- nize the affection. What is the prognosis ? The prognosis is favorable if the case is properly treated, even in the severer varieties. How should it be treated ? The cause should be sought, and, if possible, removed. Great attention must be paid to the diet, to cleanliness, and to the state of the digestive tract, and potassium chlorate gargles may be employed. In follicular stomatitis, in addition, the ulcers should be touched with a strong solution of silver nitrate, while in the ulcerative form strong nitric acid may be used locally, and quinine and stimulants given internally. DISEASES OF THE MOUTH—MUGUET—GLOSSITIS. 123 Muguet. What is this disease ? Muguet, thrush or sprue is an inflammation of the mouth, pro- bably due to the growth of a vegetable parasite which is always present in these cases, and is called the o'idium albicans. It occurs especially in infants, and is favored by unhygienic conditions, as by want of care in cleansing the bottles from which the child nurses. What are its symptoms ? The sjTnptoms are identical with those of the other forms of stomatitis, viz.: pain increased on eating, increased saliva, foetid breath and diarrhoea, the stools being greenish and of an acid reac- tion. The mucous membrane of the mouth shows, on examination, patches of marked congestion which are the seat of whitish, curdy deposits, consisting of epithelium and the fungus, and which resemble curdled milk. These deposits coalesce and spread from the lips and mouth into the pharynx and often into the oesophagus. What is the treatment of muguet ? Absolute cleanliness, not only of the parts, but of the nursing- bottles and tubes as well; washing the baby's mouth after each feeding with some mild disinfectant, as borax, and paying scrupulous attention to the digestive system and to the secretions, usually effects a speedy cure. Glossitis. Describe glossitis. It is an acute or chronic parenchymatous inflammation of the tongue, characterized by enlargement and pain, occasioning difficulty in articulating, and in chewing or swallowing the food. Causes. Acute glossitis is due to some chemical, mechanical or thermal irritant; chronic glossitis is usually localized, and is produced by some local irritation, as from a broken tooth. Symptoms. In acute glossitis there is fever, rapid pulse, intense congestion and swelling of the tongue, which is often very great, sometimes so 124 ESSENTIALS OF PRACTICE OF MEDICINE. much so that it cannot be contained in the mouth and protrudes as a large inflamed mass beyond the lips; the mouth is hot, there is much pain, and the salivary secretion is increased. If the patient can articulate at all the voice is muffled and indistinct; deglutition is interfered with and causes much suffering; the cervical glands are often enlarged and dyspnoea is usually marked. Sometimes sup- puration occurs. Chronic glossitis is usually confined to the border and edges of the tongue. The symptoms are less marked and there is no fever. Prognosis. Acute glossitis usually terminates favorably. Occasionally suffo- cation occurs, ending fatally. Chronic glossitis is a protracted and often an incurable affection. Treatment. Remove the cause if possible. In acute glossitis the fever and constitutional symptoms must be treated by a fever mixture con- taining aconite. The tongue should be incised freely, and if the swelling is great, the incisions should extend deeply into its sub- stance. The application of cold in the early stages, or of hot water when the disease is further advanced, often affords relief. If there are symptoms of impending suffocation, laryngo-tracheotomy must be promptly performed. Acute Tonsillitis. What is acute tonsillitis ? It is an inflammation of the tonsils, with a tendency to suppura- tion. What is its synonym ? It is also called quinsy. How is this disease produced ? It is sometimes epidemic, especially in the damp cold weather of the Spring and Fall. In those who are predisposed to it, any ex- posure to inclement weather is apt to produce an attack. One attack predisposes to another in the same individual DISEASES OF THE MOUTH—ACUTE TONSILLITIS. 1 23 What are the symptoms and duration of this affection ? It generally begins in one tonsil, but soon both are alike involved. There is sore throat, difficulty in swallowing and in breathing, fever, and upon examining the throat, one or both tonsils are seen to be red and swollen, and sometimes so much so as almost to close the passage of the fauces. After lasting five or six days the disease terminates, usually in suppuration, although sometimes resolution takes place and no pus is formed. When suppuration occurs all the symptoms rapidly subside as soon as the pus is evacuated. The bowels are usually constipated throughout the attack. How is this disease diagnosed ? The diagnosis is easy. The fever, difficulty in swallowing and in breathing, and an examination of the throat, which reveals the ton- sils red and swollen, and shows the absence of membrane on the pharynx (which is only slightly, if at all, inflamed), with the absence of sufficient depression and constitutional involvement to denote diph- theria, all render the diagnosis clear and positive. What is the prognosis ? The prognosis is favorable. In a very few cases death has occurred from rupture of the abscess during sleep, and escape of the pus into the larynx, causing asphyxia. How should it be treated ? (1) Prophylaxis. Persons who are subject to attacks of tonsillitis should keep the tonsils constringed with local applications of astringents (as solutions of zinc or tannin, or Monsel's solution diluted with water), and avoid exposure to damp. (2) Abortive Treatment. If the case is seen very early in the attack, a prompt emetic will sometimes abort it. (3) General Treatment. When the disease is fully developed, the mouth and throat should be kept disinfected by means of gargles of boric acid, thymol, or potassium permanganate ; no astringents or caustics should be used in this stage. Heat applied externally, or hot gargles of milk and 126 essentials of practice of medicine. water, or of potassium chlorate, hasten suppuration and often ease the pain in some degree. Guaiac is often very efficacious, but sometimes signally fails to afford any relief. It is employed in the form of the ammouiated tincture, in small, frequently repeated doses. When it is well borne by the stomach, it is generally useful. Pilocarpine is also employed in doses sufficiently large to cause slight salivation and diaphoresis. When there is much swelling or great difficulty in swallowing, scari- fication with a bistoury should be promptly resorted to. Iron and quinine may be given throughout the attack, and should be admin- istered at any rate as the inflammation subsides. The bowels should be moved daily by a saline, as Seidlitz powder. If the patient complains of much weakness, milk punch may be ordered, giving from Jss-iij of whiskey in twenty-four hours. As soon as pus forms it must be evacuated. Chronic Tonsillitis. What is this affection, and how is it treated ? This is the condition which results from repeated attacks of the acute disease, and consists of chronic sore throat and an enlargement of the tonsils from hyperplasia of the connective and glandular struc- tures which compose that organ. The treatment is rather surgical than medical, and consists in the frequent application of astringents, or, if the enlargement is great or shows a tendency to resist treatment, in the removal of a portion of the tonsil with scissors, a bistoury, or, better, with the tonsillotome. Angina and Pharyngitis. What are these affections ? They consist of acute or chronic inflammation of the fauces and upper part of the pharynx, characterized by sore throat, difficulty in swallowing, hawking, some cough, and more or less change in the voice, which generally has a nasal twang. diseases of the mouth—angina and pharyngitis. 127 What are the causes ? They are generally produced by exposure to cold and damp; sometimes by mechanical or thermal irritation ; sometimes by dis- orders of the alimentary canal, especially by disorders of the stomach and upper part of the bowel; and occasionally they are intercurrent in other acute diseases, as the exanthemata. What are the symptoms ? The acute disease begins suddenly with dryness of the fauces and throat, fever, perhaps preceded by chilliness or an actual chill, pain on attempting to swallow, and, when the pharynx is involved, a coustant desire to clear the throat, and a nasal intonation when speaking. There is much thirst. As the inflammation progresses, the secretions, which are at first scanty become reestablished and profuse, and give rise to a constant desire on the part of the patient to swallow, each attempt being attended with acute pain. Earache is a frequent concomitant of this stage of the disease due either to involvement of the Eustachian tube in the inflammatory action or to plugging of the tube by mucus. When the throat is examined, the mucous membrane of the soft palate, fauces and posterior pharyngeal wall is seen to be much congested and swollen, the uvula elongated and the parts at first dry, afterwards covered with a thick tenacious mucus. Sometimes little white membranous patches are seen on the surface, which, however, do not tend to spread or to coalesce. Small ulcers are also sometimes seen. Inflammation of the lower part of the pharynx is a rare affection. Chronic sore throat results from repeated attacks of the acute disease, and is apt to be converted into the acute trouble at any time, on exposure to cold and damp. There is habitual cough, constant tendency to clear the throat, lengthening of the uvula, thickening of the posterior half-arches, and in some cases, enlarge- ment of the mucous follicles. This latter form is follicular pharyn- gitis and is usually called " clergymen s sore throat." The follicular enlargement may even extend into the larynx. What is the treatment of these diseases ? In the acute attacks a fever mixture, containing, if there is much elevation of temperature, a few drops of aconite in each dose, is 128 ESSENTIALS of practice of medicine. beneficial. Sometimes the severity of an attack can be materially lessened by pilocarpine administered in the very early stages, or by repeated minute doses of morphine combined with very small doses of tartar emetic. Locally, in the early stages, demulcents, as a solution of acacia flavored with lemon and sugar, are very grateful to the patient, and small pieces of ice allowed to dissolve in the mouth, tend to allay the inflammation. Spraying the throat with Dobell's solution or applying a weak solution of cocaine is also advantageous. Strong solutions of silver nitrate protect the surface when applied to it locally, and in this way afford much relief, as well as tend to relieve the congestion by their astringent effect upon the tissues and blood vessels, but within the last few years it has been claimed that this treatment does harm, as the salt acts as a superficial caustic, and produces permanent alterations in the tissue to which it is applied. As the acute stage is subsiding mild astringent gargles, as tannin or alum, are very useful. Gargles with potassium chlorate may be employed in any stage. Chronic sore throat and the chronic forms of pharyngitis require rest for the voice, and avoidance of such irritation as is produced by smoking, for example. Change of air is often beneficial. Tonic treatment is usually indicated. The sufferer should avoid all expo- sure which is apt to lead to an acute exacerbation, and should employ strong astringent gargles, as alum, or have the parts painted with zinc sulphate in solution (3j-f^j) or with tannin glycerole, several times a week. If the follicles are enlarged, and this treat- ment does not succeed, it may be necessary to destroy them by means of the galvano-cautery. DISEASES OF THE 03S0PHAGUS. Oesophagitis. What is oesophagitis? Oesophagitis is an acute inflammation of the oesophagus resulting from chemical, mechanical or thermal irritants, characterized by groat pain and difficulty in swallowing, hiccough, intense burning in the throat and between the shoulders, fever and great anxiety. DISEASES OF (ESOPHAGUS —STRICTURE OF (ESOPHAGUS. 129 On inspection the mucous membrane is seen to be vividly red and swollen. What is the termination, prognosis and treatment ? It may terminate—- (1) In slow but complete recovery, or (2) In stricture of the oesophagus. What is the prognosis ? It is usually favorable but tedious. It is unfavorable if there is much tissue destroyed. What is its treatment ? Very little food should be given by the mouth, and that little should be mild and emulsive in character, as milk or gum-water; solid food should be strictly interdicted. The patient should be principally nourished by nutritive enemata. Minute doses of calo- mel and sodium carbonate should be placed on the tongue, and bismuth subnitrate may be blown down the throat; small pieces of ice in the mouth and a bladder of ice applied intermittently between the scapulae afford much relief. To prevent stricture, an oesophageal bougie should be passed after the acute symptoms subside, at least every two weeks for a year. Stricture of the (Esophagus. What are the varieties of stricture of the oesophagus ? (1) Spasmodic stricture, due to a spasm of the oesophageal muscles. (2) Organic stricture, an inflammatory narrowing of the tube. Describe spasmodic stricture. (1) Spasmodic stricture is found most frequently in hysterical women or in hypochondriacal men. Symptoms. There is difficulty in swallowing any kind of food, especially liquids. The spasm is frequently inconstant. If swallowing is at- tempted during the spasm, the face becomes livid and symptoms of 9 130 ESSENTIALS OF PRACTICE OF MEDICINE. approaching suffocation supervene. Hysterical symptoms are fre- quently present. Diagnosis. An oesophageal bougie is readily passed into the stomach, or is only arrested by the spasm, which gentle perseverance will overcome in a few days at most. Treatment. It is of the utmost importance to gain the confidence of your pa- tient. Bromides and other nerve sedatives should be given in full doses, and bougies should be used every few days. The hysterical symptoms should be treated by good hygiene and food, and medici- nally by zinc and tonics. What is organic stricture of the oesophagus ? (2) The symptoms of organic stricture usually follow an acute inflammation, or oesophageal cancer. They come on gradually with difficulty in swallowing, especially of solid matters, and symptoms of spasm when deglutition is attempted. As the constriction in- creases the symptoms gradually grow worse, until finally there is difficulty in swallowing even fluids. Diagnosis. An ordinary bougie cannot be passed, and a small one may only be passed with difficulty. Differential Diagnosis. (1) From spasmodic stricture, by the history, the gradual increase of symptoms, the greater difficulty in swallowing solids, and the passage of the bougie. (2) From cancer of the oesophagus; in this affection there is severe pain, hemorrhages, cachexia, and the stricture grows in spite of treatment until the patient starves to death. (3) From aneurism pressing on the oesophagus; always examine the chest for signs of aneurism before passing the bougie. (4) From diseases of the epiglottis; an examination of the epi- glottis will reveal the disease. Prognosis. If the stricture follows inflammation, the prognosis is favorable ; if, however, it is due to cancer, it will terminate fatally in spite of treatment. DISEASES OF THE STOMACH—ACUTE GASTRITIS. 131 Treatment. When the stricture follows inflammation it should be gradually dilated by bougies, increasing in size, and passed very gently and carefully. If it is due to cancer, bougies do no good, and may do much harm by causing a rupture of the oesophagus. Should the difficulty arise from an aneurism pressing on the oesoph- agus, bougies must not be used, as there is danger of rupturing the aneurism. The patient should be treated in these cases by rest, and the cardiac action regulated by aconite or veratrum viride, while iodide of potassium is administered in as large doses as can be borne. DISEASES OF THE STOMACH. Acute Gastritis. What is acute gastritis ? It is a violent acute inflammation of the stomach, generally due to an irritant poison. What are its causes, symptoms and termination ? It is most frequently caused by the ingestion of mineral, animal or vegetable poison ; but may arise independent of poisoning, from extension of inflammation from adjacent viscera or from traumatism. Symptoms. Severe burning pain in the epigastrium increased by breathing, pressure or taking food; the pain is constant, but is liable to exacer- bations. There is great thirst, incessant nausea, vomiting often of mucus, fcetor of the breath, at first constipation, later severe diarrhoea, moderate fever and a small, tense pulse. Termination. The inflammation may either cause collapse with clammy sweats, or subside in a few days leaving an irritable stomach. In case of death, what is found on post-mortem examination ? There is intense congestion and inflammation of the mucous mem- brane, which is softened and coated with a strongly alkaline mucus ; localized spots of intense redness are found and ecchymoses are fre- 132 ESSENTIALS OF PRACTICE OF MEDICINE. quent. The microscope shows an interstitial infiltration of embry- onal cells into the muscular coat and between the tubules, which are undergoing degeneration, and often atrophied from pressure. What is the diagnosis, prognosis and treatment of this affec- tion? The disease is recognized by the history, the pain, vomiting, thirst, fever, pulse, and condition of the bowels. Prognosis. The prognosis of acute gastritis, independent of the poisoning which may cause it, is usually favorable. It will vary with the in- tensity of the inflammation and the amount of tissue destroyed. Treatment. If it is due to poisoning, and the case is seen in the earlier stages, antidotes should be administered, the contents of the stomach evac- uated, and, as a rule, the organ thoroughly washed out. For the pain, the patient should be kept under the influence oi morphine hypodermically administered. The patient should be nourished by the rectum, and the stomach kept perfectly at rest; small pieces of ice may be allowed to dissolve in the mouth, or small quantities of iced milk or eggs in a little water administered for their demulcent effect. For the gastric irritability hydrocyanic acid may be given, or calomel, gr. TV, with sodium bicarbonate, gr. j, dusted on the tongue. After the acute inflammation has subsided, bismuth, with soda, may be administered internally. Acute Gastric Catarrh. What is acute gastric catarrh ? It is a catarrhal inflammation limited to the mucous membrane of the stomach, attended with swelling, and at first a diminished, after- wards increased secretion. What is its synonym? It is frequently spoken of as a bilious attack. DISEASES OF THE STOMACH—CHRONIC (iASTRITIS. 1 .'53 What is its cause ? It usually follows errors in diet; it may depend on atmospheric influences, and is sometimes almost epidemic. What are its symptoms, diagnosis and treatment ? Symptoms. There is loathing of food, a heavily-coated tongue, offensive breath, vitiated secretions, and a bad taste in the mouth, nausea, bilious vomiting, constipation, the stools being black and offensive, slight epigastric pain, little fever, intense thirst, sometimes vertigo in the early morning when rising, and occasionally headache, dis- turbed vision and irregular pulse. Diagnosis. The disease is recognized by the history, the slight pain and fever, the nausea, vomiting, and coated tongue, and the various nervous disturbances. Prognosis. Is favorable. If the cause continues, the attacks are apt to be repeated, and finally to end in permanent gastric catarrh. Treatment. A brisk purgative, as podophyllin, or calomel, or blue mass, fol- lowed by a saline, should be given, and the diet should be regulated. For the irritability of the stomach, bismuth and soda, or carbolic acid, gtt. j, every hour or two in a little mint-water, may be given. Chronic Gastritis. What is chronic gastritis ? It is a chronic catarrhal inflammation of the mucous membrane. What are its synonym and causes? Synonym. Chronic gastric catarrh. Causes. It is usually found after middle life. It frequently occurs from continual moderate drinking, or from repeated attacks of acute gas- 134 essentials of practice of .MEDICINE. trie catarrh. It is also seen in chronic heart disease following pro- longed venous congestion. What are its symptoms, duration and termination ? Symptoms. One of the most characteristic symptoms is early morning vom- iting, the vomited matters consisting principally of glairy mucus. There is delayed digestion, flatulency and acid eructations, due to the fermentation of food; the patient is sleepy after meals, is consti- pated, has a coated tongue, suffers from great thirst and anorexia, has very little pain, but slight epigastric tenderness. Aarious nerv- ous symptoms, as vertigo, headache, restlessness, disturbed sleep and irregular action of the heart, are apt to be present. Duration. It is a very chronic disease, finally becoming incurable. Termination. It may end in gastric ulcer, or in pyloric thickening (rare). Gen- erally the patient dies worn out by his bad habits, as drink, or by the disease of the heart, which has caused it. What is found on post-mortem examination ? There is a persistent swelling of the mucous membrane of the stomach, occurring in patches, which are usually discolored, being grayish or ashen in appearance. The mucous and sub-mucous coats are thickened, the tubules are degenerated and atrophied, the mu- cous follicles hypertrophied, and the surface of the mucous mem- brane coated by a thick, offensive mucus. What is the diagnosis and treatment of this disease ? Diagnosis. The history of the case, the morning vomiting and the tenderness with the absence of pain, of fever, and of signs of a tumor, should render the diagnosis clear. Treatment. It is absolutely necessary for the patient to break off all bad habits which act as causative agents. He should nave a bland and easily- digested diet, rather scanty in quantity, mostly of animal food. Pepsin should b > administered with meals. The salts of silver, with diseases of the stomach—gastric ulcer. 135 opium or belladonna or bismuth, are sometimes useful. Mildly pur- gative mineral waters or salines should be administered, to act on the portal circulation. The vegetable tonics and mineral acids should only be used temporarily when large amounts of alkaline mucus col- lect in the stomach, as their continued use favors the formation of this secretion. Washing out the stomach with a stomach-pump affords tempo- i ary relief. Gastric Ulcer. What are the causes of gastric ulcer ? Gastric ulcer is most common in women about twenty years of age. The most frequent cause is malnutrition of the stomach, due to altered states of the blood, as anaemia. It also occurs from chronic congestion, such as is seen in chronic gastritis, or in diseases of the right side of the heart. It may follow diseases of the left side of the heart, where the branches of the gastric artery become plugged with emboli. What are its symptoms ? Anorexia and general dyspeptic symptoms may or may not be present. Symptoms due to the disease which causes the ulcer are usually complained of. The Special Symptoms are pain, which is fixed and does not radiate ; it is usually under the ensiform cartilage and between the scapulae, is increased by pressure, is increased immediately on taking food, but often occurs in paroxysms independent of food. Vomiting occurs soon after the taking of food, due to the irrita- tion produced by the food on the ulcer ; the vomited matters often contain blood-streaked mucus. ILematemesis occurs in about half the cases. The blood is gene- rally black, unless the ulcer is very large. The amount of blood varies. What is the pathology of gastric ulcer ? The ulcer is developed in the same manner as ulcers in other parts of the body. It may be single or multiple, circular or oval; it may perforate the stomach and penetrate into the peritoneum, 130 ESSENTIALS of practice of medicine. or adhesions may form in the peritoneum between the stomach and adjacent organs, and the ulcer open into a neighboring viscus without opening the peritoneal sac. It may perforate the stomach down to the peritoneal coat and then cicatrize, or its progress may be arrested at any stage. It is generally found on the posterior wall or at the pyloric end. How is ulcer of the stomach recognized ? The Diagnosis is made from the age, the sex, anaemia or other causes, the localized pains, especially on taking food, the vomiting, the haematemesis and the absence of signs of tumor. What is the prognosis? The prognosis is generally favorable under proper treatment and under good conditions. It will depend to some extent upon the cause. How should ulcer of the stomach be treated? The stomach must be given as much rest as possible. A'ery little food should be given by the mouth, and that little should consist of milk and lime water, or, as cicatrization commences, finely chopped meat with pepsin. The patient should be nourished by nutritive enemata and should be confined absolutely to bed. Arsenic in small doses or the nitrate or oxide of silver with opium may be administered. To allay the pain morphine may be used hypodermically. If ancemia is present, iron may be given in small doses when the stomach will bear it. If the ulcer tends to perforate, keep the patient under the influence of opium. Gastric Cancer. What are the causes of gastric cancer? It is generally hereditary, and is the most common seat of primary cancer in the male, and, next to the uterus, the most frequent seat in the female. It usually occurs after middle age. What varieties of cancer are found in the stomach ? Any variety of cancer may be present, but the scirrhus and the encephaloid are the forms most frequently met with. diseases of the stomach—gastric cancer. 137 What part of the stomach is usually affected? It is most common at the pyloric end, next in frequency the car- diac end is affected. It is sometimes found in the anterior, but is rare on the posterior wall. It begins in the submueous tissue, grows into the cavity of the stomach and ulcerates. Occasionally it is found as an interstitial cancer between the coats of the stomach. What are its symptoms ? General Dyspeptic Symptoms are frequently, not always, present. There is usually great flatulence, acid eructations and acid vomiting from fermentation of the food ; there is much foe tor of the breath and, as the disease progresses, emaciation and cachexia. Hy- drochloric acid is said to be absent from the gastric juice. The temperature is always subnormal in cancer. Special Symptoms. (1) Pain.—Severe in character, independent of eating, often ra- diating or shooting from the epigastrium, the patient rarely being free from it. It is more severe in the encephaloid and other rapidly growing cancers than in scirrhus. (2) Vomiting, which occurs immediately after eating and is more like a regurgitation of the food, if the cancer affects the cardiac end of the stomach. When the pylorus is affected the vomiting occurs several hours after eating, is acid in character, and often contains sarcina ventriculi. (3) Hcematemesis occurs in half the cases. (4) A tumor is present in 80 per cent, of cases, is more marked as emaciation proceeds and is found in the epigastrium and right hypoehondrium as a hard, resisting mass. As it grows, it may finally cause dropsy from pressure. What is the duration and termination of cancer ? The duration is from one to five years; it usually terminates by death from starvation. What are the complications ? The pancreas, gall bladder, or liver may become secondarily involved. How is cancer of the stomach diagnosed? This disease is recognized by the age of the patient, the gastric 138 ESSENTIALS OF PRACTICE OF MEDICINE. symptoms, the pain, vomiting, haematemesis, tumor, emaciation, and cachexia. Differential Diagnosis. (1) From chronic gastritis with hemorrhage due to congestion; the paroxysms of pain, the emaciation, cachexia, tumor, subnormal temperature, and progress of the disease in spite of treatment, dis- tinguishes cancer from the latter disease. (2) From gastric ulcer, by the age, the radiating pain, which is not influenced by food, the tumor, cachexia, subnormal temperature and absence of localized tenderness. What is the prognosis ? Death occurs sooner when the cardiac end of the stomach is in- volved. What is the treatment of gastric cancer ? The patient's diet must be regulated and should consist of easily digested meat with pepsin, or of milk. Corrosive sublimate in small doses long continued, or Fowler's solution, are supposed to retard the development of the cancer. For the fermentation, eructations nudfcetor of the breath, carbolic acid (gr. 4) may be given in glycerine or mint-water. For the pain, morphine may be administered hypoderniically or by the rectum. For the excessive, acidity, aromatic spirits of ammonia, solution of potassium, or the citrate of lithium do good. For constipation, enemata of castor oil give the best result. Sulphur, compound liquorice powder, or aloin may be used. When the eructations are excessive charcoal is sometimes of value. The stomach should be washed out occasionally to get rid of the mucus which is apt to accumulate. Haematemesis. What is haematemesis ? Haematemesis or hemorrhage from the stomach, is not a disease, but a symptom, and may be due to disorders of various organs. DISEASES OF THE STOMACH—HAEMATEMESIS. 139 What are its causes ? (1) It is often a symptom of organic disease of the stomach, as ulcer or cancer. (2) Anything which causes gastric congestion from obstruction of the portal circulation may produce hemorrhage from the stomach ; thus, cirrhosis of the liver, splenic enlargement, tumors pressing on neighboring vessels, or various cardiac diseases may be factors in its production. (3) Diseases of the blood, as anaemia or scurvy, may cause a hem- orrhage, (4) Or it may be vicarious, resulting from the arrest of the men- strual discharge or the bleeding from piles. What are the symptoms, irrespective of cause ? There is a discharge of blood by the mouth, bowels, or both. If the vessels give way suddenly, and a large amount of blood is poured out, it will be red in color. Usually, however, the bleeding into the stomach takes place gradually, and when vomited the blood is black, clotted, and like coffee-grounds, being altered by the acid secretions. Nausea precedes the haematemesis, and is one of the earliest symptoms. Faintness.—There is epigastric weight and oppression ; cold, clammy skin, and symptoms due to shock, the duration of which vary and are generally relieved by the vomiting. There is vomiting of food mixed with blood. Black, chocolate-colored stools are passed. How is hemorrhage from the stomach diagnosed ? Blood coming from the stomach is recognized by the history of the case, by the fact that the blood is generally black, that it is vomited, that it is usually mixed with food, and by the dark, tarry stools. Differential Diagnosis. (1) From Haemoptysis.—In this case the blood is light in color, frothy, and mixed with bronchial mucus. It is usually coughed up. (2) In a child blood may be vomited which has been previously swallowed, having come originally from the lungs or from the nose. 140 ESSENTIALS OF PRACTICE OF MEDICINE. What is the prognosis of haematemesis ? Very few persons die during the hemorrhage, except when it pro- ceeds from the ulceration of a large vessel or from scurvy. The prognosis is unfavorable in proportion to the likelihood of return. What is its treatment ? (1) To check the bleeding, cold water, pellets of ice, or a little brandy may be administered. If the stomach is not irritable, tannic or gallic acid (gr. xx every half hour) or Monsel's solution (gtt. ij-v) freely diluted, or sulphuric acid in the same doses, are beneficial. Ergot is used, but is not so good. Absolute rest in a recumbent position is important. To aid in procuring this, as well as to tranquilize the nervous system, mor- phine may be administered hypodermically. If the bleeding continues ergot should be administered hypodermi- cally in addition to the medicines above enumerated. The after-treatment should consist in treating the cause, opening the bowels, and regulating the diet. Dilated Stomach. What are the causes of dilatation of the stomach ? It maybe due to cancer or other organic obstructions to the pylorus, or to functional causes, as gastric weakness, atony of the muscular fibres, etc. It is not a rare disease. What are its symptoms ? The patient is probably a large eater, and is not in very robust health. He suffers from general dyspeptic symptoms. The epi- gastric region is exceedingly tympanitic except at the lower part, where there will be dullness over the accumulated food. There are occasional fits of vomiting, the vomited matters being enormous in quantity, often containing sarcina ventriculi, and consisting of partly digested food which probably has been accumulating in the stomach for several days or a week. The vomited matters will be more or less digested, according as the gastric tubules are atrophied or degenerated. DISEASES OF THE STOMACH—GASTRALGIA. 141 What is the prognosis ? If treated early the progn, .sis is favorable. After a time, however, the gastric tubules become atrophied and the patient will finally die of exhaustion. What is the treatment ? The patient should live on small quantities of dry solid food with very little liquid. Strychnine should be administered by the mouth or hypodermically, and carbolic acid should be given for the fermen- tation. The offensive eructations are best treated by the administra- tion of charcoal with soda and bismuth. Gastralgia. What is gastralgia ? Gastralgia, or gastric pain, is generally a symptom of organic disease of the stomach. AVhen it recurs in young persons it is usually caused by ulcer, when idiopathic it is of nervous origin, it being either a neuralgia of the stomach or occurring from spasm of the muscular coat. Functional or Neuralgic Gastralgia. Describe functional gastralgia. It is usually seen in hysterical women or over-worked, over- burdened men. It occurs also as a symptom of lithgemia. What are the symptoms ? (1) Digestive disturbances may be present or absent; generally there is a want of digestive tone, a feeling of fullness, and flatulency after meals. (2) Intense pain in the epigastrium, lasting from a half to two hours, relieved by pressure, bearing no relation to meals unless organic disease is present. Eating may ward off a threatening attack. (3) The stomach feels hard to the touch during the attack. (4) Sympathetic disturbances are often present, as feeble pulse, intermittent cough, vertigo, anxiety, cold extremities, local sweats, etc. 142 ESSENTIALS OF PRACTICE OF MEDICINE. How is this recognized ? It is recognized by the history, the digestive and sympathetic disturbances,kthe intense intermittent pain, relieved by pressure, and not aggravated by taking food, the absence of hemorrhage and of tumor. Differential Diagnosis. From Intercostal Neuralgia.—Neuralgia is usually limited to the left side, and spots of localized tenderness are found over the nerve. What is the prognosis ? It is an intractable but not a dangerous disease. How should it be treated ? The diet should consist of easily digested food, animal food and a little stimulant generally being best. For the pain, morphine should only be used when absolutely necessary, as from the intractable nature of the disease there is great danger of the formation of the opium habit. Paregoric in teaspoonful doses often gives immediate relief. Bismuth with minute doses of morphine and aromatic powder is frequently of service. Nitro-muriatic acid in small doses gradually increased and freely diluted, sometimes does good. Carbolic acid is of use, especially if there is gastric irritability, combined with minute doses of morphine. Fowler's solution in small doses given for a long time produces satis- factory results. Dyspepsia. What are the causes of functional dyspepsia ? Too rapid eating ; too much water at meals, especially ice water; improper food ; want of exercise ; too much tea or coffee ; and the abuse of tobacco, are the principal causes of this disturbance. What are the symptoms ? The patient suffers from general dyspeptic symptoms, as listless- ness, languor, headache, extreme vertigo, disturbed sleep, jerking of the muscles during sleep, irritable temper and a frequent, irregular heart, with disturbed action of the liver if the disease continues for DISEASES OF THE STOMACH—DYSPEPSIA. 143 any length of time. The urine is high-colored, contains urates and phosphates, the bowels are constipated, the tongue is usually flabby, broad, and indented by the teeth, and not much, if at all, coated. The patient is gloomy and imagines he has some organic trouble. What are the principal varieties of dyspepsia ? (1) Atonic or Nervous Dyspepsia. In these cases there is anorexia, and a sensation of weight after meals is usually experienced. During digestion the patient is heavy, stupid and often falls asleep. There is irritability of temper, dread of organic disease, and other nervous disturbance. (2) Acid Dyspepsia or Heartburn. The patient suffers from weight, listlessness, pains after meals and extreme acidity. This form is seen in people who "bolt" their food without properly masticating it. The stomach becomes over- taxed, and fermentation occurs from the improper secretion of gastric juice. (3) Flatulent Dyspepsia. In these cases there is delayed digestive operations, and perhaps acidity from fermentation of the food. There is offensive breath, distention of the abdomen after meals, and often eructations of gas with much noise. (4) Pyrosis Or Water-brash. In these cases vomiting, which is not common in functional dys- pepsia, usually occurs. The vomited matters consist of thin, glairy, alkaline fluid from the upper part of the oesophagus or stomach. Flatulency and other dyspeptic symptoms are present. (5) Hysterical Dyspepsia. These cases occur in hysterical patients, especially in women, and are characterized by vomiting after meals, enough food, however, remaining in the stomach to nourish the patient, who does not lose weight. What is the diagnosis of functional dyspepsia ? It is recognized by the delayed digestion, the clean tongue, no tenderness on pressure on the epigastrium ; by the pyrosis and other dyspeptic symptoms. From Chronic gastritis it is differentiated by the fact that there is 144 essentials of practice of medicine. no diffused pain, no tenderness, but a clean, flabby tongue, not coated behind with red tips and edges ; that there is no similarity in causation, no excessive thirst, not much, if any, vomiting, but great prominence of nervous and heart symptoms, and vasomotor dis- turbance, with perhaps some fever. What is the prognosis of dyspepsia ? The prognosis is favorable. Nervous dyspepsia with oxalates in the urine, or dyspepsias char- acterized by vomiting are more obstinate than the other forms. In what does the treatment consist ? (1) Avoid the cause if it can be discovered, and prevent any nerv- ous strain, especially at meal times. (2) Regulate the diet, giving the patient whatever agrees with him best. Usually a meat diet is most suitable; potatoes, starches and bread are not good; peas, spinach, celery, onions are better. Fish and oysters suit some. Sweetmeats, pastry, etc., must be interdicted. Milk is not as good in functional as in organic dyspepsia. (3) Properly regulated exercise is always of use. (4) Keep the bowels open by small doses of aloes. (5) If the patient be a man let him smoke very little. (6) Give small doses of pepsin after meals and mineral acids with meals combined with bitters, as nux vomica, gentian, cascarilla or colomba. DISEASES OF THE INTESTINAL TRACT. Colic. What is colic ? It is a twisting, griping pain around the umbilicus, occurring in paroxysms without fever. It is often due to flatulence, sometimes to nervous depression or errors in diet, to constipation or to poison- ing by certain metals. It is of short duration, passes gradually away, leaving some soreness behind, but is apt to recur as long as the cause remains. What are the symptoms of colic ? The patient writhes with pain, which is relieved by pressure, the diseases of intestinal tract—COLIC. 145 extremities arc cold ; there are often clammy sweats, great anxiety and sometimes vomiting, which, however, is rare. ArARIETIES. (1) Colic from Constipation.—There is usually a history of habit- ual constipation and the general symptoms of colic. The disease continues until the cause is removed. (2) In colic from mechanical irritation, such as unripe fruit, the general symptoms of colic are present with irritative fever, and per- haps vomiting. (3) Metallic Colic. Certain metals, as lead, copper, corrosive sublimate, etc., also give rise to colic. (a) Copper colic causes violent recurrent paroxysms of pain, more or less present all the time, persistent nausea, tenderness and vomit- ing, secondary muco-enteritis with fever. The history of exposure to copper, especially among persons working in copper filings, gives the key to a diagnosis. (b) Lead colic is very common ; it is particularly seen in painters who do outdoor work and who use white paints with much turpen- tine. Some persons are exceedingly susceptible to poisoning by lead. The use of snuff wrapped in tin-foil, or water contained in lead pipes, may also produce colic. The symptoms are those of colic generally, constipation, no fever, soreness of the abdomen, legs and arms, and if much lead has entered the system, a blue line will be found on the gums. It is a chronic, persisting disease, the patient rarely being free from pain until the lead has been removed from the system. It is often associated with other symptoms of poisoning by lead, as violent headache, wrist drop (in which the muscles do not react to electricity), sometimes convulsions, irregular heart, which is apt to be hyper- trophied, and sometimes granular, contracted kidney. What is the prognosis ? The prognosis generally depends upon the cause. It generally passes away quickly when the cause is removed. The metallic colics are obstinate. How is colic treated ? For the immediate relief of pain, warmth externally, and inter- 10 146 essentials of practice of .medicine. nally by means of carminatives, such as mint, ginger, fennel seed, chlorodyne or hot water, is of service. If the pain is very severe, an opiate may be administered, and mustard plasters applied to the surface of the abdomen. To prevent the recurrence of the pain, small doses of nux vomica with regulation of diet, or small doses of alcohol, not continued for too long a time, are of service. In any case endeavor to ascertain the cause and remove it. If constipation exists, treat it by castor oil and other laxatives. If there is mechanical irritation caused by improper foods, laxa- tives may be administered, and later, astringents, as bismuth and opium, to counteract the resulting diarrhoea. In metallic colics the same treatment is indicated, and care must be taken to remove the metal from the system. In colic due to copper the violent muco-enteritis must be treated by bismuth and opium, regulation of the diet and small doses of mercurials. In colic due to lead the obstinate constipation should be treated by castor oil in large doses, and with warm water injections. Croton oil (gtt. i, t. i. d.) may also be used to aid in the elimination ; sulphuric acid and strychnine sulphate, with potassium iodide, is the best treat- ment. Belladonna or atropine is said to relieve lead colic very quickly. Persons who are exposed to lead poisoning should be scrupulous in their personal cleanliness, particularly of the fingers and nails, as lead is often conveyed to the mouth with the food. They should also drink diluted sulphuric acid in the form of lemonade, as this acts as an antidote to the lead. Constipation. What are the causes of constipation ? It is often a symptom of dyspepsia, is frequently due to atony of the bowels, especially of the colon, is seen in persons who lead a sedentary life, particularly in women, and is sometimes due to defec- tive secretion of mucus. DISEASES OF INTESTINAL TRACT—CHOLERA MORBUS. 147 What are the symptoms ? There is an irregularity of the bowels. Some persons naturally only have one passage in several days. If this has always been their habit, and there is no bad symptoms, and it does not interfere with the health, do not do anything. Besides irregularity in the passages from the bowels there is generally headache, vertigo, gastric disturb- ance, disordered sleep, mental hebetude and feeling of weight in the abdomen. How should constipation be treated ? Exercise is of importance. Massage of the abdomen sometimes stimulates peristalsis. The great thing in the treatment of constipa- tion is to form a habit of having a passage every day at a certain time. For temporary purposes enemata may be used. The diet of the patient is also of importance. They should take very little milk or meat, live as much as possible on fruit, vegetables, oat meal, and similar substances. The less medicine they take the better. Purgative mineral waters may be taken temporarily, but should not be used for any length of time, because they cause a drain of albumen from the blood. Aloes or aloin in small doses is frequently given. It maybe combined with rhubarb, or colocynth, or with extract of bella- donna and strychnine, when it is given to stimulate the organic mus- cular fibres of the bowels. AVhen constipation has existed for some time it may be necessary to give castor oil or small doses of croton oil or compound liquorice powder in order to assist the action of the bowels. None of these are good for persistent use. Cholera Morbus. What are the causes and symptoms of cholera morbus ? Cholera morbus is produced by changes in the weather or errors in the diet, particularly by eating unripe fruit. Symptoms. It begins with vomiting; the vomited matters at first consisting of the contents of the stomach, then mucus and, later, bilious matters ; purging often severe, the stools at first being faecal, then bilious, and, later, serous in character ; cramps in the stomach and extremi- 14S ESSENTIALS OF PRACTICE OF MEDICINE. ties, probably due to the loss of fluid from the blood ; cold, clammy surface ; feeble pulse ; great anxiety and recovery or collapse. If collapse occurs, the symptoms resemble those of Asiatic cholera. What is the pathology and diagnosis of this affection? There is over-secretion of the mucous glands, resulting in irritation of the mucous membrane. Diagnosis. The disease is recognized by the history, the vomiting, the purging and the cramps. Differential Diagnosis. (1) From Irritant Poisoning.—In the latter case there is a his- tory of some irritant having been taken ; the sudden onset of the symptoms soon after eating; the great tenderness ; the appearance and chemical examination of the vomited matter and the stools, and, perhaps, symptoms referable to the poison which has been swallowed. (2) From Asiatic Cholera.—The latter begins abruptly; there are usually serous discharges almost from the first; the collapse is ex- treme ; the surface and breath are icy; it is epidemic; there is no history of cause, and the cholera bacillus is always present in the discharges. How should cholera morbus be treated ? If seen early, a brisk emetic and cathartic should be given. For the relief of pain, morphine (gr. $•) with atropine (gr. ^v) may be administered hypodermically, but should not be repeated in less than one hour. For the vomiting, carbolic acid (gtt. ss-j) perhaps combined with morphine (gr. ^), may be given every fifteen or twenty minutes. Effervescing waters are also grateful, and, locally, the application of mustard is of service. For the irritability of the stomach which follows, bismuth is an excellent remedy. If the attack is unyielding, sprinkle on the tongue calomel (gr. J), with sodium bicarbonate (gr. j), every half-hour until a change occurs in the symptoms, after which the dose should be decreased. For the cramps, ginger, capsicum or applications of chloral, dis- solved in soap liniment, or even chloral given hypodermically, may be employed. DISEASES OF INTESTINAL TRAGI1—ACUTE DIARRIKEA. 149 When the stomach becomes less irritable, lime water and small amounts of broth may be given, but the diet should be restricted for several days. Acute Diarrhoea. What are the causes of acute diarrhoea ? It may be caused by sudden changes in the weather, by errors in the diet, by various reflex nervous disturbances as teething in chil- dren. It is also seen in those who eat arsenic for their complexion and in chronic cases of the opium habit. What are the symptoms, duration and termination ? The patient experiences griping pains in the abdomen, tenderness with frequent stools, which vary in character and constitution ; the tongue is coated, and fever often occurs. It lasts from a few hours to a few days and passes off gradually, leaving the patient weak and often constipated. What is its pathology ? There is generally increased peristalsis of the muscular layer of the bowel or increased intestinal secretion, sometimes both. An in- creased secretion of bile or increased epithelium proliferation are sometimes seen with or without the first two conditions. What is the prognosis ? The prognosis of acute diarrhoea is generally favorable. Some- times it passes into a chronic condition. How should it be treated ? If it is due to an irritant and is seen early, a light laxative, as castor oil, should be administered. If it is not seen in the early stage, some form of opium combined with other remedies, according to the indications, should be used. (1) When the passages are loose, watery and without much color or smell, the acids, as Hope's Camphor Mixture, hydrochloric, nitric or sulphuric acid, generally give the best result. (2) When the stools are loose and offensive and contain much mucus, bismuth, with opium or Dover's powder, if the stomach is not irritable, is indicated. 150 ESSENTIALS OF PKACTICE OF MEDICINE. (3) If the stools are more than moderately loose, with mucus, grip- ing and abdominal tenderness (especially in children), the antacids, as chalk mixture with opium, should be given. (4) When there are bilious discharges which are yellow or greenish, with weight in the abdomen and coated tongue and sometimes vomit- ing, the alkalies, as the preparation of sodium or ammonium, or minute doses of calomel frequently repeated, are serviceable. In any case the diet should be plain, consisting of milk, soft boiled eggs, and as little fluid as possible. Corn starch sometimes docs good. AVhen there is not much mucus or catarrhal difficulty arrow- root answers well. The patient should not have too much to eat. Chronic Diarrhoea. Describe chronic diarrhoea. Chronic diarrhoea differs from chronic dysentery only in affecting the small not the large intestine at first. After a time the disease extends to the large intestine also, and the affections are so merged as to be identical. Symptoms. Those of chronic dysentery, with the exception that the stools contain little or no mucus, no blood, and there is no straining until the large intestine is involved. The Treatment is the same as in chronic dysentery, (q. v.) Alcohol, especially port wine, is of service. Duodenitis. What is duodenitis? It is the catarrhal inflammation of the duodenum following cold, errors in diet, but more especially due to malaria. What are the symptoms ? There is pain, which is often severe, and comes on a few hours after eating, especially after starchy food is taken, when it lasts for some time, and is accompanied by flatulence. There is marked tenderness in the upper part of the abdomen, great discomfort, often DISEASES OF INTESTINAL TRACT—DUODENITIS. 151 slight fever, despondency, reflex symptoms pointing to sympathetic disturbance of other organs, as gastralgia or irregularity, often inter- mittence of the cardiac beat, utter loathing of food, constipation, coated tongue, and frequently jaundice. What is the duration and prognosis ? The disease lasts several weeks and slowly susbides. The prognosis is generally favorable, if there is no duodenal ulcer. If an ulcer forms, it is usually due to an embolus. The symptoms denoting it are, an increase of all the symptoms, particularly of the pain and tenderness, which become almost intolerable. Bloody stools are frequently passed. What is the treatment? Dietetic Treatment. Strict attention should be paid to the diet, which should consist principally of skimmed milk, with small amounts of animal foods, or broth combined with pepsin. Occasionally he may be allowred an e^g. Game, oysters and fish may be given, but no starchy vege- tables, as potatoes, and no bread should be taken. A little celery or spinach will do no harm. The Medical Treatment. The alkalies should be given, to deplete the mucous membrane, unload the portal circulation and act as a sedative to the inflamed structures. For this purpose sodium phosphate or bicarbonate, mag- nesium sulphate, cream of tartar, Rochelle salts, or the alkaline mineral waters are the best. For the pain belladonna may be used locally and internally. Can- nabis indica or hyoscyamus may be given. Opium should be with- held if possible. If the disease persists bismuth subnitrate should be given in gr. x doses. If this treatment fails, Fowler's solution (gtt. j) with deodor- ized tincture of opium (gtt. ij), every hour or two, will sometimes prove serviceable. If the bowels become irritable late in the disease, check the pas- sages, as in diarrhoea. If duodenal ulcers form, or if the disease becomes chronic, silver nitrate or oxide is highly recommended. 152 ESSENTIALS OF PRACTICE OF MEDICINE. Catarrhal Enteritis. What is catarrhal enteritis ? Catarrhal enteritis, Hit is or muco-enteritis is a catarrhal inflam- mation affecting the mucous membrane of the ileum. What is its cause ? It is sometimes epidemic, especially during the prevalence of influ- enza ; it is also produced by cold and exposure, or by the other causes which favor the development of catarrhal processes in general. What are its symptoms ? The symptoms are those of acute diarrhoea, which is often nothing else but this disease. There is moderate fever, griping ]tains around the umbilicus, thirst, loose passages and anorexia. It lasts'for a few days and gradually passes away, leaving some abdominal tenderness behind it. How is it treated ? The patient's diet must be restricted. He should live principally on broths, rice, arrow-root, etc. He should not drink much water, and what he takes had better contain a little lime-water mixed with it. Claret and apollinaris water form an agreeable substitute for ordinary water, and, besides, the claret is somewhat of an astringent. He must be kept as quiet as possible and have a moderate amount of opium in the form of paragoric, deodorized tincture or supposi- tory. If this does not check the trouble, give him bismuth or lead acetate, with opium and small doses of ipecac. Membranous or Croupous Enteritis. What is membranous enteritis ? It is a form of enteritis in which a cast or mould of the small intestine is formed, consisting of mucus, epithelium, leucocytes, etc. It cannot be said to be either a rare or a common affection. What is known of the cause of this affection? It is found especially among women, particularly those of a hys- DISEASES OF INTESTINAL TRACT—MEMBRANOUS ENTERITIS. 153 terical temperament, and is often associated with membranous diar- rhoea. It is a very protracted disease. What are its symptoms ? (1) Intestinal Symptoms. (a) Between the attacks, which recur every few months, the patient is usually pretty well, but suffers from constipation, and has a flabby, coated tongue. (b) During the attacks there are violent colicky pains and abdomi- nal tenderness ; fever, with a quick, irritable pulse, and constipation. These symptoms last for four or five days, after which the membrane is formed and comes away in shreds or masses, and the symptoms abate. (2) General Symptoms. All kinds of curious hysterical symptoms may be seen during the attack, which usually pass away promptly when the membrane is expelled ; thus temporary aphasia is sometimes found, or symptoms simulating tetanus. How is this disease recognized ? The diagnosis is made by the symptoms of enteritis and the pas- sage of the membrane, which is soft and easily breaks. The membrane is distinguished from tapeworm by breaking easily, and by a microscopic examination. What is the prognosis ? The patient always recovers from the attack, but it is a chronic disease, and the attacks are constantly recurring until the patient is worn out by them. What is the treatment of this disease ? The diet of the patient need not be restricted. Purgatives, as small doses of salines, compound liquorice powder, senna or sulphur, should be administered as necessity demands. Tar persistently used, in the form of the wine or fluid extract, is occasionally beneficial. Arsenic in small doses, continued for a long time, has sometimes proved of service. Change of climate and scene, as traveling, or visiting the mountains or sea-shore, does some good. A sea-voyage is also useful. When the membrane is being passed, a laxative is indicated, and 154 ESSENTIALS OF PRACTICE OF MEDICI NK. for this purpose castor oil, sweet oil, or magnesia answer better than any others. For the pain, opium may have to be administered, but should be deferred as long as possible, and cannabis indica, hyoscyamus and other remedies of that class tried first, although, in the long run, opium has usually to be resorted to, and the patient generally becomes a confirmed opium eater. Poultices, or fomentations with turpentine and laudanum or with infusion of poppies, should also be used externally when the pain is great. If membranous dysmenorrhoea also is present, the womb should be treated, in the hope that if one can be cured, the other affection may pass away at the same time. Enteritis. What is enteritis ? Enteritis is an inflammation attacking not only the mucous mem- brane, but all the other coats of the bowel as well, and characterized by marked fever, griping pains, local tenderness, constipation followed by diarrhoea, and throbbing of the abdominal vessels. What is its cause ? It is generally caused either by exposure or by mechanical irrita- tion, as from eating indigestible food. What are its symptoms ? There are violent cramps in the abdomen, with intense pain in the neighborhood of the umbilicus; nausea, vomiting, high fever, a quick, irritable, tense pulse. The bowels are at first constipated, but soon become loose, the stools being watery, but containing very little faecal matter, and being attended with great pain. There is, in fact, a localized peritonitis. The abdominal vessels throb so markedly that the patient generally complains of it very much, and it can be readily felt and usually seen by the physician. How is this affection recognized ? It is known by the fever, the marked local tenderness, the griping pains, the throbbing of the abdominal vessels, and the constipation followed by diarrhoea. DISEASES OF INTESTINAL TRACT—COLITIS—DYSENTKKV. 155 What is the prognosis ? The prognosis is not as favorable as that of catarrhal enteritis, but the majority of patients recover under proper treatment. What is the treatment ? The diet should be light and of the mildest possible character. Internally, opium must be given in large doses (gtt. x of the deodorized tincture every hour, the dose being increased if the medi- cine is well borne). Mercurials may be given in small doses, and later a laxative, as castor oil, may be prescribed. Locally, if seen early, leeches should be applied to the abdomen. If not seen until later, or if the patient is too weak to leech, the application of hot cloths, sprinkled with laudanum, or wrung out of infusion of pop- pies, answers best. Poultices may be applied if their weight is not objectionable. Colitis. What is colitis ? It is a catarrhal inflammation of the large intestine, characterized by symptoms similar to those which are seen in muco-enteritis, except that the pain is limited to the locality of the colon. The treatment is the same as that for the latter affection. Acute Dysentery. What is acute dysentery? It is an inflammation of the descending portion of the large intes- tine, generally catarrhal in character, but which may become diph- theritic, ulcerative or even gangrenous. It is often epidemic, and is characterized by constipation, tenesmus, bloody, muco-purulent stools and constitutional disturbance. What are its causes ? Dysentery is due to atmospheric changes ; to exposure to cold and damp ; to errors in diet (not a very common cause), and sometimes to epidemic influences. Malarial dysentery is often caused by drinking water impregnated with the malarial poison ; or when the disease is epidemic, infection 156 ESSENTIALS OF PRACTICE OF MEDICINE. may occur from the stools. The disease disappears under good drain- age and improved hygienic conditions. AVhen epidemics occur in armies, the disease usually is of the diphtheritic or of the gangre- nous variety. What is the pathology of dysentery ? (1) Ordinary Catarrhal Dysentery. In this variety the mucous membrane is swollen, red and thick- ened. The proper secretion is at first arrested, afterwards increased and finally becomes muco-purulent. Exudation occurs into the sub- mucous tissue. The engorgement of the small vessels is so great that they often rupture, causing either hemorrhage from, or ecchy- mosis under, the surface of the mucous membrane. The disease gradually subsides. (2) Ulcerative, Croupous, or Diphtheritic Dysentery. Ulcers form on the surface of the mucous membrane. They have a greenish, unhealthy base, and irregular, thickened borders. There is a deposit of a croupous or diphtheritic material (resembling a false membrane) between the coats of the bowel. (3) Gangrenous Dysentery. In this form, the above processes continue, until finally large portions of the bowel become gangrenous and are discharged in the stools as sloughs. What are the symptoms, duration and termination ? (1) In Acute Catarrhal Dysentery there is tenesmus with a constant desire to go to stool; the alvine dejections are purulent and bloody. Constipation exists in reality, for although the sufferer is going so frequently to stool, yet there is little, if any, faecal matter in the passages. If, however, the disease begins above in the small intestine and gradually passes down into the larger bowel, diarrhoea may exist. There is reflex nausea and vomiting and reflex irritability of the bladder. Marked fever is present while the acute symptoms last, the tem- perature frequently being as high as 103°, and having a morning remission and an evening exacerbation. The pulse is small, often full and compressible; there is thirst, restless nights, and some pain diseases of intestinal tract—dysentery. 157 and tenderness over the bowel. The disease lasts a week or ten days and gradually subsides, more faecal matter passing by the stools, and with less straining and tenesmus. Or the disease continues, and finally passes into chronic dysentery. (2) Ulcerative, Croupous or Diphtheritic Dysentery pre- sents the same symptoms as the foregoing variety, but they are much more severe. There is almost continual tenesmus ; large quantities of mucus and pus with shreds of membrane and of tissue are passed with the stools, which are black and offensive and are swarming with bacteria, which are said to be identical with those found in the diphtheritic membrane of the throat. The extremities are cold, the skin clammy, the internal temperature high, delirium is frequent and often marked. The disease usually runs a rapid course and often terminates fatally, from heart failure. (3) Gangrenous Dysentery is seen particularly as an epidemic among troops. The symptoms are similar to the foregoing variety, except that large shreds of gangrenous tissue are passed from the bowels, and the disease runs a much more rapid course, the prostra- tion being much more severe. What are the sequelae of dysentery ? (1) Abscess of the liver is frequently seen, in hot climates especially, and is due to emboli which have been washed from clots in the in- ferior hemorrhoidal vein into the portal vein, and so to the liver. (2) Pycemia may occur (and in the graver varieties is frequently seen) from absorption of the products of decomposition. How is this disease diagnosed? Dysentery is known by the bloody stools, which contain mucus, but no faecal matter, and by the tenesmus, together with the consti- tutional symptoms. (1) Differential Diagnosis. (1) From muco-enteritis, it is differentiated, by the character of the stools, the tenesmus, and the absence of diarrhoea and of griping umbilical pains. (2) From enteritis, by the absence of constipation followed by diarrhoea, and of griping umbilical pains, and by the presence of tenesmus and bloody stools. 15 ber, over five handled pages.) By Henry Morris, M.I)., Auihir ol Ks- ^■^ sentials of Materia, Mediea and Therapeutic-, etc., cic. z£ No. 10.—Essentials of Gynaecology. With numerous i) lustrations. 2 By Edwin B. Cuaigin, M.D., All.-mini.;- Gynecologist, Roosevelt llos- pital, Outpa'ients Department; Assistant Surgeon New York Cancer •^ Hospital, etc., etc. r\ No. II.—Essentials of Diseases of the Skin. 75 illustrations. By \J Henry W. Stelwagon, M. !>., Clinical Lecturer on Dermatology in the < Jefferson Medical College, Philadelphia; Physician to Philadelphia Dis- pensary for Skin Diseases ; Ch'.cl'ol the Skin Dispensary in the Hospital ^ of Universitj'of Ponusylvii'iui; Physician lo Skin Department of thu ^ Howard Hospital; Lectin- v on Dermatology in the Women's Medicid (*f College, Philadelphia, etc , etc. c and Throat Dispensary of the Hospital of the University of I'etnisyl vu- nia; Assistant in the Noseand Throat Department ot tlv I uie i Dlspcn- sary; Member of the German Medical Society, Philadelphia, Polyclinic Society, etc., etc. No.. 15.—Essentials of Diseases of Children, illustrated", uv QC William M. Powell, M. D., Physician to Hie Clinic for the Dis<-a-e.- ot f\ Children in the Hospital of the University of Pennsylvania; Examining tJU Physician to llv Children's Seashore House for Invalid children, at At- lantic City, X, J.; former!v Instructor in Physical Diagnosis in the fl Medical Depart ment of the University of Pennsylvania, and Chief of the ^. Medical Clinic of tha Philadelphia Polyclinic. >J No. 16.—Essentials of Examination of Urine, colored "Yogbx _ Scale," and numerous Illustrations. By Lawrence Wolff, M.D., author Cfj of " Essentials of Chemistry," etc,, etc ; price, 7."> cents. —4 No. 17.—Essentials of Diegnosis. By David d. Stewart, m. d. L'Cturer on Diseases of the Nervous Sy>t''in al the .f'irersoii Medical College; Late Chief of tho Medical Clinic .Jefferson Medical College Ho>- pital; Physician toSt. Mary's and Si. Christopher's Hospitals; Fellow ol ihj College of Physicians of Philadelphia, etc, etc. No. 18.—Essentials of the Practice of Pharmacy. By L. i: Satke, Professor of Pharmacy and Materia Mediea in the University of Kansas. (In preparation.) (f) For Sale by all booksellers. (/) PRICE: Cloth, $1.00; Interleaved for Taking Notes, $1.25. h o < < 2 UI CO CO UJ DISEASES OF INTESTINAL TRACT—CHRONIC DYSENTERY. 159 (3) The opium treatment consists in giving gr. ss of the drug every two hours, until an impression is produced on the system ; or in administering morphine hypodermically in corresponding doses. The drug acts better than its alkaloid in this disease. If no effect is produced in forty-eight hours under either of the two former plans of treatment, they should be abandoned, and the opium treatment tried. If for any reason none of them can be used, or if they fail, bismuth (gr. x-xx), or lead acetate (gr. ij), should be given every two hours, combined, in either case, with opium (gr. ss). If the dysentery becomes croupous or gangrenous, or if the typhoid state supervenes, brandy must be freely given, and quinine adminis- tered as a tonic. Turpentine is serviceable in these cases. If there is much tenesmus, opium must be administered by sup- pository or enema. Locally, washing out the bowel several times a day with ice-water, not only relieves the tenesmus, but gets rid of the mucus, which is adding to the irritation. Chronic Dysentery. What are the pathological changes in chronic dysentery ? The mucous membrane is thickened, its surface is ulcerated, the ulcers being irregular in outline, and of an unhealthy appearance. The remains of old ulcers can be seen, the tissue being cicatrized, and often showing actual loss of substance. Abscesses of the liver are often found, due to emboli washed into the liver from the inferior hemorrhoidal vein. Sometimes (not often) little polypi are found in the rectum. What are the symptoms of this disease ? From four to twenty passages take place from the bowels in twenty-four hours, mostly in the daytime. They are persistently loose, and consist partly of mucus and pus, but contain some frecal matter also, and sometimes blood. They are not very large, but are extremely offensive. The abdomen is sunken and tender; the patient emaciated, the face of an earthy, ashen hue, and wearing 160 ESSENTIALS OF PRACTICE OF .MEDICINE. constantly an anxious expression. The spirits arc depressed. There is no appetite, and toward evening there is some rise in temperature, amounting to slight fever. There is a good deal of tenesmus from which the patient suffers nearly all the time. Later, malnutrition is manifested in various ways, as by ulceration of the cornea, aiuvmia, dropsy, cardiac disturbances, etc. What is the diagnosis and prognosis ? The Diagnosis is made from the history of the case-, the tenes- mus, and the character of the stools. The Prognosis is grave. This is a serious disease; from which few really recover, although life may be prolonged for years. What is its treatment ? The diet must be restricted to articles of food which are easily digested, as milk, meat, soft-boiled eggs, rice, corn-starch, or arrow- root. Very little bread should be allowed. Bismuth (gr. x) combined with opium may be given four or five times a day, and is particularly efficacious in the chronic dysenteries of children. Mineral acids (especially the nitro-hydrochloric acid), or the mineral astringents (as cupric sulphate, gr. xV~ii if it does not nauseate ; zinc sulphate, gr. j-ij, or silver nitrate, gr. J, or oxide, gr. ss) combined with opium and administered four times daily, are often serviceable. Iron, if it agrees well with the stomach, is an excellent remedy, acting not only as an astringent, but as a haema- tinic as well. It may be given in the form of the sulphate (gr. ij) or as Monsel's solution ("lij-v) or as the solution of the nitrate (not officinal) (gtt. xx-xxx, t. i. d.). Opium may also be employed in suppository (gr. j) at night. Various injections into the bowels have been tried with a view of healing the ulcers. Silver nitrate has been used in this manner without much effect. If everything else has been tried and has failed, turpentine (gtt. x-xv) may be given in emulsion with a little morphine, and small blisters applied over the spot of greatest tenderness on the abdomen. DISEASES OF INTESTINAL TRACT—TYPHLITIS. 161 Typhlitis and Perityphlitis. What are these diseases ? Typhlitis is an acute or chronic inflammation of the caecum, ascending colon and often of the vermiform appendix (the latter sometimes spoken of as appendicitis), characterized by the signs and symptoms of localized peritonitis, by fever, and often by the signs of intestinal obstruction. It often results in ulceration, etc., sometimes in perforation of the bowel. Perityphlitis is an acute inflammation of the connective tissue in the neighborhood of the caecum, usually resulting in the formation of pus and characterized by the signs and symptoms of an abscess. There is often a localized peritonitis associated with it. What are the causes of these affections ? They are not uncommon diseases, and are caused by mechanical irritation froni the lodgment of foreign substances, as seed or hardened faeces, in the caecum or appendix vermiformis ; by injuries to the abdomen, or by extension of inflammation from contiguous structures. Occasionally they arise from exposure to cold and damp. What are their symptoms ? In typhlitis there is localized pain associated with tenderness over the region of the right iliac fossa and ascending colon, with more or less swelling ; the patient lies on his right side, to relax the abdom- inal muscles; his bowels are usually constipated, or there may be alternating constipation and diarrhoea, the passages consisting of small watery stools which have found a passage between the hard- ened masses of faeces occupying the sacculations of the large bowel. There is fever, which in severe cases may be quite high. Vomiting often occurs, and in case there is complete obstruction of the bowel, it will finally become stercoraceous in character. If the impaction persists, or if perforation of the intestine occurs from ulceration, general peritonitis will result, with great depression, and usually terminate fatally, sometimes in a few hours. Perityphlitis usually develops slowly with paroxysms of acute pain in the right iliac fossa, and the presence of a hard mass in the same 11 162 ESSENTIALS OF PRACTICE OF MEDICINE. situation, which, if suppuration takes place, becomes soft and fluctu- ates. The symptoms of the suppuration will then be added, as irregular chills and fever attended with profuse sweating. If it follows typhlitis, all the symptoms of the latter will increase much in severity and be superadded to those of the latter. How are these diseases diagnosed ? The diagnosis is often obscure. Typhlitis is recognized by the fever, the pain and tenderness confined to the right iliac fossa, and constipation, or the constipation alternating with diarrhoea. Perityphlitis, by the paroxysms of pain, and the hard or perhaps fluctuating mass felt over the same situation. Differential Diagnosis. (1) From Malignant Growths in the Iliac Fossa.—These are harder, grow more slowly at first, more rapidly in their later stages, but are never associated with fever, and finally produce an unmistakable cachexia, with great emaciation. (2) From Ovarian Tumors.—In these cases the history is very different; there is no fever ; they are very slow in their growth ; there are no symptoms of gastro-intestinal disorder, and the pain and ten- derness is not so great. An examination per vaginam or a recto- abdominal examination, will show the connections of the tumor. (3) From an Aneurism.—The symptoms and physical signs of this disease are so distinct from those of perityphlitis, that a mistake is inexcusable. (4) Diagnosis between Typhlitis and Perityphlitis. —In the latter affection the local tenderness and marked signs of local inflam- mation are more pronounced, and a tumor is present in the right iliac fossa from the beginning of the disease, which will fluctuate if suppuration occurs. What is the prognosis of these affections ? The prognosis in typhlitis is good, if ulceration does not occur. Perforation is almost always fatal. In perityphlitis the prognosis depends upon where the abscess opens and upon free drainage. What is the treatment ? Absolute rest in bed must be insisted on, and a mild diet with a fever mixture prescribed. diseases of intestinal tract—proctitis. 163 In typhlitis, when the case is seen in the early stages, leeches must be applied, and they in turn followed by ice-bags, used inter- mittently. Opium must be given by the mouth, rectum or hypo- dermically, to keep the bowel absolutely in a state of rest. An occasional purgative should be administered to prevent faecal accu- mulation. For this purpose magnesium sulphate, with diluted sulphuric acid and syrup, or Rochelle salts in small but frequently repeated doses, or castor-oil, answer best. If ulceration with perforation and peritonitis should occur, large doses of opium must be given and the patient's strength kept up by stimulants, frequent feeding, and other supporting measures. Laparotomy and removal of the sloughing or ulcerating portion of the bowel has been resorted to, and occasionally with success. It is a desperate remedy after perforation has taken place. The surgical treatment has, however, been more successful in those cases in which the disease has become chronic, where the patient is suffering from repeated attacks of the acute malady, and in which eventually, perforation is almost certain to result. It is better to operate in the interval between the exacerbations. If perityphlitis results, the remedies must be pushed, and an occasional blister applied over the iliac fossa. If it increases, poultices must be used. If pus forms, quinine should be given, and the abscess evacuated as early as possible, the parts being treated antiseptically. This is Better than aspirating the abscess. It must be borne in mind that all pus in the neighborhood of the caecum has a faecal odor, whether it connects with the bowel or not, hence the odor of the pus cannot be relied on to determine whether there is a perforation of the intestine. Proctitis. What is proctitis ? Proctitis is a catarrhal inflammation of the mucous membrane of the rectum, caused by irritation from hemorrhoids, the habitual use of enemata, or other mechanical irritants, as hardened masses of faeces in persons of a constipated habit. It occasionally arises from cold and exposure, as from sitting on the damp ground. It is not a very frequent disease. 164 ESSENTIALS of practice of medicine. What are its symptoms ? There is an uneasy sensation in the rectum, with a constant desire to have a passage, in bad cases. The stools are preceded and followed by burning in the rectum and tenesmus, which is often very great. They consist of mucus or of niuco-pus, which is bloody, or at least streaked with blood. In severe cases there is some febrile reaction, and inflammation of the surrounding cellular tissue may occur (peri- proctitis), which usually results in suppuration and the formation of anal fistulae. What is the prognosis? The prognosis is favorable in uncomplicated cases. Periproctitis adds much to the patient's suffering, and while not a fatal disease in itself, may lead to pyemia ; or the resulting fistulae may render him a chronic invalid. Hepatic abscess occasionally results from this dis- ease in the same manner that it does from dysentery. What is the treatment ? The bowels should be evacuated by salines, aided by injections of oil and opium, administered principally by enemata with starch water. The stools should be rendered soft, so as to produce as little irritation as possible, and a daily movement should be insisted upon. ^\Tarm enemata of plain water give much relief, both by softening the faecal masses in the rectum, and by removing the mucus and muco-pus, which, by collecting there, keeps up the irritation, and produces much of the pain and tenesmus. If periproctitis ensues, it should be treated in the same manner as abscesses in other situations. Intestinal Obstruction. What is intestinal obstruction ? It is a closure of the intestinal canal, produced by faecal accumu- lations, peritoneal adhesions, herniae, twisting of the intestine or invagination, and characterized by severe pain, obstinate constipa- tion, stercoraceous vomiting, and, if speedy relief does not occur, collapse and death. diseases of intestinal tract—intestinal obstruction. 165 Describe the symptoms of these affections. The symptoms may come on gradually or suddenly, and manifest themselves first, as a rule, by invincible constipation, which cannot be overcome either by injections or by purgatives, both of which the patient has probably tried before calling medical aid. There are intense pains diffused over the abdomen, colicky at first, soon becoming very violent, somewhat paroxysmal, and associated with great tenderness. The intestines are in continual motion, and their peristaltic action becomes so violent that it can be seen through the abdominal wall. There is vomiting, first of the contents of the stomach, later of bilious matters, and finally of a nauseous fluid, containing small masses of fax-al matter and having the characteristic smell of faeces. This is called stercoraceous vomiting, and is supposed to be due to reversed peristalsis. If the patient is not soon relieved, collapse will supervene, with a cold clammy skin, feeble thready pulse, sunken eyes, and death will ensue. If the case terminates in recovery, small amounts of faecal matter will be passed from the bowel, and the patient slowly recovers. How are these diseases diagnosed 1 The diagnosis is often very difficult. Obstruction is recognized by the obstinate constipation, the pain and tenderness, followed by vio- lent peristaltic action, and stercoraceous vomiting with collapse. Differential Diagnosis. (1) As to variety:— (a) If from faecal accumulation, there is generally a history of habitual constipation, and the obstruction comes gradually. (b) If from peritoneal adhesions, there is usually a history of pre- ceding peritonitis. (c) If from hernia, sudden twisting of the intestinal hx>ps (vol- vulus), adhesions or invagination, the obstruction is generally very sudden, and often occurs when the patient is in perfect health. (d) Invagination is common in children, and probably often occurs as a temporary condition, a portion of the bowel slipping into another portion, and after a time slipping out again, without causing any symptoms whatever. Should it remain invaginated from any cause for a sufficient length of time, adhesions will form between the peritoneal surfaces of the two portions of intestine, which will 166 ESSENTIALS OF PRACTICE OF MEDICINE. prevent its return. The invaginated portion becomes strangulated, and symptoms due to this condition arise. Occasionally the inva- ginated portion sloughs off, and if the adhesions holding the two portions together are sufficiently strong, recovery may take place, the slough passing off by the rectum. The symptoms are those already described ; there is also generally an elongated tumor in the abdomen, tender to the touch ; the dis- charges consist of blood and mucus, with some pus, but the local symptoms are evidently higher up in the abdomen than they are in dysentery, and there is stercoraceous vomiting. (2) Of the site of the obstruction. There is usually no positive way of diagnosing the site of the obstruction. If it is high up in the duodenum or upper part of the ileum, it is said that the amount of urine passed will be small. There is usually great tympanitic distention above the seat of the obstruc- tion. (3) Diagnosis from peritonitis. In the latter disease there is much more diffused pain and tender- ness, and more constitutional disturbance early in the case. There are also some faecal discharges from the bowel. What is the prognosis ? The prognosis depends upon the cause. In faecal impaction it is favorable ; in twists or adhesions, unfavorable ; in invagination the patient may recover, if the bowel sloughs and inflammatory adhe- sions glue the two ends together. What is the treatment ? No matter what the cause, all purgatives must be discontinued as soon as a diagnosis of intestinal obstruction is made. Opium should be given, both for the pain and to quiet the peristalsis. If tin obstruction is from invagination, the opium must be given in very large doses. Various methods of distending the bowel have been resorted to, with the idea of causing the invaginated portion to slip back, or of aiding the bowel to untwist: thus, copious warm-water enemata have been slowly forced into the bowels by means of a long tube and a funnel or fountain syringe elevated above patient's head, thus using hydrostatic pressure in making the injection. This sometimes acts very well, as does also large injections of DISEASES OF THE PERITONEUM—ACUTE PERITONITIS. 167 warm sweet-oil, particularly in those cases caused by impaction of faeces, but if the case is one of invagination, and the bowel is begin- ning to slough, the adhesions not yet being firm, this practice is not unattended with danger. The latter remark also applies to injecting large amounts of air into the bowel, and of causing the generation of carbonic anhydride' by injecting solutions of tartaric acid and sodium bicarbonate. If the situation of the obstruction can be diagnosed, laparotomy and the removal of the strangulation, or resection of the sloughing mass, should always be attempted. As, however, every inch of intestines which passes through the hands of the operator increases the danger to the patient, the operation does not give very satisfac- tory results, because the diagnosis of the site of the obstruction is uncertain. The excessive tympany may be relieved by aspiration, but the gas will rapidly reaccumulate. DISEASES OF THE PERITONEUM. Acute Peritonitis. What is acute peritonitis ? It is an inflammation of the peritoneum, which may be either localized or diffused, and is characterized by intense pain and tender- ness, tympanites, fever, a small, tense pulse, vomiting and prostration. What are its causes ? It may be caused by traumatism (blows and injuries to the ab- dominal wall); may depend on perforation of the intestines (as in typhoid fever, typhlitis, or ulcer of the stomach); abscesses bursting into the peritoneal cavity also produce peritonitis. Cold and expo- sure, the extension of inflammation from adjacent structures, or puerperal inflammations also result in peritonitis. What is the pathology of this disease ? The peritoneum is at first dry and the vessels are irregularly en- gorged. In from twenty-four to forty-eight hours a plastic exuda- tion (embiyonic tissue) occurs upon the surface of the membrane, 168 ESSENTIALS OF PRACTICE OF MEDICINE. which then appears as if smeared with a thin solution of gum. Soft, fibrous bands are seen holding the coils of the intestine to- gether. If much lyniph is effused and but little serum, these bands are converted into granulation tissue, which, in its turn, is transformed into connective, and finally into fibrous tissue, resulting in firm ad- hesions. If, however, there is much serum and but little lymph effused, a turbid, bloody fluid, containing flocculi of lymph, will be found oc- cupying the peritoneal cavity. This fluid may be absorbed or may remain permanently. The visceral, as well as the parietal, layer of the peritoneum shares in the inflammation. The bowel is paralyzed and distended with gas. There is no inflammation of the mucous coat of the intestine. What are the symptoms of peritonitis ? Local Symptoms. There is extreme, diffused, extensive tenderness, the patient lies with his thighs and knees flexed on the abdomen, and the legs on the thighs, so as to relax the abdominal muscles as much as possible. There is marked tympanites, and constipation, which sometimes alternates with diarrhoea. General Sy.mptoms. There is a chill, marked fever (the temperature ranging from 102° to 105°), with a morning remission and evening exacerbation. The pulse is frequent, tense and small, feeling like a whip-cord or fine wire under the finger. Vomiting is a constant feature of this disease, and is both an early and a late symptom. There is great restlessness, anxiety, and, in bad cases, pinched features and collapse. What is its duration and prognosis ? If it is due to perforation, it is generally fatal; the patient dying in from two to five days. If it follows traumatism, or arises spon- taneously, the prognosis is more favorable, recovery often taking place after two or three weeks. It is always a grave disease. Lo- calized peritonitis is serious in proportion to the extent of peritoneum involved, and its tendency to spread. DISEASES OF THE PERITONEUM—ACUTE PERITONITIS. 169 How is this affection diagnosticated ? Peritonitis is recognized by the great pain, the tenderness, the fever, the pulse, the vomiting and the constipation. Differential Diagnosis. (1) From enteritis. In the latter disease the tenderness and other symptoms are local, not diffused. (2) From rheumatism of the abdominal walls. In these cases the temperature is not above 100° ; there is no obstinate constipation, no vomiting, but a rheumatic history and, perhaps, some swelling of the joints. (3) Hysteria sometimes simulates peritonitis. In these cases there is no fever as a rule, or if there is, the temperature varies greatly in the course of a very short time. The patient rarely assumes the characteristic position of peritonitis, and although there is generally great tympanites and the patient complains of much pain on the slightest touch, yet if her attention is distracted from the abdomen, the pressure may be gradually increased without any complaint. There are usually other symptoms of hysteria present, or at least there is a history showing that she is of an emotional disposition. What is the treatment of peritonitis ? Local Treatment. If seen early, before it has become diffused and before effusion has taken place, leeches applied to the abdomen and followed by the intermittent application of ice, or of cold water (the German method of treatment) is very serviceable. Later in the disease, hot cloths sprinkled with turpentine and laudanum, or with the former alone, are indicated. After effusion has taken place, an ointment of equal parts of mer- curial and belladonna ointments may be used, or the turpentine fomentations continued. Poultices are indicated, but are objection- able in diffused peritonitis, on account of their weight. General Treatment. Opium must be given, and pushed to the point of tolerance. It is given for its effect, independent of the dose required to produce that effect. Usually the deodorized tincture can be given to an adult in doses of gtt. xx every hour, and doubled after the second dose if 170 ESSENTIALS OF PRACTICE OF MEDICINE. it is well borne ; or morphine may be administered until the patient is thoroughly under the influence of the drug, when the deodorized tincture may be substituted for it. Atropine is sometimes advanta- geously combined with the opium treatment. The opium may also be administered by the bowel, but answers best when given by the mouth, provided the stomach is not too irritable to tolerate it. When there is much tympany, turpentine (gtt. x) in emulsion, may be given if the stomach is not too irritable. If the peritonitis is due to perforation, stimulants must be given to sustain the powers of life. Peritonitis from puerpend causes must be treated by stimulation, tonics (as quinine) and digitalis, at the same time that the most thorough antiseptic injections are used for the vagina and uterus. Chronic Peritonitis. What is chronic peritonitis ? It is a chronic inflammation of the peritoneum, generally following an acute attack, but which, in tubercular subjects particularly, may be chronic from the commencement. What is its pathology ? Tubercle is nearly always found on the coils of intestine in a case of any duration, whether it occurs in a tubercular subject or follows an ordinary acute attack. The mesenteric glands, also, are cheesy and the seat of tubercular deposit. What are its symptoms ? The abdomen is enlarged and tender. Dropsical fluid is present in the abdominal cavity, giving rise to fluctuation. There is often a history of tubercle, with hectic fever, and perhaps signs indicating tuberculosis of other organs, as the lungs. What is the treatment ? Counter-irritation over the abdomen is advantageous, and is best produced by small flying blisters. Diuretics and diaphoretics should be given to cause absorption of the effused fluid, and iodine and cod-liver oil administered to promote the absorption of the tubercle. The patient should be well and systematically nourished, and should use stimulants in moderation. DISEASES OF LIVER—ICTERUS. 171 DISEASES OF THE LIVER. Icterus. What is icterus ? Icterus or jaundice is a symptom of disease of the liver, not a disease itself. It may be due to obstruction of the bile ducts either from catarrhal inflammation, from gall-stones, or from various me- chanical causes, such as plugs of mucus in the gall ducts, etc. It may also be due to disorders of the blood, as in pregnancy, yellow fever, malaria, following snake bites, etc., or to disease of the liver itself, as in acute fatty degeneration, or to mental emotions, as violent anger. What are its symptoms? A yellow discoloration of the entire skin, mucous membranes and conjunctiva, is seen in strong daylight. All objects appear to the patient to have a yellow hue. The urine when tested on a white porcelain plate by fuming nitric acid, gives a play of colors. The pulse is slow, the temperature is depressed, there is intense itching of the skin and conjunctiva, gastric disturbance, constipation with clay-colored stools, from want of bile, although sometimes they may be black and offensive. What is the pathology of jaundice ? Where there is obstruction of the ducts, resorption takes place of the bile which has been previously formed. The skin and mucous membrane endeavoring to excrete this bile from the blood become tinged with its coloring matters and the various symptoms are due to the bile in the circulation. Where no obstruction of the ducts exists and the bile is not formed, the hydrocarbons which are usually converted in the liver into urea or uric acid are probably converted into biliary acids in the blood, and produce the same train of symptoms. How is jaundice recognized? The yellow conjunctiva and skin, the play of colors in the urine when treated with uric acid, establish the diagnosis. What is the prognosis ? The prognosis depends upon the cause. Where it lasts, from any 172 ESSENTIALS OF PRACTICE OF MEIUCINE. cause whatever, for more than three months, dilatation of the bile ducts and alteration of hepatic cells is apt to result. How is it treated ? The disease of which it is a symptom should be ascertained and treated. The skin should be kept active by baths and diaphoretics. The action of the kidneys should be maintained by diuretics, and the portal circulation should be unloaded by purgatives, especially salines, as sodium phosphate, Rochelle salt, potassium bitartrate or acetate, or magnesia sulphate. Podophyllin and calomel are some- times required. For the itching of the skin let the patient soak himself in warm water with sodium bicarbonate (1 ounce to a gallon), or potassium carbonate or borax. Sponging with carbolic acid is sometimes efficacious. If these means fail potassium bromide (gr. xxx) at bedtime will sometimes prove useful. Acute Hepatic Hyperaemia. What is this disease ? It is an acute congestion of the liver, not very common in this country, caused by very hot weather, by arrested menstruation or sometimes by errors in diet. What are its symptoms, duration and treatment ? There is pain and weight in the hepatic region, with increased dullness on percussion. Slight jaundice ; anorexia; coated tongue ; depressed spirits ; constipation, and sometimes vomiting. The dis- ease lasts for from five to six days, and gradually passes away. Treatment. The diet should consist principally of animal foods, broths, etc., with very little starchy or fatty matters. The patient should be given small doses of calomel (gr. i) with bicarbonate of sodium, fre- quently repeated and followed by a saline. If there is much pain over the liver leeches and cups are to be employed. DISEASES OF LIVER—ACUTE HEPATITIS. 173 Chronic Hepatic Hyperaemia. What is this disease ? It is a chronic congestion of the liver, more common in this climate than the acute disease, and caused by chronic cardiac diseases, espe- cially dilated heart, long continued heat, or hemorrhoids. It is chiefly due to interference with the abdominal circulation. What are its symptoms ? There is a feeling of weight and tension over the cardiac region, with a bad taste in the mouth ; black, offensive stools ; moderately increased area of percussion dullness ; slight jaundice ; depressed spirits; drowsiness ; mental hebetude ; nausea, often vomiting ; anorexia, and usually the patient imagines he is the subject of an incurable affection. What is the prognosis of chronic congestion of the liver ? The prognosis of chronic, as of acute congestion, is good as far as the attack itself is concerned. If it is caused by a chronic disease it will return, and the ultimate prognosis will depend upon the affection which produces it. How is it treated ? The diet and general treatment should be the same as in the acute disturbance. The patient should take active exercise. Alkalies should be administered internally. He should have a Turkish bath twice a week, and friction should be employed over the liver. Acute Hepatitis. What is acute hepatitis ? It is an acute inflammation of the liver seen particularly in tropi- cal climates, due to long continued heat and errors in diet, with want of exercise. What are its symptoms, duration and termination ? The patient complains of great pain and tenderness in the hepatic region. There is high fever with evening exacerbations and morn- ing remissions ; constipation, and often clay-colored or black stools; 174 ESSENTIALS OF PRACTICE OF MEDICINE. moderate jaundice, and frequently irregular sweats. The duration is from one to two weeks, and it terminates by gradual recovery, or by the formation of abscesses, which may be recognized by recurring chills, repeated sweats and exhaustion. How should it be treated ? In the early stages, leeches or cups should be applied over the liver. Purgatives, as calomel and the salines, should be adminis- tered. The diet should be restricted, alkaline diaphoretics should be given, and, in the later stages, quinine should be administered. Chronic Hepatitis. What is this disease ? It is a chronic inflammation of the liver, occurring especially in India and hot climates, and commonly known as "liver disease." The symptoms are the same as those of chronic congestion, except- ing that at times there are irregular accessions of fever and a vari- able increase in the size of the liver. The danger in these cases is the formation of abscesses. The patient will usually recover on going to a cooler climate. Treatment. The treatment is the same as in chronic congestion. It is of im- portance to keep up the action of the skin. Quinine should be also administered, and the occasional use of massage over the liver has a good effect. Acute Catarrh of the Bile Ducts. What is this affection ? It is an inflammatory disease of the common choledoch duct, spreading to the smaller ducts and finally to the liver itself. It is more commonly known as catarrhal jaundice, is due to errors in the diet, to malarial or epidemic influences, or the extension of inflam- mation from the duodenum. What are its symptoms and duration ? It usually begins suddenly with gastro-enteric disorder for a day DISEASES OF LIVER—ACUTE CATARRH OF BILE DUCTS. 175 or two; marked jaundice supervenes with tenderness or swelling over the liver, nausea, vomiting, anorexia, clay-colored stools, slow pulse and intense itching of the surface, and other symptoms com- mon to jaundice, and sometimes, symptoms referable to gout. There is no fever. After two or three weeks it gradually passes away. Sometimes the jaundice persists for several months, and secondary inflammation and hardening of the connective tissue ensues. This is especially seen in old people, particularly those subject to gout. What is the prognosis ? The disease usually passes away gradually, the patient being con- valescent in about six weeks. Sometimes, however, the case grows steadily worse, and nervous symptoms, as stupor and delirium, super- vene and are followed by death. In these cases there is usually permanent occlusion of the bile ducts from adhesive inflammation. What is the diagnosis and treatment of this affection? Diagnosis. The disease is recognized by the history and gastric symptoms, succeeded by jaundice and marked hepatic swelling. Treatment. Unload the portal circulation by means of salines, particularly sodium phosphate, given in drachm doses three or four times a day. Act on the kidneys by alkaline diuretics, such as potassium acetate, and on the skin by alkaline baths. Mercury is not generally serviceable in the early stages. Locally, if seen in the beginning, a few leeches, followed by poultices, in the region of the liver, or if seen later, small fly blisters in the same situation, are of use. When the disease does not yield readily, or the patient is of gouty diathesis, colchicum or potassium iodide may be used. Should the disease become chronic or the patient be syphilitic, corrosive sub- limate or potassium iodide should be employed. If the disease is very obstinate, ammonium chloride (gr. xv-xx t. i. d.) will sometimes have a good effect. For the intense itching of the skin the same treatment should be employed as has already been spoken of under jaundice. 176 ESSENTIALS of PRACTICE of MEDICINE. Passage of Gall-stones. What are the symptoms of the passage of gall-stones ? There is intense pain recurring in paroxysms in the epigastrium, or right hypochondriac region; violent retching and vomiting, and, if the attack lasts, intense jaundice. All the symptoms rapidly disappear when the stone passes into the bowel. What is the duration of an attack ? The passage of a gall-stone usually occupies from two hours to two or three days. It may, however, last a long time, even thirteen or fourteen months. What is the termination of the attack ? Usually the stone passes into the bowel through the duct, and rapid recovery takes place. Gall-stones may, however, cause ulcer- ation, and escape into the peritoneal cavity, or, when adhesion precedes the ulceration, they may pass into the bowel through a fistulous opening. Sometimes they become impacted and give rise to chronic catarrhal jaundice, and multiple abscess of the liver may result. Of what do these stones consist ? They consist of cholesterin, mucus, bile, etc. They vary in their size and in number. How should this affection be treated? During the passage of a stone morphine should be.administered hypodermically in doses of gr. £-i, combined with atropine Sr- ilo~&(» repeated every two hours, if necessary, to allay the pain. Ether or chloroform may be inhaled for the same purpose. Large amounts of weak alkaline waters, as sodium carbonate, gr. ij to the pint, taken hot, relieves the nausea and vomiting, and perhaps facilitates the passage of the stone. If it is long in passing, or if secondary catarrh results (shown by the tenderness and jaundice), leeches followed by poultices should be employed, and purgatives, as sodium phosphate, podophyllin, or even mercurials, should be administered. DISEASES OF LIVER—HEPATIC ABSCESS. 177 To dissolve the stones or prevent their formation, Durand's remedy (ether three parts, turpentine one part, gtt. x-xx, three times a day, on an empty stomach), or chloroform (gtt. x-xx, well diluted, three times a day), have been employed. Neither of these remedies, however, are of much avail. The patient should take active exercise in the open air, and should drink alkaline mineral waters, or weak solutions of sodium carbonate, and magnesium sulphate occasionally. Small doses of the mercurials should be given at intervals. Hepatic Abscess. What are the causes of abscess of the liver ? It usually follows acute or chronic hepatitis in hot climates, or may occur after dysentery. It is especially frequent in malarial districts. What are its symptoms ? The symptoms are very latent, sometimes there being no symptoms but depressed spirits and sallowness of the skin. Generally, how- ever, there is pain with a sensation of weight and itching in the hepatic region ; nausea and vomiting ; clay-colored or black stools ; irregular chills, and a remittent fever which is not influenced by quinine; irregular sweats; emaciation and scanty, high-colored urine, depositing urates on standing; tenderness and swelling over the right lobe of the liver ; the right rectus muscle is rigid and there is great throbbing of the abdominal aorta. Fluctuation is present, at first obscure, but becoming more and more marked ; jaundice is as often absent as present, excepting in cases of multiple abscess. In multiple abscess the swelling is more uniform, there is much more constitutional disturbance, the symptoms being of a marked asthenic type, and the disease runs a more rapid course, lasting for a few weeks only, while ordinary abscesses last for months. What is the morbid anatomy ? An hepatic abscess is ordinarily large and single, is usually situated in the right lobe and contains from an ounce to a gallon of pus. Pyaemic abscesses are multiple and are usually preceded by extravasa- tion of blood, and plugging of the vessels. They follow dysentery, etc. 12 178 ESSENTIALS OF PRACTICE OF MEDICINE. How is abscess of the liver recognized? Abscess of the liver is diagnosed by the history of liver disease with the physical signs of an abscess in the hepatic region, by the hectic fever, chills and other general symptoms of abscess. Differential Diagnosis. (1) From Cancer of the Liver.—By the fever, the fluctuation, the absence of hard nodules, and the localized, not diffused, tender- ness. (2) From Cancer of the Stomach (where there is marked gastric symptoms and swelling over the pylorus). —By the fever and jaundice. (3) From Abscess of the Abdominal Walls.—By the absence of the history of traumatism, by the long duration and by the use of accurate percussion of the liver in conjunction with hepatic symp- toms. In case of abscess of the abdominal walls, motion is much more difficult and painful than in the abscess of the liver, and the exploring needle introduced into the abscess may bring away shreds of muscle with the pus. What is the prognosis ? Abscess of the liver is always a serious disease. Pyaemic abscesses terminate fatally. The prognosis of the ordi- nary abscess depends upon its size, number, and the destruction of the surrounding tissues, and upon the direction in which it opens. Should it open into the lung, the prognosis is favorable; into the intestine or through the abdominal wall, it is favorable also; into the peritoneal cavity, it is almost invariably fatal. The patient may die worn out by the hectic fever. How should it be treated ? As soon as pus is present it should be evacuated either by aspira- tion or by abdominal section. In case of doubt, it is best to aspi- rate. The patient's strength should be sustained by good food, tonics and stimulants, and quinine should be administered. The sulphites have been employed, but are not of much service. DISEASES OF LIVER—INTERSTITIAL HEPATITIS. 179 Interstitial Hepatitis. What is interstitial hepatitis ? It is a low grade of interstitial inflammation of the liver substance, resulting in the hypertrophy of the connective issue, which finally, by contracting, presses upon the liver cells and the vessels, inter- fering with their functions. What are its synonyms ? It is called cirrhosis or sclerosis of the liver, gin-liver, or hob- nail liver. What are its causes ? The chief cause is alcohol, especially when it affects man. Some- times it arises without apparent cause, particularly among women. Sometimes it is produced by inherited syphilis, especially in children. Occasionally, it is seen after long-standing disease of the liver, or from congestion due to cardiac (mitral) disease. What are its symptoms ? There are general dyspeptic symptoms from congestion or. chronic catarrh of the stomach, produced by disturbance of the portal circu- lation ; enlarged spleen, congestion or hemorrhage from the intes- tine, or bleeding piles, produced in the same manner. Abdominal dropsy (ascites) is a common symptom. The symp- toms referable to the liver itself are not well marked. Jaundice may be slight or absent. The liver in the first stages is enlarged, after- wards diminished in size ; the diminution being difficult to detect, frequently, on account of the dropsy. There is difficulty in the digestion of fatty substances because the bile is altered in character. The liver does not properly defibrinate the blood, the urea remains in the blood and system, and the patient is pale and anaemic. There is a tendency to low grades of inflammation of serous membranes, such as peritonitis, pericarditis or pleurisy. It is a chronic, progressive disease, lasting for years ; the patient finally dying, worn out from exhaustion, dropsy or, with cerebral symptoms, from uraemia. What is its pathology and morbid anatomy ? A low grade of inflammation of the interstitial connective tissues 180 ESSENTIALS OF PRACTICE OF MEDICINE. around the minute vessels and ducts of the liver takes place, and gradually leads to an increase of the connective tissue (hyperplasia) along the capsule of Glisson, with swelling and enlargement of the liver. Finally, by contracting, it compresses the lobules, and causes an irregular-shaped (hob-nail) liver, diminished in size. Under the microscope the hepatic cells of the compressed lobules are atrophied, and have undergone granular degeneration ; the radicles of the hepatic ducts and vessels are compressed and obliter- ated or tortuous and enlarged. When a section is made, bands of connective tissues arc found between the lobules, causing hardness and resistance to the knife. How may this disease be recognized ? The diagnosis is made from the history of steady drink ; chronic heart disease, etc. From the gastric, splenic and intestinal disturb- ance, and the tendency to hemorrhage ; from the ascites, the enlarged abdominal veins, and area of hepatic dullness which is at first increased, afterwards diminished. What is the prognosis ? If treated early, before contraction takes place, the patient may recover; after contraction occurs, life may be prolonged, but the disease can never be cured. How should it be treated ? In the early stages, before contraction has taken place, leeches may be applied, and the salines, as magnesium sulphate or potassium bitartrate should be administered, conjoined with potassium iodide. After contraction has commenced, no radical cure can be accom- plished. Corrosive sublimate in small, repeated doses, alternating with potassium iodide, is supposed to retard the progress of the disease. No matter when seen, the portal circulation should be acted on by salines, and the secretion of the kidneys maintained by digitalis or infusion of broom. For the gastric symptoms regulate the diet, avoid alcoholic stimu- lants, and treat as occasion may require. For Dropsy.—When diuretics and diaphoretics fail, paracentesis abdominis must be performed. DISEASES OF LIVER—FATTY LIS'ER. 181 Acute Yellow Atrophy. What is acute yellow atrophy ? It is an acute inflammation of the hepatic cells, resulting in their degeneration, characterized by rapid atrophy of the liver with deep jaundice and grave nervous symptoms (uraemic?), terminating in a week or ten days. It is also called acute parenchymatous degenera- tion of the liver. Cause. It is especially seen in pregnant women. It may result from the action of phosphorus, arsenic or other metals, or be due to venereal excesses or syphilis. Symptoms. It begins with gastro-intestinal catarrh, headache, slight fever and slight jaundice. The jaundice deepens, the pulse becomes slow, and the headache increases. The liver dullness rapidly dimin- ishes in extent. There is sleeplessness, convulsions, coma and death. The liver is found to be reduced in size and weight, and acute fatty infiltration and degeneration has taken place. Prognosis. Almost invariably fatal. Treatment. Free purgation may be tried in the early stages, and the mineral acids may be administered. Phosphorus in small doses has been re- commended. Fatty Liver. What is fatty degeneration of the liver ? It is a disease in which a gradual fatty degeneration of the liver cells and a fatty infiltration of the liver tissue takes place, caused by over-eating, especially when rich food is habitually indulged in, by want of proper exercise, or by wasting diseases, such as cancer or consumption. What are its symptoms, prognosis and treatment ? The patient is pale and sallow, with a greasy complexion. Fatty 182 ESSENTIALS OF practice of medicine. or starchy foods are not properly digested, and the stools are discol- ored, usually black, due to altered bile. The area of hepatic dull- ness is increased, the margins of the liver rounded, the edges not distinct, but smooth, and there is no dropsy. Prognosis. It is not immediately dangerous", but lessens the vitality of the patient. Treatment. The patient should "be put on a regulated diet, and should not be over-fed. He should take active exercise, and should make use of occasional salines and diaphoretics. Albuminoid Liver. What is albuminoid liver ? Albuminoid, or waxy amyloid liver is a disease characterized by an infiltration of the liver tissues with a peculiar waxy material, resulting in their degeneration, and caused by syphilis, long con- tinued suppuration, especially when caused by bone disease, or by malaria. What are its symptoms ? There is anaemia and albuminuria which may be slight or absent. The patient suffers from marked dyspeptic symptoms. Fatty and starchy matters are not digested ; the stools are usually clay-colored or may be dark, due to altered bile, and the liver is enormously enlarged. What is the pathology and post-mortem appearance ? There is a deposit of albuminoid or waxy material among the liver cells and along the capillaries, giving rise to an enormous increase in the size of the liver, interfering materially with its func- tions. The spleen and kidneys are similarly affected, as a rule. On post-mortem examination the liver is pale, smooth, shining, and has a waxy appearance on section. A solution of iodine passed rapidly over its surface produces a mahogany-brown discoloration. diseases of liver—cancer of liver. 183 How is this disease diagnosed ? Waxy degeneration of the liver is recognized by the history and cause, by the enormously enlarged, smooth liver, the absence of jaundice and dropsy, the marked anaemia, the albuminuria and probably the enlarged spleen. Differential Diagnosis. (1) From Cancer of the Liver.—In the latter disease the liver is irregular in outline and nodulated. (2) From Hydatid Cyst of the Liver.—In this case the history and symptoms are different. The cyst may be discovered on palpation, and fluctuation can generally be detected. What is the prognosis of this affection? The patient never entirely gets well but improves very much under treatment, and the liver decreases much in size. How is it treated ? The cause should, if possible, be ascertained and treated, The patient's diet should be properly regulated, very little fatty, starchy or saccharine food should be given, and he should live prin- cipally on albuminous articles. He should take active exercise, and the occasional use of salines, as Rochelle salt or the natural mineral waters, are efficacious in relieving portal engorgement. Ammonium chloride (gr. x, increased to gr. xx, t.i.d.), continued for periods of three weeks, or until it irritates the stomach, when it may be alternated with the syrup of iodine of iron (gtt. xx-3j, t. i. d,) is the most efficacious remedy. Ammonium iodide may be used, or cod-liver oil may be given with the ammonium chloride. Cancer of the Liver. What are the causes of cancer of the liver? Cancer of the liver is a very common disease and may be either primary or secondary. The liver is the most common seat of inter- nal cancer after the uterus and stomach. The disease is more frequent in women than in men. It is rarely 184 ESSENTIALS OF PRACTICE OF MEDICINE. seen in young people, generally coming between forty and sixty years of age. What are the symptoms, duration and morbid anatomy ? Symptoms. The jaundice, which is slight, except when the cancer presses on the ducts ; the dropsy is also slight, except where the cancer presses on the portal vein or vena cava. Gastric symptoms are common, from interference with the portal circulation. The urine is high colored and may contain leucin and tyrosin. There is pain and tenderness in localized spots, over the region of the liver. The area of percussion dullness is increased, sometimes upwards, but more generally downwards, and is irregular in outline; on palpation nodosities are detected over the liver. There is no fever. As the disease progresses the patient becomes markedly cachectic. The average duration is about one year. Morbid Anatomy. The diseased process is generally diffused throughout the liver in small cancerous nodules, the intervening structures being healthy; the liver is more enlarged than in any other disease, excepting waxy degeneration. The surface is irregular and nodulated. How is cancer of the liver recognized ? The diagnosis is made from the localized pain and tenderness; from the enlargement of the liver, the irregular outline, absence of fever in the presence of cachexia. Differential Diagnosis. (1) From Cirrhosis of the Liver (in the stage of enlargement). In this disease there is no pain, no tenderness, and no cachexia ; the enlargement is not as great; the surface of the liver not so nodulated and more dropsy is present. (2) From Hepatic Abscess.—In the latter disease there is no emaciation, and no numerous spots of localized tenderness, but fluctuation and fever. (3) From Cancer of the Stomach.—The greater prominence of gastric symptoms should prevent a mistake. (4) From Cancer of the Kidney.—An examination of the urine renders the diagnosis clear. DISEASES OF LIVER—HYDATID CYST OF LIVER. 185 What is the treatment ? The treatment is palliative. To retard the growth of the cancer, small doses of arsenic have been used persistently, or corrosive sub- limate given continuously for a long time. Conium plasters worn over the hepatic region persistently has been said to retard its growth and to relieve the tenderness. For pain, morphine or opium must be used. For dropsy, the treatment should be conducted on general principles. Hydatid Cyst of the Liver. What are the symptoms of this disease ? Hydatid cyst is not common in this country, but is frequently seen in Iceland and Australia. The liver does not increase much in size, but as the cyst grows, it projects forward from under the ribs and upon palpation, gives rise to a jelly-like vibration. There is no pain, but little fever and almost no constitutional disturbance. What is the morbid anatomy ? It consists of a multiple cyst of the liver, due to the ova of the tapeworm from dogs, which, entering the body probably from the food, travel through the portal vein to the liver and there become encysted. The hooklets of the ova are found in the cyst, which also contains a gelatinous fluid causing the vibration on palpation. What is the prognosis ? Recovery is frequent. The ova are killed by bile and the cysts may shrivel up, or may be discharged into the intestines, lungs or externally. The duration is from five to thirty years. What is the treatment ? Glycerin administered internally is said to draw the fluid from the cyst and cause it to disappear. Large quantities of sodium in solution are likewise recommended. These remedies are only partially suc- cessful and often fail. The surgical treatment consists in aspiration, and the injection of iodine into the cyst. This is attended with some risk, as hepatitis often results. Electrolysis has also been resorted to. 186 ESSENTIALS OF PRACTICE OF MEDICINE. Functional Disease of the Liver. What are the causes and symptoms of functional disease of the liver ? They are caused by too rich food, with want of exercise ; by ex- posure to great heat; by malaria, or by hepatic congestion. If functional disease of the liver should continue for a long time it will result in hepatic congestion, even should the latter not have existed before. Symptoms. There is a bitter taste in the mouth, gastric catarrh, palpitation, loss of memory, listlessness, and a tendency to bronchial catarrh. Speotal Symptoms. Pain in the right shoulder is a common symptom. Constipation usually exists, due to absence or diminution in the secretion of bile. There is alteration of the glycogenic function of the liver, and as the bile-making function is also interfered with, fatty substances are only emulsified irregularly, resulting in excessive corpulence, or, in some cases, emaciation of the patient. The urine is high-colored, scanty and full of urates. Occasionally sugar is found in the urine in small quantities, which, however, passes away under the use of active purges. Diagnosis. From organic hepatic diseases. These should always be sought for and excluded. What is the treatment ? Active exercise should be taken in the open air and baths should be indulged in daily. The diet should be properly regulated, purga- tives, as salines or podophyllin, with the occasional use of a blue pill, should be regularly administered. Diluted nitrohydrochloric acid should be given before meals, and may also be used in baths, either to the surface generally, or locally applied to the region of the liver. The pain in the right shoulder is best treated by purgatives. ACUTE AND CHRONIC RENAL HYPEREMIA. 187 DISEASES OF THE KIDNEYS. Acute and Chronic Renal Hyperaemia. What is acute renal hyperaemia ? It is an acute or active congestion of the kidneys, caused by trau- matism, exposure, or renal irritants, such as copaiba, sandalwood, turpentine, cantharides, etc. Symptoms. The urine is passed frequently in small amounts, is high-colored, and is not associated with pain, which serves to distinguish it from inflammation of the kidney. It contains a little blood and traces of albumen, due to the presence of blood. There is a dull pain in the back, little or no fever. Sympathetic vomiting, headache and feel- ing of general discomfort. What is chronic renal hyperaemia? It is a chronic congestion of the kidney, usually dependent upon cardiac disease, especially on dilatation of the heart, with disease of the mitral valve. The symptoms are similar to those seen in acute congestion, but are more chronic, and associated with disease of the heart. The urine is scanty, high-colored and concentrated, and contains an abundant deposit of urates. There is a feeling of weight in the loins and dragging pain in the testicles. What is the prognosis of these diseases ? The prognosis of acute hypercemiei is always favorable. That of chronic hyperaemia is favorable if it is not too long continued, and is not associated with very advanced cardiac disease. How should these diseases he treated? Dry cups should be applied over the loins. Hot baths should be employed to stimulate the skin and kidneys. Infusion of digitalis is the best diuretic that can be used. Alkaline waters (as Saratoga 188 ESSENTIALS OF PRACTICE OF MEDICINE. or Vichy water) should be given, or pure water may be used, to dilute the urine. Saline purgatives should be occasionally adminis- tered. No stimulating diuretics should be employed. Acute Parenchymatous Nephritis. What is acute parenchymatous nephritis ? Acute parenchymatous nephritis, also called acute tubal nephritis and acute Bright's disease, is an inflammation of the secreting struc- ture of the kidney, attended with scanty, high-colored urine, of high specific gravity, and containing blood and epithelial casts. What are its causes ? The most frequent cause is scarlet fever ; it also follows other exanthemata ; is supposed to be due to exposure, or to traumatism, and occasionally follows congestion of the kidneys. Both kidneys are always affected. What are the symptoms ? The urine is dark, smoky (from admixture with blood), scanty, and of high specific gravity. The microscope shows some free blood corpuscles, casts of epithelium, with blood corpuscles in the casts, and some free epithelial cells, from the tubules of the kidney. Chemical tests show a large amount of albumen. There is moderate fever, some thirst, nausea, vomiting and diarrhoea. Symptoms due to uraemia are often present, as stupor, headache, and occasionally, not often, convulsions. After the inflammation has lasted some little time, the blood begins to disappear from the urine, and general dropsy may suddenly supervene. What is the morbid anatomy of this affection ? The cortical substance of the kidney is swollen and congested, and encroaches on the tubules and pyramids, which become red and con- gested likewise. Small capillary hemorrhages take place into the pelvis of the kidney. Under the microscope the Malpighian bodies are found to be turgid with blood ; the tubules are full of blood corpuscles, epithe- lium and embryonic cells. This condition lasts for about ten days. ACUTE PARENCHYMATOUS NEPHRITIS. 1N<) The redness slowly disappears, leaving the tubules swollen and con- gested in patches for several weeks. The epithelial casts are due to the distention of the tubules with a fibrinous deposit, and the blood corpuscles, which are washed out by the urine, carrying with it the old epithelial cells. What is the diagnosis and prognosis ? Diagnosis. The disease is diagnosed by the history ; the cause ; by affecting young adults especially; by the appearance of the urine, the pres- ence of blood and blood-casts seen under the microscope. Prognosis. These cases usually recover. Sometimes serous effusions take place, as into the pericardium or pleura, or into the ventricles of the brain, which prove rapidly fatal. What is the treatment ? Absolute rest in bed must be insisted upon. The diet must be limited to milk, no stimulating diuretics should be employed, but the kidneys should be kept acting by means of fluids, especially water. If the patient is strong, and it is due to a cold, wet cups should be applied over the loins. If the patient is weak, and it follows a debilitating disease, dry cups should be employed, followed by the application of a counter-irritant, as croton oil. Digitalis, either in the form of the infusion (f3j-ij every few hours, watching its effect upon the heart), or of the tincture (gtt. iij-x), or of the fluid extract (gtt. j-iij) should be administered. Cream of tartar in 3ss doses, or potassium citrate in gr. xx doses, are excellent adjuvants to the digitalis. If the secretion of urine is small, the patient dull, the temperature 103° (threatening uraemia), particularly if he has been previously cupped, pilocarpine (gr. i) should be given hypodermically or the fluid extract of jaborandi (gtt. x-xx) administered internally, pro- vided the heart is sufficiently strong to withstand their depressing effect. Active purgation with podophyllin, croton oil or elaterium, should also be employed. 190 ESSENTIALS OF PRACTICE OF MEDICINE. Should symptoms of uraemia be actually present, active purgation and free diaphoresis should be resorted to, If urcemic convidsions occur, the inhalation of chloroform may be employed to stop the convulsions, and chloral and bromide of potas- sium given to prevent their recurrence. Uraemic asthma is best treated by the inhalation of a few drops of amyl nitrite, followed by the administration of nitroglycerine, to neutralize the urea in the blood. Benzoic acid may be given if the stomach will bear it, or hydrochloric acid or nitro-hydrochloric acid may be substituted, if the former produces vomiting. Chronic Parenchymatous Nephritis. What is this affection? This disease, also called chronic Bright s disease, and, in its later stages, large white kidney, or fatty kidney, is a chronic inflammation of the secreting structure of the kidney, characterized by a scanty, high-colored urine of high specific gravity, containing much albumen with granular or fatty casts; dropsy and various disorders of the nervous, circulatory and gastro-intestinal systems are present, due to the circulation of urea in the blood. What is its cause and morbid anatomy ? Causation. It occasionally follows the acute disease ; sometimes occurs with- out known cause ; is frequently due to continued exposure to cold, and at times to chronic digestive disturbances associated with mental worry. Morbid Anatomy. The kidney is large; is yellow or white on section, the tubules appearing red and congested on the cut surface. The cortex is swollen, thickened, infiltrated, and the capsule easily separated. If this condition alone exists, gradual absorption of the exudate may take place and the diseased kidney recover. Sometimes, however, the disease progresses, the epithelium undergoing fatty degenera- tion and the case terminating fatally. The tubules are filled with CHRONIC PARENCHYMATOUS NEPHRITIS. 191 granular epithelium, which is shriveled and detached. A fibrinous exudation takes place under this epithelium, forming casts of the tubules, which, when washed away, carry the granular epithelium with them. Should fatty degeneration occur these casts will contain epithelial cells full of oil-globules. What are the symptoms ? The urine is generally scanty and of high specific gravity. Occa- sionally the amount passed is normal, and the specific gravity low or normal. It does not contain blood, sometimes a few corpuscles may be seen, but granular casts are found containing shrivelled granular epithelium, and as a late symptom fatty casts. Dropsy is often a prominent symptom ; commencing in the eyelids it invades the face, hands, legs, and later, as a serous effusion, it occurs in the internal cavities, as the peritoneum, pleura, or peri- cardium. Progressing ancemia, due to the drain of albumen from the blood, is a frequent symptom, which, together with oedema of the face, gives rise to a characteristic expression. Gastro-intestinal disturbance, as vomiting and occasionally diar- rhoea, is due to the attempts of the mucous membrane to eliminate the urea from the system. Chronic bronchial catarrhs occur from the same cause. Nervous symptoms, as headache, impaired memory, irritable temper, drowsiness and defective eyesight, are frequently complained of. The ophthalmoscope often shows a low grade of retinitis leading to atrophy of the optic nerve and blindness. Cardiac Symptoms.—There is at first functional disturbance of the heart; afterwards hypertrophy takes place, associated, at a later stage, with dilatation. What is the diagnosis of this form of Bright's disease ? The disease is recognized by the dropsy, the large amount of albumen, the scanty urine of high specific gravity, the casts, the secondary effects, and the absence of fever. What is the prognosis ? The prognosis is hopeful. It is bad if there are marked cardiac 192 ESSENTIALS OF PRACTICE OF MEDICINE. complications, or if the casts contain very granular or very fatty epithelium. How should it be treated? Dietetic Treatment. If the patient can live on a strict diet of skimmed milk, which he usually can if he has no work to do, the result will be most favorable. If this cannot be done, skimmed milk with eggs and easily-digested meat, but no wine or liquor, may be given. If the patient is much run down, or if he be a weak child, a small amount of port wine may be taken with the meals. No food should be given which will throw work upon the kidneys. Medical Treatment. Tincture of the ferric chloride (gtt. xv-xx, t. i. d), particularly in the form of Basham's mixture, is the best remedy. This is especi- ally of service where the urine is scanty, in which case potassium acetate may be substituted for the spirits of mindererus. When the iron does not act, ergot may be given, or the chloride of gold and sodium employed. For dropsy, purgatives should be administered, as compound jalap powders, Rochelle salts, podophyllin or elaterium. Diaphoretics, as vapor baths or minute doses of Dover's powder, with nitrate of po- tassium (aa gr. iij, frequently repeated) or pilocarpine, where its depressing effect upon the heart is not feared, are of great service in this condition. For uraemia active purgation, pilocarpine, vapor baths and small doses of benzoic or nitrohydrochloric acid should be administered, as in acute Blight's disease. During urccmic convulsions chloroform may be inhaled, and chlo- ral and bromide of potassium given, as in acute Bright's disease. For pericarditis potassium iodide, purgatives, stimulants and iron should be given. Opium must be administered very cautiously, if at all. For pleuritic effusions the same treatment is indicated. chronic interstitial nephritis. 193 Chronic Interstitial Nephritis. What are the synonyms, causes and duration of this disease? Synonyms. It is also known as small, granular kidney ; gouty kidney ; cirrho- sis of the kidney, etc. Causation. It almost invariably begins as a chronic disease, rarely, if ever, following other affections of the kidney. It is due to the abuse of alcohol, syphilis, cold and exposure, gout, overwork, mental worry, or chronic lead poisoning, and usually occurs after fifty years of age. Duration. It is a very chronic affection, life being prolonged for years if proper care is taken. What are its symptoms ? The symptoms are very obscure, being referable to almost every other organ of the body except the kidney ; thus the patient suffers from dyspepsia, headache, chilliness, defective eyesight, palpitation, which is always seen in cases of long duration, and local palsies. There is no dropsy, except late in the disease, due to dilated heart. The urine is passed in large amounts, has a low specific gravity, and contains a very small amount of albumen, which may be detected by the nitric or picric acid tests, or by potassium ferrocyanide. The presence of albumen is variable, and several specimens may have to be examined before it is discovered. Sooner or later small granular or hyaline casts are found. What is the pathology ? The kidney is small, contracted, and dense. There is very little cortical substance. The Malpighian bodies are atrophied, from pres- sure, and there is a proliferation of the connective tissues, at first in the cortical substance and then between the tubules, causing more or less general atrophy of these structures. The changes are very gradual. What is the prognosis ? It is a disease of long duration. Degeneration of the vessels may 13 194 essentials of practice of medicine. take place and the patient die of apoplexy. Cardiac hypertrophy results in long standing cases and sometimes causes death. Uraemic convulsions or coma may come on rapidly at any time and terminate fatally. Hopeless blindness, from atrophy of the optic nerve, may develop. How is it treated ? The diet should be bland and easily digested, consisting of milk, eggs and meat. Milk is not as successful, however, as in the kidney diseases already discussed. Potassium or sodium iodide should be given where there is not much dropsy. Small doses of corrosive sublimate are supposed to retard the development of the connective tissue. Syrup of the ferrous iodide may be alternated with either of the above remedies, and counter-irritants over the kidneys (as applications of croton oil) may be used to advantage. Nitro-glycerin internally also does good. Iron is not as efficacious as in the other kidney diseases. Albuminoid Kidney. Describe the albuminoid kidney. Synonyms. It is also called waxy or amyloid kidney. Causation. It is caused by wasting diseases, particularly long continued sup- purations and bone diseases ; also by syphilis. Symptoms. A large amount of urine is passed which has a low specific gravity and contains much albumen and waxy casts, which are large, trans- parent, and devoid of epithelium. Dropsy is a late symptom. The liver and spleen are usually enlarged, having undergone a similar degeneration, and anaemia is present. Post-mortem Examination. The kidney is enlarged, smooth and pale on section, presenting a waxy appearance. A solution of iodine passed rapidly over the sur- face causes a mahogany-brown discoloration. The disease depends cystic degeneration of the kidney. 195 upon an interstitial deposit of an albuminoid or waxy material. The spleen and liver are similarly affected. Diagnosis. The disease is recognized by the history, cause, chemical and microscopical examination of the urine, and the marked anaemia, with the enlargement of the liver and spleen. Treatment. The treatment consists in regulating the diet, giving mostly albu- minous food and making the patient indulge in active exercise. An occasional saline purgative is advantageous, and the administration of chloride of ammonium (giving gr. x, increased to gr. xx t. i. d. for periods of three weeks, or until it produces gastro-intestinal irritation, when it should be replaced by the syrup of ferrous iodide in doses of gtt. xx-3j) is the best treatment. The iodide of ammonium may also be used, or cod-liver oil may be con- joined with other treatment. The cause of the affection should be borne in mind and treated. Cystic Degeneration of the Kidney. Describe this affection. Causation. Cystic kidney, or hydatid cyst of the kidney, is sometimes seen in chronic Bright's disease, especially in contracted kidney. It some- times occurs from echinococci (similar to hydatid of the liver). Cystic degeneration may be due to impaction of a renal calculus. It often occurs without any apparent cause, in middle or early life. Both kidneys are usually affected. Symptoms. The first symptom is usually frequent urination, the urine some- times containing blood with very little albumen, except when much blood is present. There is no sugar, and only rarely are there a few tube casts. The patient's strength gradually fails, the kidneys reach a large size, bulging out the abdominal wall. They are felt through the integuments as soft, slightly resisting bodies. 196 essentials of practice of medicine. Prognosis. This depends upon the size of the tumor and the amount of kidney involved. Death may occur from exhaustion or from uraemia. It is a very chronic disease. Treatment. Treatment does not do much good. Iron has been given and slight amounts of stimulants with good food to keep up the strength of the patient. Any symptoms which may call for treatment should be promptly met. Passage of Renal Calculi. Describe the symptoms, diagnosis, and treatment of the passage of renal calculi. The portions passed are usually but a part of a larger calculus in the kidney. Symptoms. The symptoms are intense pains in the loins, shooting down the ureters and finally in the head of the penis. The pain is intense and is followed after half an hour to an hour by a lull, and after a time by a fresh accession of pain. As a rule the whole attack lasts from four to six hours. There is much soreness and inability to move during the paroxysm, the testicle is retracted and in women there is a soreness over the ovary. During the paroxysm there is much irritability of the stomach, and often actual vomiting. The action of the heart is rapid, ex- tremities cold, skin clammy, but little urine is passed and that comes away drop by drop, is very high-colored, frequently contains blood and gives rise to scalding pain in the urethra. Sometimes these paroxysms of pain continue for hours followed by a lull which may last several days. Diagnosis. (1) From malarial congestion of the kidney with intense pain. In this affection there is a malarial history, and the symptoms of malaria ; a marked periodicity in its recurrence, and it is materially benefited by quinine. FORMATION of renal calculi. 197 (2) From intestinal neuralgia it is diagnosed by the absence in the latter of any signs of urinary irritation or of blood in the urine. Prognosis. The prognosis of the passage is favorable. Usually after the attack has lasted for a longer or a shorter period the calculi is passed into the bladder and the pain ceases. ^ Occasion- ally it causes ulceration of the ureter followed by peritonitis. Treatment. Morphine (gr. \) combined with atropine (gr. 'its) should be prompt- ly administered hypodermically, and if in half an hour some relief is not obtained, opium may be given by the rectum. If the pain is very severe, inhalations of ether may be used between injections. Large fomentations should be applied over the ureter and kidney, or draughts of hot water or of alkaline waters should be taken. If the calculus is long in passing, the fluid extract of belladonna (gtt. ij omn. hor.) may be employed until its physiological effects are obtained. Formation of Renal Calculi. What are the causes favoring the formation of renal calculi? A little plug of mucus in the pelvis of the kidney often forms a nucleus for a calculus, and the abundance of any of the salts in the urine, as seen in uric acid or phosphatic diathesis, acts as a predis- posing cause. Uric acid crystals may form in the tubules of the kidney, and growing in size cause atrophy of the surrounding structure, or by irritation lead to abscess. What are the principal varieties of renal calculi ? (1) The uric acid calculi, the most frequent, are found in persons subject to acute lithiasis and torpidity of the liver. (2) Phosphatic crdculi usually consist of alternate layers of phos- phates and urates. (3) The so-called mulberry calculi, consisting of oxalate of lime. They are small, jagged, and give rise to much pain. The number of renal calculi varies. Usually there are several small ones, occasionally one large one. 198 ESSENTIALS OF PRACTICE OF MEDICINE. What are the symptoms ? When the calculus is in the pelvis of the kidney, symptoms of pyelitis will be present; when located in the kidney's structure there will be very little pus in the urine, which will only be a tem- porary symptom. There is pain in the loins on motion or jarring reflected to the testicle and glans penis. Nausea and gastric disturbance is frequent. The urine, especially after a fall or jar, will contain blood for several days at a time, disappearing and appearing at irregular intervals. Under the microscope the urine contains a large amount of the crystals of the substance of which the calculus is composed. If during the passage of the calculus the urine is nearly healthy, it shows the calculi are in one kidney only. What is the prognosis ? The prognosis is favorable as a rule. Ulceration does not often occur. Sometimes the kidney becomes disorganized, undergoing cystic degeneration. What is the treatment ? Examine the urine to determine, if possible, the composition of the calculus. If it is uric acid, the amount of nitrogenous food should be limited, the patient living principally on milk and vegeta- bles, very little acid of any kind, drinking large amounts of water to keep the kidneys freely washed out. He should also take active exercise, make free use of baths, and take an occasional laxative. Carlsbad water or Carlsbad salts are of service. The alkalies act not only as diuretics, but they render the uric acid more soluble. For this purpose the citrate or carbonate of potassium may be em- ployed, and, best of all, the citrate of lithium used. If it is a phosphatic calculus the mineral acids, as nitric or nitro- hydrochloric in gtt. iij-v doses, freely diluted with water, are of ad- vantage. Benzoic acid or ammonium benzoate will very rapidly render the urine acid. These calculi are more frequently found in the pelvis than in the kidney proper. If it is an oxalic cedculus, a long course of nitrohydrochloric acid is supposed to give good results. PYELITIS. 199 This variety ot. calculi gives rise to the most pain and is the hardest of all to prevent. No matter what the variety of calculus, the kidneys should always be kept acting freely by the use of water, milk and buttermilk, it the urine is not too acid. .„ If one kidney is hopelessly destroyed, the other being healthy, or it pyelitis is present with symptoms of septicemia, the kidney may be aspirated, and, if stone is present, it maybe cut down upon and removed; a drainage-tube being inserted into the wound and tho- rough antisepsis practiced. Pyelitis. What is pyelitis? Pyelitis is suppuration connected with the kidney. It may be a suppurative catarrh of the pelvis or kidney, or an ab- scess in its tubular structure. What are its causes ? It may arise from catarrhal inflammation due to cold or exposure from rheumatism; from certain irritant substances, as cantharides or turpentine; from debilitating diseases, as diphtheria or typhoid fever • from renal calculus, when it is called calculus-pyehtis; or from 'inflammation extending upward from the bladder, as may follow chronic cystitis, or occasionally gonorrhoea. What are the symptoms of pyelitis ? There is frequent urination without pain, dull aching over the loins, the urine contains much pus, and columnar epithelial cells from the pelvis of the kidney, and the reaction is generally acid, unless the bladder is also diseased. The pus cells are distinct, having large, well-marked nuclei. If the disease is limited to the pelvis of the kidney, there will be but slight fever, not much albumen, and no tube casts. If the structure of the kidney is also involved, a large amount of albumen will be present, tube casts will be found in the urine; there will be hectic fever and grave constitutional disturbance. How is this disease recognized? Pyelitis is apt to be confounded with inflamniatiou of the bladder, 200 ESSENTIALS OF PRACTICE OF MEDICINE. but in the latter affection the urine is generally alkaline, the epithe- lial cells are squamous, not columnar, and there is pain in the supra- pubic region upon urination. Calculus-pyelitis is diagnosed by the history of attacks of the passage of calculi, and by bloody urine. What is the treatment of pyelitis ? The urine should be diluted and the kidneys kept washed out by means of water, particularly light alkaline waters ; or, if the urine is acid, by a neutral mixture. The diet should be light, nourishing, but unstimulating, consisting of milk, eggs, and a very little meat. Numberless remedies have been used in this disease, as tar-water, oil of sandal wood, cubebs, copaiba, etc., which, however, are apt to disagree with the stomach ; turpentine occasionally does good. Eu- calyptus is more frequently of service, as is carbolic acid (gtt. ss), or salol, which will usually diminish the amount of pus. Tincture of the chloride of iron and cod-liver oil as a nutrient when the stomach will bear it, are useful. Benzoic acid, or the benzoates, are of advantage, particularly if cystitis complicates the disease. Hematuria. What is hematuria ? This name is applied to the presence of blood in the urine. It is a symptom of many diseases rather than a disease itself. What are its causes ? The principal cause is the presence of a renal calculus. Other causes are, acute Bright's disease ; scurvy or puerpera ; parasites in the kidney, which, however, very rarely occurs in this country, and which is seen particularly in the Mauritius ; and malignant growths, as cancer, cysts, etc. What are the symptoms and diagnosis of this condition? Symptoms. The only symptom is the presence of blood in the urine ; the two being intermixed, giving rise to a dark, smoky appearance. HEMATURIA. 201 Diagnosis. Blood is found in the urine ; it may come from the kidney, blad- der, or urethra. When it comes from the kidney it is intimately mixed with the urine, giving rise to a smoky appearance ; the urine contains more albumen, and the blood corpuscles are round, full and well devel- oped. When it comes from the bladder it is not intimately mingled with the urine. Little clots are passed; the urine is passed more fre- quently, and is accompanied with vesical tenesmus; the blood is sometimes present, sometimes not. The microscope shows small, shrivelled, broken-up cells, and a few drops of pure blood are apt to follow the passage of the water. When it comes from the urethra it is accompanied by scalding or burning at the beginning of the act of urination, and the passage of the urine is apt to be preceded by a few drops of blood. What is the prognosis and treatment ? Prognosis. The prognosis is generally favorable. The patient does not die of the hemorrhage itself, though he may of the disease of which it is a symptom. Treatment. The treatment depends upon the disease which causes it. The general treatment for haematuria consists in the administration of gallic acid, ten grains, increased to twenty if the stomach will tolerate it, every hour or two until some effects are observed. Sulphuric acid may be given, if it is not contra-indicated, alone or alternating with the gallic acid. The fluid extract of ergot (gtt. xx-f3j), may be administered every hour or two. The patient should have plenty of water to keep the kidneys active and wash out the accumulating blood, and should be placed absolutely at rest. 202 ESSENTIALS OF PRACTICE OF MEDICINE. Tubercular Disease of the Kidney. Describe this disease. This affection, which is not very common, is apt to co-exist with pulmonary tuberculosis, and seems to be hereditary. Pathology. A deposition of tubercle takes place in the cortex of the kidney, the deposits run together, and break down. Similar deposits occur in the pelvis and in the ureter, which undergo tubercular ulceration. Gradually the whole mass of the kidney becomes degenerated. Both kidneys are involved, though not equally. Symptoms. There is marked pain, more severe than in cancer of the kidney, due to ulcer of the pelvis and ureter, and probably, also, to the small masses of tissues which are softening and being voided. There is no tumor. The water dribbles. Small amounts of bloody urine, sometimes containing broken-down tissue, are passed; there are marked sweats and sometimes other hectic symptoms, the patient either dying worn out from the pain, from uraemia, or from septi- caemia. This disease runs an acute course. Diagnosis. It is recognized by the pain, which resembles that caused by the passage of calculus ; by the family history ; by the hectic; by the character of the urine, which probably contains the bacillus tuber- culosis, by the absence of a tumor, and by the production of tuber- culosis in rabbits by the inoculation of sediments of the urine. Prognosis. Fatal. Treatment. The treatment is entirely symptomatic. Opium should be given for the pain, and the kidneys should be freely washed out by large amounts of diluents. CANCER OF THE KIDNEY—PERINEPHRITIS. 203 Cancer of the Kidney. Describe cancer of the kidney. It occurs as a primary or secondary affection, usually in childhood or old age. Medullary carcinoma and scinhus are the most common forms. The kidney is usually much enlarged and irregular in shape; cancer elements are found invading the bowels and intertubular structures, and frequently involving the pelvis and ureter. Cancer elements may even involve the renal vein. Symptoms. There is pain of a greater or less degree in the lumbar region; haematuria is a common symptom early in the case. The kidney is much enlarged, forming a tumor in the abdomen which is easily recognized. Albumen is sometimes present in the urine, as is the debris of broken-down tissue. Characteristic cachexia develops later in the disease. One kidney alone is generally involved. Prognosis. It is generally fatal. The disease runs a rapid course, especially in children. Diagnosis. The diagnosis is made by the cachexia, the tumor, the bloody mine, the pain and the occurrence especially in children. Treatment. It is merely symptomatic. The endeavor should be made to sustain the patient's strength as long as possible. Perinephritis. Describe this affection. This is an inflammation of the areolar tissue surrounding the kidney. It is a common disease, especially seen in childhood, particularly among boys. The right side is most frequently affected. 204 essentials of practice of medicine. Cause. It is usually due to traumatism, as blows, sprains, or too much exercise, but occasionally follows low states of the system, as typhoid fever or diphtheria. Pathology. This is the same as that of ordinary inflammation, usually termi- nating in suppuration, the abscess bursting externally in the loin or perhaps into the peritoneal cavity. Symptoms. There is pain and. tenderness in the loin of one side. Pain is in- creased by motion ; there is a feeling of dull weight, a fullness rather than swelling over the situation of the kidney, with fluctuation, some irritative fever, and although the urine is almost invariably healthy, occasionally it contains a trace of albumen from pressure. It is a long disease. Prognosis. It is generally favorable. Treatment. Absolute rest, easily digested food in the early stages, frictions with liniments, or counter-irritation over the seat of the inflammation, or if seen early, the application of ice. Later in the disease poultices afford much relief. Quinine should be given in decided doses throughout the disease, and the pus should be evacuated as soon as it is formed, either by the knife or by aspiration. Floating Kidney. What is this affection? Movable or floating kidney is one which through the loosening of its attachments becomes abnormally movable. It is due to blows, sprains, or other injuries, which loosen its attachments. It occurs usually in weak anaemic patients or in debilitating diseases. It is more frequent in women than in men, and the right kidney is usually the one affected. diseases of the pancreas—pancreatitis. 205 Symptoms. A tumor is felt under the ribs or forward against the abdominal wall; it is tender to the touch ; the outline is found to be kidney- shaped ; is movable, and the patient generally enjoys good health. Sometimes grave symptoms will appear for a few hours, such as chill, nausea, and vomiting, intense anxiety, and interrupted flow of urine. These symptoms are probably due to the kidney and ureter be- coming twisted and stopping the passage of water. Diagnosis. The diagnosis is easy. The shape and position of the tumor, which can be pushed back in position, and the absence of the kidney in its normal situation, are sufficient to distinguish the disease. Prognosis. No one dies of it. It is only dangerous when adhesions form, fixing the kidney in some abnormal position, and then the danger is from pressure. Treatment. Replace the kidney and have the patient wear an abdominal band- age. Improve the general condition by tonics. For the symptoms of collapse, should they supervene, rest, stimulants, etc., form the best means of treatment. DISEASES OF THE PANCREAS. Pancreatitis. What is pancreatitis ? It is an inflammation of the pancreas, occasionally terminating in suppuration, affecting women more frequently than men, and occur- ring without known cause. Symptoms. There is pain in the epigastrium, often shifting to the shoulders or back, nausea and vomiting, flatulency and constipation. There is fever, irregular heart, and frequently collapse, terminating in death. 206 essentials of practice of medicine. Sometimes the inflammation gradually declines, giving rise to a chronic inflammation, or ending in abscess. Chronic pancreatitis resembles in its pathology cirrhosis of the liver or kidneys. It frequently gives rise to cysts by obstruction of the ducts. The symptoms are emaciation, gastric disturbance, and the appear- ance of an excess of fat in the dejecta. Treatment. Entirely symptomatic. Morphine must be administered for the relief of pain, and digestives, as bismuth, pepsin, etc., given. Chronic interstitial pancreatitis is best treated by minute doses of corrosive sublimate, iodide of potassium, and other remedies of a similar nature. Cysts of the Pancreas. Describe cysts of the pancreas. Cysts of the pancreas are usually due to chronic interstitial pan- creatitis. Anything causing obstruction of the duct, as a calculus or the pressure of a tumor, will give rise to cystic degeneration of the whole gland. Cancer of the Pancreas. Describe cancer of the pancreas. Scirrhus is the most common variety of cancer of the pancreas. Medullary and colloid cancers are also met with. The head of the pancreas is the most frequent seat of the disease. It occurs more frequently among males than females, and is more common under forty years of age. Pain is the usual symptom. It is persistent, radiating, and in- creases rather than diminishes in intensity. It is somewhat relieved by bending the body forwards. Progressive and rapid emaciation sets in. The patient rapidly loses strength. A tumor is found in about one-third of the cases. The lymphatic glands are also enlarged. There is an excess of fat in the stools, and cancerous cachexia is rapidly developed. AC17TE AFFECTIONS OF THE SPLEEN. 207 Jaundice is sometimes present from secondary affection of the liver, or from pressure on the common choledoch duct. The disease is rapidly fatal; the case rarely lasts over a year. The treatment is palliative. DISEASES OF THE SPLEEN. Acute Affections of the Spleen. Describe acute affections of the spleen. Acute affections of the spleen are usually miscalled acute splenic tumors. They are generally secondary to some cachexia; for exam- ple, they are found in malaria, typhoid fever and diphtheria ; there is some enlargement also in scarlet fever, measles and smallpox ; so that in general terms the spleen may be said to be enlarged tempo- rarily in all acute affections. In acute affections of the liver also, from interference with the portal circulation, and particularly in acute yellow atrophy, the spleen enlarges. What are the physical signs of enlarged spleen ? The enlargement is recognized by percussion ; normally the splenic dullness extends downwards in the axillary line from the sixth or seventh rib almost to the border of the last rib. If the dullness ex- tends below this the spleen is enlarged. In all acute affections of the spleen the enlargement extends downwards and forwards and the hilum of the spleen can often be detected on palpation. What are the symptoms ? When it occurs secondary to general maladies there are no symp- toms except enlargement, which, however, may be due to local causes, as congestion, inflammation, or abscess of the spleen. Splenic Hyperemia. This may occur after traumatism, from blows and injuries, or after too violent -exercise, particularly exercise following upon a hearty meal. 208 ESSENTIALS OF PRACTICE <>F MEDICINE. Symptoms. Steady pain in the region of the spleen and shortness of breath; sometimes rupture of the vessels and fatal hemorrhage takes place. Acute Splenitis. This is sometimes called Splenic Fever. There is enlargement of the spleen, pain and tenderness in the splenic region, irritative cough, shortness of breath and fever; sometimes it results in a splenic or in diaphragmatic abscess. Splenic Abscess. There is a tumor which fluctuates, preceded by the symptoms of splenitis and attended with hectic fever. There is sometimes deliri- um, and nausea and vomiting are common symptoms ; death usually results from rupture of the abscess. The abscesses are generally metastatic and are often found in connection with emboli resulting from endocarditis. How should acute affections of the spleen be treated ? In all cases of acute splenic disease, if seen early, leeches should be employed and prompt purgation by means of salines, of podo- phyllin or of colocynth practiced ; later cold may be applied exter- nally and ergot given to contract the vessels. If an abscess form the treatment is symptomatic. The pus should be evacuated by aspiration, the patient's strength sustained by all possible means, and quinine given for the hectic fever. Chronic Diseases of the Spleen. Describe chronic diseases of the spleen. Large splenic tumors are seen following malaria or in leukaemia, or in amyloid degeneration of the spleen (in which case the liver and kidneys are also affected). Less frequently large splenic tumors arc found as the result of cancer (rare) or syphilis. The spleen is often full of pigment, and after a time there is an increase in the connective and fibrous tissues, causing a permanent enlargement. A large swelling takes place; the tumor projecting sometimes towards the crest of the ileum, and even as far forward DISEASES of chest—physical diagnosis. 209 as the pubis. In all these affections there is marked anaemia, and dropsy, partly from anaemia and partly from the pressure produced by the tumor. Hemorrhage from the bowels is a frequent symp- tom of chronic splenic enlargement. Treatment. Keep up the patient's health and nutrition by all possible means. Give the different preparations of iron for the anaemia. Give quinine in small doses continued for long periods of time, with occasional short intermissions. To reduce the splenic enlargement, ergot may be employed hypo- dermically two or three times a week, or an ointment of the red iodide of mercury may be thoroughly rubbed in over the tumor before a hot fire ; the former gives the best result. DISEASES OF THE CHEST. Physical Diagnosis. What is physical diagnosis ? Physical diagnosis is the art of discovering a disease by means of the sight, touch, hearing, or a combination of these senses. What are the methods employed to gain this result ? The methods employed are inspection, palpation, mensuration, percussion and auscultation. Inspection. What is inspection ? Inspection is the act of carefully examining a person or thing by means of the sense of sight. As applied to diseases of the chest it enables the examiner to determine the size, form, color and move- ments of the parts. By carefully comparing the movements of the two sides of the chest he can arrive at an idea regarding the relative action of the two lungs. He can also see whether the patient is breathing freely, deeply or superficially. He can observe any bulg- ing or obliteration of the intercostal spaces on the one hand or any depression of them on the other. He can also observe the apex beat 14 210 ESSENTIALS OF PRACTICE OF MEDICINE. of the heart, see whether it is diffused or localized, and whether it is strong or feeble. By means of inspection also he may arrive at a conclusion respecting the performance of the nutritive functions of the patient. Palpation. What is palpation? Palpation is the application of the hands and fingers to the surface of the patient's body, to correct the impressions arrived at by inspec- tion, to judge of the enlargement or displacement of various organs, to locate spots of tenderness, to determine the consistence and attach- ments of tumors, and the frequency of breathing, or the strength, force, diffusion wad frequency of the apex beat of the heart. The existence and character of various vibrations, spoken of as fremitus, produced naturally, or by a state of disease, are also deter- mined by palpation. Vocal fremitus is a vibration produced normally in the chest wall by the act of speaking or of crying. Rhoncal fremitus is the vibration produced by rales in the chest. Friction fremitus is produced by two roughened surfaces rubbing together, as in the dry stages of pleurisy. When both fluid and air are present in the cavity a distinct vibration is imparted through the walls by shaking the patient, and this is accompanied by a splashing sound, known as the succussion sound. Vocal fremitus is normally felt over the entire chest wall, but is more distinct toward the right apex. Anything producing a more solid condition of the lung increases this vibration. Anything inter- posed between the lung and the examiner's hand, as a serous effusion into the cavity of the pleura, diminishes or prevents this vibration from being felt. Mensuration. What is mensuration ? Mensuration, as applied to the chest, usually consists in measuring with a tape the circumference of the thorax during the acts of in- spiration and expiration. The measurement in the former should exceed that in the latter state by about three inches. Measurements may also be taken from the vertebral column to mid-sternum on either side, and thus an idea of the relative expansion of the lungs may be gained. diseases of chest—physical diagnosis. 211 Percussion. What is percussion ? Percussion is the sound produced by tapping lightly over the surface of the body, and as it differs according to the amount of air contained in the body, or, in other words, its solidity, the physician is enabled to judge of the composition of bodies by this means. Percussion may be immediate when the surface is struck directly without the use of any intervening medium, or mediate (which is now almost exclusively employed), when the physician strikes on an intervening body, as the fingers of the other hand, or a pleximeter, applied closely to the surface. In percussing, one or two fingers only should be used to strike with, the movement taking place from the wrist, and being a light, even stroke. The fingers are the best instruments for this purpose. Where much percussion has to be performed, instruments are used to save the fingers; thus various forms of light hammers, usually on a flexible handle, are employed, and a pleximeter consisting of a small plate, made of hard rubber, wood, ivory or other substance, placed on the surface to be struck. What is the normal sound elicited by percussion over a healthy lung ? When a healthy chest is percussed, a clear sound is elicited, which is always of relatively low pitch, but which will vary in inten- sity, depending upon the force of the stroke and the thickness of the cutaneous, adipose and muscular coverings of the chest wall. The percussion note is normally clearer anteriorly and above, on the left side. A clear sound denotes a certain amount of air enclosed in elastic tissue. In percussing a chest, the corresponding portions of either side should be alternately percussed, and the sounds elicited carefully compared. How is the normal percussion note altered by disease ? (1) The percussion note may be hyper-resonant ; that is, the nornudpulmonary resonance may be increased. This note is pro- duced in all cases in which there is a relatively increased proportion of air in the lung, provided there is no alteration in the tension of the chest; thus it is seen where from consolidation of one lung, the healthy lung is forced to do more than its ordinary share of work. 212 ESSENTIALS OF PRACTICE OF MEDICINE. (2) TJie normal resonance may be decreased wherever there i- a relatively diminished amount of air in the lungs. When it is slightly diminished, the resonance is said to be impaired ; when much decreased, the note is said to be dull ; and where there is absolutely no resonance it is said to be flat. The pitch of the note, is heightened in proportion to the diminution in its resonance. Any disease that consolidates or condenses the pulmonary tissue gives dullness on percussion. The more absolute the dullness, the more absolute is the exclusion of air. (3) A tympanitic sound is that produced on percussion by large quantities of air enclosed within walls which arc yielding and clastic. The typical tympanitic sound is produced by percussion over the intestines. This sound is not usually perceived over the chest, as the required conditions are absent, but should there be a large cavity in the lung, it may be elicited. If the natural tension of the lung is altered, as sometimes occurs in the upper part of the chest, when there is large pleuritic effusion below, or as also occurs when there is a distention of the air vesicles, a tympanitic sound may be produced. It is more ringing in character and of a higher pitch than the normal percussion note. The tympanitic note is sometimes modified as follows :— An Amphoric or Metallic sound is a concentrated tympanitic note produced by percussion over a cavity containing a large amount of air, and surrounded by walls which are only moderately tense, as is seen in cases of pulmonary consumption. T/ie Cracked-pot or Cracked-metal sound is produced when a cavity communicates directly with a bronchial tube and depends upon the rapid forcing out of the air from the former into the latter, caused by a strong, quick blow of the percussing finger, and best heard when the patient's mouth is open. In children it is occa- sionally heard without these conditions being present. Respiratory Percussion. What is respiratory percussion ? Respiratory percussion consists in percussing the chest not only while the patient is breathing normally, but also during a deep DISEASES OF CHEST—RESPIRATORY PERCUSSION. 213 inspiration and a forced expiration. The examiner is enabled to detect slight changes in the percussion note, which might otherwise escape his attention. Auscultation. What is auscultation ? Auscultation is listening to the sounds produced within the chest during respiration, coughing, or speaking. For this purpose the ear may be applied directly to the chest wall (which is spoken of as im- mediate auscultation) or various media may be employed to conduct the sound to the ear (called mediate auscultation.) When mediate auscultation is employed, an instrument called the stethoscope, made of wood, rubber, or gun-metal, is used. The ear-piece should be large enough to cover the ear, and may be made of the same or of a different material from the rest of the stethoscope. The stethoscope which is most generally preferred is made of gun-metal with an ear- piece of hard rubber. Binaural stethoscopes are also used. They are made upon the principle that the physician can hear better with two ears than he can with one. Differential stethoscopes have been invented, the examiner being supposed to hear and compare simul- taneously the sounds in both lungs conducted to either ear by means of separate tubes. They are practically useless. In examining the chest immediate auscultation is the better for diseases of the lungs, mediate for diseases of the heart. What sounds are heard on auscultating the respiratory ap- paratus ? When the air is passing through the larynx, trachea or bronchi, it produces a high-pitched tubular sound, heard on both expiration and inspiration. This sound is, however, masked when the ear is applied over the normal lung, by the sound produced in the air vesicles (called the vesicular murmur). This is a soft, breezy, inspiratory sound, best heard at the upper part of the lung. It is almost indefi- nite in duration and is followed by a pause, followed in its turn by a short, scarcely-to-be-heard, expiratory sound. The vesicular mur- mur is most typical at the left apex anteriorly, the expiratory sound being heard best at the upper part of the chest posteriorly. The vesicular murmur is caused by the expansion of numerous air cells, the walls of which present a certain resistance to be overcome in the 214 ESSENTIALS OF PRACTICE OF MEDICINE. act of inspiration, thus producing the sound. As, however, on ac- count of their elasticity, they not only offer resistance, but even aid in expiration, there is no sound produced by this act, or if there is any, it is almost inaudible. Bronchial respiration, on the other hand, is produced in the bron- chial tubes by the air passing through them, and is a blowing sound, similar to that produced by blowing through a tube, hence it is often called tubal breathing. Though this bronchial sound exists, it is not heard normally, being overpowered by the sound produced in the air cells. Bronchial breathing may be heard in a person under the influence of fright, because then the breathing is shallow, and the air vesicles not being expanded, the bronchial sound is not masked. Pneumonia, or any disease which produces consolidation of the air vesicles, will obliterate the vesicular murmur over that portion of the chest, and allow the bronchial respiration to be distinguished. What changes occur in these sounds as the result of disease? (A) Vesicular Murmur. This sound may be altered in intensity, in rhythm or in character. (1) Alteration in Intensity. (a) The intensity may be increased, and is then called puerile breeithiug, from its resemblance to the loud, strong breathing of a young child. This is generally seen when the lung of one side, or a portion of it, has more than the usual amount of work thrown upon it, by disease or compression of other portions of lung tissue. (b) Diminished respiration is a lessening of the intensity of the normal vesicular murmur, and is often spoken of as feeble breathing. Anything which will prevent the air from thoroughly distending the air vesicles, will produce this change in the intensity of the vesicular murmur; thus, a plug of mucus in a bronchial tube will produce feeble respiration over that portion of the lung to which the tube and its branches lead. Emphysema, by lessening the elasticity of the lung and allowing the air cells to remain distended at the close of the expiratory act, causes feeble breathing. Intercostal neuralgia or rheumatism, or the pain of pleurisy, by interfering with the ex- pansion of the chest, give rise to feeble breathing. An effusion, by mechanically compressing the air cells, will produce the same result. (c) The vesicular murmur may be absent or suppressed, as when DISEASES OF CHEST—RESPIRATORY PERCUSSION. 215 the lung is compressed by the presence of fluid or air in the pleural sac or in atelectasis. (2) Alteration in Rhythm. (a) The rhythm may be interrupted or jerky, in various spasmodic affections of the air tubes, and in the early stages of pulmonary phthisis, in which it is most marked at the left apex of the lung. (b) A change may occur in the length of expiration, relatively to inspiration ; thus expiration is prolonged in the early stages of consolidation of the lung, due to the diminution in the elasticity of the air cells caused by the inflammatory action. When expiration is prolonged at the apex of the lung it indicates beginning consoli- dation from tubercular deposit. When the air cells lose their elasticity, as occurs in emphysema, expiration is also prolonged because a longer time is required to empty it. (3) Alteration in Character. (a) The respiration may be harsh, or vesiculo-bronchial. This indicates that the bronchial sound is becoming manifest while the vesicular sound is disappearing, or vice versa ; it therefore shows imperfect consolidation. When heard at the apex of the lung it is usually a sign of commencing phthisis ; when heard over the body of the lung it indicates that the consolidation of pneumonia is either beginning or ending. (B) Bronchial Breathing.— This also has its varieties. (a) Simple bronchial breathing is produced where there is entire consolidation of the air vesicles, so that the vesicular murmur is absent; it therefore indicates consolidation, and is heard to perfec- tion in the second stage of pneumonia. (b) Cavernous respiration is a modification of bronchial breathing. It is heard over a cavity of moderate size. By cavernous respiration is meant a breath sound similar to bronchial breathing, but more hollow (cavernous); of lower pitch, softer, less harsh, and equal both in inspiration and expiration. It is often mingled with gurgling, a sound produced by fluids in the cavity. It is only heard in cavi- ties of a certain size, and usually indicates the third stage of con- sumption, although it may be heard over pulmonary abscesses of any kind, or indeed over dilated portions of a bronchial tube. (c) Amphoric or metallic respiration is a sound produced by the 216 ESSENTIALS OF practice of medicine. air entering a large cavity with firm walls. It is a soft, blowing sound, having a certain metallic ring, and can be imitated to some extent by blowing in the mouth of a jug. What sounds are sometimes heard in the chest, as a result of disease, that are entirely foreign to those normally produced there ? Adventitious sounds may be divided into rales, or rhonchi, and friction sounds. (A) Rales are the vibrations produced either in the bronchial tubes or in the air-vesicles by the air passing through fluids contained in those structures. (1) Bronchial rales may be either dry or moist, (a) Dry rales are produced by the air passing through thick fluids which are not broken up by it in its passage. When these are produced in a large bronchial tube, they are low- pitched and to some extent musical. They are called sonorous rdlcs. When however they occur in a small tube, the air whistles as it passes the mucus, and the resulting sound is high-pitched. These are called sibilant rales. (b) Moist rales are produced in a fluid which is sufficiently thin to allow the air to break it into bubbles in its passage. When the vibration produced is the result of fluid in the larger tubes the bub- bles will be large, and the rales are called large, bubbling or mucous rales. When they are formed in the smaller tubes fine bubbles are found, and the sound is spoken of as small bubbling, mucous orsub- crepitant rales. (2) Vesicular Rales. The crepitant rale is a sound produced in the air-vesicles and intercellular passages, or about the termination of the finer bronchi- oles. It is a fine sound, heard only on inspiration and somewhat resembling the sound made by throwing salt upon a hot fire, or by rubbing a lock of hair between the finger and thumb in front of the ear. It is a very fine, crackling sound. This is the rale of beginning exudation, and shows that a sticky fluid is present in the air-cells. They are specially heard in the first stage of pneumonia, disappearing when complete consolidation occurs, and reappearing again as the exudate is absorbed. diseases of chest—respiratory PERCUSSION. Crackling rales are modifications of the former. They are fine, dry sounds, especially heard at the apices of the lungs in the inci- pient stages of phthisis. Hollow bubbling or gurgling rales, or cavernous rales as they are sometimes called, are heard over large cavities communicating freely with a bronchial tube, and are especially found in the latter stages of phthisis. Their names well describe them. (B) Friction Sounds. These sounds are produced when two roughened surfaces, as those of an inflamed pleura, are rubbed against each other. They are said to sound like the croaking of sole-leather. The rustling of silk or the movements of the body against a chest-protector might be readily mistaken for friction sounds. Certain rales also might be coufounded with them, but they are very superficial, uninfluenced by cough, and purely localized, which is not apt to be the case with rfdes. What is vocal resonance ? Vocal resonance is the vibration produced upon speaking, when transmitted to the ear of the examiner placed against the patient's chest. Anything intervening between the lung and the examiner's ear will diminish the vocal resonance or perhaps entirely prevent the transmission of the vibration. In this way when a pleuritic effusion or pneumothorax is present, vocal resonance is entirely absent. On the other hand it is exaggerated by any condition which produces solidification of the lung tissue, as in tuberculosis or pneumonia. Bronchophony is a vocal resonance, not only of exaggerated inten- sity, but of elevated pitch, and shows complete consolidation of the lung tissue over which it is heard. Pectoriloquy is an exaggerated bronchophony., the voice of the patient sounding near to the examining ear and the articulated words being distinct. It is found either where there is a cavity in the lung, or when consolidation is absolute and complete. Whis- pering pectoriloquy possesses the same characters as the foregoing, the slightest whisper of the patient being distinctly heard. jEgophony is a modified bronchophony, the voice having a certain tremulous or bleating character. It is heard at the edge of a pleu- 218 ESSENTIALS of practice of medicine. ritic effusion, where a thin layer of fluid intervenes between the lung and the examiner's ear. It is therefore a sign of pleurisy or of pleuro-pneumonia. Amphoric or metallic voice is heard under the same conditions which produce other amphoric or metallic phenomena. The auscultation of the voice is not of much practical importance, with the exception of its absence in pleuritic effusion and in the presence of bronchophony in consolidation. These methods of investigating disease, when taken separately, are not of much value. It is by their association in any given case that they are at all important. The following table, taken from Da Costa's "Medieal Diagnosis," shows the manner in which they should be employed in the study of diseases of the respiratory organs, and their importance when properly combined : Pkrcus- Auscultation of Auscut.ta- Vocat. Physical sion. Respiration. tion of Voice Fremitus. Conditions. Clear. Vesicular mur- Normal vocal Unimpaired. Lung tissue heal- mur or its modifi- resonance. thy or nearly so; cation. at any rate n o increased density from deposits, etc. (Bronchial or harsh Broncho- Increased. Solidification of respiration. phony. pulmonary struc- ture. Absent respiration. Absent voice. Diminished or Effusion into pleu- absent. ral sac. Tynipan- Cavernous or Uncertain; Uncertain; Increased quan- itic. feeble, according to cavernous or mostly dimin- tity of air within cause. diminished. ished. the chest, due to cavity or to over- distention of the air-cells. Amphoric Amphoric or Amphoric or Mostly dimin- Large cavity with or metallic. metallic. ished. elastic walls. metallic. Cracked Cavernous respira- Cavernous Uncertain. Generally a cav- metal tion. respiration. ity communicat- sound. ing with a bron- chial tube DISEASES OF LARYNX-ACUTE LARYNGITIS. 219 DISEASES OF THE LARYNX. Acute Laryngitis. What is acute laryngitis? Acute laryngitis is a catarrhal inflammation of the mucous mem- brane, characterized by slight fever, suppressed voice, painful de- glutition, some dyspnoea and more or less spasmodic cough. What are its causes and symptoms? Causes. . . . It is caused by exposure to cold and damp, inhalation of irritating substances, and straining the voice, as in addressing a meeting in the open air. The cedematous variety may be intercurrent with Bright s disease. Symptoms. The symptoms are oppression in breathing; a change in the voice varying from slight hoarseness to total extinction ; difficulty in swal- lowing ; tickling in the windpipe; slight fever, and dry hoarse cough, more frequent at night than in the day. This lasts for about a week and the cough becomes looser, the expectoration freer and the fever disappears. Sometimes it passes down and results in bronchitis. In oedema of the glottis the difficulty of breathing increases, with much pain in the throat and paroxysms of dyspnoea which threaten suffocation. The cough and voice become suppressed and there are signs of faulty aeration of the blood. The paroxysms occur more and more frequently, and unless relief is quickly afforded the patient very soon dies. What is the pathology of the affection? It is a catarrhal inflammation of the laryngeal mucous membrane, which is inflamed in patches throughout. There is at first swelling and diminution of secretion, followed by an increased secretion and return to the normal state ; or serous in- filtration resulting in oedema occurs into the loose connective tissue 220 ESSENTIALS OF PRACTICE OF MEDICINE about the rima glottidis, which may be entirely occluded, if the swelling is great. The infiltration may be purulent. What is the diagnosis, prognosis and treatment ? Diagnosis. The diagnosis of simple laryngitis is easy. The active onset, with alteration of the voice, feverishness, difficulty in breathing, and swal- lowing, some dyspnoea and harsh dry cough can belong to no other disease. Should there be any doubt, an examination with the laryngoscope will settle the question. QZdematous laryngitis is recognized by the same history and the sudden occurrence of attacks of suffocation, with an examination of the larynx. By depressing the tongue thoroughly, the epiglottis will usually be seen much swollen and cedematous in these cases. Prognosis. The prognosis of simple lai-yngitis is favorable. (Edematous laryngitis is less amenable to treatment, particularly if it occurs as an intercurrent affection, or in children. Treatment. The air should be kept moist and the temperature of the room about 68°. The patient should have a mild diet, principally of liquid food, as that is more readily swallowed without pain. Little pieces of ice held in the mouth aid in relieving irritation. A hot foot-bath may be administered and the bowels opened by a mild aperient. Locally the inhalation of hot vapor is of service. The inhalation of the steam arising from compound tincture of benzoin, foj, with spirits of chloroform, gtt. ij—v, poured into a teacupful of boiling water, is often of benefit. The application of bags of ice to the neck is of great service in severe cases. Internally, in the early stages, mild diaphoretics are useful, as a little Dover's powder with nitrate of potash, or minute doses of tar- tar emetic and morphine. When the cough becomes loose it may be necessary, if it lingers, to use expectorants, as the ammonium salts or squill. In the cedematous variety scarification, brisk purgation and pro- fuse diaphoresis (by means of pilocarpine, if not contraindicated) DISEASES OF LARYNX—CHRONIC LARYNGITIS. 221 will generally afford relief. If these means do not succeed, trache- otomy may be resorted to. For the fever, aconite may be adminis- tered if necessary. Chronic Laryngitis. What is chronic laryngitis ? It is a chronic inflammation of the mucous membrane of the larynx, manifesting itself by irritative cough, change in the voice, difficulty in swallowing, and causeless attacks of oppression. Causation. It may follow acute laryngitis, may be due to continued straining of the voice and the inhalation of irritating substances, to syphilis, tubercular ulceration or various neoplasms. Pathology. Examining with a laryngoscope the cords are seen thickened and inflamed. A certain amount of oedema is usually present, and polypi or other neoplasms may be found. Treatment. The treatment depends upon the cause. The patient should be made to save his voice. He should stop smoking and correct his habits. Any constitutional cause should be treated. His system should be built up with iron, quinine and strychnine, and an occa- sional laxative should be given. In catarrhal cases inhalation of compound tincture of benzoin, or the application of a solution of nitrate of silver (gr. xx-fgj), or of zinc sulphate two or three times a week, or of glycerole of tannin, is usually sufficient to effect a cure. -If ulceration of the larynx is present, the application should be stronger. In tubercular ulceration the parts may be brushed or sprayed with cocaine, which lessens the tendency to cough. Phosphates, cod-liver oil, iodide of iron, etc., should be given internally, and tannic acid (gr. xx-fgj) may be applied by the atomizer. The parts may also be touched with strong solutions of the mineral astringents, but the application should not be made too often. Demulcents, as the infusion of Irish moss, are very grateful to the patient. In syphilitic ulceration the treatment is the same, iodide of potas- sium being given internally in large doses. 222 essentials OF PRACTICE of medicine. Should small polypi he found at the junction of the cords, causing incessant irritating cough, but no difficulty in swallowing, or loss of voice, they may be touched with a strong caustic, as chromic acid, and in favorable cases excised. Croup. What is croup ? Croup is a catarrhal inflammation of the mucous membrane of the larynx with a spasm of the glottis, recurring in paroxysms. There are two varieties of croup, false croup, or spasmodic croup, to which the above definition applies, and true croup, in which there is in addition a pseudo-membrane in the larynx, sometimes extending into the pharynx, or downward into the bronchial tubes. What are the causes of croup ? It is a disease of childhood, although not confined to any age. Its development is favored by dampness. It would appear to be hereditary. What are the symptoms of croup ? (1) False Croup. The attack usually comes on at night; the child starts up with a peculiar, dry, croupy cough, recurring in paroxysms and without expectoration. During the paroxysm there is great difficulty in breathing, sometimes a sensation as of impending suffocation ; noisy, stridulous respiration, and a harsh croupy voice and cry. After a longer or shorter interval the paroxysm passes off, per- spiration breaks out, and the child is relieved, although the hoarse voice and harsh cough remain during the next day. There may be slight fever ; the pulse is about normal. Usually the paroxysms return for two or three nights, after which the attack generally passes off, leaving a loose cough for several days. (2) True Croup. In true or membranous croup the symptoms at first are those just described, but usually more severe. The breathing remains embar- rassed between the paroxysms, and the voice and cough croupy. There diseases of larynx—CROUP. 223 is more fever ; the respiration is noisy all the time ; the paroxysms occur in the daytime as well as at night, although the former are milder. Each paroxysm is worse than the preceding until the third day, when the disease is at its height. There is then great difficulty in breathing, the circulation is embarrassed, and the vesicular mur- mur is very feeble, usually absent. Sometimes portions of the membrane are expectorated. In some cases the membrane may be seen in the pharynx. In bad cases the cough and voice become entirely suppressed. Should the case terminate favorably the paroxysms become less frequent and less severe, and more membrane is expectorated. The dyspnoea, the cough and fever lessen and the voice gradually returns. Should the case terminate fatally the attacks become more and more frequent and severe, expectoration is absent, and the cough and voice entirely suppressed. The respirations become frequent and shallow, interference with the circulation is more marked and the patient dies of asphyxia. What is the diagnosis, prognosis and treatment of croup ? Diagnosis. The diagnosis of simple croup is easy. True croup may be sus- pected if symptoms of the first paroxysm continue for two or three days ; if there is much fever ; and if the respiration is embarrassed, and the vesicular murmur absent between the paroxysms. If the membrane can be seen in the throat, the diagnosis is estab- lished. Differential Diagnosis. (1) From spasm of the glottis it is differentiated by the age, the histoiy, the fever and the catarrhal symptoms. (2) From a tumor or swelling pressing on the windpipe. In the latter case the symptoms continue. There is no cessation between the paroxysms. (3) From oedema of the glottis : by the history and the absence of cause, the greater violence of the attacks of suffocation and depres- sion in oedema, and by the laryngoscope. (4) From laryngeal diphtheria, by being a local disease, the re- sult of catarrhal inflammation and non-contagious, followed by no paralysis or sequelae. There is no albumen in the urine, no enlarge- 224 essentials of practice of medicine. ment of the cervical glands, and the membrane extends from, not into the larynx. In laryngeal diphtheria the constitutional symp- toms precede the local symptoms and preponderate, the reverse be- ing the case in membranous croup. Prognosis. The prognosis of false croup is favorable. True croup is always dangerous. Favorable prognostic signs are the return of the respi- ratory murmur, the cough losing its harsh sound and the paroxysms returning less frequently. Treatment. The treatment is the same in both varieties, with the exception that if it be membranous croup the treatment should be more energetic, and surgical interference may be necessary. (1) During the paroxysm, the child must be placed in a hot bath and kept there for some time, and small amounts of hot water administered internally. In addition to this emetics must be given at once ; alum and the syrup of ipecac, or ipecac alone, may be given every ten minutes until emesis is produced. Antimony is preferred in England as an emetic, and sulphate of copper in Ger- many. The hot baths and the emetics should be repeated every time the paroxysm recurs. (2) Between the paroxysms, nauseants should be given in small doses, frequently repeated. For this purpose squill and paregoric, or small doses of antimony (Kermes mineral, gr. £-4, with a minute amount of Dover's powder) or turpeth mineral answer best. During the second night an opiate should be administered (pare- goric or Dover's powder) to quiet the nervous system and, if possible, prevent a recurrence. (3) If the inflammation continues for thirty-six hours, and it is feared that a membrane is forming, mercurials should be given in small doses with opium, frequently repeated and pushed to slight constitutional effects. Potassic chlorate is used by many in these cases in place of turpeth mineral. (4) The patient should have a mild, easily digested diet, but suf- ficient in amount and liberal. (5) Local treatment. Too many persons should not be allowed in the room. The air should be kept moist; temperature 68° to 70°. diseases of bronchial tubes—BRONCHITIS. 225 Much relief is afforded by the inhalations of the vapor of slaking lime. To dissolve the false membrane a saturated solution of pepsin may be used by the atomizer, or a solution of trypsin applied in the same manner ; the latter is said to give better results. Papaine is also employed for this purpose. (6) Surgical treatment. If the case gets worse and suffocation is imminent, intubation may be resorted to, or, as a final resource, tracheotomy may be performed. The mortality after this operation in croup justifies its performance, while for laryngeal diphtheria it is of very doubtful utility. If the child is strong, if he is over five years of age, and if there is no dullness anywhere over the lungs, tracheotomy may be resorted to to prevent suffocation. After the paroxysms have been checlted and the patient is recover- ing, stimulating expectorants may be given. To prevent subsequent attacks cold sponge baths may be employed morning and evening, or an ordinary tepid bath with cold sponging to the neck and chest may be used ; but the cold bath is the better. No chest protector should be worn. The bowels should be kept regulated, rich food should be avoided, and great attention should be paid to the condition of the stomach. DISEASES OF THE BRONCHIAL TUBES. Bronchitis. What are the varieties of bronchitis? Bronchitis may be acute or chronic. Acute bronchitis may affect the large tubes as a catarrhal inflam- mation (the most common variety), or it may be attended with plastic exudation into the tubes themselves. Acute bronchitis may also affect the small tubes, when it is called capillary bronchitis. (1) Acute Catarrhal Bronchitis of the Larger Tubes. What is this disease ? It is acute catarrhal inflammation of the larger bronchial tubes, due to cold and exposure; various diatheses, as the gouty, rheu- 15 22G essentials of practice of medicine. matic or lithaemic; following the exanthemata, especially measles; seen also in typhoid fever, and occasionally due to syphilis. It is also called acute bronchial catarrh. What is its pathology ? In the first or dry stage secretion is arrested. The bronchial mucous membrane is covered with a thick coating, is swollen and injected. This gradually passes into the second or moist stage, in which the secretion is reestablished and finally becomes profuse, the swelling disappears, and the mucous membrane slowly returns to its normal state. What are the symptoms of the first stage ? It begins sometimes with a chill and slight fever. In the first stage there is a harsh, dry cough, occurring chiefly in paroxysms; expectoration slight, stringy and streaked with blood ; some short- ness of breath ; anorexia; nausea, sometimes vomiting; aching pain in the limbs and headache. In the second stage the cough becomes looser, the expectoration freer, and, under the microscope, the sputa is seen to consist of muco-pus and epithelium, with no blood and no shreds of lung tissue. The fever declines, and cough gradually lessens, although it may continue for some time after recovery. The average duration is from ten days to two weeks. What are the physical signs of acute bronchitis ? On Percussion, a clear note is heard. On Auscultation, the vesicular murmur is almost normal, there is harsh respiration over both lungs in the early stages, and dry, sonorous rales heard throughout the chest, which in the second stage are replaced by large bubbling rales. Vocal fremitus and vocal resonance are normal. How is the disease recognized ? It is recognized by the physical signs, the symptoms and the course which it runs. What is the prognosis ? The prognosis is favorable unless it becomes capillary, or runs DISEASES of bronchial tubes—bronchitis. 227 into broncho-pneumonia, which rarely happens except when it is an intercurrent affection. How should it be treated? Keep the atmosphere moist and the temperature of the room about 68°. In the early stages let the patient have a light diet consisting of milk, oysters and other easily digested food, and in the later stages keep him well fed. In the first stage, if the patient is a robust young adult and breathing with much difficulty, the chest should be thoroughly wet cupped. Dry cups may be used in all other cases when there is difficulty in breathing. If the disease is mild, counter-irritation may be applied to the chest by means of mustard plasters. Act on the skin freely in the very early stages by pilocarpine, potassium citrate, small doses of tartar emetic, ipecac or small doses of Dover's powders. Let the patient have mucilaginous drinks, which, in some way, appear to allay the irritation. For the cough let him inhale the vapor arising from the tincture of benzoin (3j) in boiling water (Oss) every two hours, or give him broken doses of Dover's powders. If improvement does not take place, or if the disease shows a tendenqj to move downwards, the fluid extract of veratrum viride (gtt. j) may be given every two or three hours, guided by the effect on the pulse. In the second stage give stimulating expectorants, as ammonium chloride or carbonate, combined with a little deodorized tincture of opium, and squill or senega. (2) Plastic Bronchitis. How does this differ from the disease just described ? In this affection a fibrinous exudation occurs, forming pseudo- membranous casts of the tubes. The symptoms and physical signs are identical with those of acute bronchial catarrh, with the excep- tion that there is more dyspnoea, usually more fever, more depres- sion, and the paroxysms of cough are more severe. 22S ESSENTIALS of practice of medictne. The disease terminates by the expectoration of small, membranous casts of the tubes. The treatment is similar to that of acute bronchial catarrh, but should be more active. The patient should be kept well nourished, and, in the later stages, even free stimulation may be necessary. Bronchitis Affecting the Smaller Tubes—Capillary Bronchitis. What is capillary bronchitis ? Capillary bronchitis, or suffocative catarrh, is a catarrhal inflam- mation of the smaller bronchial tubes, having the same pathology as acute catarrh of the larger tubes. A plug of mucus will often be forced by inspiration into a small tube, completely blocking it up. On expiration this plug will be dislodged sufficiently to allow the passage of air upward from the lungs, but on inspiration it will again block up the tube, and thus, finally, the portion of the lung to which the ramifications of the tube extend, being deprived of its air, will collapse. The lung structure itself is rarely involved, except when second- ary adhesive inflammation occurs in the collapsed portion. The plug of mucus which has caused the collapse will frequently be dis- lodged by coughing, vomiting, or from some other mechanical cause, thus allowing the air again to enter the collapsed vesicles. This disease occurs especially in badly-nourished children and in old, debilitated subjects. What are the symptoms ? The symptoms at first are those of ordinary acute bronchitis, but as the inflammation extends downwards there is more fever, more depression, and symptoms indicating the want of aeration of the blood, as great difficulty in breathing, feeble circulation, blucness of the lips, prominence of the veins, etc. As the disease progresses the patient becomes weaker and weaker, until he has not sufficient strength to expectorate, and the cough itself becomes suppressed. The patient is dull, stupid, delirious, with cold hands and extrem- ities, profuse sweats, irregular pulse, convulsions, and finally death. The expectoration often consists entirely of pus. DISEASES OF BRONCHIAL TUBES—BRONCHITIS. 229 What are the physical signs of this disease ? Percussion elicits a clear note, excepting over the spots of col- lapsed lung, where the note is dull. The dullness, however, shifts from time to time as the secretion moves and the collapsed lobules fill with air. On Auscultation diffused sibilant rales are heard in the early stages, and the respiratory murmur is feeble. In the second stage, the sibilant rales are replaced by subcrepitant rales, widely diffused over the chest. As the case improves the rales lessen, harsh respiration is heard, and recovery takes place, as in acute bronchitis of the larger tubes. If the case does badly, the vesicular murmur is more and more feeble, and the rales disappear as patient loses strength. What is the diagnosis ? The disease is recognized by the age at which it occurs, the physi- cal signs, and the symptoms of want of aeration of blood. Differential Diagnosis. (1) From Broncho-pneumonia.—In the latter disease there is not the same difficulty of respiration or of expectoration. Dullness is persistent, not shifting, and the disease is not so diffused. What is the prognosis and treatment ? Prognosis. The disease is always dangerous, especially in old persons. Treatment. If the case is seen early, the disease is still spreading dowmra rd a n d the patient is strong enough, leeching or wet cupping must be thoroughly employed. In an old person use dry cups. In either case the use of diaphoretics and of veratrum viride is beneficial. When the disease has become capillary and there is great difficulty in breathing, if the patient is strong enough, the bold use of emetics, continued as long as the strength of the patient will admit, is of undoubted utility. Emetics act mechanically by relaxing the system and getting rid of the secretions in the tubes. Thus, ipecac, zinc sulphate or apomorphine may be employed, and frequently repeated. In addition to this treatment the chloride or carbonate of ammonium 230 essentials of practice of medicine. should be administered ; quinine given as a tonic by the mouth or rectum, the patient fed systematically every hour, and stimulants, as champagne, brandy or whiskey, used freely. A jacket-poultice is sometimes of service. Chronic Bronchitis. What is chronic bronchitis ? Chronic bronchitis is a chronic catarrhal inflammation of the larger bronchial tubes which may follow an acute attack, but usually is slowly developed, giving rise to a certain amount of winter cough, which disappears in the summer to return the following winter, with very slight impairment of the general health ; affecting persons of advanced years, and often associated with certain diatheses, as gout or rheumatism. The expectoration may be slight or profuse. Pathology. The pathology is similar to that of the acute disease, but is slower in progress and of longer duration. Finally, a structural alteration occurs in the mucous membrane, which is thickened, as is also the underlying connective tissue. In some cases the bronchial tubes will be dilated as a consequence of long-standing disease. What are the physical signs ? Percussion of the chest elicits a clear note. On Auscultation, the vesicular murmur is not interfered with, but is combined with some harshness, almost amounting to bron- chial breathing. Rales are frequently heard, especially posteriorly, which will, however, vary with the amount and character of the secretion. What is the diagnosis, prognosis and treatment of chronic bronchitis? Diagnosis. The history and the physical examination render the case clear. Prognosis. Favorable as to life. The disease, however, is very obstinate. Treatment. The treatment consists in clothing the patient warmly, giving nourishing food, and preventing him, as far as possible, from taking DISEASES OF BRONCHIAL TUBES—ASTHMA. 231 fresh cold. Cod-liver oil and the iodides, especially the iodide of iron, are very useful. Change of climate is often of service, a mild, dry climate being usually the best. If the secretion is scanty, the alkalies, particularly the chloride and iodide of ammonium, may be advantageously given. Prepara- tions of tar and of iodine may be inhaled with good effect. Sulphur and arsenic are also used internally. Should the secretion be profuse the ammonium salts may be admin- istered as alteratives, while astringents should also be employed, as the preparations of zinc or of tannic acid. Cubebs and copaiba are also given. It is better not to use opium without it is absolutely necessary ; in these cases the combination of codeine with diluted sulphuric acid and prunus Yirginiana will gen- erally answer the purpose, opium itself being reserved for cases of absolute necessity. Asthma. What is asthma ? Pure asthma is probably a spasm of the bronchial mucous mem- brane. What are its causes ? It is often inherited. The gouty diathesis, particularly in women, often causes this affection. In some cases it is due to the inhalation of irritant particles. Emphysema is often associated with it, but does not cause it. It is seen in middle age as a rule, rarely in the very young or very old. So-called "cardiac asthma" and "renal asthma'' are cases of dyspnoea, not asthma, and are due to a con- gested condition of the lung. The exciting causes of asthma are bronchitis or an attack of lithaemia. What are its symptoms ? The attack is apt to be preceded by digestive disturbance ; the urine is loaded with urates, and perhaps some slight dyspnoea occurs, lasting for several days. The attack itself is ushered in by greatly embarrassed respiration, with loud, wheezing rales, usually expiratory. The patient experiences great difficulty in breathing, with a sense of oppression in the chest, and calls into play the extraordinary 232 ESSENTIALS OF PRACTICE OF MEDICINE. muscles of inspiration, in order to enable him to breathe more freely. After a time there is profuse expectoration, and gradually the paroxysm subsides, to be repeated again on the ensuing evening or evenings, and finally to pass away entirely. It is apt to lead to emphysema, or to cardiac disease, by impeding the circulation through the lung. What are the physical signs ? On Percussion the chest is resonant. On Auscultation, loud, wheezing, expiratory rales are heard, which, later in the attack become large, moist rales. How is the disease recognized ? The diagnosis is easy. Difficulty in breathing, with the physical signs, render the case plain. Differential Diagnosis. (1) From Cardiac Dyspnoea.—The latter is more persistent, hav- ing nothing paroxysmal about it, and the presence of the cardiac trouble should prevent mistake. (2) From Difficulty in Breathing caused by Nas(d Polypi.—Al- though nasal polypi may sometimes act in a reflex manner and cause asthma, yet, as a rule, the difficulty in breathing is nasal, rather than bronchial. An examination of the nose will reveal the diffi- culty. (3) Reflex Asthma from Uterine or Hepatic Disease.—In these cases there will be symptoms calling attention to the organ involved. (4) Laryngeal irritation or laryngeal polypi causes noisy respira- tion which is sometimes paroxysmal. In cases of doubt the laryn- goscope will decide the question. What is the prognosis and treatment of asthma ? Prognosis. The prognosis, as regards life, is favorable, though the underlying causes to which the disease is due, or the affections to which it leads, may cause death. It is a chronic malady. Treatment. (1) Of the Paroxysm.—The patient should be kept in a moist atmosphere and counter-irritation, especially by dry cups, applied over the chest. DISEASES OF LUNG-TISSUE—EMPHYSEMA. 233 Nauseants, as lobelia, may be given frequently in doses not huge- enough to produce actual emesis. Inhalation of the fumes arising from burning stramonium leaves is of use. Coffee, caffeine or cocaine are of service, especially in uncomplicated cases where the nervous element is pronounced. Grindelia is sometimes of service. Where the case lingers and is very severe, chloroform may be administered by inhalation. Ammonium salts may be given to promote expectoration. Hypo- dermic injections of pilocarpine sometimes materially modify the affection, particularly if the urine is scanty. In these cases dry cups may be applied over the kidneys. Diffusible stimulants, as Hoff- man's anodyne, and alcoholic stimulants are of value. (2) To prevent the recurrence of the attacks, potassium or ammo- nium iodide may be administered in decided doses for a prolonged period. Arsenic or belladonna may also be used for this purpose. Change of climate exercises a decidedly beneficial effect. The high lands of Colorado suit the majority of patients. Some cases are benefited, however, by low altitudes, and in some a very moist climate gives the best result. Some cases are benefited by inspiring compressed air, and others by inspiring rarefied air. DISEASES OF THE LUNG-TISSUE. Emphysema. What is emphysema ? Emphysema is usually a dilatation of the air-vesicles of the lungs, or, occasionally, the rupture of these air-vesicles, the air traveling along the connective tissue of the lobules of the lung. What is its pathology ? The air-vesicles are distended or dilated and lose their elasticity, in some places running together, especially along the anterior edges of the luu- The tubes which terminate in these air cells are inflamed, giving rise to bronchial catarrh. The lung is pale and 234 ESSENTIALS OF PRACTICE OF MEDICINE. anaemic, because the vessels are pressed upon by the dilated vesicles. It is rarely a local disease, both lungs being more or less affected, though not equally. The vesicles rupture into one another, or into the neighboring bronchial tubes; they rarely rupture into the pleura. The pulmonary circulation is impeded, and dilatation of the right heart results. This is the great danger in emphysema. Under the microscope the walls of the vesicles are seen to have undergone degeneration. The lung, of course, is lighter than normal, and con- tains more air. What are its causes ? It is often hereditary. It may be acquired by prolonged expira- tory efforts, as when it occurs in performers upon wind instruments; chronic bronchitis is also a cause. Degenerative tissue changes in the walls of the air-cells, without other cause, may produce it. What are the symptoms ? There is shortness of breath, increased by the slightest exertion. The patient frequently suffers from attacks of bronchial catarrh. In cases of long standing, symptoms due to dilated heart, as dropsy, weak heart, palpitation, and interference with the function of the liver and kidneys from backing up of the blood in their veins, with more or less enlargement of these organs, supervene. The patient also suffers from dyspepsia, caused by interference with the venous circulation of the stomach. His face is melancholy, and he is depressed and gloomy. What are the physical signs ? On Inspection, the thorax is barrel-shaped, the intercostal spaces being obliterated or bulging. There is a want of proper ex- pansion on inspiration relative to the size of the chest. On Percussion the vesiculotympanitic note is elicited. Res- piratory percussion shows no change in the note, a point of importance. On Auscultation the vesicular murmur is feeble and expiration is prolonged. Bronchial rales are often present, from temporary catarrh, and may mask the auscultatory signs. Later in the disease the signs of dilated heart are present. DISEASES OF LUNG-TISSUE—PULMONARY HYPEREMIA. 235 How is this disease recognized ? It is recognized by the shortness of breath and the physical signs which are present on both sides of the chest. What is the prognosis ? Though few patients recover, the disease is not dangerous to life, but may produce cardiac disease, which will cause death.. What is the treatment? The patient must, if possible, live in a dry climate, but the alti- tude should not be great, on account of the tendency to cardiac disease. To prevent or control the bronchial catarrh he should be protected as much as possible from exposure. Should an acute exacerbation occur he should be put to bed, thoroughly cupped, and diaphoretics and diuretics administered. This complication should be very actively treated. Iodide of po- tassium is of service by relieving the chronic bronchitis and lessening the tendency to the attacks of asthma. With the above treatment should be combined frequently repeated small blisters applied to the chest. Inspiring compressed air and expiring into rarefied air is reported to have done good. For the tendency to cardiac dilatation digitalis is preeminently of value. The secretion of the kidneys should also be kept up, and the portal circulation acted on by blue pill, by the salines, etc. If rupture of the air-vesicles tak(S place, as may occur in whooping- cough or during the violent expulsive pains of labor, there will be, in addition to the difficulty in breathing, cough, and frequently the presence of air in the aireolar tissue of the neck. The treatment should consist in keeping the patient perfectly quiet and giving opium to prevent the recurrence of the coughing, and if there is a crepitating swelling externally, puncture it and let the air out. Pulmonary Hyperaemia. What is pulmonary hyperaemia ? Pulmonary hyperaemia is an active or passive congestion of the lung, which is exceedingly rare as a primary affection, and when 236 ESSENTIALS OF PRACTICE OF MEDICINE. present is usually secondary to, or intercurrent with, some other disease. It is characterized by shortness of breathing, slight cough, and the physical signs indicating some impairment in the respiratory powers of the lungs. What are its causes ? Active congestion may occur after violent efforts in singing or talk- ing ; or after violent exercise, as in ascending high mountains. An over-acting, powerful heart, by forcing more than the normal blood into the lungs, may also produce congestion in them, as in other parts of the body. Passive congestion is seen when the blood slowly accumulates in the lungs, as sometimes occurs in low forms of fever (e. g., typhoid fever) ; or in Bright's disease ; in certain cardiac diseases, as mitral insufficiency, or in anaemic states if the patient lies on his back con- tinuously for too long a time. What are the symptoms ? The symptoms are the same in either variety, and are, marked shortness of breath; cough, without much expectoration, but what there is will be streaked with blood; quickened circulation, with little or no fever, and restless nights. What are the physical signs ? On Percussion the resonance is slightly impaired, but only to a trifling extent. On Auscultation the vesicular murmur is diminished in inten- sity ; a few fine bubbling rales (subcrepitant) and occasionally, per- haps, a vesicular rale (the crepitant rale) will be heard. What is the prognosis of pulmonary hyperaemia? In active hyperaemia the prognosis is favorable; in the passive, form it is not so good, and will depend upon the cause of the con- gestion. How are pulmonary congestions treated ? In active congestion, if very severe, wet cups may be employed, or even venesection resorted to. The action of the heart must also be regulated, if very strong and forcible, by aconite. In passive congestion digitalis should be administered for its effect on the heart. DISEASES OF LUNG-TISSUE—HEMOPTYSIS. 237 In either variety dry cups are very useful, and purgatives must be used freely, as must, also, diaphoretics. In passive congestions oc- curring in Bright's disease, the kidneys must be thoroughly cupped, and diuretics administered. (Edema of the Lung. Describe oedema of the lung. This may follow either acute or chronic pulmonary hyperaemia, as a result of which it is much to be dreaded. It sometimes follgws alcoholic excesses, and consists of an effusion of serum in the pulmo- nary tissues and into the air-vesicles. The Symptoms are those of congestion of the lung, with great difficulty in breathing, much anxiety, constant, short cough, and a frothy expectoration, often streaked with blood. The Physical Signs consist of slightly impaired percussion reso- nance, feeble or distant vesicular murmur, and fine vesicular rales diffused over both sides of the chest, with loud rales, from.a serous effusion into the bronchi. The Prognosis is very grave. It is worse if the disease follows passive congestion. Treatment. The treatment is identical with that of congestion of the lungs, in addition to which, as the fluid accumulates in the vesicular structure and the dyspnoea increases, stimulating expectorants, particularly ammonium carbonate, should be freely used. If cardiac failure threatens, digitalis should be administered hypodermically. Haemoptysis. What is haemoptysis ? Haemoptysis, or hemorrhage from the lungs, is a symptom rather than a disease. (1) It often results from congestion, especially of the acute variety, and occurs from this cause in those who are ascending high moun- tains, or who strain their voices to the utmost, as in public speaking, particularly in the open air. 238 ESSENTIALS OF PRACTICE OF MEDICINE. (2) It is very frequently due to the structural alterations of the lungs, and especially to tubercle (this should always be suspected if there has been no excitement or other cause leading to acute con- gestion) ; also to abscesses, gangrene or cancer. (3) It sometimes occurs as a vicarious hemorrhage, taking the place of, or accompanying, menstruation or the bleeding of hemor- rhoids. (4) It sometimes occurs in individuals with peculiar idiosyncrasies, whenever they indulge in certain articles of food, as honey. (5) Occasionally it is seen in women who do not belong to the class of haematophilia, and who are apparently in perfect health. In these cases it may occur daily, and continue for years without ap- parent cause, and without the slightest injury. Pulmonary hemorrhages may be due either to rupture of a vessel or to transudation through its walls. What are the symptoms of pulmonary hemorrhage ? It often comes on suddenly, the patient having a slight cough and spitting up blood, a mouthful at a time. There is a feeling of utter demoralization, the breathing is quickened, and the patient pale and alarmed. The blood is red and frothy, and at first is uncoagulated, but as the case proceeds, coagulated blood which has remained in the bron- chial tubes will finally be expectorated. These hemorrhages are very apt to occur in series, the bleeding taking place frequently for some time, and then ceasing, an interval of several months elapsing before the hemorrhages recur. Pulmonary apoplexy is the name given to this affection when the patient bleeds internally, but very little blood escaping externally. In this condition the blood flows into the vesicular structure of the lung, and while in an ordinary hemorrhage the lung clears up when the trouble is over, in this condition it remains in the lung, sets up a secondary inflammation, and results in pneumonia. It is usually seen with cardiac disease, and is due to thrombosis or to embolism. It is not common. What are the physical signs of haemoptysis ? There are no physical signs of any importance in this affection. Some rales may be heard during the hemorrhage, but the blood is DISEASES OF LUNG-TISSUE—H-fEMOPTYSIS. 239 expectorated, and the lung clears up entirely, or at least returns to the condition in which it was previously, as soon as the hemorrhage ceases. In pulmonary apoplexy the blood remains in the lungs, and the signs of enfeeblement of the respiratory powers followed shortly by those of pneumonia result. What is the diagnosis of haemoptysis ? (I.) Diagnosis of the Ornun of the Blood. (1) From Hccmatemesis.—In this affection the blood is black and clotted ; there is usually preceding nausea and vomiting ; and the blood is usually mixed with the contents of the stomach. Sometimes, however, in hemorrhage from the stomach, the blood will be red. In these cases a large vessel has generally been pierced by an ulcer, and the blood poured out in such large quantities that it has irritated the stomach, and caused vomiting, before it had time to become altered by the secretions. Here, however, the stools will be black, which is not the case in haemoptysis, except in children who are too young to expectorate the blood, and consequently swallow it. (2) From Epistaxis.—The blood may trickle down the throat from the posterior nares, and be subsequently vomited. In these cases an examination of the throat will reveal the blood trickling down; or a laryngoscopy examination of the posterior nares will make the diagnosis plain. (3) Hemorrhage from the gums may be diagnosed from haemop- tysis by examining the gums. (II.) Diagnosis of Cause. The patient must be questioned closely in order to elicit the true cause of the hemorrhage. Pulmonary apoplexy is recognized by the slight external hemor- rhage and the great amount of oppression ; by the spots of localized dullness, and the underlying cardiac disease. What is the prognosis ? The prognosis is favorable as regards the result'of the hemorrhage itself. People never die of pulmonary hemorrhage, except when it occurs as the result of the rupture of an aneurism, when death is usually almost instantaneous. 240 essentials of practice of medicine. Vicarious hemorrhages are not dangerous. Pulmonary apoplexy is apt to eventuate in consolidation and to terminate in pneumonic phthisis. The hemorrhage is of little moment; the cause of the hemorrhage is the matter to be determined from a prognostic point. How is haemoptysis treated ? Absolute rest must be insisted on. The sufferer must not be allowed to speak a word, and must be kept perfectly quiet. He should be given easily digested food in small quantities, with small pieces of ice in his mouth, but not much to drink. Ex- ternally, mustard plasters or turpentine or dry cups may be employed when they can be used without disturbing the patient too much. The circulation should be attended to, and if the pulse is strong, aconite must be administered, giving gtt. j of the tincture every hour until it is reduced. In active hemorrhages ice applied to the chest is of use. The best haemostatics in pulmonary hemorrhage are ergotin, f3ss doses, administered every hour or two. It may be used hypoder- mically. It is often alternated with gallic acid. This drug is given in doses of gr. xx repeated every fifteen or twenty minutes until ithe blood turns black, when the intervals between the doses should be increased. If it induces nausea, add a few drops of a mineral acid to each dose. Lead acetate may be given in doses of gr. ij. with opium gr. \, every two hours; diluted sulphuric acid gtt. x, or turpentine nix, combined with opium and given every two hours sometimes succeeds when other remedies have failed; small and repeated doses of cupric sulphate (gr. xs-i) combined with opium, or the tincture of niatico (3j every two hours) are also useful. Whatever remedy is used, opium should be combined with it, to calm any irritative cough, or nervous perturbation which may be present. Acute Lobar Pneumonia. What is acute lobar pneumonia ? It is an acute, croupous inflammation of the lung tissue, attended with exudation into the air-vesicles. DISEASES OF LUNG-TISSUE—ACUTE LOBAR PNEUMONIA. 241 What are its synonyms ? It is called croupous pneumonia, pneumonitis and pneumonia. What is its pathology ? The disease consists of three stages. In the first stage (that of congestion) the blood vessels are engorged, proliferation of epithelium takes place in the air-vesicles, partly occluding them, but sufficient air remains to make the lungs float in water. In the second stage (the stage of exudation, consolidation, or red hepatization), the lungs are solid and firm. The small tubes and air- vesicles are filled with embryonic tissue and retained secretions. On section the lung is of the color of a piece of liver, hence called red hepatization, and a portion of lung-tissue placed in water sinks. Third stage. The disease either ends in resolution or in gray hepatization. If it ends in resolution, the exudate undergoes fatty degeneration, and assumes a yellow appearance, due to fatty degene- ration of the embryonic tissue, which is either absorbed or expecto- rated. This is sometimes spoken of as '''yellow hepatization." If it ends in gray hepatization the exudate and air-cells soften, un- dergo caseous degeneration, break down, and form a sort of puru- lent infiltration, spoken of as "gray hepatization." The whole lung softens, but abscess rarely forms, there being no circumscribed cavity containing pus, but purulent infiltration of the lung tissue. Sometimes the pleura is slightly involved. The bronchial tubes are also slightly inflamed. There is a tendency to cerebral or men- ingeal congestion. Endocarditis is not uncommon, perhaps leading to heart-clots, which sometimes prove fatal. Congestion of the kidneys with albuminuria is also frequently found. What is the seat of this disease ? In two-thirds of the cases, the lower lobe of the lung on the right side is affected. If the upper lobe is affected, the whole lung usually is consolidated. Double pneumonias are very rare. What is the cause of this disease ? It may occur at any age, but is most common between the ages of twenty to forty years. Pneumonias of children and of old persons 16 242 ESSENTIALS OF PRACTICE OF MEDICINE. are usually catarrhal. Sometimes it appears to be epidemic, and is considered by some to be due to a specific germ (the pneumococcus). It is usually, however, due to exposure to cold and damp. It may follow bronchitis, is produced by malaria, and may be intercurrent in rheumatism, Bright's disease, or any affection characterized by blood-poisoning. What are its symptoms ? There is a chill, more or less severe; flushed face; headache; fever, the temperature rarely being above 105°, and falling rapidly to or below the normal during convalescence. There is some oppression in breathing, the respirations being hurried, from twenty-four to eighty per minute. The pulse does not rise in proportion to the rapidity of the breathing, and during convalescence falls below the normal. Some cough is present, paroxysmal in character, but not very marked. The expectoration is striking, it is of a rusty color, sticky, tenacious, and adhesive. The urine is deficient in chlorides during the height of the disease, but they rapidly reappear as recovery takes place. Albuminuria occurs in bad cases. Delirium is sometimes seen, and is a bad sign. In typhoid pneumonias or pneumonias of the upper lobe in children, it is usually present. When it occurs in an adult, always examine the urine for kidney complications. There is pain in the neighborhood of the right nipple, shooting downwards to the region of the ileo-caecal valve. Jaundice is also occasionally seen. In the third stage, when absorption takes place, perspirations more or less profuse occur ; the urates and chlorides return to the urine; the cough becomes looser, the sputa is freer and loses its rusty ap- pearance, and the fever rapidly declines. If gray hepatization occurs, there is great prostration. The res- piration becomes faster, shallower, and more labored ; there is flap- ping of the ahB nasi; the hectic flush disappears from the face, and signs of impeded circulation are present. The sputa is dark, offen- sive, and purulent, loses its rusty color, and becomes light brown (calledprune-juice expectoration). What is the duration ? The average duration is from ten days to two weeks. The first DISEASES OF LUNG-TISSUE—ACUTE LOBAR PNEUMONIA. 243 stage usually lasts from one to three days ; the second stage for five days or more, and if resolution takes place, it occurs from the seventh to the eleventh day of the disease. Gray hepatization may occur from the fifth to the seventh day, terminating in death after two or three days. What are the physical signs of this disease ? In the first stage the percussion resonance is somewhat impaired. On inspection, the respiratory movement is diminished on the affected side. On auscultation, there is a feeble inspiration, prolonged expiration and crepitant rales (pathognomonic of pneu- monia), heard only on inspiration. During the second stage there is marked dullness on percus- sion, marked deficiency of respiratory movement on the affected side, the movements of the sound lung being increased; marked bronchial breathing on auscultation, the vesicular murmur being absent, and marked exaggeration, as a rule, of both vocal fremitus and vocal resonance. During the third stage, if the exudation is being absorbed and expectorated, the dullness on percussion lessens, the movement of the chest increases, some slight vesicular breathing is heard, the bronchial breathing is less distinct, and the crepitant rales return. When, on the other hand, gray hepatization and softening of the lung is taking place, the signs of consolidation remain as in the second stage, without change. How is this disease diagnosed? The diagnostic points are the hurried respiration, the rusty-colored sputum, the pain, the physical signs, and the short duration. (A) Differential Diagnosis. (1) From Acute Bronchitis.—By the dull percussion note and other physical signs indicated in consolidation. (2) The first stage might be mistaken for that form of congestion leading to oedema, in which there are crepitant rales, hurried breath- ing, slightly impaired resonance and moderate fever; but the latter occurs in fevers, or intercurrent with Bright's disease, or in cardiac diseases, and the signs are diffused over both lungs. In case of 244 ESSENTIALS OF PRACTICE OF .MEDICINE. doubt, a few days will give dullness and the sounds of consolidation in pneumonia, which readily distinguish it from congestion. (3) Tlie first stage of pneumonia differs from the first stage of pleurisy, in that there is less pain in the former, more cough, rusty- colored sputum and crepitant rales, but no friction sound, such as is heard in pleurisy. (4) The stage of consolidation might be mistaken for jlcurisy, with effusion; but in pneumonia there is a severe chill and the fever is higher, there is rusty-colored expectoration, and the physical signs of consolidation of the lung (bronchophony, increased vocal fremitus and marked bronchial breathing) are all absent in pleurisy. (B) Diagnosis of Complications. (1) The Cardiac Complications, from Acute Endocarditis.—A car- diac murmur may occur in pneumonia without the supervention of acute endocarditis ; the former is due to blood changes and alteration in pressure, and is an inconstant murmur, while the latter persists. (2) The formation of heart-clots in pneumonia is diagnosed by the increasing difficulty in breathing, cold hands and feet, and signs of impeded circulation usually occurring during the second stage. Death may take place suddenly, in these cases, from cardiac paralysis. (C) Diagnosis of the Different Forms of Pneumonia. (1) Epidemic pneumonia, embolic pneumonia, and pneumonia due to cold and exposure cannot be differentiated absolutely except by the history. If the temperature is very high it is probably a general (epidemic) pneumonia. If the bloody sputa continues for a long time, especially if cardiac disease is present, it is probably an embolic variety. What is the prognosis ? Eight to twenty per cent, die of this disease. Unfavorable symp- toms are, temperature above 105°; very rapid pulse; early delirium; repeated attacks; relapses, and double pneumonias. Intercurrent pneumonias are exceedingly dangerous. Acute pneumonias, or pneumonias occurring in drunkards, give a very grave prognosis. Pneumonia occurring during pregnancy is also very serious. What is the treatment ? The patient must be confined to bed and kept quiet. He should DISEASES OF LINO-TISSUE—ACUTE LOBAR PNEUMONIA. 245 be fed moderately, stimulants only being required in typhoid pneu- monias or in the third stage with purulent infiltration. Venesection generally does harm. If the disease is caused by cold and exposure, and occurs in a strong, active adult, with a flushed face and much oppression in breathing, with a tense and frequent pulse, and if he is seen in the first stage before consolidation has occurred, fsviij-xij of blood taken by wet cups from the chest will relieve the oppression, but has no influence on the course of the disease. In the first stage, before consolidation is present, if the patient is young and the circulation very active, a few drops of veratrum viride, or of aconite, may be given every few hours, watching the effects closely, and discontinuing the medicine as soon as consolida- tion occurs. When consolidation is present quinine should be administered, giving from gr. xij-xviij or xx in twenty-four hours, in divided doses. It lowers the temperature and limits the amount of exuda- tion, and is especially useful in intercurrent, typhoid or malarial pneumonias, and in those of old persons or of drunkards. Digitalis should be combined with quinine in this stage, the dose being pro- portioned to the effects produced. It acts by reducing the pulse equalizing the circulation, strengthening the heart, and keeping up the secretion. Alkalies, especially ammonium carbonate, are given throughout the case, not as expectorants, but to liquify the exudation. They may be administered alternately with quinine and digitalis. If the ammonium salts are not well borne by the stomach, potassium ace- tate or citrate may be substituted for them. Locally, if there is much pain or oppression, dry cups are of use. If the case is complicated with pleurisy, poultices are of service In all other cases, if there is much pain, mustard plasters or turpen- tine stupes should be resorted to. When resolution is taking place stimulating expectorants are useful, as squill or senega, in addition to the ammonium preparations already given. If consolidation lingers, the ammonium salts, the iodides, or corrosive sublimate should be administered. Repeated blisters are also of value. If grey hepatization takes place, or if the pneumonia becomes ty- phoid in character, sustain the vital powers by stimulants, promote 246 ESSENTIALS OF PRACTICE OF MEDICINE. free expectoration, give iron and quinine, and administer brandy judiciously. During convalescence keep up the secretions by laxatives and diuretics, and give quinine and other tonics. Stimulants have dofle as much harm as the lancet in pneumonia. If, however, the patient is weak, or the heart-sounds feeble or irreg- ular, or if the stage of gray hepatization is present, stimulants must be administered, as in any other disease. In pneumonias of drunkards, stimulants are required because of the weakness and the feeble heart. Broncho-Pneumonia. What is broncho-pneumonia ? It is a catarrhal inflammation of the vesicular structure of the lungs, resulting in patches of consolidation diffused over both sides, affecting especially young children or old persons, and usually com- mencing in an attack of acute bronchitis. What are its synonyms ? It is also called catarrhal or lobular pneumonia. What is the pathology of this affection ? It is a catarrhal process, beginning as a bronchitis and extending down into the air-vesicles. The pathology is similar to that of lobar pneumonia, excepting that in this disease the lobules, not the lobes, are involved, and that it usually affects both lungs symmetri- cally. The process of resolution is similar to that of lobar pneumonia, but the spots of consolidation are apt to linger, may undergo caseous degeneration, and result in pneumonic phthisis. What are the symptoms ? When the inflammation is about to invade the lung structure, the temperature rises considerably and may be very high ; the cough increases and often gives rise to much pain; the sputum is purulent, tenacious and streaked with blood, but is not rusty-colored, or, at any rate, only for a short time; there is violent headache, often delirium, and sometimes early in the disease convulsions occur. The breathing is not nearly so frequent as in ordinary lobar pncu- DISEASES OF LUNG-TISSUE—BRONCHO-PNEUMONIA. 247 monia, and there is nothing resembling a crisis in the remotest degree, on the contrary, the fever continues for several weeks—much longer than in ordinary pneumonia, and gradually subsides. Some- times spots of consolidation remain, leading to chronic pneumonia, and often eventuating in pneumonic phthisis. This disease does not so frequently attack adults as does lobar pneumonia, but is more frequent among children than is the latter. When it attacks adults the nervous phenomena are not so marked as they are when the disease occurs in children. What are the physical signs ? The physical signs are those of acute bronchitis, with here and there spots which are dull on percussion, and over which are heard fine vesicular rales and an approach to, or perfect bronchial breathing with other signs of consolidation as in lobar pneumonia. These spots are usually symmetrically distributed over the lungs, and much more commonly affect the apex, than does the other variety of pneumonia. Signs of pleurisy are often present. How is this disease recognized ? It is diagnosed by the ages at which it occurs; by following an attack of bronchitis ; by the symptoms, and by the signs of patches of consolidation, symmetrically distributed over both lungs. Differential Diagnosis. (1) From Acute Lobar Pneumonia, it is differentiated by the preceding bronchitis; the higher temperature and more continuous fever ; by the absence of rusty-colored sputum, and by the physical signs of consolidation diffused here and there in spots over both lungs. (2) From Capillary Bronchitis with collapse of various lobules. In this disease there is no dulness unless the lobules are collapsed or inflamed (when it passes into broncho-pneumonia). Where the lob- ules are collapsed the spots of dulness will shift, as the plug of mucus is dislodged by the cough and the lobules again expand. In pneumonia the spots of dulness are fixed and diffused ; the signs of deficient aeration of the blood are not so pronounced as in capil- lary bronchitis ; there is less difficulty in breathing and the disease is not so grave, nor attended with so much depression of the vital powers. 24S ESSENTIALS OF PRACTICE OF MEDICINE. What is the prognosis ? The prognosis does not differ materially from that of acute croup- ous pneumonia. It is more liable, however, to leave behind spots of consolidation. How should it be treated? The patient should be confined to bed and must remain there for a long time. He must be kept perfectly quiet and not allowed to talk too much. If he is active, strong and young, a few leeches may be advantageously applied to the chest. Counter-irritation by means of turpentine or mustard plasters, fol- lowed by the application of poultices, often give great relief. In other respects the treatment is the same as that for other forms of pneumonia, except that expectorants must be used more freely. The ammonium salts, with quinine and digitalis, are all indicated, the two latter being useful not only as tonics and alterants, but as tending also to reduce the temperature. When the morbid process is extending, or when it lingers and chronic pneumonia is feared, potassium iodide must be given in decided doses and pushed, with the hope of causing absorption, at the same time that counter-irritation, by blisters, may be employed over the spots of consolidated tissue. During convalescence cod-liver oil and the iodide of iron must be administered, and a change of scene should be ordered if the patient can afford it. Chronic Pneumonia. What is chronic pneumonia ? Chronic pneumonia may follow acute pneumonia, a spot of con- solidation remaining after either variety of the affection, or it may develop slowly, being chronic from the start. It is usually so closely associated with tuberculosis that it will be discussed in connection with the latter affection, under the head of "pneumonic phthisis." DISEASES OF LUNG-TISSUE—PULMONARY GANGRENE. 249 Pulmonary Gangrene. What is pulmonary gangrene ? Gangrene of the lung is a rapid breaking down of lung-tissue fol- lowing pneumonia, traumatism, pyaemia or embolism, and character- ized by cough, rapid wasting, profuse sweating, a horrible, sickening, gangrenous odor, especially after coughing, and the physical signs of a cavity. What are its symptoms ? The symptoms are, rapid wasting, with great prostration and pro- gressive loss of strength ; dyspnoea ; hemorrhage, often profuse ; a rapid irritable pulse, and a cough accompanied by a disgusting, sickening odor, and a profuse greenish-brown expectoration. What are the physical signs of gangrene ? The signs at first are those of consolidation, followed shortly by those of a cavity, usually situated at the lower part of the lung and generally confined to one lung only. How is it recognized ? It is recognized by the symptoms, particularly by the persistent odor, and by the signs of a cavity resulting from the breaking down of the lung-tissue. What is the prognosis ? The vast majority of cases die of exhaustion, or of hemorrhage. It is not, however, entirely hopeless, as occasionally the gangrenous portion of the lung sloughs and is expectorated, and the patient recovers, the cavity having cicatrized. How is gangrene of the lung treated ? The patient must be well fed on a liberal diet, freely stimulated, and everything done which will sustain his strength. There should be free ventilation of his room, and the air and sputa must be thoroughly disinfected. Tonics, as iron and quinine, should be administered. Turpentine administered by inhalation and given internally at the same time (ttVx-xv four or five times a day in emulsion) appears to produce the best effect. Terebene has also been used, as has car- bolic acid, internally and by inhalation in the form of spray. 250 ESSENTIALS OF PRACTICE OF MEDICINE. Tuberculosis. What is tuberculosis ? Tuberculosis is an acute or chronic disease, usually the latter, caused by the deposition, softening and breaking down of tubercle in the lung, and the ultimate formation of cavities in those organs, and characterized by fever, accelerated pulse, cough, emaciation, and other symptoms of hectic fever, attended with signs denoting con- solidation of lung structure, and afterwards of the formation of cavities. What is the pathology of tuberculosis ? Tuberculosis is a specific disease. A tubercle is one of the infec- tive granulomata, and causes, is not caused by, inflammation. It is preeminently a disease of the lung, although it may be found in any organ of the body, usually, however, associated with infection of the lung also. Like all other low-grade tissues of new formation, it has a ten- dency to undergo caseous degeneration, to soften and break down. The neighboring tissues become inflamed, and, softening in their turn, break down also, and thus cavities are formed. Tubercle is due to the presence of the bacillus tuberculosis, which is found in the tubercular masses, in the breath and in the sputum of those suffering from this disease. This is a rod-shaped body, blunt at both ends, and absolutely motionless, which varies from T^Vu to ^Vcr of an inch in length, and produces spores. It cannot be seen, even by the microscope, without having been previously stained. Under the microscope a tubercle is seen to consist of a giant cell, which contains the bacillus, and which is surrounded by a reticulum consisting of delicate filaments interlacing with each other and con- taining within their meshes numerous embryonal cells, fatty globules and broken-down connective tissue. It seems positively settled that without the presence of the bacil- lus tuberculosis there can be no tubercle, and yet if this is the cause of the disease, it is difficult to understand how heredity can play a part in its production, as it undoubtedly does. It certainly acts as a DISEASES OF LUNG-TISSUE—ACUTE TUBERCULOSIS. 251 carrier of infection, and its presence, when recognized under the microscope, is an invaluable aid to diagnosis. What are the causes of tuberculosis ? The ever-present cause appears to be the bacillus tuberculosis. It is strongly hereditary ; is slightly infectious, in the sense that a per- son, as a nurse, constantly breathing the atmosphere of a sick room impregnated with the bacillus, may finally contract the disease. Any- thing which lowers the vitality aids in developing the disease : thus it occurs in those who lead a sedentary life ; in persons overworked in mind and body, and often develops at the close of debilitating diseases, especially the acute fevers. Perhaps in those who inherit a predisposition to this disease, and in those whose vitality is other- wise depressed, the bacillus or its spores find a suitable nidus for their development, while in a healthy individual the tissues possess sufficient vitality to resist the disease, or the bacillus, not finding suit- able pabulum, is cast out of the system even after it has entered the body. Acute Tuberculosis. What is acute tuberculosis ? It is an acute disease, characterized by fever, sweats, rapid pulse, great emaciation, cough and dyspnoea, running a rapid course, and due to the deposition from the blood of miliary tubercle, diffused throughout the lungs and other organs of the body. It is usually called galloping consumption. Although not so common as chronic tuberculosis, it is by no means unfrequently seen. What is the pathology of acute tuberculosis ? The pathology is the same as that already discussed when speak- ing of tubercle. The bacillus tuberculosis is deposited from the blood in lungs, bowels, brain, etc., and usually produces diffused miliary tuberculosis. It is generally a disease of childhood or of young adults. What are its symptoms ? There is some cough, which is usually slight, and not at all violent. Emaciation takes place rapidly, and is out of all proportion to the 252 ESSENTIALS OF PRACTICE OF MEDICINE. violence of the cough. Fever is always present, the, temperature being high and irregular, varying much in the course of twenty-four hours, a point of diagnostic importance. Profuse colliquative sweats are seen, which are out of all propor- tion also to the violence of the cough. The pulse is irritable and very frequent, and there is great dyspnoea. Delirium, photophobia and other symptoms of cerebral disorder are present, even in those cases where there is no deposit of tubercle in the brain. These symptoms are then probably the result of sympathetic disturbances, possibly induced by the rapid circulation, the fever and the exhaustion. Hemorrhage is not of frequent occurrence, although the disease sometimes begins with haemoptysis. Diarrhoea is sometimes present, and may be severe. There is often some pain in the chest. The disease runs a rapid course, and usually terminates fatally from ex- haustion. Occasionally the acute process is arrested, and the dis- ease proceeds as chronic tuberculosis. What are the physical signs ? The physical signs are generally very obscure at first, being simply those of diffused bronchitis. Later in the disease, signs of consoli- dation are usually present at the apices of the lungs, followed by those of softening and the formation of cavities, as in chronic tuber- culosis. How is this affection recognized ? This disease is diagnosed by the fever, pulse, emaciation, sweats and dyspnoea, all of which are decidedly out of proportion to the cough; and later by the physical signs. Differential Diagnosis. From Acute Bronchitis.—In the latter disease there is not the rapid wasting, nor the high temperature, rapid pulse, profuse sweats and great dyspnoea which are found in the former, nor do the physical signs ever point to consolidation, nor to the formation of cavities. What is the prognosis ? Recovery sometimes takes place, calcareous degeneration occur- ring in the softened tubercle, the caseous process thus being arrested. DISEASES OF LUNG-TISSUh—CHRONIC TUBERCULOSIS. 253 Or the acute symptoms may subside and the disease continue as an ordinary case of chronic phthisis. The disease usually, however, terminates in the death of the patient within a very short period, one case being reported in which death occurred eleven days from the onset of the disease. What is the treatment ? The indications for treatment are to reduce the temperature and hectic, to nourish the patient and to treat those symptoms which may require it. The patient should, therefore, have a light, easily- digested, nourishing diet, but he should not be overfed, as this tends to increase tissue waste. Quinine and digitalis are preemi- nently the remedies needed in these cases, to which opium may be joined, as in Xiemoyer s pill, in case there is much irritating cough. Chronic Tuberculosis. What are the synonyms of this disease ? It is called tubercular phthisis, tubercular disease of the lung, and consumption. What are the causes and pathology of this disease ? It is strongly hereditary, and is predisposed to by a sedentary life. In some rare instances it is unquestionably due to breathing the ema- nations of a patient suffering from the disease, as in the case of a husband nursing a wife. The pathological cause is tubercle, which has already been discussed. What are its symptoms ? The disease consists of three stages, the stage of deposit, the stage of consolidation, and the stage of the formation of the cavity. First Stage.—The disease may start as a neglected cold, or as a slight, hacking cough, with loss of flesh and health, and a certain amount of digestive disturbance coming on gradually ; or as a slight cough followed by hemorrhage; or simply as loss of flesh. No matter how the disease begins, the circulation is always quickened. Second Stage.—The cough increases, expectoration is more pro- fuse and is purulent or nummular, and emaciation progresses more 254 ESSENTIALS OF PRACTICE OF MEDICINE. rapidly. There is a tendency to diarrhoea, and irritative fever in the latter part of the day. The heart is irritable, and there is a quick, irritable pulse, the frequency of which continues even when the patient is free from fever. Night-sweats now occur, and the patient is much exhausted in the morning; the appetite is poorer and poorer; the diarrhoea is apt to increase ; hemorrhage may occur at any time, and the respi- ration is accelerated. Third Stage.—The cough, weakness and dyspnoea increase, and the emaciation is more marked ; the irritative fever and night-sweats are more pronounced ; the patient is hopeful; and the mind is clear. Hemorrhages are rare in this stage of the disease. In cleanly per- sons, a red line is seen on the gums, which appear to be retracted from the teeth, making the latter look longer than natural. This is called the gingival line, and as a diagnostic point is of some value. The nails become clubbed at the ends, and bluish in color from defec- tive aeration of the blood. Swelling of the feet occurs as a late symptom. Occasionally acute cerebral symptoms appear with pain in the head, delirium, irregular pulse, and the patient (usually a child) dies of tubercular meningitis ; or acute pleurisy may occur; or pneumonia be intercurrent; or pneumothorax supervene and cause death. What are the complications ? (1) Laryngeal phthisis. Always a grave complication. It usu- ally begins as a simple catarrhal laryngitis, with thickening and swelling of the mucous membrane, tubercular infiltration afterward taking place. The infiltrate spreads downward to the cartilages and ulceration occurs. The symptoms of these cases are, great difficulty in swallowing from involvement of the epiglottis; fre- quent, harsh, paroxysmal cough, and change in the character of the voice. (2) Diarrhoea. This is sometimes only a catarrhal trouble. At other times it is caused by tubercular infiltration of the walls of the bowel, of the peritoneum, or of the mesentery glands. An ulcera- tive process sets in and the patient's life is much shortened. In all cases of tuberculosis where there is persistent diarrhoea resisting ordinary treatment, tubercular ulceration should be suspected. DISEASES OF LUNG-TISSUE—CHRONIC TUBERCULOSIS. 255 Less Frequent Complications are (3) Tubercular meningitis, especially seen in young people. (4) Localized pneumonia or pleurisy occurring after exposure. (5) Pneumothorax. What are the physical signs ? In the first stage, or that of exudation or early infil- tration, the signs are limited chiefly to the apex of the lung, usually to that of the left lung. On inspection there is a want of expansion of the upper part of the lung, which is flatter than that of the opposite side. On percussion there is a slight impairment of the normal reso- nance in the same situation (the left apex is normally somewhat clearer than the right). Respiratory percussion renders the sound relatively more dull than before. On auscultation a few fine subcrepitant or crepitant rales are heard, limited to the left apex. There is prolonged expiration and feeble or harsh respiration. There is slight increase of the vocal resonance. On palpation a want of expansion is detected at the left apex, and the vocal fremitus is increased in this situation. Second stage, or that of complete infiltration. When this stage is reached in the left lung, infiltration has usually com- menced at the other apex also, hence the signs of the first stage will now be detected in the second lung. Percussion will show decided dulness at the left apex. On auscultation vesiculo-bronchial breathing is heard, and broncho- phony is marked ; crackling rales are also heard, not as much limited to the left apex as they were in the earlier stage. On palpation there is increased vocal fremitus. Third stage, stage of softening and formation of cavi- ties. There is absolute dulness on percussion. On auscultation large, moist rales and vesiculo-bronchial breathing are heard, but are not so limited in extent as in the second stage. Over a cavity, percussion produces a vesiculotympanitic resonance. On auscultation there is cavernous breathing, cavernous voice and gurgling. 256 ESSENTIALS OF PRACTICE OF MEDICINE. If the cavity is large, percussion will elicit an amphoric note, and on auscultation there will be an amphoric respiration and voice. How is chronic tuberculosis diagnosed ? In the early stages the disease may be recognized by the slightly elevated temperature; the loss of flesh; the family history ; the quickened pulse; the impaired resonance on percussion, limited to the left apex ; the prolonged expiration, and the few fine rales heard in the same situation, and the microscopical examination of the sputum in which the bacillus tuberculosis can be seen. If there are any physical signs limited to the apex of the lung, with loss of flesh, tubercle probably exists. Later in the disease the marked physical signs at one or both apices, the fever, sweating and other characteristic symptoms, render the diagnosis clear. Differential Diagnosis. (1) From chronic bronchitis, tuberculosis is differentiated by the dulness and other signs limited to the apex, and by the deterioration of health. (2) Lingering consolidation after pneumonia usually affects the lower part of the lung, is preceded by the acute disease; the health is not as much impaired, and there are no bacilli in the sputum. (3) Bronchial dilatation. In these cases the general health is good, there is no fever, no hurried respiration, no bacilli in the sputa, and the cavities due to the dilated bronchi are in the posterior and at the lower part of the lung. There are diffused rfdes over both sides of the chest. On percussion the chest is resonant, the note being but little changed from that of health. It is not dull here and tympanitic there, as in the case of the tubercular cavities. There is, therefore, a disproportion between the physical signs and the symptoms, which is not found in phthisis. (4) From chronic malaria. In these cases the absence of the physical signs would exclude phthisis. Phthisis should, however, always be sought for where there are recurring chills, fever and sweats conjoined with loss of flesh, before a diagnosis of chronic malaria is made. (5) From emphysema. The hemorrhages, emaciation and other DISEASES OF LUNG-TISSUE—CHRONIC TUBERCULOSIS. 257 symptoms, and the great difference in physical signs make the diag- nosis clear. What is the prognosis ? A certain proportion of cases absolutely recover. If these cases die from other diseases, the post-mortem examination shows little calcareous masses, usually highly pigmented, occupying the site of the former tubercle. If there is no hereditary predisposition, and the disease follows a cold (pneumonic phthisis), the prognosis is all the more favorable. If the disease starts with a high pulse, soon followed by fever, it is generally a rapid case. Hemorrhages do not add to the danger without they are repeated and severe. If a case is marked by per- sistent evening temperature of 102°, the prognosis is bad, unless the temperature soon becomes normal again, which will indicate the arrest of the tubercular process. Persistent diarrhoea, profuse night-sweats, swelling of the feet, etc., indicate a bad case. When cavities are present the disease is generally very serious, although in rare cases they may cicatrize. What is the treatment of phthisis ? The treatment of phthisis may be divided into the radical and symptomatic treatment. (A.) Radical Treatment. This is of the utmost importance. (1) The patient must lead an out-of-door life, no matter where he fives. (2) The climate should be such as will allow him to live in the open air. An equable climate, especially if dry, is best suited for nearly all cases. Colorado is a good climate if there are no laryngeal complications and no excessive action of the heart. If the heart is irritable, the altitude of Colorado is too great. It is especially good in the early or the second stage of the disease. New Mexico is also good for the same class of cases. Southern California is better for those cases with laryngeal com- plications, or where there is an irritable heart, or where they do not bear our winters well. 17 258 ESSENTIALS OF PRACTICE OF MEDICINE. South Carolina is dry and not very high. Florida is a useful climate where there is much bronchial irrita- tion and when it is desirable to increase the expectoration. The Nile or Algiers are good climates when there is some bron- chial irritation, and where altitude is not to be desired. In summer, mountainous regions usually suit all classes of cases best, provided the altitude is not too great. The Adirondacks is suitable for many cases during the hot weather. (3) The patient should be warmly clad, but not sufficiently so to produce perspiration. He should wash with cold water in the morn- ing, bathing his neck and chest, and undergoing what is called a hardening process. (4) Food.—He must have a plain but nourishing diet, and abun- dance of meat if it is well digested. If, however, the stomach becomes disordered, he must be placed upon a milk diet, gradually increasing the amount until he is able to take it in large quantities. The ex- tract of malt, beer, etc., are foods, not medicines, in this disease. (5) Drink.—The average consumptive should take small amounts of alcohol in the form of wine or whiskey, especially when he is leading a life in the open air. If he takes whiskey, let him have about half an ounce three times a day with his meals. If there is much irritability of the heart or a quick pulse and an irritable, ner- vous system, alcohol does more harm than good. (6) The patient may smoke in moderation, if the heart is not irritable. (7) Should the physician be consulted regarding the marriage of a consumptive, it is his duty to lay the question of heredity before both the contracting parties. Marriage itself does not affect the prognosis of the case. During pregnancy the tubercular process is retarded. After childbirth, however, it is apt to be hastened in its development. No consumptive mother ought ever, under any cir- cumstances, to nurse her child, both for her own sake and that of the child as well. (8) Drugs.—The best remedy is cod-liver oil, which should be given in doses of from f3j-iv three times a day, stopping when the weather becomes warm, as it is then more apt to disagree with the stomach. It may occasionally be omitted with benefit, even in cold weather. It is better given pure, if the patient can take it, and DISEASES OF LUNG-TISSUE—CHRONIC TUBERCULOSIS. 259 may be prescribed in malt, soda water, with whiskey, or with a few minims of ether, which for a time appears to aid its digestion, but cannot be taken for a long period. Arsenic.—Fowler's solution may be given in small doses, ^ij-iij, or sodium arsenite, gr. ^j, three times a day. These may be given early in the disease and continued for a long time. They are espe- cially useful where there is not much bronchial irritation. Iodine.—In the form of Lugol's solution, or, if the patient is anaemic, as ferrous iodide, is very useful. If there is much bronchial catarrh, potassium iodide answers better. The hypophosphites only act as an ordinarily good tonic, but have no specific effect. The inhalation of compressed air is moderately good in the early part of the disease, but has no curative effect. The same may be said of oxygen inhalations. Inhalations of iodine and carbolic acid do some good in bronchial complications, or for the relief of foetor where there are cavities, but never cure. To kill the bacillus, disinfect the sputum with corrosive sublimate solution or chlorinated lime, and thus prevent the spread of the disease. As yet, no means has been invented to destroy the bacillus in the lung. Symptomatic Treatment. As this is a disease of nutrition, the more attention that is paid to the general health, and the less the symptoms are treated, the better for the patient. Cough. If the cough is not excessive, if it does not prevent the patient from sleeping, the less it is treated the better. Should it be necessary to give some remedy to allay it, opium in some form or other has the best effect. Codeine allays the cough, and does not con- stipate as much as opium. It should be given in about double the dose of morphine. Diluted hydrocyanic acid (gtt. j) or the fluid ex- tract of Prunus Virginiana are also useful. The diluted acids are also good as adjuvants to opium. For the irritative fever, small doses of aconite or a combination of digitalis with quinine and opium should be given every three or four hours. Where the high temperature persists, antipyrine has been employed in doses of gr. v, repeated every hour, until twenty grains 260 ESSENTIALS OF PRACTICE OF MEDICINE. are taken, or quinine may be given in doses of gr. x, repeated three times at intervals of an hour. Night sweats. Do not keep the patient too warmly covered at night. A hot sponge-bath with alum or borax is sometimes of value. Zinc sulphate, gr. j every three or four hours, or ergot, or ergotine, gr. ij two or three times a day, or aromatic sulphuric acid, gtt. xv-xx, freely diluted three times a day, or most potent but most disagreeable in its after-effects, atropine, gr. -^ at night, may be employed. For the laryngeal complications. Iodoform has been successfully used in these cases, but the taste and smell constitute strong objec- tions to its employment. Cocaine in solution (four to eight per cent.), applied by a brush to the larynx or even to the epiglottis, affords great relief to the patient, and allows him to swallow without pain. For loss of appetite and debility, the best remedies are quinine and ignatia. For diarrhoea, if it is possible let it alone, and treat the disease. Should it continue and prove obstinate, bismuth, silver nitrate, cu- pric sulphate, or the mineral acids (as Hope's Camphor Mixture) may be combined with opium. Pneumonic Phthisis. What is this disease ? It begins acutely like pneumonia, but the consolidation lingers, and after a time tubercles form in the consolidated lung. After the deposit of tubercle, the symptoms and the physical signs arc identical with those of tuberculosis, the signs being, however, in the lower part of the lung instead of at the apex. The prognosis is far better than that of tuberculosis, as the results of treatment, and especially the change of climate, often produce wonderful effects. The treatment is the same as that of chronic tuberculosis. DISEASES OF LUNG-TISSUE—FIBROID PHTHISIS. 261 Fibroid Phthisis. What is the cause of this disease ? It occurs in stone-cutters, knife-grinders, miners, weavers, etc., from the inhalation of small particles of foreign substances floating in the atmosphere, due to their occupation. These produce a low grade of interstitial pneumonia which results in hypertrophy and hyperplasia of the connective tissue of the lung, which contracting compresses the air-vesicles. After a time the lung becomes the seat of secondary tubercular infection. Pleuritic adhesions may also form, causing contractions of that side of the chest; dilatation of the heart is apt to result from interference with the circulation of the lungs, and cardiac dropsy occurs. It is a late symptom. In some instances the disease is arrested before the lung becomes the seat of tubercular infection. The symptoms are like those of tuberculosis, but the disease is much more gradual in its development. Physical Signs. There is sinking in of the chest wall on one side, dulness on per- cussion with areas of tympanitic resonance over dilated bronchial tubes. There is bronchial breathing over the contracted lung or signs of a cavity over the dilated bronchi. Later in the disease the signs of tubercles are present. Prognosis. This is a disease of long duration. It may develop into tubercu- losis, or it may recover without tubercular infection. Treatment. What has already been said of the general treatment of tubercu- losis applies to these cases as well. Potassium or ammonium iodide is also of use. Counter-irritation by repeated blisters over the chest are much more useful in this than in other forms of phthisis. If there is much offensive expectoration, disinfectant inhalations, as iodine, creasote, carbolic acid, etc., should be employed, and ammonium carbonate should be administered internally. 262 ESSENTIALS OF PRACTICE OF MEDICINE. DISEASES OF THE PLEURA. Acute Pleurisy. What is acute pleurisy ? It is a plastic inflammation of the pleura, characterized by a sharp pain in the side, dry cough, fever, and difficulty in breathing on account of the pain. What is its synonym? Acute pleuritis. What is the cause ? Acute pleurisy may follow cold and exposure or traumatisms. It is often secondary, occurring during an attack of pneumonia or other lung disease, pericarditis, smallpox or other exanthemata, Bright's disease., rheumatism or other diathetic disease, or following blood affections, as pyaemia, snake bites, ete. What is its pathology ? The inflammation may be localized or diffused. It is usually limited to one side. The pathology is similar to that of inflamma- tion affecting the other serous membranes. The pleura is at first red and congested in spots, and the epithelial cells covering its surface undergo rapid proliferation, causing it to become opaque. This exudation of lymph may undergo changes common to other plastic exudations terminating in strong, fibrous adhesions which bind the opposing surfaces of the pleura together. The lung immediately under the inflamed area is generally slightly congested. Instead of this exudation of lymph a serous exudation may take place, very little lymph being formed. This fluid may become gradually absorbed, and adhesions form at a later stage. In this way the dry stage (where there is little serum and much lymph) may end in adhesion, or may be followed by a moist stage (where much serum is exudated), which in its turn may be followed by adhe- sion. Or the fluid may remain as a chronic condition or may become purulent. DISEASES OF PLEURA—ACUTE PLEURISY. 263 What are the symptoms of acute pleurisy ? The symptoms are obscure and occasionally may be entirely absent. Pain.—There is usually sharp, lancinating pain, increased by coughing and by breathing, which is generally referred to the seat of the inflammatory action, but may be reflected to other parts and sometimes to the opposite side. When the fluid is poured out the pain lessens or disappears. There is shortness of breath, due in the early stages to the pain, and later on in proportion to the amount of fluid effused, and caused by the resulting compression of the lung. There is dry cough, or perhaps it is accompanied by a little frothy expectoration. There is a certain amount of fever, usually preceded by a chill; temperature rarely being over 102°, the local temperature being higher on the side affected. The pulse is frequent and compressible, varying from 90 to 110 per minute. The urine is suppressed or greatly diminished in quantity, espe- cially when the effusion is taking place. The case lasts from ten days to two weeks and the effusion is rapidly absorbed, the patient convalescing or perhaps having permanent adhesions remaining. In other instances the effusion remains and the case becomes chronic. What are the physical signs of acute pleurisy ? (1) The Dry Stage (when the pleura is roughened by lymph). Inspection and palpation show that the chest does not fully expand on the inflamed side during inspiration. On percussion the note is not materially modified. On auscultation the vesicular murmur is weaker because the chest does not expand on that side. The vrjcal resonance is not much, if at all, impaired. A friction sound is heard both on expiration and inspiration. It is rough, superficial and creaking, is not influenced by cough, and is usually better heard in the lower part of the chest. It may cease when the side of the chest is strongly compressed below. It ceases when liquid effusion takes place. (2) In the Stage of Effusion, there is dulness on the lower part of the chest on percussion. On auscultation there is great enfeeblement of the vesicular mur- 264 ESSENTIALS OF PRACTICE OF MEDICINE. mur in the lower part of the chest, or it may be entirely absent, while in the upper part it is frequently exaggerated. The vocal resonance and fremitus is also greatly diminished or absent. jEgophony is heard at the edges of the effusion, while higher still the friction sound may be present. These physical signs become more marked as the effusion becomes greater. The chest wall frequently bulges, and the viscera are often displaced; thus, if the right side is affected the liver is displaced downward ; if the left side is affected the heart is forced toward the right side. (3) In the Stage of Absorption. As the effusion is being ab- sorbed the dulness lessens, the respiratory sound becomes stronger and stronger, the vocal resonance and fremitus gradually increase, the friction sound returns, and the viscera resume their normal posi- tion. (4) If permanent adhesions form, the chest remains contracted on that side and feeble breathing is present for life at this point, while a chronic friction sound may, but generally does not remain. How is acute pleurisy diagnosed ? In the dry stage it is recognized by the slight fever, the pain, the cough, but especially by the friction sound and other physical signs. In the moist stage by the dyspnoea, the scanty urine, but especially by the feeble or absent respiratory sounds, the diminished or absent vocal fremitus or resonance, the absolute dulness over the seat of the effusion and the other physical signs. Differential Diagnosis. (1) From pleurodynia. It is differentiated by the absence of physical signs in the latter. (2) From intercostal neuralgia. By the absence of fever and physical signs in the latter, and the fact that the pain is strictly limited to one or two of the intercostal nerves with a tenderness on pressure over their corresponding nerve points. (3) From acute pneumonia. In the early stages of the latter dis- ease the crepitant rale is heard, while in the dry stage of pleurisy the friction sound is present. In the second stage of both diseases there is dulness on percussion; but in acute pneumonia ausculta- DISEASES OF PLEURA—CHRONIC PLEURISY. 265 tion reveals bronchial breathing, bronchophony, and exaggerated vocal fremitus, while in acute pleurisy there is feeble or absent respiration with diminished or absent vocal resonance and fremitus. What is the prognosis ? Prognosis is usually favorable if it is a primary affection. When it is secondary, the prognosis will depend upon the disease which it follows or complicates. How should it be treated ? Morphine should be administered hypodermically to relieve the pain as soon as the patient is seen. If it is the result of cold, dry cups should be freely applied to the chest, or if the patient is strong and robust leeches or wet cups may be used ; large jacket poultices afford much relief. Internally, if the patient is strong and the pulse is full and bound- ing, tincture of aconite, gtt. j, may be given every ten or fifteen min- utes, in neutral mixture or spirit of mindererus until it is reduced. After effusion has taken place the aconite must not be given. The amount of liquid the patient takes should be much restricted. Active purgation should be resorted to, and diuretics, as digitalis or the acetate of potash, used. Small doses of concentrated solutions of the saline purgatives frequently repeated, aid materially in the absorption of the fluid. When the effusion is being absorbed, or if it lingers, iodide of potassium or a combination of calomel with squill and digitalis are advantageous. If the effusion is large or is increasing, or if there is an effusion in both pleural cavities, as sometimes occurs when it is secondary to the exanthemata or blood affections, the pleura should be aspirated and the fluid removed. Chronic Pleurisy. What are the causes of chronic pleurisy? It may follow an acute attack, or, more commonly, a subacute attack, the symptoms of which have been latent, or it may result from a gradual accumulation of fluid in the pleural cavity, as is sometimes seen in chronic pneumonia. 266 ESSENTIALS OF PRACTICE OF MEDICINE. What are its symptoms ? There are no symptoms of any moment, shortness of breath being the only positive one. The disease lasts for months, or it may be years. If it lasts for more than six months, the effusion is probably purulent (empyema). If the patient is not relieved, he will usually die in a year or eighteen months. What is the prognosis? About 17 per cent, of cases get well spontaneously, the pus being evacuated through a fistulous opening in the chest wall. As a rule, the cases of empyema, when untreated, die of exhaustion, worn out by the hectic fever, or from tuberculosis developing in the pleura or lung. What is the diagnosis ? The diagnosis of chronic pleurisy is similar to that of pleuritic effusion, except in point of time. Empyema is diagnosed by the symptoms and physical signs of chronic pleurisy, with the irregular chills, fever, night-sweats, and rapid pulse of hectic fever. If in doubt, introduce the needle of a hypodermic syringe and draw off some of the fluid. Differential Diagnosis. From hydrothorax. This disease is a pleuritic effusion, double- sided, and being part of a general dropsy due to the Cardiac or renal disease. The diagnosis is therefore easy. How are chronic pleurisy and empyema treated ? If the effusion is serous, an effort should be made to cause its absorption. Very little liquid should be given to the patient, but diuretics, as Basham's mixture, and diaphoretics, with laxatives and occasionally active purgatives, should be freely administered. Blisters applied to the chest favor the absorption of the effusion. If there is no sign of absorption within six or eight weeks the fluid may be removed by aspiration, the needle being passed into the cavity of the chest near the lower angle of the scapula, and nearer the upper than the lower border of the rib, so as to avoid injuring the intercostal arteries. If the symptoms lead to a diagnosis of empyema, the pus should be evacuated, and quinine, iron and salines administered. It is bet- DISEASES OF PLEURA—PNEUMOTHORAX. 267 ter to evacuate the pus by a free incision than by aspiration. The cavity of the pleura should be thoroughly washed out with boiled water, creolin, boric acid or other antiseptic. A .drainage-tube should be inserted and the parts dressed antiseptically, the disinfect- ant washings being repeated two or three times a week until the formation of pus is arrested, when the drainage-tube is withdrawn and the wound allowed to heal. Adhesions usually take place and adhesive pleurisy results. Pneumothorax. What is pneumothorax? It is an accumulation of air in the pleural sac, which, by causing irritation, leads to inflammation and serous exudation, and is charac- terized by sharp pain, dyspnoea and peculiar physical signs. What is its aetiology ? The air may find an entrance through the chest wall by a wound or it may pass through from the lung itself, due to the broken rib, to the rupture of the air-vesicles, as in emphysema, or in gangrene ; but the most frequent cause is the softening and breaking down of tubercle on the surface of the lungs. What is its pathology ? The air which has gained entrance into the pleural cavity fre- quently causes a pleuritic effusion, and is then sometimes called hydro-pneumothorax. The air gradually becomes absorbed if the opening through which it enters closes, and a case of chronic pleurisy results. What are the symptoms ? This disease is very latent. There is usually dyspnoea, suddenly developed, generally intense, associated with sudden and sharp pain and irritating paroxysmal cough; but dyspnoea may be the only symptom. What are the physical signs? On inspection the chest is distended, the intercostal spaces are 268 ESSENTIALS OF PRACTICE OF MEDICINE. effaced, the thorax upon the affected side bulges like the side of a barrel. The respiratory movement of that side is absent, and the apex beat is often displaced if the left side be affected. On percussion over the air, a tympanitic or amphoric note is pro- duced. Over the fluid it is dull. On auscultation, if the opening in the lung is closed, absolutely no sound is heard. If, however, it is open, we have amphoric or metal- lic breathing, amphoric or metallic voice and frequently metallic tinkling is heard from drops of fluid or the bursting of small bub- bles. If a silver dollar is pressed firmly against the chest over that portion of the pleura which contains air, and is struck lightly by an- other piece of silver while the examiner's ear is applied to the chest above the line of the fluid, a clear metallic note like a silver bell will be distinctly heard, if the opening has not closed. If he shifts his ear placing it over the fluid and the dollar is again struck it does not resound, but gives a dull sound, such as would be produced by strik- ing two pieces of lead together (Bruen). A succussion sound is heard upon shaking the patient. This is very significant, as it requires for its production the presence of air as well as of fluid in a large cavity. The viscera are, of course, dis- placed, the liver being displaced downwards if the disease affects the right side, or the heart being pushed toward the right, if the left is the seat of disease. After the air is absorbed the physical signs of a pleuritic effusion remain. What is the prognosis ? When the result of injury the patient usually recovers, and even when it is caused by tubercle, recovery from the acute disease may occur. What is the treatment ? If there is much pain, morphine should be given hypodermically. For the relief of the dyspnoea, morphine, cannabis indica, the inha- lation of ethyl iodide or the administration of aromatic spirits of ammonia may be used. If the dyspnoea is extreme, as a last resort the fluid and air may be removed by aspiration. After the air has been absorbed, the case should be treated as one of chronic pleurisy, with diuretics, as Basham's mixture, diaphoretics, laxatives and plenty of good food and stimulants. DISEASES OF THE CIRCULATORY SYSTEM. 26'.l DISEASES OF THE CIRCULATORY SYSTEM. What are the physical signs elicited on the examination of a normal heart ? On inspection and palpation the impulse, caused by the apex of the heart striking the chest wall, is seen and felt between the fifth and sixth ribs, occupying only one intercostal space, and about an inch to the outer side of the nipple line. On percussion the portion of the heart uncovered by lung tis- sue can be ascertained by the dulness elicited. It extends from about the fourth intercostal space below the middle of the clavicle, down- wards for nearly two interspaces (sometimes normally even a little more), and is from 2 to 2 J- or even 3 inches in a transverse direction. This area varies with inspiration and expiration. On auscultation two sounds are heard with intervening pauses. The first sound is loud, dull, heavy and booming ; it is caused by the contraction of muscular fibres, the apex-beat against the chest-wall, and the closure of the auriculo-ventricular valves ; the timbre of the first sound is owing to the muscular contraction, and will vary as the latter is more or less powerful. After a very short pause the second sound is heard. It is a short, sharp click, not so loud or so pro- longed as the first sound, and is due to the sudden closure of the aortic and pulmonary semilunar valves. It is heard in greatest per- fection at the base of the heart, while the first sound is better heard at the apex. How are these sounds altered by disease ? (I) Inspection. The cardiac impulse may be displaced if the heart is pressed or drawn to one or the other side by pleuritic effusions or adhesions. It may be more forcible and occupy more intercostal spaces than usual in hypertrophy, or from strong emotion. It may be feeble and wavy in dilatation, weakness, debility or pericardial effusions. (II) Palpation. Palpation of the impulse shows similar changes to those described under the head of inspection. 270 ESSENTIALS OF PRACTICE OF .MEDICINE. (Ill) Percussion. The area of percussion dulness may be increased in hypertrophy, when the enlargement usually occurs to the left, or in dilatation when the enlargement occurs to the right. (IV) Auscultation. The cardiac sounds may be variously modified by disease. The first sound is increased in volume and strength in hypertrophy or in a heart which is over-acting from excitement or other temporary stimulus. It is diminished in force in dilatation, weakness, debility or pericardial effusion. The second sound may be accentuated in all states of high arterial tension. FEEBLE HEART SOUNDS. Advanced fatty degen- eration ; dilatation. First sound, Neurosal influences. enfeebled. ) Changes in, or dimin- ished vasomotor ten- sion. The above conditions. Also reduced vasomo- Second sound tor tonus in aorta in pulmona- or pulmonary ar- ry artery or • tery, whether from aorta, enfee- feeble cardiac sys- bled. tole, or owing to de- generative or neu- rosal causes. Pericardial effusion is a prominent cause of the enfeeblement of the heart sounds. First sound, accentuated. ACCENTUATED HEART SOUND3. Mitral obstruction,pos- sibly aortic obstruc- tion and regurgita- tion. Degenerations or dila- tations of the ventri- cle. Chronic forms of Bright's diseases. Palpitation when the heart muscle is normal. Hypertro- phy of the heart. Atheroma; increased vasomotor tonus from neurosal causes. Circulatory o b s t r u c- tion iu the lungs. Pleurisy with effusion. Emphysema. Mitral valvular dis- ease, especially mi- tral obstruction. Aortic second sound, ac- centuated. Pul monary second sound accentuated. (Bruen's " Physical Diagnosis.") Sometimes two first or two second sounds may be heard, which merely shows perverted nerve action. What adventitious sounds may be heard when the heart is auscultated in disease? The adventitious sounds are classified either as pericardial or endocardial. (A) Endocardial Murmurs. These are chiefly of a blowing character. They vary in kind, DISEASES OF THE CIRCULATORY SYSTEM. 271 some being rough and some soft; some musical and some not, and others having no distinguishing mark except their abnormality. The chief point of importance in connection with them is the time at which they occur, in other words, what sound of the heart they supersede, and their point of greatest intensity. Should they be masked by the respiratory sound, they can be better heard if the patient is made to hold his breath. The sound is loudest at the point where it is produced, and travels in the direction of the blood current, hence is sometimes much more distinct at a little distance from its point of production in the direction in which it is transmitted. Endocardial murmurs may be divided into three classes. (1) Organic Murmurs. These mUrmurs are produced when there is an altered relation between the blood and the openings of the heart. The great char- acteristic of these murmurs is their persistency and harshness or roughness. (2) Temporary Murmurs. These are of a functional character and originate from a temporary improper action of the valves. This class of murmurs is usually most marked over the left ventricle, and they are soft in character, usually systolic, and better heard at the apex than elsewhere. They may be produced by excitement, and, often, by excessive exercise. If there is any doubt whether a murmur is functional or organic, it is better to let the patient rest in a recumbent position for some time and examine him again, when, if it is functional, it will very often have disappeared. (3) Blood Murmurs. In profound states of anaemia a murmur is frequently heard over the base of the heart, systolic in point of time, soft and blowing in character and transmitted into the arteries of the neck. It depends upon the altered condition of the blood. A venous hum is frequently heard in these cases in the large veins of the neck. (B) Pericardial Murmurs. In health no sound is produced in the pericardium. If it is rough- ened by inflammatory exudation, a friction-sound will be produced as the two surfaces rub against each other during the movement of the heart. Sometimes these murmurs have a whistling sound and simu- late those of endocardial origin, but the pericardial friction sound 272 ESSENTIALS OF PRACTICE OF MEDICINE. differs in being strictly localized, never being transmitted in the direction of the blood current. They follow the movements of the heart, coming after, but never replacing the cardiac valve sounds, and they frequently change their seat between the visits of the examiner. These murmurs are distinguished from pleuritic friction sounds by making the patient hold his breath, when, if it is of pleuritic origin, the murmur will cease, but if of pericardial origin, it will continue. DISEASES OF THE HEART. Cardiac Hypertrophy. What is this disease ? It is an increase in the muscular tissue of the heart, characterized by a forcible impulse; a loud, booming first sound; a strong, full pulse, distention of the arteries, and a tendency to active congestion of various organs. What are its causes ? It may be produced by a long continued obstruction to the flow of blood through the arteries in any part of the body whatever ; thus a narrowing of the valves of the heart itself will eventuate in hypertrophy. A dilatation of the orifice of the valve allowing regurgi- tation will also often result in the same affection. Any disease im- peding the flow of blood through the lungs, as emphysema, will have the same effect. States of high arterial tension, such as are seen in chronic Bright's disease, will also produce it. It may result eventually from excessive functional disturbances where the heart is continually excited and in a state of irritation, as is seen in those who indulge to excess in the use of tea, coffee or tobacco ; persons who dance to excess ; in athletes, soldiers on forced marches, porters, women with chronic uterine diseases, or as a result of venereal excesses or of masturbation. What are the varieties of hypertrophy? (1) Simple hypertrophy is a simple increase in the thickness of the walls of the heart, the size of its cavity remaining normal. DISEASES OF HEART—CARDIAC HYPERTROPHY. 273 (2) Concentric hypertrophy is an increase in the thickness of the muscular wall at the expense of the size of the cavity. This is a very rare form of cardiac hypertrophy. (3) Eccentric hypertrophy. This is an increase in the thickness of the cardiac walls with an enlargement of the cavity of the heart. It is also called dilated hypertrophy, or hypertrophy with dilatation, and is usually seen in the latter stages of all valvular diseases of the heart. What are the symptoms of cardiac hypertrophy ? The symptoms are indicative of a too active circulation. The pulse is fuller and firmer than in health. The temporal arteries throb, as do also the carotids ; the face is florid and epistaxis is com- mon. Arertigo, dull headache, ringing in the ears, disturbed sleep, jactitation during sleep, sometimes symptoms like those of congestive apoplexy may be seen. The conjunctiva are injected ; the patient sees objects floating before his eyes ; there is often a dry cough and dyspnoea on exertion. .These symptoms are usually aggravated during digestion. Cardiac Symptoms.—The cardiac symptoms are not prominent. Attacks of palpitation are not common, though incessant exertion will sometimes occasion them. Pain is usually absent, and when present, is dull and not very prominent. There is often a tumefac- tion of the thyroid gland and sometimes prominence of the eye, In these cases, however, the hypertrophy probably forms a part of the disease, and is not a cause primarily of the symptoms. What is the pathology ? The pathology consists in a true hypertrophy of the muscular and fibrous tissues of the heart. The hypertrophy is usually limited to the left side of the heart, the left ventricle especially suffering. What are the physical signs ? On Inspection the precordial region has often an appearance of fullness or of prominence. The impulse is distinct, diffused and powerful. On Palpation the impulse is felt diffused in several intercostal spaces, is usually lower and more to the left, is forcible and powerful. On Percussion there is an increase in the area of cardiac dul- 18 274 essentials of practice of medicine. ness, especially upon the left of the sternum and to the outer side of the nipple line. On Auscultation there is no murmur, the first sound is duller, longer, heavier and more powerful than normal. The second sound is unchanged, or, it may be, accentuated. What is the diagnosis of this disease ? The disease is recognized by the evidences of a very strong, active circulation; by the strong, forcible and extended impulse; by the increased area of percussion dulness; by the accentuation of the cardiac sounds, and by the absence of a cardiac murmur. Differential Diagnosis. From Functional Disease.—The increased area of percussion dul- ness in the former serves to differentiate these affections. What is the prognosis ? If the patient is young and the hypertrophy not very great he may recover entirely. If the disease comes on at puberty, following functional disorder, and is not very great, nor associated with dilatation, an increase of the disorder may be prevented. The unfavorable cases are those which are caused by organic dis- ease, as chronic Bright's disease or uterine affections. Hypertrophy, when occurring as compensatory to valvular disease of the heart, is of advantage to the patient, provided it be not too excessive. How is it treated ? It is better to reduce the amount of food which the patient takes, as in this way excessive nutrition of the heart is prevented. The patient should not be starved, however, as this appears to increase the hypertrophy. The diet must be unstimulating, consisting of milk, vegetables and fish. He must eat very little, if any, meat; live moderately and avoid stimulation, tea, coffee and tobacco. He may drink cocoa. Moderate exercise may be taken, but all active exertion, as running, jumping, boat-racing and athletic games must be sedulously avoided. He should rest in the recumbent position for several hours each day. An occasional laxative must be given, particularly a saline, and the action of the skin and kidneys maintained. diseases of heart—cardiac dilatation. 275 Special Agents. Small doses of aconite, (tincture, gtt, j-ij) should be given four times a day, and continued until it produces some cardiac impression, when the dose may be reduced. This remedy should be administered for months. Veratrum viride (tincture, gtt, v) may be given instead of the aconite. If it nauseates, a small amount of tincture of ginger, or of brandy given with it, will frequently overcome this effect. Ice applied intermittingly over the heart also is of use. These are the best remedies for combating this disease. Cardiac Dilatation. What is cardiac dilatation ? It is a disease in which one or more cavities of the heart are in- creased in size, out of proportion to the development of its muscular wall, and is characterized by a feeble action of the heart, accumula- tion of blood in the veins, oedema or general dropsy and exhaustion. What is the pathology of this affection ? Occasionally a partial dilatation is seen, often called aneurism of the heart. Usually, however, there is a general dilatation in which all the cavities share, being greater and more serious, however, on the right side of the heart, and affecting the ventricles more than the auricles. The muscular tissue is anaemic, and frequently under- goes degeneration. The orifices of the cavity often share in the general dilatation, and in consequence the blood will be allowed to regurgitate. What are the causes of this affection ? Acute dilatation often occurs as a temporary condition, accom- panying fevers, and passes off as the fever subsides. Chronic dila- tation is more common. It affects persons in feeble health, especially where there is some strain on the heart, as occurs when the circula- tion is obstructed in the lungs, liver, or uterus, which, in a strong, robust person, would lead to hypertrophy. In children of feeble parents, dilatation sometimes occurs at 276 essentials of practice of medicine. puberty. In persons of a gouty diathesis it may occur late in life. Organic valvular diseases usually terminate in dilatation. What are the symptoms ? The symptoms all indicate a feeble circulation. The veins are turgescent; the skin is pale or cyanosed. There is puffiness of the ankles ; a languid, feeble pulse ; dull headache ; vertigo, despond- ency, and oppression in breathing, sometimes amounting to severe dyspnoea, occurring in paroxysms, and usually at night. Some cough is often present from passive congestion of the lungs or larynx. The liver is slightly enlarged, congested, and somewhat tender; the con- junctiva is yellow and the tongue coated. The kidneys are congested, the urine is scanty and sometimes albuminous. Palpitation is frequent, and a certain amount of uneasiness is often complained of in the cardiac region as the disease advances. Not only is there oedema, but anasarca, and dropsical effusions in the internal cavities come on late in the disease. The patient becomes weaker and weaker; dis- orders of the digestion occur from interference with venous circula- \ tion, and he finally dies of exhaustion or of cardiac paralysis. What are the physical signs ? On inspection, the veins of the surface, especially those of the right side of the chest, and frequently those of the abdomen, are dilated. The cardiac impulse is indistinct, wavy and diffused. On palpation, the pulse is fluttering, feeble, and extended, but uncertain. Percussion shows an increased area of cardiac dulness, especially in a transverse direction, and usually extending to the right of the sternum. On auscultation the first sound is feeble, short and indistinct; the second sound is sharp and valvular. No organic murmurs are present without there is valvular disease in addition to the dilatation. I What is the diagnosis of this disease ? Dilatation is recognized by the feeble health, the symptoms and signs of feeble circulation, the increased area of cardiac dulness, and the dropsy. Differential Diagnosis. (1) From hypertrophy. In dilatation there is dropsy, feeble heart DISEASES OF HEART—CARDIAC DILATATION. 277 and pulse, pale face, distended veins, cold extremities, fluttering impulse, and a weak first sound. (2) From hypertrophy with dilatation. Simple dilatation can be differentiated from that occurring in hypertrophy by the weakness of the cardiac impulse, and the dropsy, which is never present as long as the hypertrophy compensates for the dilatation. What is the prognosis ? The patient may be very much benefited by treatment, but can- not be cured. How should it be treated ? Persons suffering with feeble heart should avoid sudden excite- ment, as this, by putting too much strain upon a weakened heart muscle, might result in cardiac paralysis. The diet should be nourishing, but easily digested. A meat diet is of advantage. A moderate amount of wine taken with meals and a little whiskey taken at bedtime, are of much use. He should be warmly clothed; have some regular systematic exercise, not too I severe, and should avoid all strain of mind or body. Special Agents. Digitalis is of preeminent value in cardiac dilatation. It strength- ens the muscular fibre, at the same time acting as a diuretic. It is best given in infusion (f3j t. 1. d.), or the powder, fluid extract or tincture may be employed. It must be discontinued temporarily every now and then, so as not to reduce the frequency of the cardiac beat too much, for the pulse will continue to sink for some hours or days after the medicine has been withdrawn. It should there- fore be intermitted for a week or two at a time, during which period strychnine (gr. ^j) may be substituted for it. If digitalis causes nausea or acts almost entirely upon the kidneys, or if it is too slow in manifesting any effect, strophantus, or its active principle, strophanti^ (gr. ttjo-................ 40 Chyluria........• •........... ' Haematuria and Hsemoglobmuria,.............. .... 44 Albuminuria, ................ . 47 Urinary Sediments,................ Tube Casts,........................_. . ' .......54 Glycosuria, ............... fil Lead and Mercury in Urine,................. Dietrich's Table,................... Vil THE EXAMINATION OF THE URINE. Which are the objective points in the examination of urine for clinical purposes? The quantity, appearance, color, odor, reaction, specific gravity, increase or decrease of normal ingredients and presence or absence of abnormal or adventitious substances. When should the specimen he obtained for examination ? For qualitative purposes the specimen may be taken at any time of the day, the morning urine in preference. For quantitative ex- amination a specimen of the total urine in 24 hours must be used. How is the total urine of the 24 hours to be collected ? The urine passed at a certain hour is to be thrown away, all sub- sequently passed up to the same hour of the next day is to be col- lected in a clean glass jar or bottle and the amount measured. How soon thereafter should the urine be examined, and why? Shortly after the specimen is obtained, as putrescence will rapidly set in, which will change the character of some of the ingredients. What is the average daily quantity voided under normal conditions ? 1200 to 1500 c.c, or about 40-50 fluidounces. Under which normal conditions is this increased or di- minished ? Copious drinking increases the quantity; also, a lower tempera- ture or great humidity of the atmosphere ; free sweating, purgation or emesis will diminish it. Which pathological conditions increase the quantity and which diminish it ? Diabetes insipidus and diabetes mellitus largely increase the quan- 18 EXAMINATION OF URINE. tity, acute febrile affections diminish it. It is also increased in cer- tain nervous affections and diminished in hydropic conditions and some renal diseases. In which way is the appearance of the urine to be noted ? If clear, turbid, or containing a sediment. Which are the principal causes of turbidity or sedimentation in the urine ? The presence of mucus, precipitation of the earthy phosphates from alkaline reaction, separation of urates by lower temperature, and pathologically the presence of pus or fat in minute subdivision, the latter causing a layer to rise to the surface. What is the normal color of urine, and how are the varia- tions expressed ? The normal color of urine is yellow, the variations being expressed by Vogel's scale, which contains three yellow, three red and three brown tints, termed respectively pale yellow, light yellow, yellow, reddish-yellow, yellowish-red, red, brownish-red, reddish-brown, brownish-black. (See Frontispiece.) Which are the normal urinary coloring bodies ? Indican and urobilin ; others frequently described are modifications of the latter. How is urobilin derived ? From the blood ; the haemoglobin changing to haematin, this to bilirubin, which by taking up hydrogen is changed to hydro-bilirubin, identical with urobilin. What is indican, and how derived ? This is sometimes called uroxanthin, and is chemically potassium indoxyl-sulphate, a normal component of the urine, varying in quan- tities, and derived from disturbances of intestinal digestion and con- sequent absorption of the indol of the faeces. How is the presence of indican in the urine demonstrated, and how determined ? Indican can be demonstrated by mixing urine with about £■ quan- tity of HCl, when, upon standing 24 hours, a red, purple, or blue color will appear, which if shaken out with chloroform and the sepa- COLOR AND ODOR OP URINE. 19 rated solution compared with a standard solution of indigo in chloro- form diluted to the same tint, may be expressed in the quantity of indigo it represents. What is the color of urine in icterus, and by what produced ? The urine in this condition is of a yellow or greenish, or even greenish-black color, caused by the presence of biliary coloring matter. How may the presence of blood in the urine affect its color ? It will cause a change of color from light red to brown and almost black. Do medicinal agents change the color of the urine ? Many of them do: Thus, it is turned brown or black after inges- tion of carbolic acid and gallic acid, yellow after santonin, rhubarb (changed to red by addition of ammonia), also, after senna, logwood, etc. What pathological condition gives rise to a dark brown or blackish color of urine, and why ? Melanotic tumors, owing to the elimination by the kidneys of uromelanin, a black coloring body corresponding to the choroidal pig- ment. Describe the odor of fresh normal urine. Fresh normal urine has a specific, not disagreeable, aromatic odor, due to the organic acids of the aromatic series. How does this change on standing ? The urine turns alkaline in reaction, and then ammoniacal decom- position takes place, giving rise to a disagreeable ammoniacal odor. This may take place already within the bladder m cystitis. In what conditions and by which medicines or food is the odor of the urine modified ? In diabetes the urine has often a fruity odor, due to acetone. Asparagus gives it a disagreeable odor. Spirits of turpentine an odor not unlike violets. Copaiba, cubebs, balsam of tola and oil of sandalwood give it an aromatic odor. What is the effect of mineral acids, and what of fixed alka- lies on the normal odor of the urine ? Mineral acids interfere with the normal odor, fixed alkalies make it aromatic. 20 EXAMINATION OF URINE. Has the urine containing blood a special odor ? It has a slightly putrid odor, resembling that of high game. What is the reaction of normal urine ? What due to ? It is normally slightly acid, due to the presence of acid sodium phosphate. The acid reaction is greatest in the urine of the night, less in that voided after meals. How is the reaction of the urine ascertained ? If blue litmus paper is touched with a drop of acid urine it will be turned to a red color; if the urine is alkaline, it will turn red litmus paper blue. If, upon exposure in the latter case until dry the red color is restored, this alkalinity is due to ammonia. In which way is the degree of acidity of urine determined ? By acidimetry, 1. e., titration with a decinormal solution of potas- sium hydrate, expressing the result in the corresponding amount of oxalic acid. What is the relation of the acidity of urine to disease ? Many diseases show a direct relation with it. Thus, in typhoid fever the acidity is in direct ratio with the fever, in rheumatism with the pain, while in pneumonia, pleurisy, emphysema, etc., the urine is very acid. Which systemic conditions may cause an alkaline reaction of the urine ? Fear, nervous affections, etc., may bring about alkalinity. Irre- spective of food, it is associated with anaemia, debility, etc. This alkalinity is due to fixed alkalies. Under what local conditions may the urine become alkaline ? In cystitis the urea is decomposed into ammonium carbonate, which renders it alkaline, with ammoniacal odor. What effect has the alkaline reaction on the urine ? The alkalinity from fixed alkalies causes the precipitation of the earthy phosphates, rendering it of white color. Ammoniacal alka- lescence brings about the formation of triple-phosphate. How do medicinal agents influence the reaction of the urine ? Mineral acids do not directly influence its reaction ; alkaline hy- drates and carbonates render it less acid or alkaline ; the salts of the SPECIFIC GRAVITY OF URINE. 21 Fig. 1. vegetable acids, being eliminated as alkaline carbonates, produce alka- linity ; benzoic acid or alkaline benzoates are converted into hippuric acid and increase the acidity of the urine. What does the specific gravity of the urine represent ? The amount of solids contained in solution therein. State the average specific gravity of normal urine and its variations under various conditions. The average specific gravity of the normal urine is between 1015 and 1025. When great quantities of liquids are ingested it may fall to 1002, and when great amounts of fluids are withdrawn it may reach as much as 1040. In which diseases is the urine characteristically high, and in which relatively low ? In diabetes mellitus it is always high, and may reach 1050; in the various forms of Bright's disease, as well as in amyloid degeneration of the kidneys, it is low, reaching 1005 to 1004. How is the specific gravity of urine ascertained? With the urinometer (Fig. 1); fill the cylinder for that purpose about three-quarters full, then carefully float the urinometer in it and add enough urine to fill the cylinder to the top, reading off the degree of immersion over the top of the liquid. For very accurate determinations, the specific gravity should be taken with the specific-gravity bottle. For what purpose does the knowledge of the specific gravity of urine serve ? For the approximate determination of the quantity of solids. Thus, if by Trapp's formula the last two figures of the specific gravity are multiplied by 2, it gives the amount of solids contained in 1000 parts; (the factor 2.33 is some- times used as being more accurate, but 2 suffices for clinical pur- poses). Urino- meter. 22 EXAMINATION OF URINE. The Normal Constituents of Urine. What constitutes the normal solid components of urine ? The products of retrograde metamorphosis of nitrogenous bodies, together with the inorganic matter eliminated as waste material by the kidneys from the circulation. How are they classed according to their chemical character, and what are they respectively ? They may be classed as organic, which form the greater part, and inorganic. The principal ones of the former class are urea, uric acid, hippuric acid, kreatinin, xanthin, sarkin, oxalic acid, oxaluric acid, aromatic ethyl-sulphuric acids, sulphocyanic and succinic acids, sugar, lactic acid, pigments, and extractives. The inorganic are chlorides, phosphates and sulphates of potassium, sodium, ammo- nium, calcium and magnesium, iron, silicic acid, nitrites and nitrates, also hydrogen peroxide. Are these constant in proportion, and what influences their presence in the urine ? They are subject to continuous change : thus, a more liberal animal diet increases the amount of urea ; age, sex and great exertions in- fluence their amount as well as pathological conditions. Normal Organic Constituents of the Urine. Which is the principal solid ingredient of the urine, and what is it ? Urea, a carbonyl diamide, often termed carbamide (CON2H4), the ultimate product of oxidation of the albuminoids introduced into or composing the body. How much urea is excreted under normal conditions daily ? 500 grains, or about 30 grammes, which, however, may vary ac- cording to the character of the ingested food. How may the urea be separated and demonstrated from the urine ? By acidulating the condensed urine either with nitric or oxalic acid, and allowing the nitrate or oxalate of urea to crystallize from this. NORMAL ORGANIC CONSTITUENTS OF URINE. 23 Under which pathological conditions is the elimination of urea increased ? In febrile conditions which do not suppress the renal action. Thus, it is increased in meningitis, typhoid fever, smallpox, erysipelas, in- termittent fevers, pneumonia, pleurisy, articular rheumatism with endocarditis, etc. What pathological conditions diminish the urea in urine ? A diminished nutrition, especially of albuminoids, processes of suboxidation, such as emphysema, valvular disease of the heart and disturbances of the circulation, in which the amount of urea pro- Fig. 2. a, urea; 5, rhombic, and c, hexagonal plates of urea nitrate. duced is less; in other diseases, such as ascites and anasarca, the urea is not secreted, though produced, and is withheld in the circulation; also in cholera and diseases characterized by renal inaction, when with an amelioration the urea reappears. The wasting diseases, such as anaemia, leucocythaemia, phthisis, acute yellow atrophy, etc., are also accompanied by a diminished amount of urea in the urine. Can urea ever exist as a sediment in urine ? On account of its ready solubility it can never exist as such. How can urea be recognized under the microscope ? By evaporating a drop of urine cautiously on a slide, when, with a low power, the rhombic prisms of urea may be readily recognized (Fig. 2). 24 EXAMINATION OF URINE. How may the oxalate or nitrate of urea be prepared ? By acidulating condensed urine with either oxalic or nitric acid, when the respective oxalate or nitrate will crystallize out on cooling, in hexagonal plates (Fig. 2). By what chemical test may urea be recognized ? By the Biuret reaction. This consists of heating a specimen of urea until it ceases to give off ammoniacal vapors; when to the residue a little potassium hydrate is added and a drop of cupric sul- phate solution, the color is changed to a reddish violet. Which are the principal agents to break up urea ? Stronger mineral acids and hydrates of the alkalies cause it to take up water and split up into carbon dioxide and ammonia. Nitrous acid splits it into carbon dioxide water and nitrogen, as do also the alka- line hypochlorites and hypobromites. Certain microorganisms also cause it to break up into ammonium carbonate. What is Fowler's method for determining the amount of urea in urine, and how applied ? The differential density test. To apply this, the specific gravity of the urine is first accurately determined and noted and then the spe- cific gravity of the specimen of liquor sodae chloratae (Labarraque's solution) to be employed. The latter is multiplied by 7 and the product added to the amount of the sp. gr. of the urine ; the sum so ascertained is divided by 8, which gives the sp. gr. of a mixture of 1 part of urine and 7 parts of the hypochlorite solution. After this add 1 part urine to 7 parts of Labarraque's solution, and after standing for an hour or two, take the specific gravity of the mixture after the reaction has been completed. This specific gravity sub- tracted from that first computed for the mixture of the two before reaction, and the difference multiplied by 0.77 gives the percentage of urea in the urine examined. What is Liebig's method of determining urea by titration? The method depending on the formation of an insoluble com- pound of mercuric nitrate with urea, and the computation of the amount of urea from a standardized mercuric nitrate solution used for this purpose. NORMAL ORGANIC CONSTITUENTS OF URINE. 25 Which are the reagents and apparatus used in this method ? A standardized mercuric nitrate solution, of which each c.c. is equal to 1 centigramme urea. A baryta mixture of 1 part satu- rated solution of barium nitrate and 2 parts cold saturated baryta water. A saturated solution of sodium carbonate, a graduated burette, a volume pipette, watch-glasses, glass rod and beaker glass (Fig. 3). Fig. 3. Bnrette-stand and Burettes. How are the sulphates and phosphates and carbonates first separated in this process ? By mixing 40 c.c. urine with 20 c.c. baryta mixture, after which the liquor is filtered and 15 cc. is measured into a beaker glass ; these 15 c.c. correspond to 10 c.c. urine. At times, if the urine contains an excess of phosphates or alkaline carbonates, it becomes necessary to take more baryta mixture, and then the specimen to be examined must be increased always so as to represent 10 c.c. urine. 26 EXAMINATION OF URINE. In which manner is the titration of the urea performed, and how is the indicator applied ? The mercuric solution is dropped from the burette into the filtered urine, amidst constant stirring, until it ceases to produce a precipitate; then a few drops are taken out into a watch-glass and an equal amount of the soda solution allowed to flow into it. When the resulting reac- tion begins to show a yellow color, the saturation is complete, if not, more of the mercuric solution is dropped from the burette as above. How is the result now computed ? As each cc. of the mercuric nitrate solution is equal to 0.01 gramme urea, as many as were necessary to saturate it were con- tained in 10 c.c. urine, or ten times that amount constitutes the per- centage of urea ; from the number of c.c. of mercuric solution 2 cc. are first to be deducted to allow for the sodium chloride which also enters into this process. Thus if 30 c.c. were used, 28 cc. would represent 0.28 gramme urea contained in 10 c.c. urine, or 2.8 would be the percentage. If albumin is present what has to be done first ? The urine must be faintly acidulated with acetic acid, and then the albumin, coagulated by boiling, is separated by filtration before the titration of the urine. What are the principles of the azotimetric method for the determination of urea in urine ? The urea of the urine is decomposed by a solution of sodium hypo- bromite (Knop's solution), thus liberating the nitrogen of the urea while the water remains and the carbon dioxide is arrested by the alkaline test solution. The nitrogen is then corrected for tempera- ture, atmospheric pressure and tension of aqueous vapor, and the amount of urea corresponding to each c. c. thereof is equal to 0.0027 gramme. What comprises the most simple apparatus for this process ? A flask containing 15 c.c. hypobromite solution and also a test tube standing slantingly in it, into which 5 c. c. urine are added. The flask is connected by a rubber tube to an inverted burette or cylin- der graduated into c. c. ; this latter is contained in a cylinder filled NORMAL ORGANIC CONSTITUENTS OF URINE. 27 with water and is immersed therein to the zero mark, so that the water in the graduated tube and the cylinder are on an equal level. How is the Knop's solution made ? Dissolve 100 grammes sodium hydrate in 250 c.c. water and add 25 c.c. bromine. How is the process applied ? By allowing the urine to commingle with the hypobromite solu- tion, when the reaction will take place ; as the N escapes into the graduated cylinder the latter is raised so as to keep the water inside and outside always on the same level. When the reaction is com- plete and no more gas given off the number of c.c. are read off. How is the volume of N so observed corrected and how the urea computed from it ? The volume of nitrogen so observed has to be corrected for tem- perature, barometric pressure and tension of aqueous vapor. As 1 gramme urea yields 370 c.c. nitrogen at 0°C. and 760 mm. pressure the formula for correction of its observed volume is as follows for 100 c.c. urine: 100 v. (b — V)__________ U ~ 760. 370. x. (1 + 0.00366. t) In this formula U stands for percentage of urea to be determined. v the volume of nitrogen read off. b barometric pressure. b' tension of aqueous vapor. x the measure of urine employed. t the temperature (C°) at which the process is conducted. Instead of this correction the corrected weight in milligrammes for each c.c. nitrogen maybe taken from Dietrich's table by entering with barometric pressure from above and the temperature from the side, when the corrected weight will be found at the intersection of the two lines. (See Dietrich's table on last page.) Thus if 10 c.c. N were observed at 15° C. and 740 mm. pressure, each cc. N would weigh 1.1399 milligramme, or 10 = 11.399, which if multiplied with 2.14 would give the amount of urea in the urine used 24.39388 milligrammes, which if it had been 5 cc. is multiplied with 20 gives the percentage = 0.49. 2S EXAMINATION OF URINE. Does the method give absolutely correct results ? No, the theoretical amount of N is never obtained ; this may be rectified by multiplying the result with 1.044, but even then it is not absolutely correct. What modifications of the above described apparatus may be used for clinical purposes ? Such apparatus as that of Lyon, which contains on the cylinder, instead of c.c, subdivisions corresponding to the percentage of urea at a temperature of 70° F. Pressure and tension of aqueous vapor may be then neglected if the temperature is at or about 70° F. What is uric acid ? A bibasic acid of the formula C5H4N4O3 which in the form of salts is a normal ingredient of the urine and next to urea the prin- cipal eliminant of nitrogen from the body ; the quantity eliminated under normal conditions during 24 hours amounts from about 0.5 to 1 gramme. Under which normal and abnormal conditions is the amount of uric acid in the urine increased or decreased ? Nitrogenous food increases and carbohydrates diminish the uric acid in the urine. In diseases of the respiratory and circulatory sys- tem, as in pneumonia, capillary bronchitis, pleuritic exudations, pericarditis, etc., the amount in the urine is increased, also in most fever processes. Chronic diseases are accompanied by a diminished amount of uric acid in the urine ; it is diminished also after profuse hemorrhages and in anasmia, chlorosis, spinal and renal affections, as well as in chronic rheumatic and gouty conditions. During the ex- acerbations of malarial fevers there is an increase in the elimination of uric acid, as well as in typhoid fever, inflammatory rheumatism, smallpox and in septic fevers. How is uric acid separated from urine ? By acidulating 500 grammes urine with 10 grammes hydrochloric acid, when, after standing 24 hours, the uric acid will crystallize from it all but a very small amount held in solution. What are the physical properties and microscopical appear- ances of uric acid separated from urine ? Uric acid is very little soluble in water, about 1 to 18,000, insoluble NORMAL ORGANIC CONSTITUENTS OF URINE. 29 in alcohol and ether, readily soluble in the neutral alkaline phos- phates and carbonates. The crystals separated from the urine ap- pear to the naked eye as small reddish-brown particles. Micro- scopically they present a variety of shapes which, however, may be regarded as modifications of rhombic plates. The most frequent of these are the whetstone or lozenge form rounded off at their obtuse angles; other forms resemble barrels, sheaves, rosettes, combs, etc, (Fig. 4). Is free uric acid ever present in the urine ? It may be present in the urine under abnormal conditions at mic- turition, when it may give rise to the formation of urinary concretions. Fig. 4. / ,$] O \ --- d \ j a. Rhombic crystals of uric acid, of whetstone or lozenge shape, b. Barrel shaped. c. Sheaves, d. Rosettes of whetstone shaped crystals. Which are the principal salts of uric acid present in the urine ? The salts of the alkalies and alkaline earths; these form both neutral and acid salts, the neutral salts being more frequent in normal urine and are more soluble than the acid salts; the acid sodium urate and potassium urate appear frequently as sediments in the acid urine of catarrhal and rheumatic affections and in fevers, and have a red- dish color, owing to the presence of uroerythrin (lateritious deposits). They may be recognized by being redissolved in the urine on heating and on addition of alkaline hydrates, also by the microscope as pre- 30 EXAMINATION OF URINE. senting an amorphous granular appearance, as in accompanying cut (Fig. 5). The acid ammonium urate is often found in alkaline urine together with triple phosphate and presents the shape of yellow spheres with one or more hooklets attached, often occurring in attached pairs (Fig. 6). Ammonium urate is present in some vesical concretions and when preformed in the bladder may be the cause thereof. Ey which test may the presence of uric acid be shown, and how is it applied ? By the murexide test; this consists in dissolving in an evaporating Fig. 5. Fig. 6. Acid sodium urate. Triple phosphate and ammonium urate. dish a small quantity of the substance to be examined in a few drops of nitric acid, and evaporating over a moderate heat to dryness. If the dry residue is touched with a drop of ammonia water or exposed to its vapors the bright purple color of murexide will appear if uric acid was present. How is the amount of uric acid in urine determined ? By acidulating 200 cc. urine with 10 c.c. HCl and setting it aside for 48 hours. The crystals which have separated are now collected on a weighed filter and well washed with cold water; the filter is then dried until it ceases to lose weight, and for each 100 c.c. fluid employed 0.0038 gramme uric acid is to be added to the increase of NORMAL ORGANIC CONSTITUENTS OF URINE. 31 weight over that of the empty filter, which gives approximately the amount of uric acid present. What is hippuric acid ? A normal monobasic acid of the urine, of the formula C9H9N03, which may be regarded a benzoyl glycocin, as it splits up into ben- zoic acid and glycocin. In what amounts is it present in the urine and under what conditions may this be increased ? About 0.5 to 2.0 grammes are excreted during 24 hours in the urine, which is increased by vegetable and diminished by animal Fig. 7. Hippuric acid. diet. Benzoic, cinnamic and quinic acids are converted in the body into hippuric acid and excreted as such. It is said to be increased in diabetes mellitus, also in hepatic affections and in jaundice. State the physical properties and microscopic appearance of hippuric acid. It is readily soluble in alcohol, less so in ether, and dissolves only in 600 parts of water; it crystallizes in colorless, long, four-sided rhombic prisms, which frequently form stellate bundles (Fig, 7). What is kreatinin ? A constant component of the urine, of the formula C4H7N30, 32 EXAMINATION OF URINE. supposed to be derived from the kreatin of the muscles. About 1 gramme is daily excreted under normal conditions and mixed diet. State its properties. It is a basic body which, when pure, forms colorless, prismatic crystals, soluble in 11 parts of water, and readily soluble in alcohol. In alkaline solutions it changes to kreatin, which, with acids, loses H20, and forms again kreatinin. Under which pathological conditions is it increased, and under which decreased ? In acute diseases, especially typhoid fever, pneumonia, etc., it is increased in quantity ; in anaemia, chlorosis, marasmus, tuberculosis, and progressive muscular atrophy it is diminished. What are xanthin and sarkin ? Extractives of the urine closely allied in chemical composition to uric acid, C5H4N403, C5H4N402, C5H4N40, (uric acid.) (xantbin.) (sarkin.) but of no clinical interest. Normal Inorganic Constituents of the Urine. Which are the principal ones of these ? The chlorides, phosphates, and sulphates, which are principally derived directly from the food, but the latter two also result as oxidation products from albuminoids and other bodies which con- tain phosphorus and sulphur. Name the most important inorganic salts. The one which occurs in largest quantities is sodium chloride, next is sodium acid phosphate, also, calcium and magnesium phosphates, the sulphates of sodium and potassium, and traces of iron and silicic acid. What is the normal amount of chlorides excreted in 24 hours, and what is their importance ? The sodium chloride, which is the principal one of them, is excreted to the amount of about 16.5 grammes in the 24 hours, vary- NORMAL INORGANIC CONSTITUENTS OF URINE. 33 ing with the quantity ingested. A considerable amount is always retained in the circulation, serving probably the purpose of cell- nutrition by facilitating the osmotic process. A surplus appears in the urine. Under which pathological conditions are the chlorides in the urine decreased ? They decrease in all acute febrile diseases, and may, indeed, disap- pear altogether, to reappear with convalescence. Esj >ecially is this the case in diseases accompanied with exudations and transudations, which retain the surplus chlorides until their formation is complete. Thus we find the chlorides diminished in pneumonia, pleurisy, peri- carditis, peritonitis, meningitis, also in typhoid fever and rheumatic fever. A decrease of chlorides in the urine is also marked in the nephritis accompanied with albuminuria and dropsy. During the paroxysms of malarial fever the excretion of chlorides is increased. What are the indications for prognosis of a decrease or re- appearance of the chlorides in the urine ? A considerable diminution or disappearance makes the prognosis grave, their reappearance favorable, which is again disturbed by their decrease during convalescence. How may the chlorides in the urine be shown and their quantity be approximated ? To a specimen of urine in a test tube add a few drops of nitric acid, and then of a solution of silver nitrate sufficient until no more pre- cipitate forms. The precipitate will be dense and curdy if the chlorides are present in normal quantities, milky if diminished, and faint if almost or entirely absent. If the bulk of the precipitate is compared with that of a normal specimen, the relative amount may be approximated. How are the chlorides in the urine determined by volumetric analysis ? To do so accurately 10 c.c. urine are evaporated to dryness in a porcelain dish and incinerated with 2 grammes pure potassium nitrate until the charred organic matter is burned off. The residue is now dissolved in about 50 cc. distilled water and acidulated with dilute nitric acid, the excess of which is neutralized by the addition of a 3 34 EXAMINATION OF URINE. little pure calcium carbonate; a few drops of neutral potassium chromate are then added as indicator. The chlorides are now titrated with a standardized solution of sil- ver nitrate, eachcc. of which corresponds to 0.01 gramme sodium chloride. The silver nitrate solution is added from a burette to the canary-yellow fluid until a slight change to orange shows the com- plete precipitation of the chlorides. For each c.c. of the former count then 0.01 NaCl, or ten times that amount, to get the percent- age. Thus, if 10 cc. urine were used and 15 c.c. AgN03, the amount in 10 cc. would be 0.15 grammes, or the percentage 1.5. May the process of incineration and subsequent acidulation be dispensed with for clinical purposes ? Yes; unless the urine is alkaline, very highly colored or albumi- nous. If such is not the case the 10 c. c. urine should be diluted with 40 c.c. distilled water, a few drops of neutral potassium chromate added and then titrated and computed as above. As the result is generally too great, 1 c.c. is, however, deducted from the quantity of silver nitrate solution used. In which compounds is phosphoric acid present in the urine ? As phosphates of the alkalies and alkaline earths, of which there are two-thirds of the former and one-third of the latter. The phos- phates of the alkalies are principally present as sodium acid-phos- phate, to which the acid reaction of normal urine is due; those of the alkaline earths as phosphates of calcium and magnesium. The total quantity of phosphoric acid normally eliminated in 24 hours is between 2 and 5 grammes. From what is the phosphoric acid of the urine derived ? From the food and also from the retrograde metamorphosis of tis- sues containing phosphorus. Thus it is diminished on fasting, and increased by animal diet. Under which pathological conditions is the phosphoric acid of the urine increased or diminished ? In the beginning of the febrile processes, the P205 is usually di- minished, and decreases still more with fatal termination. With defervescence and convalescence the amount is increased, while in NORMAL INORGANIC CONSTITUENTS OF URINE. 35 chronic conditions no constant relations have been established, though the earthy phosphates are no doubt increased in cerebral affections, rheumatism, osteomalacia, rachitis, whereas a decrease has been established in chronic spinal disease, renal affections and dropsy. How can the earthy and how can the alkaline phosphates of the urine be separated ? If an alkaline hydrate, KOH or NaOH, is added to urine, and the mixture heated to the boiling-point, the earthy phosphates are thrown out and may be filtered off. If to the clear filtrate about one-third of magnesia mixture is added, the alkaline phosphates will be precipitated as ammonium-magnesium phosphate, termed triple-phosphate. How does triple-phosphate form from ammoniacal urine in cystitis or putrid urine ? From the decomposition of urea into ammonium carbonate; this, with the magnesium phosphate, forms ammonium-magnesium phos- phate. What is the import of triple-phosphate in the urine, and what its appearance under the microscope ? Triple-phosphate, if formed in the bladder, may give rise to the formation of concretions, and as they result from ammoniacal urine, cystitis probably exists. Under the microscope, the crystals of triple-phosphate are prismatic and highly refractive, representing the form of coffin fids, after which they are named. (See Fig. 6, page 30.) What is the deposit resulting from urine alkaline from fixed alkalies ? The earthy phosphates—i. e., phosphates of calcium and magne- sium—appearing under the microscope as granular masses. They have no tendency to form concretions. How is the phosphoric acid of the urine quantitatively approximated? By Teissier's method: Into a cylinder graduated in c.c, add 50 c.c. urine and 15 c.c. magnesia mixture; mix well and allow to settle for twenty-four hours. The total P205 will be precipitated as triple- 36 EXAMINATION OF URINE. phosphate; each c.c, by volume, represents about 0.03 per cent, of phosphoric acid, or about double that amount of phosphates. Describe the method for the volumetric determination of phosphoric acid in urine. This is effected with a standardized solution of uranium acetate, eachcc. of which indicates 0.005 grm. P205. To 50 c.c. filtered urine, contained in a porcelain capsule or a flask, are added 5 c.c. acidulated solution of sodium acetate (sodium acetate 10, acid acetic dil. 10, water to 100). These are heated to the boiling-point, and, while boiling, the uranium acetate solution is gradually added from a burette. When the precipitate has formed, the fluid is tested from time to time by letting a few drops run into a solution of potassium ferrocyanide. As long as no change of color occurs, the process is not finished, and more uranium solution is added. When, on testing, a reddish-brown color begins to appear, all the phosphoric acid has been precipitated. To compute the result, multiply the number of c.c. uranium solution with 0.005, which gives the P205 in 50 c.c. urine, and double that amount the percentage. What is the quantity of sulphuric acid eliminated in 24 hours, in which form, and where derived from ? About 2 grms. are eliminated in 24 hours, partly as sulphates of the alkalies, and a small portion as organic sulpho-acids. The sul- phates are derived directly by ingestion and also by elaboration in the body of sulphur into its acid. Under which conditions are the sulphates of the urine increased, and under which diminished ? Animal diet and exertion increase the sulphates in the urine; this is also the case in acute diseases, while in chronic affections of the kidneys, they are, as a rule, diminished. Ingestion of sulphur or sulphur compounds increases the amount of sulphates in the urine. How are the sulphates in the urine shown? By treating urine acidulated with a few drops of nitric acid with solution of barium chloride, which will give a precipitate of barium sulphate, insoluble in water or acids. ABNORMAL CONSTITUENTS OF THE URINE. 37 Describe the method for determining the sulphuric acid of the urine. This is accomplished by volumetric analysis with a standard solu- tion of barium chloride, each c.c. of which is equal to 0.01 grm. S03, in the following manner :— 100 cc. urine are acidulated with 20 drops hydrochloric acid and heated to the boiling point, when the standard barium solution is gradually dropped in from a burette until fresh additions show but a slight precipitate. This is allowed to settle, and into the clear super- natant fluid one drop added. If no further precipitate results, it must be tested for an excess of the barium chloride with one drop of a sodium sulphate solution. If this shows an excess of barium, the determination has to be made with another 100 c.c. of the same urine, using less barium solution, and thus until neither the latter nor the sodium sulphate show an excess. The standard solution contains 30.5 grms. BaCl2 in 1000 c.c, and each c.c. is equal to 0.01 S03. Thus if 13 c.c. BaCl2 was used, the percentage of SO3 was 0.13. Abnormal Constituents of the Urine. What are abnormal constituents of the urine ? Bodies which are not found in normal urine and owe their presence therein to abnormal, i. e., pathological conditions. Which are the principal abnormal constituents ? Biliary pigments, biliary acids, pus, blood corpuscles, haemoglobin, albumin, glucose, oxalic acid as calcium oxalate, cystin, leucin and tyrosin, together with certain epithelial cells and casts. Biliary Pigments and Acids in the Urine. How is the appearance of the urine affected by the presence of biliary coloring matter ? The color is changed to a deep yellow, yellowish green, or even brownish green and brown; it froths freely on being shaken ; the froth persists longer than usual, and is of a yellowish green, or brownish color. 38 EXAMINATION OF URINE. From which pathological conditions results the presence of biliary matters in the urine ? From icteroid conditions, which may be caused by either hepato- genous or haematogenous icterus. In the former, resulting from obstruction of the bile ducts, biliary coloring matter as well as biliary acids are present in the urine; in the latter, consequent upon the formation of bilirubin in the blood itself by the destruction therein of some of the red corpuscles, biliary coloring matter is found present but never biliary acids. Which is the principal test for biliary coloring matter in the urine, and how applied ? Gmelin's test; on the addition of yellow nitric acid to some urine contained in a test tube, in a manner to cause the two to form different layers, there will be a play of colors from green, blue, violet, red, to yellow, if biliary coloring matter is present; as non- biliary urine sometimes gives off colors with this reaction, it should be closely noted that the colors appear in regular order, and that green should always form first. What other convenient method or modification may be em- ployed in its stead ? To mix a little urine in a test tube with an equal quantity of a saturated solution of sodium nitrate. Hold this slantingly and allow some concentrated sulphuric acid to run through the mixture and to the bottom of it, when even the smallest traces of biliary coloring matter may be detected, as above. How may the biliary coloring matter be separated and shown ? By shaking the suspected urine with chloroform, separating the yellowish chloroform and applying the nitric acid test, as in Gme- lin's method. What other bile ingredients are at times found in icteroid urine? Biliary acids are found in the urine of hepatogenous icterus, but never in that of the haematogenous variety. They are not always readily shown directly from the urine, and will then need a separa- tion therefrom. PYURIA. 39 Which is the principal test for biliary acids, and how applied? Pettenkofer's test. This consists in adding to some urine a small quantity of cane sugar and overlaying with this some sulphuric acid, contained in a test tube, when, if biliary acids are present, there will appear a purple zone at the junction of the two liquids. A better way is to dip a piece of filtering paper into the saccharated urine, allow this to diy and then touch it with sulphuric acid, when biliary acids will give a purple color. This test may also be made by evapo- rating some of the urine, with a minute quantity of cane sugar, to dryness in a porcelain dish. If a drop of sulphuric acid added thereto gives rise to purple coloration, biliary acids are present. How is Oliver's test applied for biliary acids, and what is the composition of the reagent ? The reagent consists of 30 grains powdered meat peptone, 4 grains salicylic acid, 30 minims strong acetic acid, and water sufficient to make f ^viij. If this is added to urine containing biliary acids a turbidity will arise in proportion to the amount of acids present. This may also be shown by overlaying the urine with the reagent, when the acids give rise to a turbid zone at the junction of the two liquids. Pyuria. What is pyuria and its import ? Pyuria is the condition characterized by the presence of pus in the urine. It points toward the existence of an acute or chronic inflam- mation in the urinary tract, or the communication therewith of ab- scesses. The sudden appearance of large quantities of pus in the urine would point to the latter condition. Inflammatory conditions of the bladder and renal pelvis are accompanied by more or less pus in the urine. When considerable pus is present in the bladder and the urine strongly alkaline, it will form a viscid jelly, which cannot be readily evacuated. How may pus in the urine be differentiated from mucus ? Pus is turned gelatinous and ropy by caustic alkalies, while mucus is liquefied by them with white flakes. 40 EXAMINATION OF URINE. Which is the most definite method for detecting pus in the urine? In the acid urine pus appears as a heavy deposit, which, if in- spected under the microscope, shows the pus cells as round, opaque, granular spheres, larger than the red corpuscles ; on the addition of a drop of acetic acid to the slide, the granular contents and the cell membranes disappear, and the nuclei are readily seen (Fig. 8). Fig. 8. Pus Corpuscles aud Epithelial Cells. By what chemical test can pus in the urine be detected ? By Donne's test. This consists in separating the settled deposit by decantation and adding to the sediment a small piece of potas- sium hydrate, when, upon stirring, the pus will turn a clear and tough gelatinous mass. Chyluria. What constitutes chyluria, and what are its causes ? The presence of fat in the urine, which gives it more or less a milky or opalescent appearance; on standing and separation the fat particles rise to the surface. It may be of parasitic origin, as in tropical countries, owing to the presence of filaria sanguinis hominis or distoma haematobium in the blood, the lymph and the urine. The HEMATURIA AND HEMOGLOBINURIA. 41 non-parasitic form is met with occasionally in moderate climates, and its origin is attributed to degenerative changes of the kidneys. How is the presence of fat in the urine demonstrated ? By shaking it with ether and allowing the separated ether to evapo- rate, when fat will be found if there has been any present. The shaking with ether will not clear up the urine entirely, as the ether will precipitate some of the albumins present in chylous urine. To thoroughly exhaust the fat in the urine, some potassium hydrate solution should be added beforehand. Haematuria and Hemoglobinuria. What constitutes haematuria ? The presence of blood in the urine, as evident from the existence of intact red corpuscles therein. In which morbid affections may blood be present in the urine? If large quantities are present, it will most probably come from the urinary tract otherwise than the renal parenchyma. Thus in- flammatory or hyperaemic conditions of the renal pelvis, ureters, also ulcerations, cancer of, or stone in the bladder, may give rise to a considerable amount of blood in the urine. If small quantities only are found present, it is more likely of renal origin, and if in addition to the blood corpuscles renal casts are found in the urine, its origin from the kidneys and" the existence of parenchymatous nephritis is almost certain. How does the blood in the urine differ in appearance accord- ing to the part of the urinary tract it is derived from? That from the renal parenchyma is well mixed with the urine and gives it a smoky appearance ; if from the ureters, it is present in long semicircular clots and strings; the blood from the bladder and urethra is generally more in quantity, bright red, and settles in the urine as clots. By which means is the existence of haematuria confirmed? By the detection of the red blood corpuscles under the microscope. 42 EXAMINATION OF URINE. To this end a small quantity of the sediment, after subsidence, is spread upon a microscopic slide with a drop of the urine, when, on inspection, the corpuscles will be brought to view in their character- istic biconcave spherical form, either single or grouped in rouleau form, or they may be crenated, as in dense urine ; if they have im- bibed much water, as in urine of low specific gravity, they may be swelled up and have lost their biconcavity, and they may have partly lost their contour and be partly destroyed, if the urine is ammoniacal (Fig. 9). Fig. 9. Blood Corpuscles.—a, with biconcave depressions; b and c, contracted and crenated; d, swollen. What constitutes haemoglobinuria? The presence of haemoglobin in the urine in a diffluent condition, and not in its corpuscular state. How is haemoglobinuria caused ? By a solution of the stroma of the red corpuscles in the blood leav- ing the diffusible haemoglobin in solution therein which is secreted by the kidneys. The solution of the corpuscular element is noted in certain diseases, as in scurvy, typhus, pernicious malaria ; also as the effect of certain poisons, such as hydrogen arsenide, phosphorus, carbolic acid, and by pressure; a periodical form is observed, the cause of which has as yet not been ascertained. HEMATURIA AND HEMOGLOBINURIA. 43 By which simple test may the presence of haemoglobin in the urine be demonstrated ? By slightly acidulating some of the urine in a test tube with acetic acid and raising it to the boiling point. As haemoglobin contains coagulable albumin, this will coagulate, and will, on subsiding, be found as a reddish sediment at the bottom, the soluble haemoglobin having changed to insoluble haematin. How can the haemoglobin of the urine be demonstrated by the spectroscope ? By placing it in the light entering the prism of a spectroscope, it Fig. 10. Teichmann's Haemin Crystals. will give rise to two dark absorption bands in D and E of the spec- trum, i.e., in the yellow and in the green, the former being narrower, the latter broader. Which is the chemical test for haemoglobin? Almen's test: Add a few drops fresh tincture of guaiac to the specimen of urine contained in a test tube ; after agitation add a few drops of old spirit of turpentine or ozonic ether (ethereal solution of hydrogen peroxide); if haemoglobin is present, the color will change to a distinct blue. 44 EXAMINATION OF URINE. In which manner may the presence of haemoglobin be most definitely and positively established? By the production of Teichmann's crystals of haematin hydro- chloride, often termed haemin. To this end the slightly acidulated urine is boiled, and the coagulum filtered off; a small portion of this is dried with a gentle heat on a microscopic slide ; to the dry residue a trace of common salt (NaCl) is added and well mixed with it, and, after adding one or two drops of glacial acetic acid on the mixture, this is covered with a cover glass, and heated over a lamp to the boiling point of the acid; after cooling, and on examination under the microscope, there will be found present numerous flat, rhombic prisms or tables, of a brown or blue color, which are haemin, or better termed haematin hydrochloride (Fig. 10). Albuminuria. Which are the albumins found in the urine of albuminuria ? Principally serum-albumin, but also, and rarer, paraglobulin. Under which conditions may albumin appear in the urine ? When the blood is surcharged with albumin, as after excessive in- gestion of albuminoids ; if the blood is much diluted, when oedema- tous exudations will take place; when the blood pressure in the kidneys is abnormally increased ; also, if the chlorides of the blood are wanting, as well as if blood or pus is admixed with the urine. Which pathological conditions are accompanied by temporary albuminuria ? The acute febrile affections, such as typhoid fever, diphtheria, pneumonia, etc., also the exanthematous diseases during their efflorescence. When is the presence of albumin in the urine more persistent? In the various inflammatory affections of the kidneys, variously termed Bright's disease of the kidneys, also in heart and respiratory diseases. What are the general appearances of albuminous urine ? As a rule it is of pale color, low specific gravity, and when shaken maintains its froth for some time. ALBUMINURIA. 45 How is urine tested for albumin by Heller's test ? To a small quantity of urine in a test tube some nitric acid is added by allowing it to flow clown the sides of the inclined test tube, so that the two fluids form separate layers ; if albumin is present there will appear at their line of contact a white zone of coagulated albumin. This may be also the result of the presence of urates, but in this case the white zone is not as distinct and more toward the surface of the urine. If warmed, the urate cloud will disappear, but not the albumin. In which way is the boiling test performed ? In this test the urine should be clear, and has to be filtered if tur- bid ; if it is neutral or alkaline it has to be made slightly acid by the addition of a drop or more of acetic acid. If the upper part of the urine in the tube is now heated to the boiling point, it will be ren- dered turbid if albumin is present, and may readily be contrasted with the clear layer at the bottom. If the total volume is boiled, the entire albumin therein will be coagulated, and the flocculent co- agulum may be separated by filtration. Should too much acetic acid have been added, the coagulation may have been prevented by the formation of acid-albumin. This can be demonstrated and cor- rected by the addition of a few drops of potassium ferrocyanide solution, when the coagulum will form at once. How can the boiling test be utilized to approximate or com- paratively estimate the quantity of albumin for clini- cal purposes ? By allowing the coagulated albumin of the total urine in the test tube to subside for 24 hours and expressing the volume of the coagu- lum in comparison with the total urine boiled, as, for instance, I or £ albuminous layer. How can picric acid be utilized for detecting albumin in urine? If a concentrated solution of picric acid is added to urine there will be a coagulum formed if albumin is present. As this may, however, be caused also by alkaloids or peptones, this test can be used for the exclusion of albumin only, but if found present, it should be con- firmed by either of the preceding tests. 46 EXAMINATION OF URINE. Fig. 11. In which way may the picric acid test be used for the quan- titative estimation of albumin in the urine ? By the use of Esbach's albuminometer (Fig. 11). This consists of a test tube of strong glass, marked near its middle and upper end respectively U and R, and near the bottom with small graduations marked respectively 1,2, 3, 4, 5, 6, 7. It is used by filling up the tube with urine to the letter U and adding an acidulated picric acid solution to B. After 24 hours the coagu- lated albumin which has settled is read off in grammes of dry albumin per litre according to the small gradua- tions to which it has settled. To obtain the percent- age of dry albumin the respective figure is divided by 10. When the albumin is so abundant that the sedi- ment is above 4, a more accurate result is obtained by first diluting the urine with one or two volumes of water and then multiplying the resulting figures by 2 or 3, as the case may be. How is the acidulated solution of picric acid for this process prepared ? Dissolve 10 grammes picric acid and 20 grammes citric acid in 800 or 900 cubic centimeters of boil- ing water, which, on cooling, bring up with water to one litre (1000 cc). Describe the volumetric estimation of albumin in the urine. This consists of adding to 10 c.c. of urine 2 c.c. acetic acid, diluting with a little water, and then allowing Tanret's solution to drop in, drop by drop, from a suit- able pipette, counting the number of drops so used ; when the precipitate thus formed grows less, a drop of the urine is taken out and brought in contact with ESmfnometebU" a ^ew drops °^ 1 Per cent> corrosive sublimate solution on a porcelain plate ; if on mixing the two a red pre- cipitate occurs, the reaction is complete, and for each drop so used, less 3 drops allowed for excess, 0.5 gramme of dry albumin per litre are present. §i 1- EPITHELIAL CELLS IN URINARY SEDIMENTS. 47 Give the composition of Tanret's reagent ? 3.32 grammes potassium iodide, 1.35 grammes mercuric chloride, dissolved in 100 cc. distilled water. Is the presence of albumin in the urine alone sufficient for the diagnosis of Bright's disease ? No : as various other causes, already enumerated, may cause tem- porary or pseudo-albuminuria. If the amount of albumin, however, is large and persistently present, if the urine also contains casts and renal epithelium, the evidence points to the existence of renal disease. Epithelial Cells in Urinary Sediments. Are epithelial cells normally present in the urine, and, if present in larger quantities, what do they indicate ? Epithelial cells are always present in the urine, but according to their form, and the greater quantity present, they indicate patho- logical conditions of certain parts of the urinary tract. What form have the epithelial cells of the uriniferous tubules ? They have a spherical, granular form, with faint outlines, but clearly defined nuclei. They may be present either singly or agglu- tinated as epithelial casts. The loops of Henle are lined with tessellated epithelium, and the straight tubules with the columnar variety (Fig. 12). Which epithelial cells are derived from the renal pelvis ? Tessellated epithelium consisting of biconvex and caudate cells. The biconvex are generally as long again as they are broad. The caudate cells have an ovoid or club-shaped body ending in a fine point; their nuclei are well defined (Fig. 12). Which epithelial cells belong to ureters and bladder ? The ureters have regular tessellated epithelium, composed of poly- gonal cells, with central and clearly defined nuclei. The bladder has epithelium arranged in layers, of which the upper layer is formed by flattened polygonal cells ; the deeper layers have a more spherical appearance (Fig. 13). While the female urethra has the same epithelium, that of the male urethra resembles more the renal 48 EXAMINATION OF URINE. epithelium. Renal epithelium is subject to pathological changes, such as fatty or amyloid degenerations, recognized by the microscope and the amyloid reactions. Fig. 12. Renal epithelial cells and epithelial cells from renal pelvis. Epithelial cells, a, from male urethra; 6, from vagina; d, from Cowper's glands; e, from Littre's glands; /, from female urethra; g, from bladder. TUBE CASTS IN THE URINE. 49 Tube Casts in the Urine. Under what conditions are tube casts found in the urine, and how recognized ? In acute and chronic renal affections, tube casts may be recognized in the urinary sediment by means of the microscope. The sediment should be allowed to settle, and a specimen removed with a pipette for microscopic inspection. To make them more distinct a drop of Lugol's solution or aniline red may be added. Which are the principal forms of tube casts ? The epithelial casts, composed of coherent epithelial cells of the fig. 14. Hyaline casts, also one epithelial cast. tubes of Bellini; they are generally pale and transparent, and around them small round cells and nuclei may be recognized (Fig. 14). The hyaline casts appear as pale, transparent cylinders of various sizes and configurations, and of very delicate outlines; they are also termed mucous casts (Fig. 14). A modification of these with distinct outlines, slightly yellow color and waxy lustre are termed waxy casts (Fig. 15). Granular casts (fibrinous casts), resemble the hyaline casts but have granular contents consisting of cells which have suffered granu- lar change, giving them a darker appearance than the former. They 4 50 EXAMINATION OF URINE. may contain, also, oxalates, blood and pus corpuscles, fat globules and epithelial cells (Fig. 16). Fig. 15. Waxy casts. Fig. 16. Granular casts with fatty globules; also, blood and pus corpuscles, and epithelial cells. Have the different tube casts always positive value for dif- ferentiating the various renal affections ? Not always, as in acute and chronic nephritis, as well as in amyloid degeneration, all the varieties may be present at one time. TUBE CASTS IN THE URINE. 51 When-will they be of such diagnostic value ? When one variety only appears. Thus, if epithelial casts alone persist for several days, they point to the existence of a desquama- tive nephritis with favorable prognosis, while the simultaneous pres- ence of pus corpuscles renders the prognosis less favorable. In which cases of nephritis are hyaline and granular casts found? In the severer cases with a disposition to chronicity, as indicated by their number and persistence. If they contain numerous fat granules and fat globules the diagnosis of fatty degeneration is justifiable, especially if accompanied by fatty degenerated renal epi- thelium both in the casts and separately. What would indicate the existence of the contracted kidney? If the tube casts grow thinner and the epithelial elements appear contracted. How may amyloid degeneration be indicated ? The tube casts may here appear the same as in the other forms of nephritis, but there will be found besides the fatty degenerated epi- thelial cells, also such as have undergone amyloid degeneration, recog- nized by being colored red by methyl-violet, the others turning blue. What would blood casts show? That there is renal hemorrhage, the casts being coagulated blood with imbedded corpuscles. Which are some of the other abnormal sediments of the urine of clinical interest ? Cystin, leucin and tyrosin, calcium oxalate and micro-organisms. When and in what form is cystin found in the urine ? Cystin is found occasionally, but very seldom, as urinary concre- tion, also in urinary deposits ; it is insoluble in water, not dis- solved by heating, but soluble in alkaline hydrates, also mineral and oxalic acids. Under the microscope it appears in the form of colorless, shining, six-sided plates or prisms (Fig. 17). When and how do leucin and tyrosin occur in urinary sedi- ments ? They occur frequently in the urinary sediments in acute yellow atrophy of the liver, also in phosphorus poisoning, and point to an incomplete oxidation of the albuminoids. 52 EXAMINATION OF URINE. What is the microscopical appearance of leucin ? Yellow-colored spheres, at times concentrically striated with pro- truding delicate points or spines (Fig. 18). Fig. 17. Crystals of cystin (after Ultzmann). Fig. 18. (a) Leucin, spheres; (6) Tyrosin, needles and sheaves. How does tyrosin appear under the microscope ? Tyrosin, which appears generally associated with leucin in urinary sediments, has the form of silky, white, microscopic needles which are arranged in sheaves or stellate form (Fig. 18). URINARY SEDIMENTS. 53 In what compound is oxalic acid occasionally present in the urine? As calcium oxalate, which is frequently found in the urine, but becomes of importance only when present in larger quantities and persistently, when it gives rise to oxaluria, signifying a retarded metabolism or suboxidation. Describe the form of crystals of calcium oxalate in urinary sediments. It forms minute, transparent, brilliant octahedra presenting some- what the shape of a square envelope. At times the crystals assume Fig. 19. Calcium oxalate in octahedral (envelope) crystals; also in dumb-bells; some larger crystals of uric acid. the form of dumb-bells ; to detect them a high power objective should be employed (Fig. 19). Under which conditions are micro-organisms found in the urine? As a rule, micro-organisms are found in the urine only after it has been exposed to the air for some time, but they may be carried into the bladder by catheters or sounds, and there set up ammoniacal decomposition of the urea, giving rise to cystitis. Of greater importance are those which are derived from the blood, as in 54 EXAMINATION OF URINE. infectious diseases, such as scarlatina, typhoid and malarial fevers and renal diseases. Which are the principal micro-organisms found in the urine ? Mould (penicillium), yeast cells, sarcinae (in the urine they are smaller than of the stomach), vibriones, bacteria, bacilli, cocci, etc. Micro-organisms of urinary sediment. Glycosuria. Is sugar normally found in urine, and in what quantities ? Sugar as glucose is found normally in the urine in very small quantities, not more than 0.1 gramme in 24 hours. If found in larger quantities and persistently, what patho- logical condition is present ? Glycosuria or diabetes mellitus; it may, however, be found in the urine in larger quantities in cerebral and nervous affections; also temporarily after anaesthesia from chloroform, ether, etc., as well as after copious ingestion of sugar. What is the appearance and physical condition of the urine of glycosuria ? It is much increased in quantity, and may reach one or two gallons in the 24 hours; it is of pale or pale yellow color, often GLYCOSURIA. 55 shghtly greenish, clear, as a rule, but may contain sediments of urates or oxalates; it has a high specific gravity, generally between 1030 to 1040 and even more; the urea eliminated is abnormally increased. Which foods increase and which diminish the amount of glucose in the urine ? Starchy and saccharine food increases, and animal diet decreases the amount. In testing urine containing albumin for glucose, what has to be done first ? The albumin has first to be separated by boiling and filtration. Describe Moore's test for the detection of glucose in urine. In a long test tube mix about one part of urine with half its volume of liquor potass*;. Heat the mixed liquids in its upper half untH active ebullition ensues, when, if glucose is present, the upper part will turn dark yellow to reddish brown. If the whole volume is thus treated, it will change color in a similar manner, and if then some nitric acid is added, it is decolorized and an odor of burnt sugar is given off. What effect has glucose on certain metallic oxides if heated together in a strong alkaline fluid? The metallic oxides, especially those of bismuth and copper, are reduced; the former to metallic bismuth, the cupric oxide to cuprous oxide. Describe Bcettger's test. Bcettger's, or the alkaline bismuth test, is performed by mixing equal parts of urine and liquor potassae and adding a small quantity of bismuth subnitrate ; boil for a minute or two and if glucose is present, the bismuth will turn gray, brown or black, owing to the reduction to its metallic state. What are the advantages and disadvantages of this test ? It has the advantage that uric acid, urates and kreatinin do not affect it, but albumin or sulphides present in the urine, produce similar effects as glucose. What is Nylander's modification of the alkaline bismuth test' This consists in the use of a single alkaline bismuth solution 56 EXAMINATION OF URINE. composed of bismuth subnitrate 2 grammes, Rochelle salt 4 grammes, solution of sodium hydrate (8 per cent.) 100 grammes. To 10 c.c. urine 1 c.c. of this solution is added and the two boiled together ; if glucose is present, it turns brown or black. Upon what reactions do the alkaline cupric tests depend ? First, that on adding a few drops of cupric sulphate solution to liquor potassae a greenish-blue precipitate of cupric hydrate is formed. CuS04 + 2KHO = Cu(OH)2 + K2S04. Second, the cupric hydrate on boiling splits up into cupric oxide and water, the former appearing as a black precipitate. Cu(OH)2 = CuO + H20. Third, the black precipitate does not form in the presence of cer- tain organic matter and excess of alkaline hydrate, but remains in solution, having a deep blue color. When this alkaline cupric oxide solution is boiled in the presence of glucose, the latter takes away oxygen from the cupric oxide, leaving yellow insoluble cuprous oxide. 2CuO — O = Cu20. Trommer's test, what is it, and how performed? To some urine in a test tube add one-half or one-third volume of liquor potassae and a few drops of a 10 per cent, solution of cupric sulphate. If this is heated in its upper half to the boiling point there will be a reddish-yellow turbidity, caused by the separation of cuprous oxide, if glucose is present. The two strata will give a dis- tinct difference in appearance. How can this test be improved by the addition of glycerin ? The addition of a few drops of glycerin will prevent the precipita- tion of the black cupric oxide and admit of the test solution being first tested by boiling. If to some liquor potassae in a test tube a few drops of cupric sulphate solution are added, and also a few drops of glycerin, a clear, deep blue liquid will result. This is brought to the boiling point, and after removal from the flame a little of the urine is added; if glucose is present, the characteristic red- dish-yellow cuprous oxide will form within a minute or two. If this does not take place after the first addition of the urine it should be GLYCOSURIA. 57 brought to the boning point again and a little more urine added as before. Which is the principal alkaline cupric test, and how applied? The Fehling's test, an alkaline solution of cupric oxide, which is held in solution by Rochelle salt (sodium-potassium tartrate), (see formula under quantitative tests for sugar). This solution is di- luted with 3 to 4 volumes of water, heated to the boiling point, when a little urine is added. If sugar is present, a yellowish-red precipitate of cuprous oxide will form; if indistinct at first, boil again and add more urine. The boiling before adding the urine is necessary to establish the quality of the solution and to show if it does not decompose spontaneously at the boiling point. What is the most positive evidence of glucose in urine, and how shown? The alcoholic fermentation on addition of yeast. This may be shown by adding some yeast to a bottle filled with the suspected urine. Invert the bottle in a vessel containing the same urine ; if inside of 24 hours part of the urine is displaced by carbon dioxide, glucose was present. This may be further verified by testing the urine for alcohol by adding to the fermented urine a few drops of po- tassium dichromate solution and sulphuric acid; if, on warming, a green color appears, alcohol was formed and glucose positively present in the urine. How may the presence of glucose in urine be shown by phenyl-hydrazine ? To equal parts of urine and liquor potassae add a few drops of phenyl-hydrazine, and heat to boiling. In the presence of glucose an intense yellow or orange color develops ; on addition of an excess of acetic acid, yellow crystals are precipitated. Which are some other very delicate tests for glucose in urine ? The tests with menthol, thymol or alpha-naphthol. These are applied by using their alcoholic solutions (1 to 7 alcohol), and mixing a few drops thereof with the urine. To the mixture, in a test tube, add some sulphuric acid in a manner that they do not mix, when, if glucose is present, there will be a red color at the line of contact with 58 EXAMINATION OF URINE. thymol or menthol, or violet with greenish borders if alpha-naphthol was employed. How may picric acid be used for the detection of glucose in urine ? By its conversion, on boiling with an alkaline hydrate, into dark, reddish-brown picramic acid if glucose is present. Normal urine pro- duces a similar reaction, but not of the deep reddish-brown color as when glucose is present. By what ready method may the fermentation test for glu- cose in urine be used quantitatively ? By the differential density method of Roberts. This is conducted by accurately taking the specific gravity of the urine to be examined, the temperature of the urine being noted. With 4 ozs. of this urine in a 12 oz. flask or bottle, mix a small piece (about k cake) of compressed yeast; after setting aside for 24 hours in a warm place, fermentation is completed. The urine is then cooled to the temper- ature of the former specimen and its specific gravity also accurately ascertained. The number of degrees of specific gravity lost by fer- mentation corresponds to the number of grains of glucose in the ounce of urine. The percentage maybe obtained by multiplying the number of degrees lost by 0.22. How is the quantity of glucose in urine ascertained by polari- zation ? By filling the container of a polarization apparatus with the filtered urine, free from albumin. The urine must be almost colorless, and care must be had that no air bubbles are in the tube. The analyzer is then moved to accurately correct the difference in color in the two halves of the visual field, and the angle through which it was moved is read off by means of the scale and vernier. The amount of glu- cose is computed by the following formula : p = , 661 iin which p stands for the quantity of glucose in grammes in 1 c.c. of the urine, a the angle read off, + 56 the specific rotation for glucose, and 1 the length of the containing tube expressed in decimeters. Thus, if the angle read off were 4.5°, the tube 1 decimeter long, it would be go^-j = 0.080 glucose in 1 c.c, or 8.0 in 100 cc. Various instru- GLYCOSURIA. 59 ments for this purpose are in the market, some admitting the read- ing off directly of the percentage of glucose. Give the formula for making Fehling's solution. As Fehling's solution does not keep, it should not be kept on hand for any length of time, but should be made as two separate solutions, of which equal amounts by measure are mixed together at the time when wanted to form the complete test solution. No. 1. B. Cupric sulphate (pure, not effloresced, and free from water of crystallization), 34.64 grammes Water, q. s. to 500 c.c. No. 2. R. Kochelle salt (crystallized), 173 grammes Solution of sodium hydrate, sp. gr. 1.34, 100 c.c. Water, q. s. 500 c.c. For use, mix equal volumes of No. 1 and No. 2 as needed. Describe the method for the quantitative determination of glucose in urine by Fehling's volumetric process. Place into a capsule, beaker or flask 10 cc. of Fehling's solution diluted with 40 c.c. of water. Heat to the boiling point, and let gradu- ally run into it from a burette a mixture of one part of urine and nine of water, stirring the mixture, and continue thus until the blue color of the test solution has entirely disappeared. The diluted urine is to be added in small quantities only, and the test solution must be raised to the boihng point after each addition, when it is left to subside for a few seconds to be able to view the supernatant fluid with trans- mitted light. Toward the last only a drop or two at the time should be added, as the clear shade should have a rather yellowish tint. This process should be repeated several times until the amount of diluted urine proves the smallest quantity effecting complete reduc- tion. How is the quantity of glucose computed from this ? As 10 cc. Fehling's solution are reduced by 0.05 gramme glucose, that amount of urine which is present in the dilution which has re- duced the 10 c.c. of the Fehling's solution contained 0.05 gramme glucose. Thus, if 16 cc diluted urine (1 in 10) were used, 1.6 urine contained 0.05 gramme glucose. To obtain the percentage the fol- 60 EXAMINATION OF URINE. Fig. 21. lowing proportion will answer: 1.6 : 0.05 = 100 : x ; x = 3. 1 per cent. What is Johnson's picric-acid test for the quantitative deter- mination of glucose in urine ? It consists of converting picric acid in the presence of potassium hydrate and glucose into reddish-brown picramic acid ; the intensity of the color of the latter being proportionate to the amount of glucose present; the color of the picramic acid formed is then compared with that of a standardized solution of feme acetate, and the amount of glucose ascertained by the dilution required. How is this test performed ? Take of urine f3j, liquor potassae f3ss, solution of picric acid (gr. 5.3 to f^j) nixl, water q. s. ad f3iv into a test tube and boil for sixty seconds ; cool the mixture and bring it up to the original volume (f3iv). Of this pour 10 cc into a 100 cc. graduated cylinder, which has attached to it a test tube of equal diameter and con- taining the standard fluid (Fig. 21); dilute the boiled mixture with distilled water to equal in color the standard liquid, and for each 10 c.c. it has been distilled up to, count 1 grain of glucose in the fluidounce of urine tested. How may the measurement of the ingredients be simplified? By taking 5 cc of each, urine, potassium hydrate solution (sp. gr. 1.036), solution of picric acid (gr. 3.5 to f^j), and water. Give the formula for the standard ferric acetate solution. R. Liquor, ferri chloridi, TJ. S. P., f.^j Ammonii carb., 3j Acidi acetici, f 3 v Aquae destillatae, q. s. ad f J iijss. M. Is the above formula for the standard fluid reliable, and what should be done to make it so ? It is not reliable, and to make it so it should be standardized by LEAD AND MERCURY IN THE URINE. 61 comparing it with urine, to each fluidounce of which 1 grain of crys- tallized glucose has been added. To this the KOH, picric acid and water, is added, as above, and boiled for sixty seconds, when, after boihng, the standard iron solution is either diluted or made denser in color by addition of some liquor ferri chloridi to closely correspond in color. By doing so, not only is the error of variable strength of the ferric chloride solution corrected, but the error created by the nor- mal presence of kreatinin is also overcome. When thus executed, this method is as reliable as any other for clinical purposes. Lead and Mercury in the Urine. Is lead readily detected in urine after lead-poisoning, and is a failure to find it proof of its absence from the system? Lead is not always found in the urine after lead-poisoning, and is not always readily detected. Before testing for lead in the urine, iodide of potassium should be administered in full doses for a few days. Give a method for detecting the presence of lead in the urine. About 30 to 50 ounces of urine are brought to the boiling point in a porcelain evaporating dish, and while boiling, nitric acid (free from lead) is added in small quantities until on addition no further effervescence results ; evaporation is then continued to dryness, the residue is carbonized in a porcelain crucible with the addition of nitric acid. The residuary mass, after combustion, is boiled out with nitric acid ;.after boiling it is diluted with water, the mixture filtered and the filtrate evaporated to dryness. The dry residue is dissolved in water slightly acidulated with HN03, and a current of hydrogen sulphide is allowed to pass through it for some time. If a brownish-black precipitate results, the presence of lead should be confirmed by testing another portion of the clear fluid with potassium iodide or neutral potassium chromate ; with either of these it must give a yellow precipitate if lead is present. As the latter are not so sensitive as H2S, it maybe necessary to separate the precipitated lead sulphide, redissolve by gradual addition of HN03, evaporate excess of latter, and test after dilution and filtration as before. The 62 EXAMINATION OF URINE. lead iodide so derived will be seen under the microscope as six-sided plates. If the lead sulphide precipitated is sufficient, it may be reduced by the blow-pipe flame to a malleable particle of lead. When may the detection of mercury in the urine be of diag- nostic value ? In cases of protracted mercurialization, as in syphilis, etc. Describe a ready method for detecting mercury in urine. 300-500 c.c. of urine are acidulated with hydrochloric acid and evaporated to about one-fourth of its volume, allowed to cool and then filtered. In the filtrate boil for a little while a slip of pure, bright copper foil; after boihng sufficiently, take it out, wash off in distilled water and dry it between bibulous paper ; then roll up and put into an open glass tube ; beat at the place where the copper is to redness, when the mercury will be driven to a cooler portion of the tube, to be recognized by the shape and brilliancy of its globules under the microscope; also, by converting it into red mercuric iodide, when into the hot portion of the tube a minimal fragment of iodine is introduced and its vapors are allowed to flow over the sub- limed mercury. What other very delicate method may be employed for detecting mercury in the urine ? The method of Ludwig is the one best adapted for detecting mercury in the urine. It is conducted by acidulating 200-500 cc urine with hydrochloric acid, warming the mixture to 50°-60° C., and adding 5 grammes of pure zinc dust (to be had of dealers in chemicals). The mixture is stirred for some time while warm, and then the zinc is allowed to subside, when the supernatant fluid is separated by decantation ; the metallic sediment is well washed with distilled water and dried in a vapor bath after filtration. The mercury, having united with the zinc dust to form an amalgam, can now be driven off; this is done best in an open tube in which the zinc dust is secured by two loose asbestos plugs. The part of the tube containing the zinc is now heated and the mercury driven up to the upper and cooler portion of the tube. That portion of the tube is broken off, and the sublimed mercury is recognized by converting it into red mercuric iodide by passing a vapor of iodine over it. 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Q x CO t^ to «D 'O ,-.^.r-—i,-.^-^-,-;©©©©©©©© Xxr-t^tOtO^MOr^lCHt-CKOO rCGOC000CO'X.COt-CN <£> O W COOOlNr-MtDiHtClOlOOCCCOlNy)© rHOO030)00C0r>^(0l0»0TrT)«C0CC ^■HOOlONCO^OlOO^OOrH^tCt^ oioasTfas^Doocot-cscDOtcascor^ fNasto-^i-it^coa>Tj"WCOict- f-rH(DHtOo'CC>TT,MWr-(NtDOtf OOOiOlOOCOr-CCtd'O'^'^COCOW 0»T)<(NO)lCMNCOCO(NtOOCO»CCS«0'-i»00,^C7SCOt>rH ©csascoaor-r-to«- iot^cccccncn COCOCOi-IOOrr1'<-iCD(Nt*-CN«DOSOlTt*CO OlOOlOa^OJWCOWt^HiOO^CO «OrJ(rHO)«OMOsW-< CO i-h IO OS CN "^ CO tXNNiHffii-HOOlCOl^COINh-^W asasaoooi>t>«cicDW*TrcocccNj(N'-i T)niOl^(»COr-W(OT-iOOJ OSCOCOt-t-tC'iClO'^TfCOCCOHMi—O 00>(O^NOiefiMOOWOO«t»0«10 CONI>(Nr*i-i(OHIOO'fl"OJ«OOMtD KlOOt-r-OtClOlC^fCONWrirHO . tj< co o r- -^ i-< t l»W(DONW _. .'C0«00C-tt>.»-iiX'O10C5( .r-CDtClOlC^TriCOCO^CNf-^OC r-lftMfHOlOWOtOHt^rHtDOJM^ HlOTHOOlftOIOO^XCONr- (DO C0t>.|>«0<01Cl0^C0C0(NWrHriOO IfiMHOMCWOlCOtO^lflOiN^ oocooocct-oat--i-ito*-iCG:^oocci--. h.r-(0t0iC10^^MC0W„ DEMONSTRATOR OF OBSTETRICS IN THE UNIVERSITY OF PENNSYLVANIA. Price, Cloth, Interleaved for Notes, - $2.00 Net. *»*The New York Medical Record of April 19th, 1890, referring to this book says: " The modest little work is so far supei ior to others on the same subject, that we take pleasure In calling attention briefly to its excellent features. Small as It is it covers the subiect thoroughly and will prove invaluable to both student and the practitioner as a means ot fixing in a clear and concise from the knowledge derived from a perusal of the larger textbooks. The author deserves great credit for the manner In which he has perfoimed his work. He has introduced & number of valuable hints which would only occur to one who was himself an experienced teacher of obstetrics. The subject matter Is clear, forcible and modern. We are especially pleased with the portion devoted to the practical duties of the ac- coucher, care of child, etc. The paragraphs on Antiseptics are admi- rable, tliere is no doubtful tone in the directions given. No details are regarded as unimportant. No minor matters omitted. Weventure to say that even the old practitioner will find useful hints in this direction which he cannot afford to despise." Sent Postpaid on Receipt of Price. "W. B. SAUNDERS, Publisher, 913 Walnut Street, Philadelphia, Pa. HAVE YOU SEEN NANGREDE'S AHATOMY AHD DISSECTOR, WITH COLORED PLATES? OVER TWO HUNDRED ILLUSTRATIONS. PRICE, . • • $2.00. FDR SALE BY ALL BDDKSELLERS, ■W. B. SAUNDERS, Publisher, 913 Walnut Street, Philadelphia, Pa. SAUNDERS' POCKET MEDICAL LEXICON. The latest, cheapest, most complete pocket dictionary of medical terms yet published. Edited by John M. Keating, M.D., Fellow College of Physicians of Philadelphia; Editor of " Cyclopaedia of the Diseases of Children"; Author of •• Keating's Unabridged Medical Dictionary," etc., etc. A compact, concise, com' prehensive and convenient lexicon of medical terminology. Invaluable to the student of medicine. Price, cloth, 75 cents; morocco tucks, $1. *#* For sale by all booksellers. Mailed free on receipt of price to any post office address in the United States or Canada. SAUNDERS' QUESTION-GOMPENDS. OPINIONS OF THE PRESS. Extract from Medical Brief, St. Louis, May, 1S90. Semple's Legal Medicine Toxicology and Hygiene. "A fair sample of launders' valuable compends for the student and practitioner. It is hand- somely printed and illustrated, and concise and clear in its teachings." Extract from Southern Practitioner, April, 1890. stel wagon's Disease of the Skin. "The subject is as tersely and briefly considered as is compatible with learners, and :is a means of refreshing the memory or permanently fixing therein the most important facts of Derma- tology, it wiH-nll an important place with students of medicine." Extract frotn Medical and Surgical Reporter, April, 1890. Ci-aiein's Essentials of Gynaecology. "This is a most excellent addition to this series of Question compends, and properly used will be of great assist- ance to the student in preparing for examination. Dr. (Jraigin is to be congratu- lated udou having produced in compact form the Essentials ot Gynaecology. The style is concise, and, at the same time the sentences are well rounded. This renders the book far more easy to read than most compends and adds dis- tinctly to its value." Extract from the New York Medical Journal, May, 1890. Stelwao-on's Diseases of the Skin. " We are indebted to Philadelphia for »i,«th£r excellent book on Dematology. The little book now before us is well fitted "SnttaKf Dermatologv,*yand admirably answers.the-purpose» for whieh it is written The experience ot the reviewer has taught him that fust such a book is needed. We are pleased with the handsome appearance of the book with its clear type and good paper, and would specially com- mend the woodcuts that illustrate the text." Extract from Journal of Cutaneous and Genito- Urinary Diseases, May 1890. .. An examination of the manuals before us cannot fail to convince one .hot the authors have done their work in a satisfactory manner. that the *«™£» ™\s Kssentials of Diseases of the Skin is an admirable com- * \f «.!v knowledge of Dermatology. The author's experience as a teacher pend of out knowieu„e 01 vvi "™ unfls covering all essential points, while the fewer^ a.e CZ™SWth1ufflcle"t accuracy of detail lobe thoroughly iVKgiWe Of especial value and completeness is the therapeutical part ot the.?7^klvo!fl- in the Examination of the Urine, has given an account of the norma 'andTnath^lo-ic^l constituents of the mine and a resume of the recent and tnimvunfl trenito-nrlnarv diseases cannot too strongly be insisted on. tolog> and genito ui ma. y Gynecology embraces many morbid con- Extract from Boston Medical and Surgical Journal, May 1, 1890. «....o^;r,'a rvn-eoolofv a little book that does contain the essentials of gyne- cologyaJfdmay le*econ??nended to thestudent as a safe and useful guide to him in his studies." ■ SAUNDERS' QUESTION-COMPENDS. OPINIONS OF THE PRESS. Extracts from Annals of Surgery, June, 1889. "They may be used to no little advantage by the practitioner, in presenting'the main facts of his professional work, in a suitable form for ready reference and com- plete classification. The form of Questions and Auswers is peculiarly qualified to secure definiteness of information. Dr. Nancrede has given us a work far more exten- sive in its character'than anything of the kind. The Medical Student who shall have mastered its contents, will certainly have acquired all the essential points of Anatomy." "The Essentials of Physiology are most clearly and comprehensively outlined by Dr. Hare." Wolff's Chemistry.—"The questions are distinctly stated, and the answers, framed with marked clearness, are fully up to the times." "Martin's Surgkkv, comprehensive in scope; it is an unusually satisfactory con- densation." Ashton's Obstetrics.—"The book presents all the essentials of its subjects, and much other valuable matter." Extracts from University Medical Magazine. Martin's Surgkkv.—"The most, pronounced opponent of the system of' Quizzing' in vogue at the present day, could find no ground for objections to this excellent little book, which cleverly combines all the merits of condensation, while avoid •/ t jc errors of superficiality and inaccuracy with which such Compends commonly ah J. It is a pleasure to be able to recommend the book absolutely and without reserv. in, as thor- oughly fulfilling the purpose for which it was written, and, so far as Si ery is con- cerned, decidedly the best of its kind with which we are acquainted." Nancredk's Anatomy.—"To learn Anatomy is not merely to reniembei the names of muscles, arteries and nerves, but to study their origin and insertions, tl «.ir course and relation.-,, and their distribution. Dr. Nancrede has kept this necessity constantly in mind, and the student who masters the details of this little book in connection with conscientious work in the dissecting room, will find it a help for which his tired mem- ory will often sincerely give thanks. The questions have been wisely selected, the answers are accurate and concisely constructed, but still with sufficient detail to free them from the criticism that they are merely lists of names." Extract from New York Medical Record, May, 1889. "Saunders' Series of Student's Manuals, arranged in the form of Questions and Answers, are concise, without the omission of any essential facts. Handsome b'nding, good paper and clear type increase their attractiveness." Extract from St. Joseph's Medical Herald, March, 1889. " Wom-'f's Chemistry.—A little book that explains, clearly and simply, the most difficult points in Medical Chemistry, so that this need no longer be the great bugbear of a medical student's efforts." i i 2 X^i?^ °. V OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE \ ° / "I vaan ivnoiivn 3nioio3w do Aavaan ivnoiivn aNiomaw do Aavaan ivnoiivn i / !Y OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE | /j^// \ vaan ivnoiivn snioiqsw do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn ! /ytv !Y OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE ivaan ivnoiivn snidiqsw do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn RY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE ivaan ivnoiivn gNiDiaaw do Aavaan ivnoiivn l aNoiagw jo Aavaan ivnoiivn Q_ -a o ,NE NATIONAL LIBRARY OF MEDICINE pCINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL t>J ''V I - \ ■ tfllVN 3NOIQ3W dO Aavaan IVNOIIVN 5 [CINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL U-* , r<^ 3= J^ % \ =■ /"ts ijiiivN 3Ni3ia3w do Aavaan ivnoiivn snidiosw do Aavaan ivnoiivn snidiosv ICINE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL lliVN 3NIDIQ3W dO Aavaail IVNOIIVN 3NIDIQ3W dO Aavaan IVNOIIVN 3NIDIQ3V* vl|ciNE NATIONAL LIBRARY OF MEDICINE NATIONAL LIBRARY OF MEDICINE NATIONAL r /\y 1 w do Aavaan lfflnfeif^ S V3r*W3w d° y x^/ '■•>< m NLM ODIDSTSfl =j NLM001059589