M W [■■*;W-jv?'•';:•':••;•' • •. •;,|i Lg ■•i ll HTO*|,,'t::'(1>:Wiri ','.'" >'v "• 3 i IS ',,*• I* Bw',ii,rJ:i!:i)' -.'_ ,!■■■ ' *• ■ it ^ 7 ,?* w^'iv'^;*' ,;:';i?'v';i:i/i''"' '■::'.','■■■. ■ it: f. ij SURGEON GENERAL'S OFFICE IT Section,_____ JVo.\ -70, (y-yQ^m NLM001385664 ».*;$ UNIFORM WITH THIS VOLUME A TEXT BOOK --------OF-------- IVTateria JYJedica and ^pecial ' Therapeutics. WITH MANY NEW REMEDIES. DESIGNED AS A TEXT BOOK FOR STUDENT, AND AS A READY REFERENCE FOR THE PRACTITIONER. A COMPLETE MATERIA MEDICA. Written with' special reference to the more direct or positive aetlon of Medicines, and the Introduction of new ones. By I. J. M. Goss, A. M., M. D., former Professor of Materia Medica, now Professor of the Sciences and Art of Practice of Medicine In the Georgia College of Eclectic Medicine and Surgery. SECOND EDITION, REVISED AND ENLARGED. W. T. KEENER, Medical Publisher, Bookseller and Importer, 96 Washington St., Chicago. THE Practice of Medicine, OB The Specific Aet of Healing. BY I. J. M. GpSS, A. M., M. D. PROFESSOR OF THE PRACTICE OF MEDICINE IN THE GEORGIA ECLECTIC COLLEGE OF MEDICINE AND SURGERY. AUTHOR OF "THE AMERICAN PRACTICE," MATERIA MEDICA, PHARMACOLOGY ANJ> THERAPEUTICS. CHICAGO: W. T. KEENER, 96 WASHINGTON STREET, 1888. fJL*. Mo. SI'So t jvo. -f CSOPYRIGHTED, 1888. I. J. >I. GOSS. f PREFACE. HEN I wrote the American Practice,which was published nearly six years ago, there was no work giving the indi- cations for direct remedies except some homoeopathic works. As the American Practice by me has had a rapid sale, notwithstand- ing the many drawbacks to its sale, I am encouraged to write this work, entitled "The Practice op Medicine; or, the Specific Art of Healing," which is a larger work, and to take the place of the above-named work. I shall draw some items from the pathology of my former small hand-book, or American Practice, but the therapeutics will be very greatly improved, owing to the fact that many remedies have been tested, and being found very valuable, have been introduced; then there have been many valuable discoveries in the etiol- ogy of a very large number of epidemic diseases, hence the necessity for this larger work, "The Practice of Medicine; or, the Specific Art of Healing." In pathology I acknowl- edge my indebtedness to Green, Virchow, Koch, Skoda, Hebra, Hale, Da Costa, Davis, Bartholow, and others, from whom I have drawn many pathological facts, as it suited me. While I was taught the time-honored system of Paracelsus, in the medical department of the University of Georgia, and in that of Philadelphia, I do not hold to exclusive dogmas, nor have I allowed predilections to sway my judgment. I have endeavored to avoid extremes, and give that treatment for W iv THE PRACTICE OF MEDICINE. diseases which an experience of forty-five years have proveo successful. I do not claim, as I also stated in my former work, perfection for this work in the healing art. But I again make an humble attempt to add some new facts to the long- accumulated fund of therapeutical lore. I have witnessed the fatal mortality or death-rate under the old routine treatment of our epidemic visitations of diphtheria, scarlatina, dysentery, pneumonia, yellow fever, and hemorrhagic fever, etc., and I have seen also the success of the more rational treatment, based upon the pathology and symptomatic indications of rem- edies. Success in the healing art can be attained only by the special recognition of the pathological peculiarities existing in each epidemic visitation of diseases. Then, a thorough knowl- edge of our remedies is essential, to enable us to meet the various indications pointed out by the symptoms. The reme- dies that are successful in one epidemic visitation of a disease, may not be followed by a like success in another epidemic of the same disease. Hence the absolute necessity of carefully noting the special pathological peculiarities in every case of disease, and thus suiting the remedy to the condition. It will be noticed that I give smaller doses than are usually advised, and that is from the fact that more concentrated fluid preparations are made, such as "normal liquids" and fluid extracts. Normal liquids being assayed, contain a given quan- tity of the medicinal constituents of the plant from which they are made, hence the very great certainty of action of these nor- mal liquids. Tinctures made from crushed dry roots, barks or leaves are about equal to the 1st decimal tincture of the homoeopathic pharmacists; and when made from articles not PREFACE. V deteriorated they are reliable, but are required in much larger doses than normal liquids or good fluid extracts. The dose of medicines can not be given precisely; it is only approximative in each case. The dose that will affect one therapeutically, may produce toxical effects upon another. But there is one grand therapeutical truth to be remembered, and that is, the dose of medicine to be remedial must be short of a toxical dose, unless it is in cases where we desire the toxical or phys- iological effects, as in cases where we desire to purge, or pro- duce emesis, or anaesthesia. A certain dose is not required to produce the therapeutical effect, as the remedies are endowed with direct powers, and act accordingly. TABLE OF CONTENTS. Preface..........__________.................................... iii Introduction.....................____..............................xxv CHAPTER I. Principles of Medicine..............._............................... 1 Secretions_ _..................................................... 2 The Solids..................................■_.....?............... 3 Secretions......................................______.....___ 6 Hyperplasia ................--...................----........ 6 Alteration of Function........................._........________ 7 Alteration of Structure......._______............................. 8 CHAPTER II. Diathesis.......- ...........--------- ........................... Diathesis of Climate................-........................--- 11 The Gouty Diathesis ...........-............................--- 12 The Peculiarities of the Nervous Diathesis......................... 13 The Strumous Diathesis.........-...........----................ 13 The Bilious Diathesis___________...............-................ 14 The Lymphatic Diathesis.....____..............-...........--- 15 CHAPTER III. Vegetable Parasites____..............-.........................- 17 History of Vegetable Parasites---.............-..................- 19 Antiseptics...........-.................... ...................-- 19 Spontaneity of Production......................------.......--- 22 Organisms in Living Tissues....................--------......-- 22 Classification of Bacteria...............................---........ 22 Acute Specific Diseases............................................ 23 Contagious Diseases...................-.......-................... 23 Miasmatic Fevers......------.........................-........-- 23 Contagio-miasmatic Diseases..........._..........-----..........- 23 Septic Diseases------............................................ 24 The Schizomycetes............-.......-.................-........ ^4 CHAPTER IV. The Laws of Therapeutics, or the Specific Action of Medicines.. 27 CHAPTER V. Dietetics (Hygiene)...............---.........................-- 43 CHAPTER VI. Dose of Medicines...............----............-.....------- ^7 List of Drugs ... -...... ---................................... 4S vii viii contents. CHAPTER VII. General Remarks upon the Leading and Most Prominent Symptoms of Disease............___....................................... 55 The Pulse____________....................................... 55 The Temperature of the Body___................................ 56 Respiration....................................._____.......... 57 The Tongue...................................................... 57 Pain......................................................... 58 The Skin........................................................ 58 The Urine....................................................... 59 Examination of Urine____.....___...............___.....____ 60 EarthyPhospha1.es................................................ 60 Urea_____................................................... 60 Test for Urea............................._...................... 61 Pus in the Urine..........................._______............. 61 Bile Coloring Matter in Urine...................................... 61 Blood in Urine....................._....................___..... 61 Uric Acid............_____..........._______..............___ 61 CHAPTER VIII. Diseases of the Blood „..................__......................... 63 Cyanosis............................____..........._.........._ 65 Causes......................____......._____............... 65 Symptoms__________.............___....................__ 64 Treatment..........................__.........____.....__ 64 Anaemia.........................._________..........__________ 64 Causes____......._____..................................... 64 Symptoms................................................... 64 Treatment...................._......._..........._.......... 65 Oligocy thaemia.................................._____........... 65 Treatment.................................................. 65 Leukaemia___________________......________.................. 65 Symptoms____________............_______.....__......... 65 Treatment.............................._______............. 66 Chlorosis___..................................................... 66 Symptoms................................._______________ 66 Treatment.........................................._........ 67 Scurvy............._____....................................... 67 Causes....................................................... 68 Treatment................................................... 68 Poisons—Vulnera Veneno-Infecta______________________________ 68 Poisoned "Wounds............................................ 68 Treatment........___................................... 68 Bites of Rabid Animals................____...............__ 79 Purpura Hemorrhagica..............._____............._......._ 70 Treatment...................___........................... 70 Scrofula______.................................................. 71 Treatment................................................... 72 CHAPTER IX. Fevers: The Exanthemata ..................................... 73 Fever............................................................ 73 Infection, Contagion and Miasm................................... 76 CONTENTS. ix Malaria Haematuria........................................_...... 76 Post-mortem Appearances..................................__ 77 Treatment.................................................... 77 Typhoid Fever..............................................____ 78 Causes..................................................____ 79 Symptoms.................................._______......... 79 The Eruption................................................ 80 Temperature ...........___..........................._____ 61 Complications__________________________......___________ 81 Treatment......................................._............ 82 Typhus Fever___.............................________......___ 84 Symptoms_______....................................._..... 84 The Pulse......____________________........................ 85 The Eruption__________________________________......___ 85 Nervous Symptoms_______________,--------------......... 86 Causes_______________________....................-------- 86 Treatment____...........................--------.......... 86 Measles____.......------...................................--- 88 Modes of Propagation___..............................----- 88 Symptoms_________...................—................... 88 Temperature-------------------...............----------- 89 Treatment......___________.........-...................... 89 Treatment of Sequelae.......______................--------- 90 Scarlatina_____________________...........--.....-.............- 91 Varieties................---.....----..............------*. 91 General Symptoms-------------......----................. 92 Distinctive Features ------------......................---- 92 Cause and Modes of Propagation.......----..........------- 93 Treatment----------------...........--------.....------- 93 Smallpox—Varioloid ---.......-.......---.......--------- 94 Course and Symptoms............----.......-.....-------- 95 Treatment..........___..........-..................------- 97 Vaccinia---------.....---........----------........-------- 99 Intermittent Fever.........----........ --......-................. 100 Causes of Intermittents—Miasm Bacilli.........................102 Treatment..................-..................-......-......103 Remittent Fever________.........-.........-..................... 106 Treatment............. .....................—.............. 107 Yellow Fever____........................................-......108 History.........-------.................................---J 08 Visitations of Yellow Fever---............-........--------- 109 Treatment.................................-...........-.....l18 CHAPTER X. Diseases of the Respiratory Organs.........................---- Bronchitis...................-.......................----...... |*0 Physical Signs..........-........----..........-.........-- |*l Treatment...........-..............---.................... ^ Whooping Cough................................................ }*- Treatment.....................-.....---............--......{** Asthma----.....-.....................................---.....V™, Treatment......-..............-............................. J*° Pneumonia--------........................................... 198 Physical Signs..........-.....-..........................---if? Treatment.......................-..................-.....--- ldU X CONTENTS. Phthisis.....................................................----132 Tubercles.................................................... 132 Symptoms......................___....................'----132 Treatment..................................................- 133 Hygienic Treatment.......................................... 136 Emphysema....................................................-- 137 Diagnosis......................................___1.........138 Treatment..................__....._....._......_...........138 Pleurisy_____..............................._______............ 139 Symptoms_______........__....................._____.....140 Physical Signs.......__________......_____.................. 141 Palpation..........................__________......---141 Percussion........___........_____......_____________141 Auscultation............................................. 141 Treatment...................................................141 Haemoptysis.......-.............______________________.....---142 Treatment................_______..........................143 Pneumothorax............................................______143 Physical Signs...................................._____...... 144 Differential Diagnosis____......................___.......... 145 Treatment................................................... 145 Hydrothorax_____________..................................... 145 Symptoms_____________..............--------.............146 Treatment...................................................146 CHAPTER XL Diseases of the Heart—The Heart—Its Examination by Ausculta- tion............................................................... 149 Pericarditis...................................................... 151 Symptoms.................____........___................_ 152 Physical Signs................................................ 152 Inspection................_..............................152 Palpation................................................ 153 Percussion......................................________153 Treatment.................................................... 153 Hydropericardium__.........................................___154 Symptoms.................................____............. 155 Physical Signs-----.............................___________155 Treatment...............................................____155 Insufficiency of the Mitral or Bicupsid Valves........___.......... 156 Constriction of the Left Auriculo-ventricular Opening............__157 Defective Aortic Valves........____........................_____157 Signs . ------------.......-.............................. 157 Constriction of the Aortic Opening...................____........ 158 Physical Signs......____..................................__158 Defective Tricuspid Valves........................................ 158 Physical Signs................................................ 158 Treatment of Valvular Disease of the Heart_____...........__158 Endocarditis......-----......................................... 159 Symptoms_____...............------....................... 160 Physical Signs................................................ 160 Percussion------------..........................._____160 Treatment----------------................................. 161 Hypertrophy and Dilatation of the Heart ..........................161 Signs.........................-.-..............-.............162 Treatment___.....-------..................................162 CONTENTS. xi Nervous Palpitation of the Heart.................................. 163 Causes......................................................163 Treatment___.................._............................164 Angina Pectoris.................................................. 164 Treatment........................____....................._ 165 Diaphragmitis....................................................165 Symptoms.................................................. 165 Treatment................................................... 166 CHAPTER XII. Diseases of the Digestive Organs.................................. 167 Dyspepsia-------------------...................___........ 167 Symptoms....................................................167 Treatment..........................___...................... 168 Acute Gastritis-----............................•..............__ 171 Causes_____......_................._______.........____ 171 Symptoms........------..............___-------------- 172 Treatment___________............................________ 172 Chronic Gastritis________.......__.......__...................173 Symptoms____________..................................... 173 Treatment_________......................................... 173 Gastralgia............--..........................................174 Treatment..........____............_____................. 175 Perforating Ulcer of the Stomach..........................._____175 Symptoms______......___________________......_.......176 Diagnosis____.........................................-----177 Treatment___________...................................... 177 Cancerof the Stomach...................................------- 177 Symptoms..................----.............................178 Treatment................................................... 178 Haematemesis_________...................-------------.....178 Causes_____.........__...................-...........---- 178 Pathological Conditions---------............................ 179 Sjrmptoms................----------------------.........179 Treatment..............................-............-------179 Gastromalacia......................—.......—.....---........180 Symptoms..........................-.......-------------- 180 Treatment...........____........................-........-- 181 CHAPTER XIII. Diseases of the Intestinal Canal................................. 182 Intestinal Catarrh................................................. 182 Causes.. .............................. ---................. 182 Symptoms......................-.............-............... 182 Treatment_________.....................-..................182 Chronic Intestinal Catarrh...........................-............. 184 Causes...............................-....................... 184 Symptoms................-................................... 18* Treatment_____.............................................184 Typhlitis and Perityphlitis..........................-............. 185 Symptoms..................................................-- 186 Differential Diagnosis...............................----- 186 Treatment....................................................18" xii CONTENTS. Proctitis____.................................................... 187 Symptoms____.......................................------ 187 Treatment....................__......._........___........ 188 Dysentery____...................._____.................._____188 Symptoms ...__........... ..........___.................. 189 Prognosis............___............................._____ 190 Treatment................................................ 190 Cholera......................................................... 191 Causes________.....________...........................- 192 Treatment.................................................... 193 » Cholera Morbus.................................................. 194 Causes________..................___......._____......___194 Treatment....................________....._—...........- 194 Cholera Infantum_______.........._____......_____......____ 195 Chronic Constipation_______..................____.........___195 Treatment............________________________.....____196 Intestinal Haemorrhage.......________________......-........-- 197 Treatment.................._________.............._.......197 Haemorrhoids___...............___________________......... 197 Causes______........________....._..........._________ 198 Symptoms......._..............................______......199 Treatment............................_______........_____ 199 Peritonitis................................................._____201 Causes.................................___________........ 201 Symptoms____...........________..........................202 Treatment_______...........................................202 Enteralgia................_____..................._________203 Symptoms........____......____...............__________204 Treatment..................____....................._____204 Ascites............................______...............______205 Symptoms----------------........................______205 Treatment________•_..................____................ 206 Intestinal Worms..............------------------- ._____207 Symptoms................._______........_________.......207 Treatment................__..................................208 Ascaris Lumbricoides........___.....----.......____________ 208 Symptoms............---....................................209 Treatment_____.....__________ ___...................... 209 Taenia Solium---......______________........................ 209 Symptoms----- ........---............................___210 Treatment.................................................... 210 CHAPTER XIV. Diseases of the Liver.............................................. 212 Hyperaemia..................................................___212 Symptoms---................................................212 Treatment................---............................... 212 Torpidity of the Liver............................................ 213 Hepatitis....................................................---- 215 Symptoms...............................................----216 Treatment................................................ ... 216 Cirrhosis of the Liver................. .......................... 217 Causes.......................................................218 Diagnosis---................................................ 218 Treatment...............................----............... 218 CONTENTS. Xlll Acute Yellow Atrophy of the Liver................................219 Symptoms....................................""..'.".'.'.'.'.".".'.'. 219 Treatment..................................................._ 220 Cholecystitis ._................................. _................220 Symptoms_____..............___.........................~ / 221 Diagnosis----.................................l'."~""l"'.'. 222 Treatment____........_______................_.............222 Jaundice_____________........................................_ 223 Treatment..........______________.....___............... 224 CHAPTER XV. Diseases of the Spleen............................................228 Physical Examination............................................. 228 Splenitis...........................____........................ 228 Symptoms......................................_______......229 Treatment............................................■_....._. 229 CHAPTER XVI. Diseases of the Pancreas..........................................231 Pancreatitis...................................................... 232 Treatment........____.....______........................... 232 CHAPTER XVII. Diseases of the Kidneys...........................................233 Diabetes Mellitus.................................._.......______236 Symptoms....................................................236 Treatment................................................___236 Haematuria____.........._____.........._____.......____......237 Causes________.......................................______237 Treatment........................_________..........._____238 Acute Bright's Disease____..............................--------239 Causes____..................._____......................... 239 Symptoms--------____________............................239 Treatment___...............__________....................239 Chronic Bright's Disease _......._________.......____....._____240 Causes____.......______......_____.......................- 249 Symptoms___..........._____................._.....______240 Treatment_____.............................___..........241 Interstitial Nephritis.............................................. 242 Causes..................................................---- 242 Symptoms...............---................................ 242 Treatment________..............______.......------------ 243 Renal Colic...................................................... 243 Symptoms____..........................................---243 Treatment......................-............................. 244 CHAPTER XVIII. Diseases of the Bladder......----..................----...... 245 Cystitis____..................-......................-..........245 Causes.....................-................................. 245 Symptoms........................-.........................-- 245 Treatment.................................................... 246 xiv CONTENTS. Vesical Calculus.................................................. 247 Symptoms......_____...........................----------247 Treatment...............................................----248 CHAPTER XIX. Diseases of the Male Organs of Generation....._............... 250 Gonorrhoea _................__........................-......---250 Symptoms......................................-.............250 Treatment................................................... 252 Sequelae...............____............------------------253 Treatment of..................................--......--- 253 Vesical Gonorrhoea.......................................-......- 254 Bubo_____..................................................... 254 Stricture of the Urethra...........................................254 Treatment.........................................-----.....255 Syphilis..........................................................255 Constitutional Syphilis...........................................256 Treatment................................................... 258 CHAPTER XX. Diseases of the Testes............................................. 262 Hydrocele........................................................ 262 Treatment.................................................... 263 Orchitis____.....................................................263 Treatment................................................... 264 Varicocele..................................____................264 Treatment..............................................____264 Impotence.....___......______________......._________________265 Treatment...................................................265 CHAPTER XXL Diseases of the Prostate___.........---..............________267 Prostatitis........................................................267 Symptoms----........................................_____267 Treatment..................................... _____.......268 Onanism---................................................____269 Spermatorrhoea...................................................276 Treatment...........................................________277 CHAPTER XXII. Diseases of the Female Generative Organs........................ 279 Ovaritis..........................................................279 Causes.......................................______........279 Symptoms...................................................279 Treatment...................................................279 Ovarian Dropsy.................................................. 281 Symptoms .................................................. 281 Diagnosis................................................__282 Treatment...................................................282 Leucorrhcea......................................................283 Pathology....................................................283 Symptoms...................................................284 Treatment...................................................284 CONTENTS. XV Acute Parenchymatous Metritis........................-.........-- 286 Causes........................................-............-- 286 Symptoms___________........---------.........-------286 Prognosis........______.....-......—......... ---------286 Treatment_________________.........---------..........287 Chronic Parenchymatous Metritis.....................-......----288 Causes_______________................-----------------288 Symptoms......_____........---------..........-.........289 Treatment......................---.......---...............289 Puerperal Fever__________________________________.........289 Treatment____________.................-----.....-......290 Anteversion of the Womb.........................................291 Symptoms__......___________________.....---..........291 Retroversion of the Womb........___________________......--- 291 Prolapse of the Womb....................-----------........--- 292 Symptoms____________________________________........292 Treatment of Uterine Displacements------------.......----292 Polypus of the Womb____________________________..........294 Treatment____....._____......________________________ 294 Cancer of the Womb___......______________________________ 295 Symptoms_____________________________........------295 Treatment......._______.......---......-.................295 Metrorrhagia........____________________________...........296 Treatment......__.....--------------.........-......---297 Menorrhagia_________.....------.....--------------------297 Causes______.............................-.................. 297 Treatment____.......................---...........-........298 Amenorrhoea-.._____________.....-----......--------------299 Treatment.........................---..............--.......299 Dysmenorrhea____________________________..............--- 300 Treatment.................—.....-.......--......----......301 Pruritus Vulvae................-...........-......-...............302 Treatment____.............-.....-.........-................ f02 Mastitis___......................-......-...........•.......... - f03 Treatment........................................-..........jjjjjj Scirrhus, or Cancer of the Mammae........................--------a0<* Cause..................------...........................-----304 Treatment...............................................----304 CHAPTER XXIII. Diseases of the Spine...........-................................... 305 Anaemia______..........-......................................305 Hyperaemia-----.......................................-........ °^5 Symptoms...........................................-....... «g Treatment..................................................^Ub Spina Bifida.........-............................................ fOb Treatment.................................----............. <£>' Spinal Meningitis.............................................°07 Pathology................................................... ^07 Symptoms...................................................«"• Treatment.............................-----................ j™' Myelitis..........................................................308 Pathology................................................— - jjg Symptoms..............................................-.....gg Prognosis..................................................*« Treatment____..........................-...................dua XVI CONTENTS. Multiple Sclerosis—Chronic Myelitis...............................310 Causes............................___.......................311 Symptoms...................................................311 Treatment................................................... 311 CHAPTER XXIV. Diseases of the Motory Apparatus.............__________......312 Rheumatism___..................................-----------312 Acute Rheumatism............................---............— 312 Predisposition-........---......._____.............•-.........312 Symptoms.................________________________...... 313 Treatment_____..................................----.....- 313 Chronic Rheumatism................______...........-..........314 Treatment...................___..................-.........315 Gout.......................................................____317 Treatment............_____............................----318 CHAPTER XXV. Diseases of the Osseous System.........._..........................320 Rachitis...................................... ....................320 Treatment...................................................321 Osteitis; Exostosis................................................ 321 Causes...........................___................_______321 Symptoms..............................................____321 Treatment................................................... 322 White Swelling.................................................. 323 Coxalgia_____...................................................324 Symptoms...................---.........................__324 Treatment................................................... 325 Genu Album...........................___...................... 325 Symptoms................................................... 326 Treatment...................................................327 CHAPTER XXVI. Diseases of the Nervous System...................................328 Neuritis..........................-------.....................328 Treatment................-------.................._____328 Neuralgia....................................................... 328 Symptoms ..........................................._____329 Treatment.............................................____330 Ticdouloureux................................................__ 330 Treatment---............................................." 331 Cervico-occipital Neuralgia....................................___332 Treatment...................................................333 Anaesthesia----.............................................____333 Trigeninal Anaesthesia.........................................._. 333 Causes...........------.....................................334 Morbid Affections of the Motory Nerves----...................._" 334 Spasms, Convulsions, Cramps.....................................334 Causes.....................................................^~ 335 Exciting Causes..............................................335 Prognosis................................................'_""" 335 CONTENTS. xvii Chorea.......................................................... 336 Symptoms..............................................____ 335 Causes______..............______........................_ 337 Treatment........___....................................... 337 Hysteria...........................................----'..'."" 338 Etiology..............---------------...............____338 Symptoms..............-----------................_____338 Treatment_____........................_________„_„_____339 Trismus ; Tetanus_________........___......._____________ 340 Trismus Neonatorum.......____....................__________ 341 Causes---------...........................................342 Treatment..................................._____________342 Catalepsy............___................______________....._. 343 Causes__________...................................._____343 Treatment........................._........___..........__344 Epilepsy-----.........................._.........___.......... 344 Symptoms........................._......................... 344 Causes____.........__________________...........______345 Differential Diagnosis...................____......._______ 346 Prognosis_________............_.............___________346 Treatment.......___________............____............344 Acute Eclampsia: Puerperal Convulsions..............._________347 Treatment____...................______...............___348 Paralysis Agitans................................................. 349 Causes-----................................................ 349 Treatment___..............._______..........._________349 Paralysis______......_.........________..........__________ 349 Treatment__....._____......._......_____........._____350 Hydrophobia______......._______..........___...........___351 Premonitory Symptons.............__________.............. 351 Pathology........_________........................______352 Diagnosis..............._........................._________352 Treatment...............................................___353 CHAPTER XXVII. Diseases of the Skin............................................... 354 Acne......................_____...............................354 Treatment...................,...........................___355 Alopecia------------...............___................._.....356 Treatment.................................................... 356 Ichthyosis.....__........__________________________........356 Diagnosis.................................................... 357 Treatment___......____.....................................357 Dermatitis Contusiformis........._____.........________........ 358 Treatment............_____................................. 358 Herpes.....____........____.............................____ 359 Treatment...................................______......... 359 Urticaria..................................____.................. 360 Causes.......................................................360 Treatment.........................___....................... 361 Eczema.......................................................... 362 Causes....................................................... 362 Chronic Eczema___ _.......................____........._____363 Diagnosis.................................................... 364 Treatment_____........._____ ..................._____ 364 xviii CONTENTS. Impetigo Contagiosa..............................._..............367 Diagnosis.................-......-----........_____________368 Treatment.................................................... 368 Ecthyma......................................................... 369 Treatment___................................................369 Pemphigus________________________..............---.....-----370 Treatment..............................................-.....371 Rupia..........................................-................. 371 Treatment________........................................... 372 Furuncle....................-.......-............................ 372 Treatment________...............—.....------------------ 373 Carbuncle______________.....---..........--------------------373 Symptoms____.....-------.............--------........... 373 Treatment..................................................374 Malignant Pustule...................................-......-.....374 Treatment................................................... 375 Epithelioma...................................................... 375 Diagnosis.....___________________________________________ 376 Treatment........................_____.....................376 Paronychia......_____........................________________377 Treatment...................................................377 Felon............................................................ 378 Treatment...................................................379 Psoriasis...................._............____.......___________379 Symptons.................................................... 379 Causes..............................................._______ 380 Diagnosis.................................................... 380 Treatment..........________.....___.........._____.......380 Lichen Planus, Lichen Simplex, Lichen Agrius, Lichen Tropicus____381 Prognosis...............................................____382 Treatment................................................... 382 Prurigo: Pruritus—Itching........................._..............383 Causes..........................................._...........383 Diagmosis................................__.................384 Treatment................................................... 384 CHAPTER XXVni. Diseases "of the Scalp______________..........................388 Anatomy___......................________................... 388 Rheumatism_____________________.............._______388 Treatment________.......________...........___.....388 Dropsy of the Scalp...................________............______389 Treatment_____________...........________________________389 Erysipelas of the Scalp and Face.......................__________390 Causes___________________________________________________ 391 Symptoms----...............-----------------------------391 Diagnosis--------------.......-----..............________392 Prognosis_______________________________................._ 392 Pathology-------------------------................______ 392 Treatment______________________________.................. 393 Eczema of the Scalp____________________............___________ 394 Diagnosis___________.....--------------..........._______ 393 Causes_______________......--------................______ 394 Treatment-------------.........---............._________ 394 Seborrhoea Capilli and Vernix Caseosa---------------.......________ 395 Treatment_______.......- -......----------........________ 396 CONTENTS. Xix Favus—Tinea Favosa.........______.............................397 Diagnosis............................................"..""." 398 Treatment____..........._______.....................'."'..'. 398 Ringworm—Tinea Circinata......__________....................399 Diagnosis_____....._____________..............________400 Treatment............................_____..............__ 400 Vascular Naevus............_____....._____.........._.......400 Treatment_____....._______________________________401 Alopecia Areata; Simple Baldness__________________________401 Treatment.................................._____________402 CHAPTER XXIX. Diseases of the Brain____......_______.........................403 Anaemia_______..............._________________............ 403 Causes_____............_________................______403 Symptons______......_____________....._____________ 403 Treatment_________________________________________403 Insomnia—Wakefulness__________________________________ 405 Treatment_______.......____________..........._______407 Hyperaemia of the Brain....._________________......._______410 Congestion of the Brain______________________........._____410 Causes__________________________....................410,411 Symptoms__________________________......_______:... 412 Treatment___......__________________________________412 Vertigo_______________________________________________413 Treatment___________________________________..____414 Tubercular Meningitis___________________________________ 414 Symptoms_________________________________________ 414 Diagnosis__________________________________________ 415 Treatment_________________________________________415 Acute Meningitis_______________________________________ 416 Causes____________________________________________ 417 Symptoms_________________________________________417 Treatment__________________________________________418 Cerebro-spinal Meningitis_____________________________________419 Symptoms______________________________________________419 Sequelae________________________________________________ 420 Diagnosis_______________________________________________420 Treatment______________________________________________ 421 Sunstroke___________________________________________________ 422 Causes__________________________________________________ 422 Pathology_______________________________________________422 Symptoms______________________________________________422 Treatment______________________________________________423 Apoplexy___________________________________________________424 Varieties________________________________________________ 424 Symptoms______________________________________________ 425 Predisposition____________________________________________ 425 Causes__________________________________________________ 426 Diagnosis___________1___________________________________ 426 Treatment_______________________________________________427 Thrombosis: Embolism_______________________________________427 Predisposing Causes______________________________________428 Symptoms______________________________________________428 Diagnosis________________________________--------------428 Treatment_______________________________________________428 XX CONTENTS. Aphasia.........................................................429 Treatment______________________________________________429 Thrombosis of the Cerebral Sinuses______................--------430 Symptoms.....__________.....___.....-----.........-----430 Prognosis_______________________________________________ 431 Treatment______________________________________________431 Dementia Paralytica__________________________________________432 Pathology______________________________________________432 Causes__________________________________________________432 Symptoms______________________________________________432 Senile Dementia______________________________________________433 Treatment______________________________________________434 Delirium Tremens____________________________________________434 Treatment______________________________________________435 Dipsomania—Chronic Alcoholism_______________________________436 Physical Degeneration____________________________________436 Treatment.....__________________________________________437 Opium and Morphia Poisoning_________________________________437 Treatment______________________________________________438 Tumors of the Brain and its Membranes_________________________439 Causes_____........____________________________________439 Symptoms................._______________________________440 Treatment....................______....._________________441 CHAPTER XXX. Diseases of the Eye........_____________________________442 Diplopia.....................__________________________ 445 Hyperaemia of the Conjunctiva_________________________________446 Treatment____...........________________________________446 Conjunctivitis_______________________________________________ 447 Causes__________________________________________________447 Symptoms______________________________________________448 Treatment______________________________________________448 Catarrhal Conjunctivitis______________________________________448 Symptoms______________________________________________449 Treatment______________________________________________449 Complications____________________________________________449 Chronic Conjunctivitis________________________________________450 Purulent Conjunctivitis_______________________________________451 Diagnosis_______________________________________________451 Treatment______________________________________________451 Military Ophthalmia_________________________________________452 Treatment______________________________________________453 Opthalmia Neonatorum____1__________________________________453 Causes________.......___________________________________453 Treatment______________________________________________453 Gonorrheal Conjunctivitis____________________________________454 Treatment_____________________......___________________455 Diphtheritic Conjunctivitis____________'________.........______456 Symptoms--------------------------------........._____456 Treatment_____________________......__.....____________456 Acute Granular Conjunctivitis_______.........................___457 Causes________..........------..........................__457 Chronic Granular Conjunctivitis___...................._........._ 457 Treatment....................................................453 CONTENTS. xxi Scrofulous Conjunctivitis___________________________.....______460 Diagnosis............_____________________________________460 Treatment_______________________________________________461 Phlyctaenular Conjunctivitis____________________________________461 Symptoms_______________________________________________461 Treatment_______________________________________________461 Phlyctaenular Corneitis_________________________________________462 Treatment_______________________________________________462 Ulceration of the Cornea_______________________________________462 Symptoms_______________________________________________463 Treatment_____._________________________________________463 Corneitis____________________________________________________464 Treatment_______________________________________________465 Anterior Staphyloma__________________________________________466 Episcleritis___________________________________________________466 Hyperaemia of the Iris_________________________________________466 Causes___________________________________________________466 Treatment_______________________________________________467 Simple Iritis_________________________________________________467 Suppurative Iritis____________________________________________467 Serous Iritis__________________________________________________468 Pathology_______________________________________________468 Causes___________________________________________________468 Prognosis________________________________________________469 Treatment_______________________________________________469 Choroidal Hyperaemia_________________________________________ 470 Treatment________________________________1_____________470 Simple Choroiditis____________________________________________471 Treatment_______________________________________________471 Suppurative Choroiditis_______________________________.....---472 Symptoms_______________________________________________472 Causes_____________________________________________._____472 Treatment_____________________________________.......___472 Complications____________________________________.....---472 Hyalitis_____________________________________________________473 Treatment_______________________________________________473 Muscae Volitantes_____________________________________________473 Treatment________________________________________________474 Glaucoma____________________________________________________ 474 Pathology and Cause_______________________________________475 Treatment________________________________________________476 Retinal Hyperaemia-------------------------------------------476 Causes____________________________________________-------476 Retinitis______________________________________________________477 Causes______.....________________________________________477 Prognosis........-----------------------------------------477 Causes and Treatment______________________________________478 Optic Neuritis........_________________________________________478 Treatment...........______________________________________479 Atrophy of the Optic Nerve_______________________________.....479 Causes....................---------------------------......480 Prognosis________________________________________________480 Treatment________________________________________________480 Amblyopia___________________________________________________481 Diagnosis________________________________________________481 Causes___________________________________________________481 Treatment_______________________________________________481 xxii CONTENTS, CHAPTER XXXI. Diseases of the Ear.................................................483 Inflammation of the External Ear______.........................483 Symptoms_______.............----........................483 Causes_______________________..............-...........484 Treatment_____________________.............----------484 Boils in the Ear______________________...........----------484 Cause_________________________.........-------.......484 Diagnosis___________________---............-----......485 Treatment_________________..........-......-----......485 Abscess of the Ear____________________............--------485 Treatment___________________......-..........---......485 Eczema of the Ear__________________................-........485 Treatment____________________................-.........486 Simple Otorrhoea__________________...............------«■-- 487 Treatment________________________..........--.......-- 487 Aspergillus____________________________________________487 Symptoms_________________________......-----------487 Diagnosis______________________________________.....488 Treatment____ ____________________________________488 HardeD ed Wax_________________________________________488 Causes______________________________________........489 Symptoms____________________________________.......489 Diagnosis__________________________________________489 Treatment.........__________________________________489 Foreign Bodies in the Ear_________________________________490 Insects in the Ear_________________________________........491 Treatment........_______________________......-.......491 Catarrh of the Ear__________________________________.....491 Symptoms.......____________________________________491 Prognosis........______________________________......- 492 Treatment........___________________......-----.......492 Chronic Otorrhcea______________..................----.......493 Symptoms.............-----................----..........494 Treatment.....................................---...........495 CHAPTER XXXII. Diseases of the Nose..................----.....................496 Catarrh—Coryza.................------.......-----..........496 Causes.........................----......................... 497 Treatment......................-----------............... 497 Chronic Catarrh—Ozaena...................-----.................498 Symptoms...................................................498 Treatment..........................--.......................499 Influenza______...........................-............------500 Causes_____................................................500 Diagnosis..........................................-------500 Treatment____.................................._________500 Rose Cold—Hay Fever........................................___500 Causes_____.............-..................................501 Treatment...................................................501 Epistaxis____...................................................501 Causes_________.....-.....................................501 Treatment____.............................................. 502 CONTENTS. XX111 CHAPTER XXXIII. Diseases of the Face........._____________......................503 Erysipelas..........................----......_______.........504 Treatment........._____________........______..........505 Milk Crust..........._______.......-........_______..........905 Treatment................-.......-.......__________......506 Acne Punctata—Acne Rosacea_______.........--------------506 Treatment............_____.................-......-------507 Lupus_____..............-...............................-----508 Symptoms..............................................----508 Treatment...................................................508 CHAPTER XXXIV. Diseases of the Mouth and Throat.....----......................512 The Tongue in Diagnosis..............--------------.........512 Glossitis—Inflammation of the Tongue................----------514 Symptoms_____.....---------.....---------........----514 Treatment........................--------------......---515 Cancer of the Tongue_________......----------------......- - 516 Treatment_____________......---------------------........517 Inflammation of the Gums----.....---------------------------- 517 Treatment________________......-------------------------- 517 Dentition_______________________________________________......518 Treatment________________________________________________519 Decay of the Teeth_________________________________.......----519 Treatment...........-----------------...........---------519 Odontalgia _______.....--------------------...........-------520 Mumps—Parotitis Contagiosa-----------------................-- 520 Diagnosis_____.......---------------...........—.....— 521 Treatment........__________________........-.............- 521 Symptomatic Parotitis---------------------................----522 Treatment......-----------------------------------......-- 522 Tonsillitis......____________.....-.......---------------------- 523 Symptoms_____.............------------------------------523 Diagnosis________________........-------------.......-----523 Treatment.........._________________............-.......... 524 Uvulitis—Inflammation of the Uvula----------------------------525 Treatment...........------------------------------......-- 525 Laryngitis—Laryngo -Tracheitis......----------------------------526 Causes____________.........------.....-------------------526 Pathological Changes--------- - -.......-------------------526 Symptoms---------------------......----..........-------527 Treatment_______________________________.........--------£*' Angina Faucium: Sore Throat------.......-.........-----------528 Causes---------------.......---......------..........----528 Treatment____________________..........--------......---jj*° Chronic Sore Throat------------............................----5*9 Clergyman's Sore Throat......-------.........--------.....----52U Treatment _________________________-____-__________uou Thrush—Parasitic Sore Mouth of Infants.................--------530 Symptoms................................-----.....-.......530 Remote Causes------------.....---.......-----.....-------£;* * Treatment------------------......................---------5dl CancrumOris------------------------................---------«*" Treatment_________________________........-..............066 Xxiv CONTENTS. Diphtheria______________________.......-----------.......... 533 Sequelae___________ ___________________________________ 537 Diagnosis_______________________________________________ 537 Prognosis________________________---------------------- 538 Treatment______________________________________________ 538 Noma....._________________________________________________ 540 Treatment........________________________............---541 CHAPTER XXXV. Diseases of the Larynx and Oesophagus-----------.......---542 Bronchocele—Goitre_________________________.....----542 Treatment______________________________------542 Oesophagitis____________________________________------.----542 Symptoms_______________________ --------------------- 543 Treatment................................................... 543 Stenosis Oesophagi................................................ 543 Symptoms....................................------........ 544 Treatment...................................................544 Acute Laryngitis........................................_........ 544 Causes_________________________________________________545 Treatment______________________________________________545 Chronic Catarrhal Laryngitis___________________________.______546 Symptoms______________________________________________546 Treatment______________________________________________546 Croupous Laryngitis_________________________________________547 Differential Diagnosis_____________________________________547 Treatrnent______________________________________________548 (Edema of the Larynx_______________________________________548 Symptoms_________________._____________________________549 Treatment____....._____________________________________549 Tubercular Ulceration_______________________________________550 Diagnosis............_____________............___________ 550 Prognosis........._____________..............------------550 Treatment__________________...................__________550 Spasms of the Glottis___.....---................-------------- 551 Symptoms________.......................................... 551 Treatment...................................................552 INTRODUCTION". IN introducing this work on direct therapeutics, or the prac- tice of medicine in accordance with pathology, I am aware of the fact that many physicians disbelieve in the idea that there are direct or " specific " powers in remedial agents. But, according to the old way of prescribing, there can not be any very definite results looked for. To name a disease, and rou- tinely prescribe for that name, regardless of the pathological peculiarities presented in each individual case, will never be attended with success. The profession have hitherto ignored pathological indications for remedies, and prescribed empiri- cally. Then again, for the want of a definite knowledge of the direct or "specific" affinity of remedies for certain organs or tissues or parts, and a want of the knowledge of the precise therapeutical action of our remedies, our therapeutics has been uncertain and indefinite, and will be until we more thoroughly test our remedies. The old rule of treating disease by name, regardless of specific indications, as directly pointed out by symptoms, has proven a blighting curse to the unfortunate sick; and with the dawning light of advancing science, should now be abandoned and buried with the relics of the past. The sad mortality of many epidemics—of diphtheria, scarlet fever, yellow fever, dysentery, pneumonia and other diseases, shows the ill-success of this routine practice. And looking back forty years at the fatality that attended the crude and unsci- entific therapeutics, every man in that benign profession of " healing" should be induced to investigate more carefully the resources of his art. A system of practical therapeutics, based upon a well XXV XXVI INTRODUCTION. defined indication for a certain remedial agent or agents, is cer- tainly more rational than to prescribe for a mere name. Many of the most eminent men engaged in the practice of medicine, such as Ringer, Brunton, Potter, H. C. Wood, Bartholow and others, acknowledge the well proven fact that some of our reme- dial agents, when used in accordance with their pathological indi- cations, are very positive in their therapeutical effects, viz: Belladonna, for congestion of the venous capillaries; digitalis, for a feeble heart; aconite, for an irregularly acting heart, or for fever and inflammation; salicylic acid for arthritic inflam- mation ; quinine in periodical fever. But there are many more remedies that act as definitely as those above when given in accordance with the peculiar pathological peculiarities calling for them. And this mode of practice is destined to take the place of the old empirical method of treatment. There are but feAv authors who mention the antiseptic effects of baptisia and eucalyptus in typhoid fever and diphtheria; aesculus in haem- orrhoids, hamamelis, in varicoses; apocynum cannbinum in dropsy; cactus and convallaria, in hypertrophy and valvular insufficiency of the heart; actsea racemosa, in the lithic acid diathesis; chionanthus virginana, in jaundice; lycopus in haem- orrhage of the lungs; rhamnus purshianas, for constipation; rhus tox., for vesicular affections of the skin, and for arthritic inflammation; bryonia, for muscular pain and inflammation; ipecac, and euphorbia, in the vomiting and purging of cholera morbus and cholera infantum; colocynth, in small doses, in colic; small doses of podophyllum, in dysentery and summer complaint of children. And there are but few writers that seem to recognize the general and universal law of affiiiity of remedial agents for certain tissues, parts, and organs. But, while, by "specific" application of medicines, given in accord- ance with their known affinity for said parts, organs and tissues, and in accordance with their special pathological indications, they usually act with great uniformity and certainty in their medical doses, yet, we do not say that a certain remedy will THE PRACTICE OF MEDICINE. xxvii cure all cases of a given disease. We simply mean that the prescribing medicines in accordance with their affinity for cer- tain parts, and in view of their proven remedial powers, is far better than the old plan that merely grouped diseases by name into classes, and prescribed for them thus by mere name with- out regard to pathological peculiarities. Disease may consist of one prominent pathological condition, or of several, and the prominent abnormal con- dition may be met by one therapeutic agent, or it may require more than one remedial agent to correct that devi- ation from a normal state of health. In many diseases there are several pathological deviations from health, and each of these abnormal conditions will require a " specific " remedy to remove them. And in diseases that have existed for some time, like continued fevers are apt to do, then there may be various lesions, dependent upon the primary lesion or cause, and by relieving the primary lesion or pathogenetic effect, this may be followed by the relief of all the said lesions. A thorough knowledge of the direct therapeutical action of our remedies, and the pathological indications afforded by the symptoms in each case is required. Upon this department I acknowledge my indebtedness to Prof. John M. Scudder, of Cincinnati, Ohio. And Prof. J. M. Scudder has very appro- priately said: " Our diagnosis must be correct." It should not be based upon generalization or the genus of disease, but upon the pathological lesions indicated unerringly by the symptoms in oach individual case. Thus we may treat disease successfully, and it is the only plan that will give the possible success. We can not expect even that this will give uniform or absolute success in every case, for this is utterly impossible to obtain, but this method approaches nearer to absolute suc- cess than the old guessing, routine system of our fathers. Medicines have a dual action, as ipecac, in relieving vom- iting and nausea, podophyllum in relieving dysentery, ergot in arresting threatened abortion, and there are many other reme- xxviii INTRODUCTION. dies whose toxical effects are just opposite to their medical or therapeutical effect. These two effects are the results of the quantity employed, hence the absolute necessity of small doses. We have said that there is a specific affinity of certain drugs for certain tissues, organs or parts, and that each drug, accord- ing to its molecular composition, exerts a "specific" action upon an organ, tissue or part, in a given dose, but, that action is quickly changed by giving very large quantities. And the action of drugs is very materially changed by a change of pathological conditions in each case of disease. And it is now conclusively proven that almost all active remedies are pos- sessed of pathogenetic as well as remedial powers; conse- quently it requires uniformity of strength in our drugs and a precise estimate of the quantity required to produce the reme- dial effect as well as the quantity required to produce the path- ogenetic or toxical effect. The fact is now apparent that a great many diseases are of germ origin, such as diphtheria, catarrh, typhoid fever and phthisis pulmonalis, and hence, in addition to treat- ing certain grave lesions, we must pay special attention to the etiology of the disease. Certain antiseptic remedies are required. And while we thus endeavor to meet the first morbid element in the disease, we may also treat the febrile element at the same time. And cholera, yellow fever, remittent and inter- mittent fevers, scarlet fever, small-pox, erysipelas, measles and many other diseases, are the products of certain specific poisons in the blood that are endowed with definite affinities and pow- ers to impress the system in a given way, upon a law peculiar to their molecular composition. And many remedies, to remove these septic conditions, must oppose these septic ele- ments in the blood, and must act upon the law of " contraria— contrariis opponenda " instead of the law of " similia simili- bus curuntur." But in other diseases there doubtless is a relationship between the action of the drug and the morbid elements of disease to be combated by the drug. It is possi- THE PRACTICE OF MEDICINE. xxix ble, from a knowledge of the affinity of a drug for a certain tissue, organ or part, to cure disease empirically, without a precise appreciation of the pathological indications calling for the said remedy; but this is more of guess work than scientific therapeutics. The best success requires that the prescriber should recognize the relationship between the morbid condi- tion—the lesion and the remedy he employs. I THE Practice of Medicine, OR The Specific Art of Healing. CHAPTER I. PRINCIPLES OF MEDICINE. THE principles and practice of medicine, as taught in the lecture room and in hospitals, include the description of morbid or pathological action, and of disease in all of its various forms, tendencies and final results, together with the selection and application of the indicated remedy or remedies in each individual case. The analysis of the peculiar morbid phe- nomena is the first duty of the healer when called to the bedside of the sick. And then, the next duty is to determine the indications to be met by his remedial agents. The nature, extent and tendencies of disease being comprehended, the treatment will become comparatively an easy matter. And here in the elementary considerations of disease we are con- fronted with the oft repeated inquiry : "What is disease?" The reply of most writers and teachers is, that it is a deviation from health in some of the organs or functions of the organic structure of our body. This does not satisfy the inquiring mind, and prompts the 2 THE PRACTICE OF MEDICINE. other question, " What is health ? " Then comes the answer : " Health" is the natural condition of the structures and organic functions of the human body. But this, too, fails to advance our knowledge upon the subject. A clear and accurate knowledge of what constitutes the standard of health must be first acquired. Then the deviations from a normal state must be also appreciated. It is necessary to study the elementary forms of morbid action in order to understand disease fully. We must study the materials of the body; first, the fluids, and then the solids. The blood is one of the fluids, holding many of the elements of disease, as well as carrying in it the constituents of nutrition. We should study the products of secretory action; and also the organized structures and the solid inorganic materials deposited in them. The blood contains not only all the products of digestion and assimilation, but also the primary products of disintegration or waste of structures, and, likewise, it carries the elementary forms of organization, known as the white and red corpuscles. And besides the white and red corpuscles, the blood contains such other nutritive elements as supply the waste of the tissues, as albumen, fatty matter, certain salts, and oxygen. It also carries such elements as are the results of disintegration of tissue, such as fibrin, extractive matter, certain salts, and carbonic acid gas. Secretions.—There are three classes of secretions in the human organization, viz.: those that are wholly effete, or excrementitious, and not to be retained without very great detriment to the system. These eliminations are from the lungs, kidneys, skin, and mucous membranes of the intestines. There are others that are to be retained for specific purposes in the system, and are either reabsorbed, or disappear by entering into new combinations of a harmless character. The saliva, the gastric fluid, and the pancreatic fluid, all enter into combination with the elements of food, and disappear in the process of digestion and assimilation. And the secretions PRINCIPLES OF MEDICINE. 3 from both mucous and serous, as well as from the synovial membranes, are of this class. These last simply lubricate their surfaces, perform an important function, and are thus indispensable. Then there are others that are partly excrementitious and partly retained to aid the digestion and assimilation. The bile is a fit example of this class, the alka- line constituents of which enter into combination with the oily elements of the chyme in the duodenum, its coloring matter and its cholesterine being thrown off as other effete matter with faeces. For a more complete account of the composition, uses, and properties of the blood and the secretions, the reader is referred to physiology and organic chemistry. The Solids. — There are certain solids entering into organized structures, which consist of five proximate ele- mentary forms of organization, viz.: the nervous, the mus- cular, the capillary, vascular, the secretory, and the fibrous structures. These are not the primary forms of organic matter, but the elementary forms of organized structure, each of which is capable of performing a special function. And out of ttiese five elementary structures, with the aid of certain inorganic materials, the various and complex tissues and organs of the human body are built up, or composed. And histologists of this advancing age contend that these several distinct structures, or primary tissues, are each composed of elementary cells united in a definite way. Living organized matter is possessed of certain properties that give to it changes and certain determinate directions, and enable it to resist the action of such agencies as control the changes in inorganic matter. These properties were regarded as purely chemical by the old writers on medicine. Haller clearly demonstrated the existence of an inherent property in muscu- lar structure, which he called "irritability." But he failed to make a distinction between the elementary property inherent J.- 4 the practice of medicine. in this living fibre and the function or office it had to per- form. Dr. Martyn Paine claimed one vital principle, that he called life or vitality. I consider this vital principle endowed with the following six properties, viz.: Irritability, mobility, vital affinity, vivifi- ccdion, sensibility and nervous power. Mobility, sensibility and nervous power are functions of the nervous and muscular tissues, and irritability and vital affinity are properties com- mon to all the tissues. But recent writers on physiology confound all elemen- tary properties with nerve sensibility or nerve force. And pathologists and writers on practical medicine are now in- clined to trace the primary actions of all pathogenetic causes to impressions, either directly upon the blood or upon some part of the nerve center. Histology teaches us that the sev- eral primary structures are formed by the union of cells or organic atoms, varying from one another in their form and mode of union; and these variations constitute the apparent difference between them. The same primary structure is not homogeneous throughout its entirety, but consists of varia- tions in the union of its primary cells or atoms. In nerve structures, in certain places, the cells are aggregated into masses, as in the ganglia of the great sympathetic and spinal nerves, and the gray matter of the brain and spinal cord; and in some other parts they are united in a linear form, consti- tuting fibres proper. Since the later investigations of physiologists in regard to nervous tissue, many writers upon medicine have confounded all elementary properties with nerve sensibility, or what is called nerve force. In this theory, they have not recognized any capacity for receiving impressions or modifications of . actions in the various elementary structures, except through the medium of the nerve matter itself. Hence the effort now to trace all primary actions of morbific causes to impressions PRINCIPLES OF MEDICINE. 5 directly on the blood or upon the nerve tissue. This has rather retarded than aided our knowledge of the modus operandi of our remedies. So long as organized matter retains the capacity to exhibit the phenomena of life, so long are there seen certain inherent properties in it. Take a germinal cell of the ovum, or the chit or germinal part of a plant seed. These are devoid of even a trace of either capillary vessels or nerves, yet each is susceptible to the impressions of exterior agents. And certain determinate changes commence as soon as certain exterior influences are exerted upon these cells. Hence, we here dis- cover two inherent elementary properties; one of these endows the germ, or cell, with the capacity to receive impressions, and it is properly called susceptibility. The other (vital affinity) causes the atomic changes that result from impressions received, to follow certain laws, both the addition of new atoms, and, in the liberation of the old, effete ones to be eliminated. Susceptibility and vital affinity are seen, then, to constitute the elementary properties of living organized matter. These prop- erties in living matter give to Huxley's protoplasm and Beale's bioplasm their capability of development; and these proper- ties constitute the peculiar and elementary forces of all organ- ized matter. The imponderable, or elementary, forces of the inorganic world, are heat, electricity, attraction, etc. Having thus examined the elementary items that constitute health, we may now examine into the elementary forms and conditions of abnormal or diseased action. Disease is a devia- tion from a normal condition, of some part, or parts, of the organization; and this deviation from a normal condition, may consist of "increase, diminution, or perversion." The blood, for instance, may be increased in quantity so as to result in over-fullness of the vascular system, constituting plethora. But in other cases it is diminished in quantity, which leaves the vascular system without due distention, constituting anae- mia. Again, the blood may be neither increased nor dimin- 6 THE PRACTICE OF MEDICINE. ished in quantity, but its proper elementary constituents may be altered in their proper proportions, or they may be changed in quality, or some foreign substance may be mixed with them, causing perversion. Any one of the constituent elements of the blood is capable of being changed" from a standard of health. One, or all, of the nutritive elements may be increased, which would result in a hyperaemic or hyperplastic condition. And these constitu- ent elements may be so diminished as to constitute spanaemia, or poor blood. Then again, some foreign element may enter the blood, that is capable of so changing these constituent elements of the blood as to set up septicaemia, or blood-degen- eration. Or, an alteration of the effete constituents of the blood, or an increase to excess of these effete materials, may result in septicaemia. When a deleterious agent enters the blood, altering its properties, this condition is called toxaemia. Secretions.— The secretions may be also changed from a healthy standard. They may be diminished, increased, or per- verted from a normal state. The urine, for example, may be excessive, constituting diabetes insipidus, or it may be dimin- ished, as it often is, in fevers and inflammation; or it may not contain its normal quantity of the salts, such as urea, uric acid, and other salts, or it may contain unusual elements, as albumen, sugar, etc. And there may be a perversion of the salivary, gastric, cuta- neous, and all other secretions. The solid, or organized structures, of the body are subject to the same alteration and deviations from a healthy state. Hyperplasia.— There are persons of rich blood, active nutrition, secretion, and colorification, in whom the slightest exudation into any of the structures, or on membranous sur- faces, is very quickly organized into new tissue, causing increased growths, or indurations and adhesions. In such cases, vital affinity is above the normal standard. In some other persons the reverse condition prevails. The PRINCIPLES OF MEDICINE. 7 organic changes are very tardy; nutrition in them, like calor- ification and secretion, is but very feebly carried on; hence, when exudation happens to take place, in the place of rapid organization, and acquisition of vitality, they degenerate, resulting in softening of tissue, diffuse suppuration, deficient nutrition, and consequent tardy growth. This is truly styled the aplastic diathesis. There is still another class of cases, in which there are molecular changes, not merely increased or diminished, but so completely changed that atoms are carried to, and associated with, tissues to which they do not naturally belong; and there takes place such change of tissue that cartilage becomes bone, and muscular fibre fatty tissue. And in other cases, tumors may form by the formation of primary atoms, or cells in excess, in a certain part. Such malformations are the results of per- verted vital affinity. If there is a general deviation from a normal state, derived from hereditary influences, or acquired from feebly acting causes, the person will present a condition styled a predisposition, or diathesis. The plastic, aplastic, scrofulous, rheumatic, phthisical, cancerous, or gouty, are instances of the diatheses. Alteration of Function.—The healthy performance of any function depends upon the proper arrangement of the atoms constituting the healthy or natural structures, upon a due proportion of the normal properties, and the proper stim- ulus in this normal proportion of these properties. The failure or deficiency of either of these conditions will be followed by disturbances of functional action. And either of these ele- mentary properties may be increased, diminished or perverted, so that the natural condition will become abnormal in any of the functions of our organic structure. The secreting cells of the kidneys elaborate urine, and this functional action may be excessive or deficient, or the urine may be altered in its quality, or it may be perverted, from a want of one or more of its normal constituents, or there may be some unnatural ele- 8 the practice of medicine. ments in it, such as albumen, sugar, pus, coloring matter of bile, or some other foreign substance. Various coloring materials have been known to be excreted by the kidneys, as madder, etc. The special functions of the nervous structures are sensi- bility and transmissibility. These are often exalted, espe- cially the first named. Hyperaesthesia, or exalted sensibility, is quite common. Then this function may be diminished, constituting anaesthesia, and the sensibility may be so altered that it conveys a morbid impression. The patient may com- plain of extreme cold when he is warm, or of great heat of some part in very cold weather. The taste may be also greatly perverted, so that sapid articles taste bitter, or a bitter sub- stance may taste sweet. This illustrates the excess of action, deficient action, and perverted action. Alteration of Structure.—The structural changes are of three classes, viz.: One in which the affinity is active, and the supply of the nutritive elements plentiful, so that the addition of new atoms of nutrition exceeds the disintegration ; then there will be necessarily increased growth. But on the contrary, if the vital affinity is deficient, or the supply of nutritive material is deficient, the nutrition will be deficient, constituting atrophy. Then, if the vital affinity is perverted or altered so as to cause the attraction and accumulation of atoms not belonging to certain structures, these structures are transformed, as, for instance, the conversion of muscle into fatty matter, or cartilage into bone. In other instances, cer- tain abnormal growths, or tumors, result from this transfor- mation, which may be either osseous, fibrous, cartilaginous, fatty, fibro-cartilaginous, or even of a malignant character. Thus it is plainly seen that the attempt to build up a sys- tem of medicine upon the idea that all diseases are a unit, or traceable to one theory of morbid action, will always fail, as it has done in the past. Brown referred all diseases to either principles of medicine. 9 direct or indirect debility. Paine, Rush and Broussais traced all morbid action to irritation. Hoffman, modified by Cullen, attributed all morbid action to a primary morbid impression on the nervous system. None of them considered the grand truth, that disease is a deviation from health, and that it must present as many and varied aspects as there are varied direc- tions in which deviations may take place. Men are wont to erect a theory upon one central idea. And therapeutics has thus been hampered by these so-called systems or theories of disease. Brown's system of " debility " called for the law of powerful stimulation. The irritation of Rush inaugurated that very fatal system of depletion. And Hoffman's system of nervous irritation only added to that general destructive law of " depletion," the use of opium and antispasmodics. These pathological facts teach us the folly of all the one-sided "pathys" and "isms " that have sprung up from time to time from the fertile soil of hypothetical conjecture and misconcep- tion of the real nature of disease. Samuel Thomson, the founder of Thomsonianism, and Rush, Paine, Paracelsus, and others, all looked at the cause of disease from one single stand-point ; hence, their therapeutics, founded upon these erroneous pathological conclusions, could but fail of success. Physiology and pathology are the foundations of thera- peutics. CHAPTER II. DIATHESIS. TOO little importance is now attached to diathesis. Such is the very great tendency to routine prescribing for disease by name, that diathesis and even pathology are ignored. But thinking physicians are ready to admit that diathesis does greatly modify the process of diseases. A con- sideration of diathesis and its modifying influence over many diseases should supplement every work upon the theory and practice of medicine. I should feel that this little work was incomplete unless I prefaced it with a brief account of the diatheses. It is a well settled fact that some men do possess a procliv- ity (either acquired or inherited) to gout, rheumatism, leprosy, scrofula, struma, phthisis, tuberculosis, nervousness, lymphatic enlargement, haemorrhagic tendency, etc. The rheumatic diathesis is doubtless often the result of improper dieting, but sometimes is also a hereditary acquisition. It may be, in certain cases, a modification of the catarrhal diathesis, mainly nervous in its origin. In this case, the stress of the reflex morbid impress falls upon the tissues of the joints and unstriped muscular fibre. Gout and leprosy are also food-diatheses, that is, they are referable to certain peculiar kinds of diet and drinks. And, like other acquired constitutional stamps, after having been acquired, they are transmitted from parent to child, according to a law of our organic being. Gout, however, may be verv much modified in such transmission. There is doubtless a pathological inheritance in general, from which certain defects, such as deaf-mutism, color-blind- IO DIATHESIS. 11 . ness and haemophilia, may follow. Diathesis is a condition of our organic structure, however induced, by virtue of which the person is, for a period, or for life, prone to suffer at times from some peculiar form of disease. The effects of some dia- theses are permanent, of others transitory, or likely to recur after intervals of apparent exemption. Temperament is not diathesis. Temperament is a physi- ological impress; diathesis is a peculiar tendency or proclivity to a certain morbid condition or conditions. Temperament is a part of the original organization of the individual, but dia- thesis may be acquired as well as inherited. Diathesis may be latent at birth, but is susceptible of being excited into active development. Diathesis of Climate.—Under this head I may notice that peculiar impress upon constitutions from malaria, which includes emanations from jungles, swamps and marshy grounds. Malaria differs in different localities, both in its intensity and its character. It has the power of quickly pro- ducing very grave forms of disease in one locality, attended with arterial spasm, and thereby causing visceral congestions. Its effects seem to be rather permanent in many instances. A man once becoming contaminated with this poison will be susceptible through life. He will always exhibit a tendency to chills or rigors. Acclimatization may lessen the suscepti- bility to some extent. A poison that can be so persistent in its action, even in mild cases, is well nigh permanent in its effects, and must be able to produce that peculiar state of the physical system which is called diathesis. This is a well- marked diathesis, and is noticable to all that have come completely under the influence of this poison. There is also a climatic diathesis, as that that results in bronchocele and cretinism. While we do not know the precise operating cause, we know that this condition is confined to certain localities or telluric conditions. And this peculiar constitutional impress is transmitted from generation to gen- 12 THE PRACTICE OF MEDICINE. eration. Like malaria, it degrades the mind and body; that is, it greatly deteriorates the physical system, even affecting a race. This peculiar morbid impress may be properly called the bronchocele diathesis. A diathesis once established becomes by inheritance per- sistent, and may be transmitted from one generation to another. The scrofulous diathesis is ranked with that of tuberculo- sis by some writers. And these writers teach that both are the consequences of inflammatory action in these that are pre- disposed to these peculiar constitutional taints. But there are instances in which the proclivity to tuberculosis is so strong that it does not wait for inflammation to excite it into activity, but results as lymphatic neoplasm. But, in many instances, tuberculous and scrofulous taints act as predisposing and exciting causes, both operating in their development, etc. Tuberculosis being inherited, an existing proclivity, a catarrh, or anything capable of producing local congestion, may excite into activity this latent constitutional taint. Where there is an inherited scrofulous proclivity, it too may be excited into activity by the occurrence of an exanthem or some other acute disease. Diathesis will apply also to such malignant growths as cancer and epithelioma, etc. There is also, from some peculiarity of constitution, a tendency to the frequent recurrence of certain inflammatory diseases, as tonsillitis, croup, erysipelas, catarrh, hay-fever or rose-cold. Erysipelas has also in elephantiasis a direct con- gener. Elephantiasis is only an example of chronic erysipelas, with certain hypertrophic changes in the affected part. We may now consider the constitutional peculiarities dis- tinguishing the diathesis. The Gouty Diathesis.—Persons of this diathesis are gen- erally well developed, the osseous and muscular systems being well developed. The vascular system is well developed, and diathesis. 13 the heart large and strong. The digestive powers, in youth, are active. This diathesis furnishes hale old men of sixty years of age, who often boast they never called in a physician or took a dose of active medicine in life. But in advanced life they may have an attack of some acute disease, which either carries them off, or leaves them in bad health. Diseases assume a sthenic type in this diathesis. And men of this diathesis are often the subjects of lithiasis in its varied forms. The Peculiarities of the Nervous Diathesis.—Persons of this diathesis are generally not large. Their osseous sys- tem is not very highly developed. The muscular system of this diathesis is not largely developed, but characterized by great power for the size. Such people are small, very active, restless, and noted for their energy. Their brains are gener- ally large and active, and the development of the nervous sys- tem exceeds all other parts. They do not sleep many hours and often over-work themselves. Their highly-developed nervous system dominates over the physical man in reiterated demands. People of this class are very susceptible to narcotics, and there is difficulty in treating their diseases. This diathesis is often blended with others, such as the bilious, gouty and the strumous. It is also predisposed to insanity, hysteria, epilepsy and chorea. The Strumous Diathesis.—Under the term scrofula, with its many modifications, this diathesis has long been recognized. In this diathesis the vitality is feeble. The circulation is de- fective and very liable to disturbance. Assimilation is deficient, and nutrition is defective. The osseous system is not highly developed. The epiphyses are often large in youth, and may continue so in adult life, especially so with the small joints of the feet and hands. The thorax is often illy developed; the chest is often flat, the ribs are drawn downwards during in- spiration. The muscles are soft and contract feebly, unless 14 THE PRACTICE OF MEDICINE. this diathesis is blended with the nervous. The organic func- tions are all feebly performed. The appetite is capricious. Respiration and circulation are both feebly performed. The nervous system is imperfectly developed. In childhood, most of the chronic diseases of that age are furnished by this diathesis. Injuries of a joint are apt to be followed by arthritis, and it may be of a suppurative character. The exanthems are very liable to be followed by chronic diseases. This diathesis leads also to rheumatic arthritis. In this diathesis, if there is any disease in the thorax, it is very liable to assume a tubercular character, instead of terminating in resolution. In infancy there is a tendency to disease of the glands of the chylopoietic viscera. The inflammatory affec- tions of the serous membranes are common, and are liable to assume a tubercular form. In this diathesis, there is also a tendency to set up low forms of cell-growth. And this diathesis furnishes, the ma- jority of chronic diseases of infancy and youth. It gives a great tendency to the formation of uric acid, and vesical cal- culus. In families of this diathesis, congenital syphilis readily shows itself in the form of syphilo-strumous diathesis. In fact, this diathesis is the one that furnishes the tendency to degeneration of every form and type. This diathesis is liable to have, with the syphilitic taint, gummata or syphilitic tumors. Struma is more rife in towns than in the rural dis- tricts, from want of pure air and exercise, etc. The Bilious Diathesis.—This diathesis is not quite as distinctly marked as those that we have just spoken of, but it is, a modification associated with one or another of those already discussed. It is characterized by a great tendency to bilious disturbances from slight causes. There is a dark com- plexion in this diathesis, and the skin is not as transparent as it is in the other diatheses. When mingled with the gouty diathesis, the individual will be of a gloomy disposition. DIATHESIS. 15 And when found mingled with the nervous diathesis, the sub- jects have dark complexion, and are small, but active beings. It is often found associated with the strumous diathesis, and then the tendency is to tuberculosis. And when persons of dark hair, long eyelashes, dark complexion, take tuberculosis, it runs a speedy course, as this bilious tendency likely inter- feres with that assimilation of the fat and other hydro-carbons so necessary to the strumous, when tubercle threatens them. This diathesis may also be blended with the lymphatic dia- thesis. Purgatives are essential in the bilious diathesis. The Lymphatic Diathesis.—The subjects of this diathesis are large, unenergetic and phlegmatic, indolent persons. It is just the opposite of the nervous diathesis. A great many females are of this diathesis, and they are very subject to passive haemorrhages, especially uterine, to leucorrhcea, and in parturition they are liable to great loss of blood every time they are confined. They are apt to furnish a large quantity of milk, but it is of a poor quality. They are subject to dila- tation of the heart, with palpitation, especially about the men- opause. A man with a gouty diathesis, and afflicted with an inflammatory affection of the glandular system, may develop a scrofulous inflammation. Syphilis planted into a scrofulous or tuberculous diathesis will produce destructive ulceration, especially of the soft parts of the nose and mouth. The above are the leading diatheses, constituting groups of individuals, and even groups of families. Very often the entire family presents a well marked type of one or another diatheses, but in other instances, some individual members of a family do not present this marked type of diatheses. The appreciation of the varieties of diatheses, and the tendencies given by each, together with a knowledge of the direct thera- peutical indications thus furnished, is of inestimable im- portance to the physician ; for instance, in the haemorrhagic diathesis, which may render a very slight wound very danger- 16 the practice of medicine. ous. When known, it puts the patient on his guard in regard to the danger of any solution of tissue-continuity, and it puts the surgeon on his guard in regard to surgical interference. For, in this diathesis, the haemorrhage is seldom arrested until the system is blanched, and arterial pressure reduced. CHAPTER III. VEGETABLE PARASITES. THE special cause of many acute diseases has, until a recent date, been quite obscure. Some of the peculiar characteristics of this class of diseases are: That they occur epidemically; that they are more or less contagious and infec- tious; that each of them is distinct from the others of this group, and runs a typical course; and that the peculiar poison giving rise'to each of these diseases multiplies very rapidly; for instance, a single case of one of this class of diseases, in- troduced into a locality, may cause the death of thousands. It has been obvious that this class of diseases was caused by something that multiplied very rapidly, and that inhered to the clothing, bed-clothing, and even to buildings, ships, prisons, and camps, and that could be conveyed in the open air for a distance. For many years scientific men have en- deavored to discover this cause of contagion of disease. It was unreasonable that a mere gas would produce the phenom- ena of those contagious diseases, as diffusion in the air would soon disarm it of its virulence. A fluid could not produce the results; so contagion was finally regarded to be a solid in a state of very minute division. It has proven insoluble in the fluids in which it can live by subsidence; and by filtration the poison does not pass through a fine filter. These facts, taken with its very great power to multiply, all conspire to prove that the contagium must be some living organism. This contagium vivum, or germ, gave rise to the germ theory of disease; a theory already demonstrated in many morbid manifestations and likely, if more fully developed, to throw a flood of light upon some obscure pathological phenomena, and suggest a 2 17 18 the practice of medicine. treatment for many diseases hitherto regarded as almost, if not entirely, incurable. In the year 1840, Dr. Henle expressed his belief that living organisms, probably of a vegetable nature, were the causes of the acute specific diseases. In 1838, Bassi and Audouin had discovered the fungus nature of the musca- dine disease in silk-worms; and in 1836, Schwann and Cag- niard de Latour discovered that yeast,, the apparent cause of alcoholic fermentation, consisted of cells, multiplying by bud- ding, and apparently of a vegetable nature. They supposed that the decomposition of the sugar into alcohol, carbonic acid, etc., was directly connected with the development of this plant. Scientific men had long noticed that there was a close parallel between an infection causing disease, and a fermenta- tion. And it may be further stated that, except in cases in which yeast was added to the saccharine liquid, the source of the ferment in cases of alcoholic fermentation was as mysteri- ous as that of the source of the poison of epidemic diseases. The germ theory of disease was started by Astier, Schwann, and Cagniard de Latour, and perfected by the immortal Pas- teur; and is now adopted by a large majority of the most scien- tific men of the civilized world. It is useless to waste space to notice the Physical Theory started by Willis and ventilated by Liebig. The supporters of this theory admit the presence of organisms in fermenting fluids, but regard them as mere accidental products. But it is an established fact, that the organisms formed in a fluid may be reproduced again and again in artificial fluids, and thoroughly washed with distilled water, the reaction charac- teristic of the peculiar fermentation from which it was taken, will still occur if the organism be now inoculated upon a suitable fluid. Antiseptics have been selected on account of their supposed power to destroy the organisms. It is a settled fact now, that all the processes known as fermentations and putrefaction are due to the action of vegetable organisms. There are four vegetable parasites. 19 theories in regard to how these organisms act to produce fer- mentation. But we will not take up space to notice them in this work. The products of fermentation are as various as are the processes that form them, and the organisms that are sup- posed to give rise to them. The same food will, under the action of various organisms, be transformed into different sub- stances. For instance, sugar undergoes vinous, lactic, and butyric, mucous and mannitic fermentation. The History of Vegetable Parasites.— The vegetable organisms that have been found connected with certain dis- eases are all Thallophytes, or plants in which the leaf and stem are alike; and, as they are all destitute of chlorophyll (coloring matter) they belong to the family of Fungi, not Algae. The pathological fungi are divided into three kinds:— Bacteria or Schizo-mycetes, Yeast or Blasto-mycetes, «and Moulds or Hypho-mycetes. The bacteria cause putrefaction and several fermentations, and are the organisms that are credited with the power of producing the infectious diseases. They are for this reason the most important variety. The presence of water is necessary to the production of all fungi. The moulds require less than the yeast and bacteria. Too much water is detrimental to their development, Each of these organisms lives best at a certain temperature. Bacteria cease to flourish at 5° C. They do not die, but are rendered motionless, and some are said to be killed by very intense cold. Intense heat in a moist air kills bacteria, especially in the adult stage. Cocci and bacteria appear to be affected by a high temperature sooner than bacilli. Boiling will kill many fungi. Fungi flourish better in a still medium than in one in which the par- ticles are constantly moving rapidly. Antiseptics.— The growth or development of fungi may be prevented by adding disinfecting materials to the nidus containing them. There are a number of articles, some of quite recent introduction, that are antiseptic in their action, and they strongly antagonize the development and growth of 20 the practice of medicine. this cell-life. They prevent the development of putrefactive bac- eria. In this group there are vegetable substances and min- eral astringents, resins, essential oils, many products of tar, chlo- roform, chloride of sodium, boracic, and salicylic acids, resorcin, baptisia, eucalyptus, turpentine, chlorine, and bromine, alumina, iodine, logwood, calendula, peroxide of hydrogen, sulphur, and sulphurous acid, arsenic, mere, chlor. corros., carbolic acid, quinia, and calcium sulphide; and there are still some others not included in this list. These all vary in their antiseptic power, and, though one of them may prove to be very destructive to a certain organism, this does not show that it will prove so to another form of pathogenetic life. It is a noticeable fact, that much smaller amounts of an antiseptic will prevent the development of these organisms, than wilt totally destroy them after they have been once developed. The strength, however, should not be too highly concentrated, for most of these antiseptics are irritating to the parts to which they are applied; and some of these antiseptics are poi- sons. We have to learn by actual trial, the antidote to each parasite, and the quantity requisite to destroy it without injury to the human organism. We may approximate the proper strength of an antiseptic by adding it to a putrescible fluid, and note the quantity required to prevent putrefaction. The spores of bacteria anthracis are injured by a watery solu- tion of thymol or salicylic acid, by alcohol or glycerine, and they destroyed by chlorine, or bromine water (2 per cent.), perchloride of mercury, (1 per cent.), permanganate of potash (5 per cent.), or, in twenty-four hours, by carbolic acid (5 per cent.) They are not destroyed by drying. Where-are these microscopic vegetable organisms found? A putrid wound abounds with them. They may come from the outer world, and enter the body. They may exist in the body, developing only under special and favorable conditions. And, under specially favorable circumstances, they may be spontaneously generated in the body from certain elements of VEGETABLE PARASITES. 21 the tissues. Germs may exist in the air> earth, or water. It is a settled fact that mould taken from the earth's surface, and put into a sterilized culture-fluid, soon infects it. Cocci and bacilli are the forms that are generally developed from surface earth in this fluid. If a suitable nidus be furnished for the development of organisms, they multiply and very soon set up a characteristic decomposition. A certain depression of the vital energy of a part, or some alteration of its metabolism, may be sufficient to permit the development of germs that, under other condi- tions, would have perished. Some of these organisms are capable of living in sound, healthy tissues ; for instance, the bacteria anthracis, and the poisons producing the acute spe- cific diseases. Some individuals, however, are not subject to the specific acute fevers ; and children are more subject than adults. The infectious diseases do not often affect animals ; small-pox, however, being «n exception, as it affects cattle, when they are vaccinated particularly. Some of these poisons have a selective affinity for certain tissues or fluids of the body ; some of them multiply in the blood, some in the lymph, some in bone, others in the cebro-spinal meninges. The last produces cerebrospinal meningitis. It is possible that the majority of the human race present a congenial nidus for the development of some form of fungi. But all organ- isms seem to flourish best in the tissues whose vitality is more or less impaired. Some, in fact, can not develop unless it is in diseased tissues. Then, again, some other organisms can not multiply at all in living tissues. Clinically, we may divide those organisms into two great divisions: 1st. The pathogenic, or those that can invade and multi- ply, in living tissues, almost always producing disease. 2nd. The non-pathogenic, or those that can develop only in dead tissues, and, consequently, found mostly on the body, where sloughs and suppurations are common, as the Bacterium 22 THE PRACTICE OF MEDICINE. termo, which produces putrefaction. It is rare in any internal slough or putrescible effusion, but is found outside. Spontaneity of Production.—There is no proof that organisms originate de novo from the molecules of decompos- ing tissue, and it is generally disbelieved. The conclusion then is, that organisms found in a putrid wound have entered it from without, and it is true in regard to fungi found in pathological lesions within the tissues. If the Bacterium termo could enter a wound from within, antiseptic treatment would be useless, but, if we prevent the entrance of the germs from without, the wound remains sweet, and heals readily. Septic intoxication can be thus prevented, and life often saved by a timely course of antiseptic treatment. Organisms in Living Tissues.—Pathogenic fungi, after entering the body, may remain about a part where they entered, or they may spread to contiguous tissue, or they may pass along lympathic vessels to attjacent glands, or into the blood, and be circulated all through the system, and soon set up such chemical changes in the blood that it becomes irri- tating to certain tissues. These changes, in some cases, pro- duce chronic diseases, in other cases, acute forms of inflam- mation, up ta suppuration (pyaemia) or direct necrosis. In other cases, certain products being absorbed give rise to fever. Fungi may abstract nourishment from tissues, or they plug up vessels of some organ, as the lungs, and thus pro- duce disease. Classification of Bacteria.—There is, as yet, nothing like an accurate life-history of Bacteria. It seems that they all multiply by division, as relates to the spore-formations. But the mode of reproduction does not afford accurate means of subdivision ; hence, we are compelled to resort to morpho- logical characteristics, viz.: the form and size, as no struc- tural differences can be determined. Cohn says that distinct forms characterize orders. Some are spherical, some rod- shaped, and others are twisted like a screw. Some are VEGETABLE parasites. 23 rounded, or truncated ends of rods, and then there are varia- tions in size, and in modes of growth. The species, however, seem immutable. But the same form may be found associated with the most opposite chemical changes. Micrococci, which cannot woll be distinguished by their form or size, are found in relation with diphtheria, erysipelas, small-pox, pyaemia, and osteomyelitis. They are not the same, but they are similar forms, having specifically different physiological activities, and, hence, producing very different pathogenic effects. It is then certain that these organisms stand to disease as cause to effect, proving clearly the germ theory of disease. The Acute Specific Diseases are those that form a class of a larger group of infective diseases. These are due to the direct action of a poison or virus that has the power of in- vading living tissues and so multiplying in them as to produce diseases. These poisons may be general or local, and the virus may be able only ' to invade the tissues for a less or greater depth from the point of its first invasion; or, by its power to multiply, it may, by imparting to the blood the pro- ducts of its own action in the tissues, excite the tissues to increased metabolism, and thus cause a fever; and this virus may lodge in other tissues and excite foci of disease. The class of diseases producted by these poisons is named according to certain characteristics of the virus producing them. Contagious Diseases.—These are often endemico-epidemic but sometimes only endemic. Scarlet fever is the type. This disease can be easily communicated from one person to another. Small-pox and measles are also examples of this class. Miasmatic Fevers.—These fevers are endemic diseases, of which malarial fever is the type. This form of fever is not communicable from one person to another. The poison caus- ing this form of disease, develops outside the body, not inside. Contagio-Miasmatic Diseases.—This class includes cer- tain diseases that seem to be derived from a previous case of 24 THE PRACTICE OF MEDICINE. the disease, out not directly; the poison has first to go through a certain change outside of the body. Typhoid fever is a good example of this type of disease. Cholera is another example. Septic Diseases.—This type is produced by poisons that are derived from many putrid infusions, and when the disease has once been produced thus it can then be transmitted from one person to another. This class of diseases is kept up like fermentation. The Schizomycetes. 1.—Sphozro-bacteria or Micrococci.—These are round or oval cells, single or in pairs, or sometimes in chains, either straight or wavy. They differ in size, form, mode of grouping and also physiological action. And although they are often found in putrifying fluids, they are not the cause of putrefac- tion. There are two genera, micrococcus and sarcina. Under the genus micrococcus writers arrange the species in three groups; pigment-forming, fermentative, and pathogenic. Pigment-forming form, in the air, slimy films of various colors. These are numerous. Fermentative Micrococcus.—This causes the ammoniacal fermentation of urine exposed to the air. Pathogenic cocci are more frequently associated with dis- ease than any other fungus. Micrococci have been found in large numbers in the deposits of pyaemia. Gangrene can be produced with a specific coccus. See Koch on " Traumatic Infective Diseases." Micrococci are always found in the pus of acute abscesses. Erysipelas.—Micrococci may be found in erysipelatous ' skin, especially at the edge, of the diseased part, and the dis- ease, in its active stage will pass from one person to another by direct contact for a long time. Diphtheria.—Micrococci are found in great numbers in membranous exudate of this disease. And they have also been found in the mucous membrane under the exudate, and also along lymphatics to the nearest glands. They have also been VEGETABLE PARASITES. 25 found in the heart, liver, kidneys and other organs. Their presence in the kidneys may give rise to the albuminuria found in this disease. Gonorrhoea.—Micrococci have been described, peculiar to this disease, and they pass out in the mucous and pus. Pneumonia.—Klebs described a micrococcus that he found in pneumonia, and Koch did the same. They were found not only in the exudation but also in the lymphatics of the lungs. Cerebro-Spinal Meningitis.—Cocci have been found in the exudation, and in groups in the pia mater, in this disease. Genus Sarcina.—A micrococcus is often found in the eject- ed contents of the stomachs of dyspeptics, especially when the dyspepsia is associated with chronic catarrh of the stomach. It is extremely difficult to get rid of the fungus when once it becomes established. The Fermentative Bacteria.—The bacterium termo is the most important species, as it is the cause of putrefaction. It is not pathogenic,* as it can not exist in living tissue. It pro- duces unorganized ferments, and its products, many of them, excite fevers, though one of its products, sepsin, has special prominence. Bacteria Lactis.—This causes the lactic fermentation of milk. Cholera.—Dr. R. Koch has discovered a bacillus that is always present in cholera. It is quite actively mobile. Malaria.—Klebs and others examined the soil-water and ground-air of malarial districts near Rome in Italy, and found long, mobile spores, which, by injection into the blood of animals, grew into rods. They grow in albumen and in fluids of the body, but not in water. They excited in animals regu- lar intermittent fever, with swelling of the spleen. These spore-bearing bacilli were found in the blood, spleen, marrow, and lymph of patients that had died of pernicious fever. They were found in the blood of patients during the fever in the cold stages. In hot stages no bacilli were found, but the 26 THE PRACTICE OF MEDICINE. spores were found in large quantity. Quinine quicKly caused the disappearance of these bodies. No organisms were found in the blood in the remission stage of the fever. Typhoid Fever.—Klebs first described the micro-organisms of this disease. Since, Eberth described bacilli with rounded ends in the intestinal lesions, mesenteric glands and spleen. He found them in eighteen out of forty cases of this form of fever. Koch also found these bacilli in half the cases of typhoid fever he examined, but could never find them in any other disease. All these bacilli disappeared in convalescence. These bacilli can be found in the urine of typhoid fever patients. Injection into the blood vessels of rabbits pro- duced high fever and inflammation of Peyer's glands. Coats and Crookshank both found these bacilli in the mesenteric glands of typhoid patients. Septicaemia.—Koch injected putrid fluid into mice and produced a peculiar disease. Bacilli were found in the blood, and are supposed to be the cause of the disease thus produced. Achorion Schoenleinii.—This form of pathogenic mould constitutes a large proportion of the light, yellow, mouldy- smelling crusts of favus. It invades the roots of the hairs. Here this parasite grows luxuriantly. On the non-hairy parts the mycelium invades the deeper layers of the epidermis. Trichophyton tonsurans.—This is the cause of tinea tonsu- rans, tinea karion, tinea circinata, tinea sycosis, and tinea unguium. Chloasma Pityriasis versicolor, or microsporon furfur, in- vades the horny layer of the epidermis of the covered parts of the body, but does not attack the nails or hair of any part. CHAPTER IY. THE LAWS OF THERAPEUTICS, OR THE ACTION OF MEDICINES. IS the practice of medicine a science, or is it merely an art ? It certainly cannot yet be regarded as an exact science. In these introductory remarks, I propose to examine the vari- ous systems that men have set up from time to time. Therapeutics, or the treatment of disease, should be as accu- rate as is possible for human minds to make it. The physi- cian is dealing with human life. Mere caprice, or speculation, or chance, should not govern here, but the more unerring deductions of law should guide the action of the healer. The life of a human being often hangs upon the proper selection of a curative agent. The Ruler of the Universe has ordained exact laws for the action of each curative agent, and it is for the physician to test each individual remedy, and thus learn its precise range of therapeutical action. It is worse than criminal to set up a theory, and then endeavor to bring the action of the remedy to suit the previ- ously conjectured theory. We must study the actions that the Creator gave them; they are definite and trustworthy, specific or positive, when ascertained. And it is a fearful responsi- bility resting upon those who refuse to be instructed, but blindly grope their way amid the labyrinths of error and uncer- tainty. It appears that many men in the profession depend more upon the assumptions of a " pathy," or " ism," or an opinion, than upon the laws that are founded upon patient investiga- tion. Therapeutics, as yet, consists of a collection of facts. But much of the practice of medicine of to-day consists of 27 28 THE PRACTICE OF MEDICINE. f mere dogmatical opinions, which change from year to year, to keep pace with the speculative opinions of the leading men of the medical profession. The practice even of Rush, and others of his day, is now regarded by all scientific physicians as worse than useless— yea, as destructive. But if the God- given law of therapeutics had been the foundation of their prac- tice, it would be the same immutable truth to-day that it was then; as truth never changes. Brown-Sequard says that " very little is known of the real and ultimate action of remedies." This is emphatically true, and will remain so until therapeu- tics is more carefully studied. Therapeutics embraces all the means of prevention and cure of disease, such as knowledge of medicines, proper diet, drinks, baths, or ablutions, exercise, electricity, galvanism, etc. Hippocrates, whose genius reigned for many centuries, was nurtured in the famous Asclepias of Cos. He was born 460 B. C, and was descended from a family whose members had practiced the healing art for three centuries, in the temple of Cos. While he had much knowledge in regard to the natural history of disease, yet he made grave mistakes in regard to therapeutics. He regarded disease as a positive entity, or a real substance. He did not base his treatment on facts rela- ting to the relationship between the action of medicines and the disease, but upon the erroneous conception of the cause of disease. He admitted that law ruled all things, yet he ignored facts for imagination, or hypothetical speculation; hence he did not advance therapeutics, as he could have done. He attained to some accuracy in diagnosis, but neglected to properly test his remedial agents. His writings savor much of the specula- tive philosophy of Socrates and Plato, as he was cotemporary with them. He regarded disease as consisting of an excess of blood in the spring, of yellow bile in summer, black bile in autumn, and phlegm in the winter. He prescribed according to his crude opinion of the nature of remedies, regardless of the relationship between their real action and the disease for • THE LAWS OF THERAPEUTICS. 29 which he prescribed. He believed that the great seat of dis- ease was in the fluids of the body. His idea of the composition of the body was equally crude and erroneous. He believed that the human body was com- posed of earth, air, fire, and water, so combined as to produce the four humors, as blood, phlegm, bile, and black bile, to the changes of which he attributed disease, and health to a natu- ral condition of these. His main therapeutical means were depletion by the lancet, cathartics and expectorants. From Hippocrates arose the Empirics, who claimed to fol- low experience alone, but neglecting the study of anatomy, physiology, etiology, and diagnosis; and against this sect of dogmatists, who claimed all authority for theory, then (in Rome) there sprang up a sect called " quacks," led by Ascle- piades, a friend of Cicero. He treated his patients with baths, dieting, exercise, and a change of habits of life. And from the long quarrel of the Empirics and Dogmatists arose the sect of Eclectics, professing to select the good, and reject the bad in all the systems; and of all the medical sects, they have proved the most successful. Eclecticism not only prevails in medicine, but in religion, politics, etc., in all free countries. Galen, who lived in the second century after Christ, founded his system upon his idea of the nature of medicines. He regarded one as hot, and another as cold; one as dry, and an- other as moist, etc. He ignored observation and facts for mere speculative opinions, yet acknowledged the necessity of a rela- tionship between the action of the remedy and the body, in health or disease. And he considered the law of action to be that of " contraria contrariis," or the antipathic law of action. He did not, however, note the symptoms produced by the action of medicines on the healthy subjects, but applied his law of "contraria contrariis" according to his crude opinion of the nature of medicines and diseases. He substituted his opinion for careful investigation and scientific research. And his fol- 30 THE PRACTICE OF MEDICINE. lowers have long done the same thing, to the great detriment of humanity. We pass over the age of the great decline of medical knowledge, when disease was ascirbed to the anger of the gods, to appease whom was the sole privilege of the priests. In that age, numberless charms, spells, and incanta- tions were resorted to to deceive the sick. Gradually impu- dent quacks arose, professing to understand the secrets of nature, and to possess occult and supernatural means of cure, thus deceiving the unfortunate sick. And finally there arose a bigoted and presumptuous quack — Paracelsus—a man of the most shameless audacity, who boasted that he had discovered the " elixir vitce" the all-pow- erful remedy that the sick had long needed. Sydenham, who believed that diseased action was the effort of nature to relieve herself from offending matter, taught that the chief duty of the physician is to assist nature in regulating its perverted actions, so as to prevent excess of action-, or defi- ciency of action. His treatment consisted in means to palliate symptoms, rather than to remove their causes. In the seven- teenth century, Harvey discovered the circulation of the blood, and he and Malphighi and Ruysch taught that the cause of disease was to be found in spasm and relaxation of the vessels; but therapeutics was not much advanced then by this idea. Bonet, in Italy, laid the foundation of anatomical pathol- ogy. Morgagni, a pupil of Bonet, enlarged his investigations. But all the improvements made by morbid anatomy only led to depletion, to get rid of what was supposed to be morbid matter in the blood; but patients still died so fast that thinking men began to mistrust depletion. In the sixteenth century, Boerhaave endeavored to collect all that was valuable from preceding writers, and, with the aid of these materials, to form a system that should be truly " eclectic." Eclecticism in medicine is to test all remedies with skill, judgment and candor, which is the only possible way to attain THE LAWS OF THERAPEUTICS. 31 to ultimate successful treatment of disease. Boerhaave, like his predecessors, depended more upon mere opinions than at- tested facts. Haller, a pupil of Boerhaave, and properly con- sidered the father of physiology, contributed much to the knowledge of medicine. By very thorough experiments, he confirmed his theory of irritability and sensibility, as proper- ties belonging to the muscular and nervous systems. To these he referred all the phenomena of vitality. He rejected all speculative opinions and formed his system upon actual facts and experiments. From the day of Hippocrates to that of Haller, therapeutics was based upon mere opinions, but this great man taught that the true guide to therapeutics must be . sought for in a knowledge of the direct action of medicines upon the human body in health, and advocated the necessity of trying one remedy at a time, not heterogeneous mixtures. And after having obtained a knowledge of their action in health, he tested their action upon the sick. Then came the immortal Hahnemann, who studied very carefully to obtain an exact knowledge of the action of medi- cine; that is, its physiological, toxical or pathogenetic, and dynamic or therapeutical action upon the system. Hahne- mann, while translating Cullen's Materia Medica into German, took large doses of cinchona bark, to learn its action on a healthy body. In some three or four days he experienced the • symptoms of a chill. From this circumstance it occurred to him that the reason cinchona cures chills is because there is an inherent power in it to produce symptoms of a chill, very similar.to a real chill, in a healthy body. And, by many years patient proving of medicines thus on himself, he evolved the therapeutical law that distinguishes his peculiar system, Homoeopathy. And but for the vague chimera of this great man, that of dilution to an infinitesimal extent, potentizing a remedy, his system, ere this, would have superseded all former systems. Not resting content with the discovery of a primary law of 32 THE PRACTICE OF MEDICINE. therapeutics, and leaving the accurate deductions of facts, he attempted to build up a system, as dogmatic as those of Galen or Boerhaave. The scientific physicians of to-day are inclined to ignore the isms and pathys, and to rely on facts and upon actual experience at the bedside of the sick. Such truths may be combined into a system, worthy to be trusted by the healer of diseases. Although Hahnemann fell into the vague idea of infinitesimal doses, when cholera appeared in Europe in 1831, he acknowledged that small doses of camphor were not potent enough to meet this terrible disease, so he gave large doses frequently repeated. But many of his followers long since • refused to be deceived by this chimerical dogma of infinitesimal doses, and now assert the fact that the therapeutical law that Hahnemann discovered was independent of his vague idea of dynamization and infinitesimal doses. There are many physicians of all sects, who acknowledge that the therapeutical law of " Similia similibus curantur" does explain the curative effect of many of our most trustwor- thy remedies; but it does not account for the action of some of our remedies. But doubtless, as we more thoroughly understand the pathological indications calling for remedies, the greater certainty will there be in prescribing for disease. One great truth that Hahnemann taught was, that single reme- dies should be given. In this age, drugs are so mixed together that they counteract one another, so that there is no certainty in their action, but are actually injurious to the patient. There is one great truth that stands out in bold relief — that is, in most cases, there is a relationship of similarity between the physiological action of the remedy, and its thera- peutical action. And he that fails to recognize this funda- mental fact, will fail of success in medicine. We cannot make the laws of therapeutics fit a theory — we must fit the theory to the laws of medical action. The action of most medicines follows the relationship of similarity in the cure of THE LAWS OF THERAPEUTICS. 33 disease. We must study the direct and individual action of each of our remedies, and find out what single remedy may oppose the action of the one we give to cure. This is an important work. There is no doubt that the investigations of Hahnemann have influenced medical practice all over the civil- ized world. And it is now conceded that to understand thera- peutics, we should have an accurate knowledge of the action of medicines upon the body in health. Most late writers on ther- apeutics now give the physiological action of medicines with • great care and precision. The physiological action is a guide to the affinity of a remedy for an organ, part, or tissue. Cullen taught that there was a self-regulating principle which would regulate the system, if the disturbing cause was not too great. This he called the " vis medicatrix naturae," To look back upon the condition of therapeutics forty years ago, astonishes the medical investigator of to-day. It is instructing to retrospect the past, and see what a vague sys- tem of routine prescribing of bleeding, leeching, blistering, purging, and mercury for almost all diseases of a febrile, or inflammatory type. It is to the honor of Prof. Hughes Ben- nett that this murderous system was exposed. Dr. Brown-Sequard, one of our best physiologists, very much aided our knowledge of the nervous system. He discov- ered the functions of the ganglionic centres, and the vaso- motor nerves. Brunton, Frazer, Ringer, and Crum Brown all added to the brilliant discoveries of the immortal Brown- Sequard, in regard to the real therapeutics of belladonna, ergot, strychnia, and the bromides. Although Brown-S6quard does not speak of the dual action of these and other medi- cines, nor of the apparent relationship of their action in health, or their indications in disease; yet his experiments pointed out these so plainly, that others have perfected his discoveries still farther. Lsennec investigated the diseases of the heart, lungs, and blood-vessels more thoroughly by the aid of the stethoscope. 3 34 THE PRACTICE OF MEDICINE. And his labors in this direction led to the use of the ophthal- moscope, laryngoscope, clinical thermometer, and spygmo- graph. The ophthalmoscope was, however, discovered by Helmholtz, but was not so much used until it was improved by others. These instruments have added much to the accu- racy in the diagnosis of certain diseases. Although Zermach, of Germany, invented the laryngoscope, yet its use was more thoroughly taught by Morell Mackenzie, of England. And the utility of the clinical thermometer was brought to notice by Wunderlich. As it is known that excessive temperature indi- • cated waste, and its consequent exhaustion of tissue, the ther- mometer has encouraged the use of cold applications, anti pyrin, and other heat-reducing remedies. And modern American, or "Eclectic" practitioners, have discovered many very valuable and indispensable remedies, such as podophyllum peltatum, phytolacca decandra, gelsem- ium, lycopus virginiana, hydrastis canadensis, berberis aqui- folium, gridelia robusta, stillingia sylvatica, erigeron, vi- burum opulus, and V.prunifolium, drocera rotundifol., echine- cea angustifolium, corydalis formo., scrophularia, menisper- mum canad., and too many others to mention. And, aided by Prof. E. M. Hale, of Chicago, Prof. H. C. Wood, of Philadel- phia, and Prof. Roberts Bartholow, of Philadelphia, they have tested these new remedies, and more thoroughly tested the old ones, so that now many diseases hitherto regarded as almost, if not entirely incurable, are now met with much con- fidence of a final cure. They have also had much influence over the profession in discouraging that indiscriminate drug- ging with the enormous doses that formerly often resulted in developing the toxical effects. Eclectic therapeutics does not simply imply tolerance, and the selection of the best means to cure or alleviate disease, but it implies the proper use of such remedies as prove to be effective in counteracting the various morbid departures from health. Eclectics discard the mere opinions of men, and trust THE LAWS OF THERAPEUTICS. 35 to facts. In the beginning of the nineteenth century, inflam- mation was regarded as the great opprobium medicorum. It was treated " antiphlogistically"—that is, by the lancet, leeching, blistering, cathartics, and tartar emetic. And, inas- much as inflammation is mainly caused by partial paralysis of the vaso-motor nerves of the part affected, all this blind drug- ging was but increasing the inflammation, by lessening the native resisting power of the system. The distended blood vessels, tumid structures, accumulated heat, and increased (or at times diminished) secretions, may be all produced by the section of the sympathetic nerve in a part, or parts, and will be soon followed by these symptoms, as was demonstrated by Claude Bernard's experiments. Thus we see that the mere opinions or ipse dixit of men will not do to trust to, when we assume the dread responsi- bilities of the healing art. Galen's dogma of contraria con- trariis only confused therapeutics, until Haller's encourage- ment to the study of physiology led the profession back to the true basis of the science of healing. Modern progressive minds are fast developing great truths, and if these rapid advancements continue long, medicine will soon become a science, instead of an art. Therapeutics must be based upon laws, and it is our duty to learn those laws, it matters not who may be the teacher. " Regular medicine," priding itself in its regularity, intoler- ance, and dogmatism, refuses to learn, unless the teacher or discoverer is one of its own sect. Niemeyer, one of its most renowned writers, refuses to recognize any law in therapeutics, but clings to empiricism as the only guide. Dr. Anstie him- self endeavored to hide the " specific " or therapeutical action of ipecacuanha, in its relieving nausea and vomiting by the law of similars. Dr. Sidney Ringer, in his most excellent work on therapeutics, endeavors to attribute this action of ipecacuanha to a tonic effect that it exerts on the sympathetic nerves. Most of our works on materia medica and therapeutics 36 THE PRACTICE OF MEDICINE. ignore the laws of cure, and the indications calling for certain remedial agents, and depend upon the old classification of remedies into diuretics, diaphoretics, purgatives, alteratives, sedatives, etc. Each remedy has a special action of its own, and some of the remedies used may share certain other prop- erties with other remedies, as for instance, rhubarb; although it, in large doses, purges, yet in small doses, it cures diarrhoea by the law of similars. Euphorbia corollata produces, in large doses, profuse colliquative discharges from the bowels, with violent vomiting, and cramp of the bowels and stomach; and, if continued, it produces dysenteric diarrhoea; and yet in small doses, I have recently given it with the best success in cholera morbus, dysentery, and cholera infantum. And most of our remedies have thus a dual action. One of the main things to guide us in the treatment of disease, is a rule by which to select a remedy to meet the mor- bid condition pointed out by the symptom or symptoms. This feature has been specially adhered to in this work. Each individual remedial agent has its affinity for a part, organ, or tis- sue of the body, and it has a definite physiological action on this part, organ, or tissue, in health. This physiological action sus- tains a certain relationship to the therapeutical, or curative action; this relationship may be either of contrariety, or of simi- larity. There may be remedies that are an exception to either law of action; but that there are many remedies that have a dual action, I am fully satisfied; and I am equally as well satisfied that their actions are opposite — that is, the therapeutical is just opposite to their toxical action. I know this to be the case with remedies that I have tested myself. I took 30 gtts. of the saturated tincture of bryonia alba, and it produced a violent dysentery, And this summer I cured quite a number of cases of dysentery with this remedy, in one-half and one gtt. doses, every two hours. Colocynth produces watery purg- ing, with colicy pains at the umbilicus, and yet I have cured many cases of colicy diarrhoea with one-half to one gtt. THE LAWS OF THERAPEUTICS. 37 of tincture of colocynth. Rhubarb produces a thick, mushy purging, with griping; and yet it is believed to cure this kind of diarrhoea. Iris versicolor also purges in large doses; yet it is a remedy in diarrhoea, and some cases of flux. The bromides act upon the nervous system and brain anti- pathically, to cure epilepsy, and must be given in large doses, as is generally the case, when we want to give medicine to act upon the law of "contraria contrariis" —that is, when we want to produce the physiological effects of it. Yet I have not seen the bromides cure a single case of epilepsy. They merely suspend attacks for a time. Physostigma acts oppo- sitely to strychnia, diminishing the reflex power of the spinal cord, and hence is a remedy in tetanus, if given so as to pro- duce its physiological action. And in small doses, it acts upon the law of similarity. Small doses of the bromides, how- ever, relieve derangements of the circulation, consequent upon a deficiency of vaso-motor innervation. If a medicine will act then upon an organ, tissue, or func- tion, in health, when given in full doses, we may expect it to act in case of disease of this tissue, organ, or function. And Hahnemann contended that it was curative, because nature did not allow two diseases of similar character to remain in the body at the same time. That on account of the similarity of the medicine's action, it aroused and energized the organic force to react and expel the disease. Upon this law of simi- larity vaccinia prevents or modifies small-pox. And the experiments of Koch upon cholera patients and consumptives, are likely to throw much light upon our therapeutics. It is well known that the toxical effects of strychnia are very simi- lar to tetanus, yet many writers in the Hahnemann school give strychnia in small doses in tetanus with success. Cantharides tincture in large doses produces painful micturition, yet in doses of 1 to 5 gtts., it relieves this trouble. Galen's law of contraria contrariis is applicable in some cases: especially in some cases of acidity of the stomach the 38 THE PRACTICE OF MEDICINE. alkalies may give temporary relief, but if pushed, will increase the evil ten-fold. Turpentine in large doses produces albu- minuria, and, if pushed, inflammation of the kidneys and blad- der; but in doses of 1 to 5 gtts., it cures these troubles. Here we have the dual action of this remedy. Baptisia has the power in large doses, of decomposing the blood, and producing a septic condition, yet it is a valuable remedy in all septic diseases. This action is dual. Rhus toxicodendron (and perhaps the rhus venenata) produces an eruption, and in small doses, 10 gtts., in a glass of water, given in doses of 60 m., every two hours, cures this kind of acute skin eruption. It cures some cases of rheumatism also. These are only a few remedies out of many, whose direct medicinal action I have tested. But the developments are regularly disclosing the fact that almost, if not all, our reme- dial agents have this dual action These actions are produced by simply diminishing the dose for the therapeutical action, and increasing it for the toxical effects. It will be a rich boon to suffering humanity when physicians shall cease the routine prescribing, and, ignoring all sects in medical practice, study thoroughly all their remedies, so as to fit them to mor- bid conditions. The definite action of medicine is denied by a large major- ity of the physicians of Europe and America; and this denial has originated soly from the fact that we have hitherto ignored the pathological indications for our remedies. Furthermore, we have not singly tested (proven) our remedies, so as to get the precise affinity of each one, together with the remedial effects. The old rule of treating diseases by name, regardless of any pathological indications for the specific remedv, has been a blighting curse to humanity, and in this era of light and advancing science, it should be abandoned, with other relics of ignorance and blind-guessing. The mortality tables show how very unsuccessful this old routine plan of treating diseases has proved. And the sad results following this THE LAWS OF THERAPEUTICS. 39 unscientific method in practice, should induce every man to investigate for himself, and try the more rational practice, based upon pathology Some of the leading men of England, such as Ringer, and a few in America, such as Bartholow, acknowledge the fact that some of the remedies now used according to their pathological indications, are invaluable, viz. : belladonna, for congestion of the venous capillaries; aconite, for an excited heart, with fever, etc.; but neither of them has given us the "specific" use of our other remedial agents. They do not mention the curative effects of baptisia in a sep- tic diathesis; aesculus in haemorrhoids; hamamelis in varicosus; apocynum cannab. in dropsy; convallaria and cactus in hyper- trophy and valvular insufficiency of the heart; actaea rac. in lithic acid diathesis; chionanthus in jaundice; oil of pepo in haemorrhoids (this remedy has lately been suggested to me as a specific in piles, by Dr. M. A. Baldwin, of Cuthbert, Ga. ) ; lycopus in haemorrhage of the lungs; coto bark and magnifera iodica in chronic diarrhoea; rhamnus purschiana in constipation; kava-kava in urethral inflammation; ipecac and euphorbia in the vomiting and purging of cholera infantum and cholera mor- bus ; small doses of tincture of colocynth in colic; small doses of podophyllum in dysentery and summer complaint; nor do they even acknowledge the general law of affinity of remedies for organs and tissues. By the specific application of our remedies in accordance with their specific affinity, and the pathological indications calling for them, we do not mean to say that a certain remedy will cure all cases of a certain disease. We deny the old dogma that groups diseases by name into certain classes, and prescribes for them merely by name, regardless of pathology. Disease may consist of one pathological deviation from a nor- mal state, and be met by one remedy, or it may, and often does, consist of many pathological deviations from health, each of which abnormal deviations will demand a " specific " agent to correct it. If there are various lesions in a case, 40 THE PRACTICE OF MEDICINE. dependent upon one first lesion as a cause, then the relief of the first lesion may be followed by relief of all the lesions in the case. It is clear then that we must be thoroughly versed in the precise action of our remedies, and in the pathological indica- tions calling for them. We must know in what the lesion consists — that is, whether it be excess of action, defi- ciency of action, or a mere perversion of action. Without this knowledge, all our prescribing is done in the dark — it is unmitigated quackery. Our diagnosis must not be based upon the old generalization, or genus of disease, but upon a clear knowledge of the various pathological peculiarities pointed out by the symptoms in each case. This is the only way to treat disease successfully in general. We do not say that by this method it is possible to reach absolute success in every case; that is an utter impossibility, but we simply say that this method is a much nearer approach to general success than the old guessing system of the past. This is the distinguishing peculiarity of that class of physicians called "Eclectic;" but there are many that sail under this title that are really utterly unacquainted with the principles of modern "Eclecticism." We do not assert that there is any one law by which all our remedies act, but that remedies act upon their own law. And all physicians should "prove all things, and hold to the good." What is the difference between this pathological system of practice, and the homoeopathic system of practice ? Although we acknowledge the dual action in a great many remedies, such as ipecacuanha, curing dysentery and vomiting under certain pathological conditions, podophyllum in dysen- tery, and certain forms of diarrhoea, ergot in arresting threat- ened abortion, and some other similar instances of the dual action of our remedies, yet we do not say that all remedies thus act, nor do we hold the dogma of the infinitesimal dilu- tion of remedies increasing their action. This is a very mate- rial difference. We believe that there is a specific affinity of THE LAWS OF THERAPEUTICS. 41 certain remedies for certain organs or tissues, and that a cer- tain drug has a certain action upon an organ or tissue in a given dose, but that action is changed by greatly increasing the quantity. Its action may be quite different under differ- ent pathological conditions. We are also convinced that there are pathogenetic powers in our remedies; hence the necessity for small doses. While we regard symptoms as a guide to diagnosis, we are well satisfied that it will not do as a rule in diagnosis. For instance, we regard a great many diseases as of germ origin, as diphtheria, catarrh, phthisis, fevers, and many others; hence it will not do to confine our treatment to the mere febrile element, or manifestation of these diseases; but we must meet the first morbid cause of the organic, or functional disturbance. There is a certain septic element in the blood that causes many diseases, as typhus and typhoid fever, cholera, yellow fever, remittent and intermittent fever; here our remedies must be selected to meet this septic ele- ment, instead of the mere febrile manifestations, and after removing this septic condition, then the mere lesions may be easily met. We also oppose the old hobby of prescribing mer- curials in disease. But some members of our school admit that the biniodide of mercury, with iodide of potassium added, so as to prevent constitutional injury, may do good service; others deny even that, and ignore mercurials entirely. We do not deny but that the dual action of our remedies does fur- nish the key to scientific therapeutics. Each case should be carefully examined, and peculiar pathological condition made out; then the remedy (in its medical, and not lethal dose) prescribed in sufficient quantity to meet the indication accord- ing to the expression of the grouped symptoms. In many cases, there is doubtless a similarity between the drug's patho- genesis, and the morbid elements of the disease to be met by the drug. And we admit the fact that the empiric use of remedies has been followed by success in many cases, simply from the fact that they were prescribed from the knowledge 42 THE PRACTICE OF MEDICINE. of their affinity for certain organs and tissues. There muss the a relationship between the diseased, or morbid condition —- the pathological lesion and the remedy. Haller's law of cure prevails in most cases, but Hahnemann's chimera in regard to dynamization of medicines belongs to the old superstitions that clung to medicine in bygone ages, and not to science. All physicians should cease wrangling about pathys, and isms, and aid in improving their most noble profession. Their con- tinual unreasonable and unchristian quarreling over their vague hypotheses only lessens all sensible people's confidence in the healing art. CHAPTER Y. DIETETICS (HYGIENE). PROPER diet is essential not only to the health of adults, but to the perfect development of the young, thus ren- dering life vigorous, decay less rapid, and death more distant. The complete balance of all the organs of the body was the design of the Creator when he made man. Extended observa- tion has proved that the healing property of medicines is much retarded, and in many instances prevented by improper quantities and kinds of food. Any articles of diet that over- stimulate the system greatly lessen the susceptibility of the system to receive the action of medicines. The physician must regulate the diet of the sick by his own judgment, according to the nature of the disease, its stage and progress. Boiled milk, light soups, thoroughly cooked rice, or the essence of beef are sufficiently nourishing for most persons laboring under acute diseases. I think that invalids should eat at meal-time, not, as some writers recom- mend, every hour or two. As the disease gives way the diet may be more nourishing, such as boiled milk with good, well- raised crackers or light bread in it, or soups with bread in it. And as the digestive powers improve, the patient can take light, lean fowl, or very tender stewed or baked beef. As bread is the "staff of life" and constitutes a large share of the food of all classes of people, it may not be out of place to inquire into the kind of bread most conducive to health. It will be remembered that no single element or con- stituent of our food is alone capable of long sustaining the body. Wheat, when perfectly matured, contains the following principles: Water, 11 per cent.; gluten, 13 per cent.; starch, 43 44 THE PRACTICE OF MEDICINE. 60 per cent.; sugar, 8 per cent.; gum, 4 per cent.; oil, 2 per cent.; bran 2 per cent. The gluten lies next to the bran, with the oil. Too often these are separated from the superfine flour, since they are not so easily reduced to a fine flour, and hence the fastidious housewife rejects them, and they are now mostly thrown off in the bran. Beneath the darker layer is the heart of the kernel, which is very white and chiefly com- posed of the starch; and this is the fancy white flour that is mostly used, greatly to the detriment of the consumers' health. Besides these elements there are some mineral con- stituents, such as phosphoric acid, potash, soda, magnesia, oxide of iron, salt and silica. These constitute only about one per cent, in fine flour, but in coarse flour from four to eight per cent. But these mineral elements are essential to a healthy organization of our bodies. Phosphate of lime is required for the constant renewal of the bones. Phosphate of magnesia and potash are required to renew the wasting muscles, and soda for the wasting cartilages. The brain requires phos- phorus. Silica is required by the hair, teeth and nails. Iron is necessary to aid the formation of the red globules of the blood and the coloring matter of the eyes. The dark portion of the flour is the most nutritious constituent, as it is mostly gluten, and is not only the most nutritious, but much the sweetest portion of the wheat. The process of grinding wheat that crushes out the starch and leaves the gluten is objectionable, as the gluten is the most essential part, it being associated with the mineral con- stituents. The people, not knowing better, sacrifice the nour- ishing parts of the wheat for the starchy white flour. Liebig, one of our best chemists, states that 1,000 parts of good wheat contain twenty-one parts of nutritive salts, but fine white flour contains only seven parts in 1,000. Magendie proved by actual experiment that a dog will die if fed on fine, white, starchy flour, but if fed on brown bread — gluten flour, its health remains good. DIETETICS (HYGIENE). 45 Recently Mr. Hensel has thrown a flood of light on the chemical composition of the human body, and especially its proximate principles. He has proved that there are certain mineral tonics that tone up the blood and nervous system and are essential to perfect animal organizations. In 1,000 parts of our blood are eight parts of phosphates, sulphates, carbon- ates and chlorides of sodium, potassium, calcium, magnesium and iron. If salt and gypsum are deficient in the blood nutrition suffers at once. In each 100 grammes of blood there should be half a grain of sodium-chloride, or ^ lb. in the body. In consequence of the presence of this salt the coating of the blood-vessels is able to conduct the current of electricity, generated by the movement of the iron in the blood. And where there is a deficiency of this salt in the blood there is a deficiency of electricity in the body. It is believed that pest and cholera in the East Indies are due to the scarcity of salt among the poor, who cannot afford to pur- chase it on account of the very high duty on it. The pale cheeks of many of our young ladies are due to a want of salt in their diet. We daily excrete a certain amount of salt, hence the necessity of a daily re-supply to preserve health. Salt also aids the solution of other minerals, such as gypsum. This last is a mineral tonic of much utility in the organism. It has the power to combine on each side six molecules of ammonia bicarbonate. Gluten of good flour furnishes the gypsum, which the salt dissolves out of the gluten. Salt and gypsum influence prolificness — the vitality. The potato contains a small amount of gypsum (calcium sulphate), and from this fact the Irish cling to their long tested diet of her- ring and potatoes. Nations living on a lava soil, which is destitute of sulphates, and who live much on a diet of fruits, are fast fading from the face of the earth with leprosy and like diseases of the integument. The substance of the nerves is an oil containing ammonia combined with phosphoric acid. And we find in the bile sulphuric acid combined with taurin. 46 THE PRACTICE OF MEDICINE. Ammonia sulphate is very essential to health, which explains the therapeutical value of ammonia in all diseases of the lymphatic system. And at the same time it explains the value of ammonia in nervous diseases. This is the explana- tion of the tonic power of certain mineral salts. CHAPTER VI. DOSE OF MEDICINES. THE doses of the principal medicines prescribed in this work are for adults. Generally the dose for infants is about one-twentieth of that for adults, and for older children according to their age. In order to have a definite dose of medicines we must have uniformity of strength. What are called normal liquids or assayed fluid extracts are the most reliable preparations. These are concentrated liquid preparations, the strength of which is adjusted by careful assay, so that one fluid ounce, imperial measure, is the equivalent of one ounce avoirdupois of the crude drug of standard strength. These preparations are, therefore, of uniform strength and can be used with as much safety as the alkaloids, such as quinine, morphine, etc. Ordinary tinctures made from freshly crushed roots, barks, seeds or leaves, as may contain the medicinal principle of the article, by covering the crushed article with the proper men- struum and steeping fourteen days, then percolating, make preparations that answer a very good purpose where normal liquids can not be obtained. I have found many tinctures almost worthless, some of them from having been made from the green root or bark, as cimicifuga racemosa, the medicinal virtue of which consists of a resin, soluble in alcohol, and hence required to be freshly dried, as the water in the green root dilutes the alcohol and thereby lessens the strength of the tincture. A tincture made from the dried roots of either gelsemium or stillingea is worthless, as the medicinal prin- ciples of these articles and some others are volatile and pass off with the drying. To make good, reliable preparations, the 47 48 THE PRACTICE OF MEDICINE. pharmacist must be skilled in his profession. The physician that is not a skilled pharmacist himself should purchase his medicines from drug houses that deal only in pure, reliable preparations. Large manufacturers, who take pride in their reputation for the purity of their preparations, are the most reliable. Such firms can not afford to turn off poor prepara- tions, as they have too much at stake to risk their reputation on even doubtful preparations, much less upon worthless ones. I have given the doses below, for pure, good articles, viz.: Aconitum, tinct., pure_____.....____.................gtts. 1 to 3. Apis mellifica, tinct....................................gtts. 1 to 5. Arnica montanum, tinct.....______..................__gtts. i to 1. Arsenicum alba, tinct...........___....................gtt. 1 to 5. Apomorphia, as an emetic..............................grs. £, rV Apocynum cannabinum, tinct...........................gtts. 5 to 15. Apiol, tinct, saturated..................................gtts. 3 to 30. Antimony tartrate, dose............................___grs. jfa. Antimony iodide (2 dec. trit.)...........................grs. 1 to 3. Anacardium (oil, diluted as an oint.) Anagalis ai'venosis, tinct................................gtt. -J- to 1. Amyl nitrite, by inhalation.............................gtts. 3 to 5. Ammonium picrate (tinct. 13 tol§)....................gtts. 3 to 5. Ammonium phosphate...............................--grs. 10 to 20- Ammonium iodide.....................................grs. 2 to 10. Aqua ammonia_____.........-........-...............gtts. 10 to 30. Ammonii chloridum....................................grs. 1 to 20. Ammonii carbonas.....................................grs. 5 to 10. Arsenic iodide (2 trit.) 2 trit.............................grs. 1 to 2. Ammonii bromidum...................................grs. 10 to 15. Ammonii benzoas......................................grs. 5 to 30. Ammonii valerianas....................................grs. 1 to 2 Agaricus alba..........................................gtts. 10 to 20. Alstonia scholaris______..............................grs. 2 to 8. Alnus rubra, tinct.......................................gtts. 1 to 20. Aloes, as a purge.......................................grs. 1 to 2. Allium sativum and sepia.......................________grs. 15 to 20. Aletris forenso.................... ....................gtts. 15 to 30. Ailanthus..............................................gtts. 1 to 2. Agave Virginica.......................................gtts. f to 10. Auave Americana......................................gtts. 1 to 15. ^sculus glabra........................................gtts. 1 to 5. ^Esculus hyppocastaneum..............................gtts. 3 to 10. iEther (internally)......................................gtts. 5 to 20. DOSE OF MEDICINES. 49 Actaea racemosa (cimicif uga)---................-------gtts. 10 to 20. Acetillo bark, tinct.....................................gtts. 1 to 5. Acidum sulph. dilutum................................gtts. 3 to 8. Acidum sulphurosum--------.........................gtts. 5 to 10. Acidum nitricum.......................---......----gtts. 3 to 5. Acidum lacticum __________...........................gtts. 10 to 20. Aurum chloride................................-.......gr- jhs- Acetum lappa...................-..........-..........gtts. 30. Acidum hydrochloricum...............................gtts. 3to4. Acid, gallicum.................................-.......grs. 1 to 10. Acidum benzoicum....................................grs. 1 to 15. Achillea mellifolium...........................-.......gtts 3 to 20. Belladonna, tinct.......................-.............gtts. 3 to 5. Bryonia alba, tinct............... ....................-gtts. 2 to 3. Baptisia tinctoria (tinct.)....................... ........gtts. 5 to 10. Barium carb. (trituration, 1 cen.), 1 cen..................-grs. 1 to 2. Barium iodi (1st cen. trit.)........................-----gr. i to 1. Beberia sulphas (in chills)_____ ---............--.....grs. 1 to 20. Berberis vulgaris, tinct..................................gtts. 5 to 10. Bismuthi subnitras....................................-grs. 5 to 20. Brayera-kousso----...........--................-----grs- 20. Bromidium (for inhalation).............................10 gtts. to fl aq. Buchu, tinct............................................gtts. 15 to 60. Butylchloral hydras..................-.................grs. 1 to 5. Cactus grandifloras.....................................gtts. 5 to 30. Cadmii iodidum (1st dec).......................-------1 to 9 lard oint Caffeina (caffeine)----........-....................---gr-*• Calcii bromidum......................................gr. ^ to 1. Calcii hypophosphis, 1 trit..............................gr. J to 1. Calcii iodidum ____..... .............-...........---gr. 1 to 3. Tribasic phosphate of lime, or calcii phosphas precipitatus.grs. 1 to 2. Calcii sulphidum (Haper) 1 dec.------......-----......gr. 1- Calendula (for local use)...............................13 to 1 § aqua. Camphora (saturated tinct.)...................-.......-gtts. 5. Camphora monobromata................................grs- 1 to 4- Cannabis indica (sat. tinct)....................----.....gtts. 2 to 10. Calcarea carbonica (1st dec. trit.).........................gr. -J to 1. Cantharis (1st trit. or 1st dec.)...........................gtts. 1 to 2. Carbo vegetabilis (1st dec. trit.)..........................gr- 1- Chamomilla matricaria (3 dec.).............--...........gtts-1t0 3- Cocculus indicus (3 dec. triU.............------........gtts. 1 to 2. Colocynthis (sat. tinct.)__________......................gtt i to 1. Cuprum aceticum (3 dec. trit.)..............-----........grs 1 to 2. Capsella bursa pastoris..................................gtts- 5 to 30. Capsicum.............................................gtts. 1 to 5. 3 50 THE PRACTICE OF MEDICINE. Cassia marilandica (senna) powd..................------gr. 10 to 15. Cacelothyllum thalictoides...............................gtts. 5 to 15. Ceanothus Americanus.................................gtts. 1 to 30. Ceriioxalus............................................grs. 1 to 5. Chamaelerium luteum-helonias..........................gtts. 1 to 10. Cheledonium magus....................................gtts. 5 to 20. Chelone glabra.......................................gtts. 1 to 10. Chionanthus Virginica..................................gtts 2 to 10. Chimaphila umbellata_____.....................------3 1 to 2. Chloral hydras.......____.............................gr. 10 to 15. Chloroformum (for internal use).........................gtts. 10 to 15. Cinchoniae sulphas.....................................grs. 5 to 10. Cinchonidiae sulphas............_......................grs. 5 to 8. Cinnamonii ol. (tinct. dec.)_____........................gtts. 10 to 15. Colchici, radix, et semen................................gtts. 1 to 10. Collinsonia canadensis_____............................gtts. 1 to 15. Conium maculatum............---------------........gtts. 1 to 5. Copaiba, balsam copaiva____.........___..............gtts. 10 to 15. Coptis trifolia, used as a wash..........................gtts. 5 to 20. Corydalis formosa...........................__________gtts. 5 to 10. Creasotum (from beach tar)..............................gtts. 1 to 2. Cubeba tinct...........................................gtts. 1 to 10. Datura stramonium........_______..............______gtts. 1 to 10. Delphinium staphysagria_______________________.......gtts. 3 to 5. Digitalis purpurea____.................................gtts. 10 to 15. Dioscorea villosa...............................___.....gtts. 10 to 30. Dracontium fcetidum............................_......gtts. 5 to 20. Drosera rotundifolia....................................gtts. 10 to 30. Dubiosia myoporoides..................................gr. ^ to fa. Dulcamara—bittersweet................................gtts. 10 to 30. Elaterium, tinct.............._______..........________gtts. 1 to 5. Epigea repens.................._____..................gtts. 5 to 10. Epiphegus Virginiana...........................______gtts. 5 to 15. Ergota...............................................gtts. 1 to 30. Erigeron canadensis (oil)............................___gtts. 5 to 10. Eriodictyon Californicum.............._......._........gtts. 5 to 20. Eucalyptus globulus....................................gtts. 2 to 10. Euonymus atropurpureus...............................gtts. 5 to 20. Eupatorium aromaticum................................gtts. 5 to 20. Euphorbia corollata____...............................gtts. 1 to 15. Euphrasia officinalis........._____......................gtts. 1 to 5. Ferri acetas (effective)..................................grs. 5 to 10. Perri bromidum (not used)..............................grs 10 to 15. Ferri chloridum, tinct. (7-13)............................gtts. 15 to 25. Ferri citras............................................grs. 1 to 20. Ferri oxidum hyd......................................grs. 5 to 10. DOSE OF MEDICINES. 51 Ferri hypophosphis....................................grs. 1 to 5. Ferri iodidum.........................................grs. 1 to 10. Ferri phosphas.........................................grs. 1 to 5. Ferri pyrophosphas................................____grs. 1 to 10. Ferri subcarbonas......................................grs. 10 to 15. Ferri sulphas exsiccata..............___................grs. 1 to 2. Ferrum redactum......................................grs. 1 to 5. Gallium aparine (cleavers)..........................____gtts. 10 to 60. Gambogia, tinct. (harsh pur,)---.......................gtts. 1 to 2. Gelsemium sempervirens................................gtts. 10 to 30. Genista tinctoria......................___.....___.....gtts. 10 to 30. Gentianalutea......._________...................„.-. ..gtts. 5 to 30. Geranium maculatum.....___..........................gtts. 1 to 30. Gossypium herbaceum, fl. ex................„...........gtts. 1 to 30. Grindelia robusta......................................gtts. 5 to 30. Guaiacum officinale Am. T.............................gtts. 5 to 20. Gynocardia odorata (Chaulmugr.)___...................grs. 5. Hamamelis Virginica...................................gtts. 2 to 10. Helianthemum canadense...............................gtts. 1 to 30. Helleborus niger............................._________gtts. 1 to 10. Humulus lupulus_____................................gtts. 1 to 15. Hydrangea arborescens.................................gtts. 5 to 15. Hydrastis canadensis, fl. ex__________________......_____gtts. 10 to 30. Hyoscyamus Niger.._..................................gtts. 1 to 5. Hypericum perforatum.........................._......gtts. 1 to 5. Iberis amara (candy tuft)...............................gtts. 1 to 3. Ignatia amara..........................................gtts. 1 to 5. Iodinum, comp. tinct.....................___...........gtts. 1 to 5. lodoformum (oint. 1 to 9), tinct..........................gtts. 1 to 2. Ipecacuanha, anti-emetic................................gtts. 1 to 2. Ipecac, as an emetic...................................grs. 20. Iris versicolor..........................................gtts. 5 to 15. Jalapa, as a cathartic...................................grs. 15 to 20. Juglans cinerea, fl. ex..............................,----grs. 5 to 10. Juniperus, tinct.___...................................gtts. 15 to 20. Kalmia latifolia........................................gtts. 1 to 5. Kamala or Kameela, tinct.___.............--------.....3 1 to 2. Lappa officinalis, tinct..............................---gtts. 5 to 30. Leptandra Virginica, ti"ct...............................gtts. 1 to 10. Liatris spicata, tinct....................................gtts. 10 to 15. Lilium tigrinum.......................................gtts. 1 to 5. Liquor ammonii acetas.................................gtts. 10 to i%. Liquor ferri subsulphatis (Monsell's salt).................grs. 2. Lithii benzoas____________.............................grs. 3 to 10. Lithii bromidum.......................................grs. 5 to 15. Lithii carbonas.........................................grs. 1 to 3. 52 THE PRACTICE OF MEDICINE. Lithii citras......._____.............................grs. 2 to 3. Lobelia inflata......_.........-----...................grs. 1 to 60. Lycopus Virginicus....................................gtts. 3 to 30. Matico................................................gtts. 5 to 30. Matricari chamomilla...................................gtts. 1 to 2. Melilotus officinalis----................................gtts. 1 to 5. Menispermum canadense................................gtts. 1 to 1 3 . Mitchella repens........................................gtts. 5 to 15. Moreada punctata.......................-........______gtts. 1 to 15. Morphia sulph. and acetas......................-------grs. £ to TV Myrica cerifera..............................----------gtts. 1 to 15. Moschus (musk tinct)_______..........................gtts. 1 to 10. Nitroglycerinum, tinct., 1 cendi......._..................gtts. 10 to 60. Nuphar advena (2 decdi.).............................--gtts 2 to 10. Nux vomica.......................................gtts. 1 to 5. Nymphse odorata.......................................gtts. 5 to 10. ffinathera bicunis......................................gtts. 10 to 30. Oleum cajaputi........................................gtts. 2 to 5. Oleum tiglii (tinct., 1 to 9 alcohol)......................gtts. $ to 1. Opium (elixir, dose, 30 gtts.)...........................gr. 1. Pareira brava....................................._____gtts. 5 to 30. Passiflora incarnata........._____________________......gtts. 5 to 10. Phosphorus (tinct, ^)................................gtts. 15 to 20. Physostigma venenosum................................gtts. 5 to 8. Phytolacca decandra........................_____......gtts. 10 to 30. Pilocarpus pennatifolius____...............____........gtts. 1 to 60. Piper methysticum (kava kava)................._________gtts 10 to 30. Piscidia erythrina (Jam. dogwood).......................gtts. 5 to 15. Planta major..........................................gtts. 5 to 15. Platini (1 dec. trit.).....................____............grs. T^. Podophyllum peltatum.............................___gtts. 1 to 15. Polygonum punctatum.................................gtts. 15 to 60. Polymnia ulveldalia....................................gtts. 1 to 15. Palytrichum junipericuin...............................gtts. 30 to 60. Potassii acetas.................................___.....grs. 10 to 15. Potassii bichromas (1 dec. trit.)____.....................grs. l to 2. Potassii bitartras.......................................§|to 1. Potassii bromidum.....................................grs. 1 to 20. Potassii chloras____...................................grs. 1 to 2. Potassii cyanide (poison), used locally. Potassii et sodii tartras..................................?■!• to 1. Potassii hypophosphis............................._____grS- i to 1. Potassii iodidum.......................................„rs 2 to 15. Potassii nitras.............________....................grs 5 t0 jq Potassii permanganas...................................jrrS- 1 to 2. Prunus Virginiana....................................gtts. 1 to 15. DOSE OF MEDICINES. 53 Pteliatrifoliata.........................................gtts. 10 to 15. Pulsatilla nuttalliana...................................gtts. 10 to 30. Punica granatum (cortex, rad.), decoction. Qunise bisulphas (in the day)............................grs. 5 to 10. Resorcin, as an anti septic...............................grs. 1 to 4. Rhamnus purshiana, fl. ex...............................grs. 10 to 60. Rheum, tinct..............____.........................gtts. 1 to 30. Rhus aromatica________.................___......._____gtts. 1 to 30. Rhus glabra---.......................................gtts. 1 to 15. Rhus toxicodendron-...................................gtts 1 to 5. Ricinus communis (castor oil)...........................3 1 to 8 Robina pseudo (acacia)..........._.....................gtts. 5 to 15. Rumer crispus, fl. ex.............................._____gtts. 3 to 15. Ruta graveolens.......................................gtts. 1 to 5. Sabadilla.....------------............................gtts. £ to 1. Sanguinaria canadensis.................._____........_.gtts. 1 to 5. Santonica (santonine, dose, i to 1 gr.)................----gtts. 1 to 5. Sarracenia (pitcher plant)...............................gtts. 1 to 5. Spigelia, fl. ex.........................................gtts. 20 to 30. Sepia (succus, 3 dec. dilution)...........................gtts. 1 to 2. Scilla maritima_________............................-grs. 1 to 3. Scrophularia Marylandica___.......................---gtts. 5 to 15. Senecio aurens.......................-.................gtts. 5 to 15. Senega (syrup from the tinct.)-----......................gtts. 5 to 15. Silphium gummiferum.................................gtts. 3 to 5. Sodii bromidum______.................................grs. 5 to 20. Sodii hypophosphis.....................................grs. 1 to 5. Sodii hyposulphis......................................grs. 10 to 15. Sodii nitras -...........................................grs. 5 to 15. Sodii salicylas .........................................grs. 5 to 10. Sodii sulphocarbolas....................................grs. 5 to 10. Solanum nigrum...________ . -.......................gtts. 1 to 5. Spiritus setheris nitrosi...............-..................gtts. 10 to 30. Spongia restitatum____.........-...............■......gtts. 1 to 2. Sticta pulmonacea.........-............................gtts- ^ to !•>• Strychnia_____.....................-...........-.......g1"8 tU to srff- Sulphur (1 dec. trit.)....................................grs. 1 to 5. Sumbul ............................................gtts' 5 to 15. Thuja occidentalis.....................................gtts- 5 to 30. Thymol, tinct. (oil, 1 to 10)..............................gtts. 5 to 10. Trillium erectum......................................gtts. 1 to 10. Turnera aphrodisiaca..................................-gtts. 15 to 30. Urtica dioica___________.......................-......gtts 1 to 10. Uvaursi, fl. ex.................................-......gtts. 5 to 15. Valeriana officinalis....................................gtts. 15 to 30. Veratrum album___.................................gtts- i to ^ 54 THE PRACTICE OF MEDICINE. Veratrum viride........................................gtts. i to 1. Viburnum opulus......................................gtts. 1 to 30. Viburnum prunifolium.................................gtts. 15 to 60. Viola tricolor..........................................gtts. 1 to 15. Xanthorrhiza apifolia...................................gtts. 10 to 15. Xanthoxylum fraxinum................................gtts. 1 to 15. Xanthoxylum Carolinum..............................gtts. 1 to 5. Zinci phosphidum (1 dec.)...............................grs. ^ to -j^. Zinci sulphas (used locally).............................grs. 10 to 30. Zinci valerianas___________............................grs. \ to 1. The doses here given are for adults; for infants, one-twen- tieth of what is put here for an adult, and for children in accordance to age. The medicinal dose is less than the toxic or lethal. CHAPTER VII. GENERAL REMARKS UPON THE LEADING AND MOST PROMINENT SYMPTOMS OF DISEASE. THE Pulse.— The pulse is produced by the expulsion of the blood from the heart through the aorta, and thence into the various arteries of the body, by each contraction of the left ventricle of the heart, and by the innate contractility of the arterial walls. Hence the character of the pulse will be mod- ified by the condition of the heart and also by that of the blood-vessels, and of the blood itself. Gentleness should be observed in feeling the pulse, so as not to excite the action of the heart, especially in children and nervous persons. In ordinary cases, the pulse may be examined at the wrist. In examining the pulse, the pressure upon the artery must be very gentle and must be made by three fingers. The frequency of the pulse may be measured by the second hand of a watch, and its peculiar characteristics, as indicating diseased conditions, can only be appreciated by the educated hand of the careful examiner. Its rhythm, its fullness, or its softness should be noted ; whether compressible, strong, bounding, hard, soft, or small and wiry, intermittent, or regu- lar in beat. The healthy pulse is uniform, equal and moder- ately full, and swells slowly under the fingers ; it is smaller and quicker in children, and ordinarily also in women. In old age there is a structural change in the arterial coats, and hence, the pulse becomes somewhat harder than in the young and vigorous. In health, the average number of pulse beats in a minute at different ages, is as follows : at birth, 140 ; during infancy, 120 to 130 ; in childhood, 100 ; in youth, 90 ; in adult age, 55 56 THE PRACTICE OF MEDICINE. 70 to 72 ; in old age, 65 to 70 ; in decrepitude, 75 to 80. It is quickened by exertion or excitement ; it is more frequent in the morning and just after meals ; it is somewhat faster when standing than when sitting, and in sitting than lying ; but is retarded by sleep, cold, fatigue, hunger, and by arterial seda- tives, such as digitalis or veratrum. A rapid pulse, especially when it is strong, full and hard, indicates fever or inflammation ; if very rapid and small, it indicates debility or depression, as is the case frequently in enteric fever. A jerking pulse, with quick and forcible beat, followed by abrupt cessation for one or two beats, indicates structural lesion of the valves of the heart. The pulse may, however, be intermittent, owing to obstruction to the circula- tion of the blood in the heart and lungs, or from softening of the brain, or from inflammation of the brain, or from apo- plexy. Hernia, enteritis, and gangrene of the intestines may produce intermittency in the pulse, and it may be also pro- duced by prolonged or over-exertion, watching, want of rest or sleep, and anxiety. Indigestion with flatulence may pro- duce it in a less marked degree. A weak pulse indicates im- poverished blood and debility, and a full pulse denotes plethora, or the early stage of acute disease. The Temperature of the Body.—The normal temperature of sheltered parts of the body is 98.4 degrees or a few tenths more or less, and a persistent rising above 99.5 degrees, or a fall below 97.3 degrees are indications of a diseased condition. A normal temperature gives assurance of the absence of any- thing except local and very trifling disturbances of health ; but any very acute disease very soon elevates the temperature above the normal standard. By the clinical thermometer we readily diagnose between an inflammatory and a non-inflam- matory form of disease, and the thermometer helps us de- termine the intensity of the inflammation, by the number of degrees the bodily heat rises above the normal standard. Hysteria, for instance, often simulates inflammatory disease ; THE PROMINENT SYMPTOMS OF DISEASE. 57 the temperature in hysteria, however, is always nearly or quite natural, but never in inflammation. In typhoid fever, the thermometer not only indicates the fever, but also reveals changes that are about to take place in the patient's condition. In consumption, even when other symptoms are obscure, the thermometer will show that the temperature is about 102.3 degrees, or even higher, and the temperature will increase in proportion to the tubercular deposit. This increase of the temperature of the body often exists for several weeks prior to the loss of weight, or before the physical signs indicate tubercle in the lungs. 4In measles, the thermometer is the best means of determining that pneumonia is setting in. In acute rheumatism, if the temperature runs up to 104° it indi- cates grave complications. Respiration.—Healthy inspiration and expiration are performed with ease. An adult breathes about twenty times in a minute. Breathing is quickened by exertion and by disease, especially by fevers. Dyspnoea, or difficult breathing, may be the result of loss of lung substance, adventitious de- posits in the lungs, formations of false membranes in the air passages, as in croup or diphtheria, in tonsillitis and glossitis, and in asthma, which is a spasm of the muscles of the air tubes. Effusion of fluid into the pleura or pericardium (the serous membranes surrounding the lungs and heart), causes dyspnoea from compression of the lungs. Organic diseases of the heart, and functional diseases of this organ also cause dyspnoea. Diseases of the nerves of respiration, or their centres, may cause serious dyspnoea. Fracture of a rib, or fracture of several ribs, apoplexy, or great exhaustion, an in- sufficient supply of blood to the nerve centre of the brain, all may cause dyspnoea. The Tongue.—The tongue is an important means of diag- nosis. A dry tongue indicates diminished secretion, and is common in most acute and febrile diseases; a moist condition of this organ is regarded as a favorable sign, especially when 58 THE PRACTICE OF MEDICINE. it follows a furred and dry condition. A very red tongue is common in eruptive fevers and in remittent and intermittent fevers, especially when the stomach is involved ; it also is in- dicative of indigestion, in which case the edges are more red. If the tongue is fissured, it indicates typhus or typhoid fever. A purple or livid tongue indicates defective oxygenation of the blood. A heavy fur on the tongue indicates irritation or in- flammation of the mucous membranes ; it is also common in diseases of the brain, in all varieties of fever, and in most acute and dangerous diseases. Tobacco smokers usually have a furred tongue when well. A yellow coat upon the tongue is regarded as an indication of disordered liver ; and a brown or black coat denotes a low state of vitality or contamination of the blood. A tendency to health, after an attack of sickness, is indicated by a gradual cleaning of the tongue, which indi- cates a clearing up of the intestinal tract. If the tongue be- comes browner, drier and dirtier each day, the nervous system grows gradually feebler, and the hope of recovery less. When the fur separates in patches, leaving a glossy, red surface, the prospect of recovery is also unfavorable ; so too in cases in which a crust is rapidly removed. This rule is subject, how- ever, to exceptions. Pain.—A throbbing sensation with pain, and a sensation of tightness is a pulsative pain. A nervous pain generally inter- mits, or remits. A spasmodic pain is mitigated by pressure, or by friction, and by the application of warmth. Pain from inflammation is constant, attended by a quickening pulse and heat, and is increased by movement of the affected part, or by pressure. Pain occurs sometimes in a part distant from the seat of disease, as when inflammation of the liver gives rise to pain in the right shoulder ; so too inflammation of hip-joint may give rise to pain in the knee-joint ; stone in the bladder is accompanied by pain in the penis ; and disease of the heart gives rise to pain shooting down the left arm. The Skin.—In health, the skin feels moist, elastic, soft, THE PROMINENT SYMPTOMS OF DISEASE. 59 smooth, warm, and neither very tense nor loose. A harsh, dry, burning heat of the skin, indicates fever and inflammation. If perspiration takes place, and the improvement is general otherwise, it is a favorable sign. Partial or local perspiration indicates a deranged condition of the nervous system, or an affection of the organs beneath the sweating surface. When perspiration occurs after slight exercise, it indicates great weakness or debility. Night-sweats occur in debility, in hectic and in consumption, or chronic bronchitis. The color of the skin is also diagnostic. A bluish tint of the skin indicates structural disease of the heart. A yellow color points to bil- iary affections. A rich blush of the cheeks, especially if it be confined to a limited part, and the surrounding parts remain pale, indicates an irritable condition of the nervous system, or a diseased state of the lungs. The face will often blanch from sudden emotion, and flush from a sudden fit of anger or shame. I have seen persons who were subject to occasional flushes of the face from a morbid state of the capillaries. The Urine.—By the healthy activity of the kidneys the blood is relieved of many impurities, which, if retained, would produce disease in some part of the organic structure. Healthy urine is of a yellow or amber color, of slight ammo- niacal smell, and precipitates very little, if any, deposit on standing. The average specific gravity in healthy urine is be- tween 1.020 and 1.025. It presents varieties in disease, and furnishes valuable indications to the physician. In jaundice it is of a dark yellow or saffron color. In fevers it is generally red or high colored, and scanty in quantity. It may be bloody and slimy in affections of the kidneys and bladder, It is pale and copious when less urea is excreted, or when metamorpho- sis is checked, as in nervous and hysterical affections. It may be heavy, muddy, or of a purple color in some peculiar condi- tions of the system ; or it may be very dark or black, indica- ting its putridity. In chronic or acute inflammation of the bladder, the urine is passed with more or less pain. Some- 60 THE PRACTICE OF MEDICINE. times there is very frequent desire to micturate, with burning and scalding pain in passing the urine, especially the last drop, as in calculus. Diabetic urine is usually pale and copious, and its specific gravity is from 1.025 to 1.060. In hysteria the specific gravity may be as low as 1.007. In rheumatism the urine is usually acid, but in nervous affections it is alkaline. Examination of Urine.—It is a well known fact that certain abnormal or pathological conditions are associated with changes in the chemical constituents of the urine, and as such point to certain remedies. Hence, the microscopic examina- tion, together with certain chemical tests become necessary in such cases. The following tests are adapted to the every-day work of the busy practitioner, and the abnormal constituents detected, may directly aid the physician in his treatment : Healthy urine has usually a specific gravity of from 1.012 to 1.018 at the temperature of 60 degrees Fahr., which may be changed by diet, exercise and temperature. Slight departures from natural specific gravity are not certain evidence of disease. But if the amount of urine be greatly increased, and the specific gravity be from 1.030 to 1.040, the presence of sugar is indicated, the urinometer will give the specific gravity. By evaporation of a tablespoonful of urine, if sugar be present, it will appear in the spoon or capsule in the form of a syrup. To confirm this test, mix one part of Fehling's soda solution with one part of Fehling's copper solution. Add as much in bulk of clear urine, boil the mixture over an alcohol lamp, a precipitate (cuprous oxide), results, ranging from yellow to brownish-red if sugar is present in the urine. Earthy Phosphates.—Test: add an excess of ammonia water to the clear urine and boil ; if a precipitate follows, then the earthy phosphates are present in the urine. Urea.—This salt is almost always present in urine. It is due to the destruction of nitrogenous tissue of the body, and is the means by which the kidneys eliminate nitrogen from the body. About one ounce is often eliminated in the day and THE PROMINENT SYMPTOMS OF DISEASE. 61 night in health. An animal diet increases the quantity, and a low diet diminishes the quantity. Test for Urea.—Mix in a test tube one part of nitric acid with two measures of urine, cork the tube, cool down to 60 degrees Fahr., and let it stand one-half hour. If the mixture exhibits a mass of crystals, urea is present in abnormal quantity. Pus.—To detect pus in the urine, let the urine settle, then decant the clear liquid, and add to the sediment a solution of potassium hydroxide (caustic potash). If there is pus pres- ent a gelatinous mass results, and then albumen will likely be found in the clear urine previously decanted off. Bile-Coloring Matter.—To detect, pour hydrochloric acid into a beaker glass to the depth of half an inch ; stir urine into this until the acid is colored, then through a glass funnel introduce a layer of nitric acid upon the bottom of the beaker. If the coloring matter of bile is present, a play of colors is seen where the liquids are in contact. Now, mix the liquids with a glass rod, and the changes of color are seen through the liquid. Blood in the Urine.—To detect blood in the urine, place the urine, as voided, in a test tube, and add a solution of potassium hydroxide (caustic potash), then gently warm. And if a blood-red precipitate (earthy phosphates) forms, then blood is present in the urine. If the urine should be alkaline in reaction, first add a solution of magnesia sulphate, then the caustic potash in solution. The microscope and spectroscope are valuable in detecting blood in the urine. Use a power of 200 or 250. Uric Acid.—This is common in the urine of carniverous animals. But it occurs in combination, forming urates in the urine of men and women. Uric acid is never present in freshly voided urine, in its normal state, so as to form a visi- ble sediment. To test uric acid in any abnormal amount of precipitate, generally of a brick-dust color, place a little of the 62 THE PRACTICE OF MEDICINE. sediment in a porcelain dish, with a small quantity of water ; then add a few drops of nitric acid, carefully warming it. As soon as the uric acid is dissolved, evaporate the solution almost to dryness, on a water bath. Now, add a few drops of ammonia water, or let the vapor of ammonia come in close contact, and a beautiful purple color will be quickly seen if uric acid be present in the precipitate. The examination of the urine has received more special attention for the last few years than formerly. It is regarded of sufficient importance now as to be taught, with general chemistry, in medical colleges. Litmus paper very readily determines the acid reaction of the urine, by becoming red as soon as wet in the urine and dried. Red turmeric paper turns blue if wet in alkaline urine and then dried. CHAPTER VIII. DISEASES OF THE BLOOD. AS the blood is the life of the body it must necessarily produce great disturbance in the body when its charac- ter and composition become changed. In health, the blood consists of serum and two kinds of corpuscles—the red and white. The serum contains water, fibrin, albumen, salts, fatty or oily substances, and extractive materials. If these constituents be diminished, increased, or altered, it causes an abnormal condition of the blood. This fluid may be also poisoned by the admixture of noxious substances, such as uric acid, oxalic acid, ammonium, sulphuretted hydrogen, urate, bile, pus, and even sugar. Cyanosis. The blood having a natural affinity for oxygen, absorbs it while it is in contact with the air of the lungs. Any cause that prevents this absorption of oxygen by the blood cor- puscles, hinders the transformation of venous into arterial blood, which causes cyanosis. This disease consists in defi- ciency of oxygen in the blood corpuscles. Its causes are numerous, and may be arranged under various heads as men- tioned hereafter. Causes.—It may be the result of imperfect respiration, in consequence of spasms, or oedema, or croup, or inflammation of the larynx and glottis, or any obstacle that may prevent the air from entering the air-cells of the lungs freely. Emphysema, hepatization, hydrothorax, or paralytic affections of the respiratory muscles, or distention of the abdomen with gas or water, so as to impede respiration, may give rise to it. 63 64 THE PRACTICE OF MEDICINE. Diseases of the heart may cause it, and so may obstructions within the pulmonary vessels. Immediate transmission of the venous blood into the left ventricle, by non-closure at birth of the foramen ovale, is often the cause of this disease. Irrespi- rable gases, as carbonic acid gas, may cause cyanosis. Sometimes in typhus fever, cholera, pyaemia and tuberculosis, the blood is so changed that its corpuscles are unable to absorb oxygen. Symptoms.—Cyanosis is to be distinguished by the blue- ishness of the skin, especially of the face and lips ; coldness of the surface and extremities ; sopor ; and finally, asphyxia. Treatment.—I find that cactus will give as great relief as any remedy we have, gtt. 5 every two or three hours. Collin- sonia may alternate. Cyanosis is usually fatal. Anemia. This may be defined as a poverty of the blood, or, patho- logically speaking it may be defined as a diminution of plastic albuminates and red corpuscles. That impoverished state of the blood that follows haemorrhage, from wounds or otherwise, is not what is meant by true anaemia. Causes.—A deficient supply of nourishing food may cause this disease. A want of air and exercise, too high or too low a temperature, excessive loss of semen, too long continued lac- tation, too profuse menstruation, mental over-work, albuminuria, excessive mucous discharges, diarrhoea, or dysentery, excessive suppuration, infiltrations into the pericardial sac, or into the pleural or peritoneal cavities, malignant growths, malarial infections, certain mineral poisons, such as arsenic and mer- cury, diseases of the lymphatics and spleen, may all cause anaemia, under certain conditions. Symptoms.—Paleness of the skin and mucous membranes, dropsical effusions in consequence of deficiency of albumen in the blood, emaciation, marasmus, or atrophy of tissue, a DISEASES OF THE BLOOD. 65 tendency to haemorrhage, low temperature, dyspnoea, and pal- pitation of the heart. Treatment.—Fowler's solution in gtt. -| doses, or iron in moderate doses, with helonias dioica, gtt. 30, three times a day, will generally cure this disease. Oligocythemia. In some diseases more corpuscles die than are generated, in a given time, and this causes a state of the blood' calle.d oligocythcemia. It is characterized by weakness of the muscles; a tired feeling; nervousness; palpitation of the heart, and a murmur in the jugular veins. So rapid is this dissolution of the blood corpuscles in some cases that the blood-serum becomes surcharged with the constituents of the dead corpuscles, and is thus discolored. Sometimes the excretions of the body assume a bloody hue. The skin and mucous membrane may become colored with haeniatin, so as to render it yellowish, creating an appearance of jaundice. The dissolution of blood- corpuscles may be confined to a certain portion of the circula- tion, and constitutes an essential element of local gangrene. A general putrid dissolution may take place throughout the system, and produce general gangrene or septicaemia. This is the case sometimes in scurvy and typhus fever, puerperal fever and yellow fever, and other tropical forms of fever. Treatment.—Baptisia, alternated with gtt. 1 of Fowler's solution every three hours, is the remedy. Leukaemia. Is caused by a great predominance of the white corpuscles, and often occurs in connection with hypertrophy of the spleen, or tumors of the lymphatic glands in general. Symptoms.—The patient complains of great prostration, dull pains in the splenic region, headache, dizziness in the ears, palpitation of the heart, shortness of breath, with en- largement of the lymphatic glands of the entire body, but 5 66 THE PRACTICE OF MEDICINE. especially of the cervical, jugular, axillar, and inguinal regions. There may be tumors of the spleen without leukaemia, and so of the lymphatics. Treatment.—Thuja oca, in doses of gtt. 1 to 2, three times a day, often relieves this disease quickly. The sulphate of sodium in small doses is also a good remedy ; dose gr. 1 to 2, three times a day. If there is debility, bad digestion, con- stipation, or a want of nervous power, then nux vomica may be given, in doses of gtt., 1 to 2, three times a day. In some cases gtt., 1 to 2 of arsenic, in the shape of Fowler's solution, has been given with good effect. Menispermin, in doses of gr. 1 to 2, may be given with the best effects in many cases. The nitrate of sodium is also a good remedy ; dose gr. 1 to 2, three times a day. The acetate of sodium will often answer as well, and in some cases even better. Nitrate of potassium, in 1 to 2 gr. doses, is also a good remedy. The carbonate of lime is a valuable remedy. The phosphate of magnesium is often useful. Chlorosis. This is a diminution of haemoglobin in the blood. The albuminates and leucocytes are not Affected, and this fact must be regarded as a pathological distinction between this disease and anaemia. This disease seems to be limited to the female sex, between the fourteenth and twenty-fourth years of age. There may exist a constitutional tendency to this disease. Symptoms.—Paleness of the skin, which is either clear or yellowish, greenish, or waxy. The lips and mucous mem- branes are pale, with dark rings around the eyes, oedema of the face, eyelids and feet, decreased temperature, and great sensitiveness to cold. The pulse is slow, compressible and small, and there is generally palpitation of the heart. There is great debility, headache, noises in the ears, pains in the body, especially in the stomach and back, sadness, want of energy, nightmare, sometimes mania. DISEASES OF THE BLOOD. 67 Treatment.—Iron is a valuable remedy, and may be alternated with helonias dioica. Arsenic is also indicated in many cases. Hypophosphite of lime, alternated with nux vomica, is useful where the digestion is feeble. Pulsatilla in doses of gtt. 5 is required where in females the menstrual flow is deficient, and this may be alternated with senecio aurens gtt. 30 to the dose. Scurvy. This disease resembles septicaemia, and is very gradually developed. There is general debility, sleeplessness, depres- sion of mind, cachectic face, with blue rings around the eyes, the pulse is slow and soft, and the appetite poor, urine scanty, skin dry and harsh, and frequently constipation. The gums become bluish, swollen, spongy, and generally bleed at the slightest touch. The breath becomes foetid, and there is a bad taste in the mouth. The debility increases, the extremities suffer pain, ecchymosed spots appear on the body or limbs, and finally all over, from the size of a lentil seed to that of a half dollar. At first they look purple, and in severe cases they are black. Very frequently there is epistaxis, and haemor- rhages from other parts of the body. The debility may become so great that the patient faints upon slight exertion, and there may flow from the gums and mouth a foetid, ichor- ous, bloody fluid ; the ecchymosed spots on the skin may change into blisters, filled with an ichorous fluid and forming ulcers. The pain of the limbs may greatly intensify, and the joints and bones may become enlarged, and an effusion of fibrin take place under the skin. A thin ichorous diarrhoea may set in, with colicky pains. The spleen usually becomes greatly enlarged and often very tender to the touch. There may be haemorrhage from the kidneys as well as from the nose and bowels. There may also be an extravasation of bloody serum into the pleura, the pericardium, the lungs, or brain or its membranes, and the patient may die suddenly ; or slow 68 THE PRACTICE OF MEDICINE. convalescence may take place and the patient gradually re- cover his health. It has been divided into sea and land scurvy, but there is no essential difference between these two forms of scurvy. Causes.—A want of vegetable food and the exclusive use of salty provisions generally give rise to this disease ; but exposure to damp, cold weather, bad drinking water, rancid meat, depressing mental emotions, fear and anxiety may aid in its development—ceteris paribus. Treatment.—Where the skin is pale, the gums swollen and bleeding, dark purple blotches upon the limbs or body, limbs swollen, hard, and painful, with constipation of the bowels, the agave Americana, in the form of an extract, in doses 3 ^ every two or three hours, has made many cures, and so have lemon juice and vegetables. Poisons.—Vulnera Veneno-Infecta. Poisoned Wounds.—These may be made by venomous animals, snakes, spiders, scorpions, etc., and by animals hav- ing infectious diseases ; also by dead animal matter, by mor- bid secretions, by vegetable substances, by poisoned arrows, by subcutaneous injections, or by mineral substances. There are many venomous serpents, but the virulence of their venom differs in degree. Some cause death very quickly/ while others produce inflammation of the lungs, and others cause death by a slower process. Thero are several species of spiders that are poisonous. The centipede is also quite poisonous, and the venom is on all their feet. Treatment.—Poisons from the bites of venomous reptiles should be treated immediately. A bandage should be applied between the bitten part and the heart, to prevent the circula- tion of the poison in the system. Extraction of the virus from the wound by sucking it out should be tried, as it will not affect the patient's mouth unless there is a hollow tooth or an abrasion in the mouth. Alcoholic liquors have long been diseases of the blood. 69 regarded as the most certain stimulants. I have used brandy and whisky in several cases of the bites of serpents and spiders, alternated with ammonia, and applied aqua ammonia and oleine oil, equal parts, to the part freely and around the bitten part, with success. The patient should take the carbon- ate of ammonia in doses of 5 to 10 grs., and the brandy in doses sufficient to fully stimulate the heart to vigorous action, to aid elimination of the poison. Recently I have been in- formed by Dr. Meyer, of Pawnee City, Neb., that the echinacea angustifolia is a positive remedy. It is a fine stimulant, and at the same time it has proved a fine antiseptic in indolent ulcers, etc. It requires very active stimulants to keep the heart acting vigorously. I have had patients who would drink a pint of brandy in the course of a few hours. There are cases on record where two and three quarts of whisky were drunk in a day, or in less time. The spirits are either an antidote to the poison, as is the ammonia, or aid elimination of the virus from the system. The wound may be also filled with carbolic acid immediately, in a* liquid form, so as to thoroughly fill the wound throughout. It is believed that strong carbolic acid neutralizes the poison, and it should never be forgotten in such cases. Permanganate of potash is also good. I treated the bite of a rattlesnake once with arsenic ; a few drops of Fowler's solution every four hours. This is a good remedy where there is rapid prostration. It tends to correct the poisoned state of the blood. If carbolic acid is not at hand, the wound should be excised deeply, so as to be certain to remove the virus. I have succeeded in curing the bite of a spider with the above treatment. Dr. Samuel O. L. Potter, one of the best of therapeutists, says that ammonia is one of the best nerve stimulants in snake bite. He recom- mends it in doses of 10 to 20 gtt. of liquor ammon., in water, every half hour. The chloride of lime, a filtered solution, injected into the wound made by snake bite, proved successful in seventeen cases, says Dr. S. O. L. Potter. For the stings of 70 THE PRACTICE OF MEDICINE. bees, wasps, and other insects of like kind, the pain is much relieved by applying sugar to the part at once. Ipecacuanha, as a poultice, gives much relief. Bites of Rabid Animals.—To prevent hydrophobia, I have used the echinacea augustifolio, successfully in two cases. I also cauterize the wounds if seen in time. After hydrophobia comes on, then, if there be hyperaemic states of the brain, belladonna should be given in doses of 5 to 6 drops every 4 or 6 hours. Stramonium is also recommended by some writers. Glonoin is also spoken of in this disease. Chloroform controls the spasms. Purpura Hemorrhagica. This is a sporadic haemorrhage, of rather a brief duration, the etiology of which is not known. It differs from scurvy in not having any of those affections of the gums that attend scurvy. It may begin suddenly, without any premonitory symptoms. There appear petechiae upon the skin, or there may be epistaxis. It may commence with rheumatic pains in the legs, especially in the knees and ankles. Haemorrhagic exanthema may extend over the entire body, and may vary in size from the size of a lentil seed to that of a large pea. There may be vesicles formed out of the circumscribed haemor- rhages into the rete Malpighi from capillary loops of the papillae of the skin. If a mere cutaneous eruption constitute the disease it is called purpura hemorrhagica. Haemorrhage may take place from the mucous membrane of the nose, mouth, stomach, intestines, urethra, bronchi, or from the womb in females. Treatment.—Phosphorus, in tincture, may be required in some cases. Hamamelis is one of our best remedies and may be given in doses of gtt. 5 to 10 of the tincture of fluid extract every two hours. Arsenic may be required in some cases. DISEASES OF THE BLOOD. 71 Scrofula. Scrofulosis is a peculiar cachexia, which manifests itself in the form of a nutritive disturbance in the skin, mucous mem- branes, joints, bones, organs of sense, lymphatic glands, and sometimes in other glands, as the submaxillary. The subject may have a large head, coarse features, thick upper lip, broad cheek bones, large abdomen, swollen glands on the neck, and soft flabby muscles, and there may be whiteness of the skin, showing the vessels plainly, redness of the lips and cheeks, languid eyes, flabby appearance of the whole make-up of the body. So, too, there may be eruptions on the face, as eczema or impetigo, or porrigo, or tinia. And in some cases lupus may occur. There may scrofulous conjunctivitis, otitis, or oft occurring coryza, and even bronchitis. It may affect the joints in the form of white swellings, or cause suppurating abscesses, such as caries of the bones and destruction of the capsular ligaments. There may be ostitis or periostitis or necrosis of the bones. The lymphatics generally show the greatest nutritive disturbances. And the cellular tissue may become involved, causing suppuration and abscesses, which progress generally very slowly and heal with great difficulty, and always leave ugly cicatrices. These glandular abscesses are mostly on the neck. Sometimes the glands are greatly enlarged, but the microscope shows their enlargement to con- sist of pure hypertrophy of their own cells, and not of any foreign elements. When they inflame and suppurate they form abscesses that break, or else the puriform matter becomes desiccated into a cheesy mass, and may then be transformed into a chalky substance. These chalky substances may so irritate the adjacent tissues as to give rise to inflammation and suppuration of glands. The most common location of these swollen glands is the neck, especially behind the ears and under the lower jaws. The mesenteric and bronchial glands may also be affected. This disease may be inherited as well as acquired. 72 THE PRACTICE OF MEDICINE. Treatment.—In children, the alnus rub. in doses of £ to 1 3 of the fluid extract or tincture three times a day, alter- nated with the iodide of barium (as an ointment), will often make a decided impression on the disease. I have used the syrup of the hypophosphites with fine effect. Cistus canaden- sis and menispermium (the tincture), in doses of 3 ^ each, three times a day, do good generally. The common black walnut, in the form of a syrup of the leaves, is a valuable remedy. When the bones are attacked, then the chloride of gold, in doses of y-^ of a grain, three times a day, may be used, alternated with pot. iod. If it manifests itself upon the skin, the iodide of arsenic, in doses of y^-¥ of a grain, often acts admirably. Scrophularia possesses direct power over this disease, especially when it attacks the skin or glandular system. It may be alternated with some of the iodides, as the iodide of barium, or iodide of soda or ammonia. The scrophularia pro- motes absorption of amorphous materials and thus aids the healing of ulcerations that may have proved otherwise obsti- nate. And, from the very prompt action of echanacia in glandular and skin affections, I am of opinion that it will prove a rich boon to the victims of this disease. I have tried it in syphilitic cases with success and in cases of indolent ulcers of years' standing. CHAPTER IX. FEVERS: THE EXANTHEMATA. Fever. IN defining fever we meet with that oft-repeated question, " What is Fever ? " A question that has perplexed medical writers from the days of the dawning of medical science until the present day. Fever may be said to be a diseased con- dition of all the vital endowments, functions and faculties of the fluids and of the entire organic structure of the body. It may be said to consist in an elevation of bodily temperature, perhaps arising from alterations of the nervous system, and that also giving rise to increased tissue change—" color propter naturam " of Galen. There are sensorial or nervous irregu- larity, increased circulation of the blood, increased body tem- perature and loss of appetite for food. But the first morbid phenomena of fever may be referred to the nervous system in a peculiar disturbed condition, and that condition at first seems to be one of depression. The initial chill or cold stage, which precedes almost all febrile affections, is not easily explained upon any other hypothesis. It is true there, is something, more than the mere nervous depression, which we do not fathom. And there is something in the fever besides the mere reaction and depression. The chill differs from ordinary nervous depression. And in regard to the reaction in the febrile stage, there is something besides reaction. There is a pervading and profound impressive influence from a specific- ally acting cause in all the various types of fever, and hence fever is not, as has once been supposed, the resilience of the depressed system. It is true that the first derangement 73 74 THE PRACTICE OF MEDICINE. appears "to be in the nervous and sensorial functions; then there is derangement in the circulatory system, and then derangement in the secreting and excreting functions. The paroxysmal character of malarial fevers shows that the func- tion of innervation is embarrassed in this type of fevers, and the varied phenomena of typhus fever indicates a primary mor- bid condition of innervation. The symptoms all plainly point out this condition to be one of adynamia with irritation. There is a perversion in some functions with abnormal molec- ular actions. It is quite difficult to account for the various morbid phenomenon of fever in any other way than through the nervous system. The recent investigations of pathologists refer all fevers to specific causes, such as organic germs or infectious miasms, that enter the blood and produce their primary deleterious effect upon the nervous system. The morbid impression of each peculiar poison has its power over and its affinity for a certain part of the nervous system, directed by its peculiar molecular composition, just upon the same law that directs the action of our remedies upon certain parts or tissues. The poisons of fevers have their inherent power, per se, to disturb the elementary properties of all the organized struc- tures of the body, viz.: susceptibility and vital affinity, and this disturbance soon involves the disturbance of all the organic functions in turn. A pyretic condition may consist of mere feverishness with a temperature ranging from 99.5° Fahr. to 101.5° up to a high febrile state of from 107° to 108.5° Fahr., beyond which life can not long be per- petuated. The different diseases in which pyretic conditions are found are so numerous that fever is one of the most familiar morbid conditions the physician meets in his daily practice. Typhus fever is seen in overcrowded ships, camps and cities, wherever there is decaying animal and vegetable mat- ter; and typhoid fever marks the sanitary negligence in city, FEVERS: THE EXANTHEMATA. 75 village, or country home; and the* exanthemata are the scourges among our children; likewise ague hangs like a dreaded pall over undrained or inundated bogs and marshes. Typhoid and typhus, relapsing fever and plague originate from specific poisons developed from decomposing animal matter, or from the excretions of those sick with those dis- eases. By some these specific poisons are called idio-miasms, by others they are styled infectious or contagious. They readily float in the air, mix with water, milk and probably in articles of diet. They may enter the blood through the lungs, or stomach. These poisons have been transported in ships, trunks, boxes of goods or clothing. But they soon become inert when diluted largely in the air. It matters but little whether the poisonous infections giv- ing rise to typhoid, typhus and relapsing fever, be specific agents in the form of bacteria, micrococci, other forms of mic- roscopic infections, originating in animal excretions in a certain state, or in organic gaseous products from decaying vegetable and animal matter. Many experiments and recent developments favor the germ theory of this class, and many other forms of disease. And these specific fever-poisons do certainly exist in fever, manifesting their pathogenic power in proportion to the amount of decomposing animal matter and excretions in the badly ventilated, and in over-crowded dwell- ings, filthy cellars, cesspools, in the cities, villages, or in the country. Hence, these fevers prevail in all climates, and at any seasons of the year, wherever, and whenever excrementi- tious matters accumulate in sufficient quantities to poison the atmosphere around the dwellings. Sanitary regulations can lessen these diseases greatly, if not prevent them in toto. Yellow fever, erysipelas, and diphtheria, each depends for its causation upon a specific and distinct poison, having peculiar affinities and pathogenic power. Many other diseases are pro- duced in a like manner. 76 THE PRACTICE OF MEDICINE. Infection, Contagion and Miasm.—These terms frequently occur in treating of individual forms of disease, and it is nec- essary to clearly understand them. Infection is a substance, or materies morbi, developed by certain changes in animal matter and animal excretions outside of the living body, which is capable of propagating itself where the surrounding condi- tions favor its development, and it has the power to affect the liv- ing organism in a specific way, according to its composition and its affinities. These infections are specific in their pathogenic power, and produce the same disease. And it will be remem- bered that an infection is a disease producing agent, outside of the body and is often developed into such activity that so rapidly multiplies itself as to infect the air in a city or district of country, and thus produce an epidemic. By contagion is meant a specific poison that is developed within the body of the sick, which when it comes in contact with another person, will produce the same disease in the exposed person. Such are smallpox, measles, mumps, etc. It is believed that there are other diseases thus produced. Miasm.—Miasm is a peculiar poison from decaying organic matter, animal and vegetable, under favorable conditions. Malarial Hematuria, or Haemorrhagic Malarial Fever, is a peculiar form of malarial or marsh fever, which has been met with in many of the Southern and Southwestern States, especially those States bordering on the Mississippi river and the Gulf of Mexico. This form of fever is characterized by a chill, and often with nausea and vomiting, and very soon there is developed a yellow color of the skin and eyes, with haemorrhage from the kidneys and bladder, and sometimes from the lungs and bowels. It recently appeared in Senegambia and Cochin China. It often prevails in the Southern States in winter and rainy seasons. It may follow ordinary intermittent fever, after three or four paroxysms of that form of fever, or it may attack fevers: the exanthemata. 77 anaemic persons. After the initial chill a discharge of dark bloody urine commences to flow, and the matters vomited up or purged are copious, and as black as tar, from the coloring matter of the bile. They often change to a greenish color from exposure to light and air. They are thought to contain no blood. The tongue is generally coated, the pulse is quick, compressible and weak. The temperature varies from 99° to 104° Fahr., and the bloody discharges with the urine continue until fatal collapse ensues in most cases. The dis- ease varies in duration from twelve hours to seven or eight days, when, in most cases, it terminates in death. Hence, the prognosis is very unfavorable in all cases. Post-mortem Appearance.—There are no very marked pathological changes to distinguish this form of malarial fever. There may be found a dark fluid in the stomach mixed with altered bile. The mucous membrane of the stomach is usually injected with blood, and dark, and more or less tumified ; the spleen and kidneys are greatly congested in most cases. Treatment.—The indications are to arrest the haemor- rhage and the fever. To control the fever the milder prepara- tion of cinchonia are the remedies;grs. 3 to 5 of cinchonidia may be given every three hours in the interval, or until the fever is arrested. For the haemorrhage the fl. ext. of hama- melis, in doses of 10 to 15 gtts. every two hours may be tried, alternated with the tinct. of chloride of iron, in doses of 15 to 20 gtts. well diluted, every two hours. Dr. F. C. Fahs, of Alabama, recommends the sulphite of soda in full doses. The hypersulphite of soda may be given in doses of 30 grs., every three hours to arrest the disease, and the sweet spirits of nitre in doses of 3 1 with 3 to 5 gtts. of turpen- tine, and 5 gtts. of oil of erigeron may be given between the doses of the hypersulphite of soda. If the nausea and vomiting are persistent, the tinct. of euphorbia or ipecac- uanha may be given in doses of 2 to 3 gtts. every ten or 78 THE PRACTICE OF MEDICINE. fifteen minutes until vomiting is controlled. The patient may be sustained upon buttermilk kept in cold ice-water. After the fever and haemorrhage have been controlled, the hepatic secretion may be controlled with the tincture of chelidonium ; dose, 5 gtts. every three hours. Typhoid Fever. Enteric fever is a continued, slightly infectious fever, continuing about twenty-eight days and often longer. Its pathological effects are evident in the bowels. It is accom- panied with an eruption of a few rose-colored spots on the chest, abdomen, or back, with great feebleness and abdominal pains and tenderness, and almost always with diarrhoea. The diarrhoea increases as the disease advances, the discharges being copious, liquid, putrid, and of a light ochre color. Typhoid (tu^o^ and scdog) signifies like typhus; but while these two forms of fever have many similar symptoms in com- mon, yet typhoid is an entirely different disease, and it is necessary to be able to distinguish one from the other. The nature and cause of these two forms of fever are essentially different. Enteric fever is regarded as contagious, but less so than typhus. That we may be able to differentiate between them we should contrast the symptoms of the two fevers. Typhus feVer comes on quickly; typhoid fever comes on slowly. Typhus attacks persons at any age; typhoid fever is most common in youth, rarely occurs after forty. In typhus the eruption is of a mulberry-color, comes out in a single crop about the fourth or fifth day, and lasts until the disease ter- minates. The eruption generally appears upon the extremi- ties, is slightly elevated, and remains after death. In typhoid fever the eruptions are rose-colored, few in number, and gene- rally on the abdomen, occurring in successive crops, which in their turn fade and disappear. In typhus fever the brain is FEVERS: THE EXANTHEMATA. 79 affected, but the bowels are but little, if at all, affected, the abdomen being often natural, and the discharges being dark, but never bloody. In typhoid fever the bowels are always affected and the evacuations are of an ochre color and watery, with congestion of the mucous membrane of the bowels; very often there is also haemorrhage and the abdomen is tumid and tender to the touch. In typhus there is a dusky flush on the face and shoulders and the eyes are injected and the pupils are contracted generally. In typhoid fever the expression is bright, with a blush on the cheeks, and the pupils are gene- rally dilated. Typhus runs its course in about fourteen days. Typhoid continues from four weeks to three months, unless it be checked. In typhus relapses are of rare occurrence. In typhoid relapses are of frequent occurrence, especially in cer- tain epidemics. In typhus death occurs from coma or con- gestion of the lungs. In typhoid death may result from asthenia, pneumonia haemorrhage, or from perforation of the intestines. Typhus generally occurs from over-crowding and defective ventilation, typhoid from bad drainage, poisoned drinking water, or decaying animal and vegetable matter under certain electrical conditions. Causes.—There is a peculiar poison that produces this form of fever, wThich has its origin in a certain state of fermentation from bad drainage, or from want of cleanliness about the premises. Wherever filth is undergoing fermentation or de- composition, the poison of typhoid fever may be produced, provided the air is in a condition to aid the result. There is a certain state of putrescence in matter, either vegetable or animal, in which this zymotic poison is generated, and its gas- eous emanations are borne to us upon the gentle zephyr or in our drinking water, and, having per se an affinity for certain parts of the organization, produce this disease. Symptoms.—When the poison is not very highly concen- trated, there is a period of incubation, varying- from eight to ten days, after the expiration of which time the disease comes 80 THE PRACTICE OF MEDICINE. on slowly and progresses gradually. The patient at first com- plains of languor and indisposition to move about; is chilly; the limbs and back ache; the appetite fails; there is nausea and sometimes even vomiting; the tongue has a white coating on it; the breath is offensive; the bowels are relaxed; and the pulse is quickened. The symptoms gradually intensify daily, until the patient is seized with a rigor, then more or less fever, severe headache, and great muscular debility. This is the stage of accession, to be followed by the other stages. During the first week the prominent symptoms are, vascular excitement and nervous oppression, with a bounding pulse, about 90 or 100 per minute, great heat of the surface, thirst, and obscured mental faculties; often delirious at night. The abdomen now enlarges, is resonant upon percussion, and there is pain on pressure, especially in the right iliac fossa, where a gurgling sensation is conveyed to the fingers on pressure. About the second week, emaciation and debility become well marked, the flesh wastes away rapidly; the urine is scanty, being loaded with urea from the rapid wasting of the nitro- genized tissues. And about this time diarrhoea sets in, if not before, which is copious in most cases. The discharges are fluid, pale-ochre colored, or of a drab color, with a putrid odor, sometimes flocculent debris in them. The third week the emaciation becomes extreme; the patient lies extended upon his back, sinking toward the foot of the bed. There is gener- ally a bright pinkish flush upon the cheeks; sordes upon the lips, gums and teeth; the tongue is dry, brown or red and glazed; the urine is often retained from inaction of the blad- der ; the faeces pass off involuntarily; the patient picks at the bed-clothes, or grasps at black spots—like flies before his per- verted vision, and finally becomes deaf and delirious. In fatal cases death occurs about this time. The Eruption. —About the ninth day, or between the seventh and fourteenth day, the eruption begins to appear in the sternum and epigastrium, in the form of rose colored dots, fevers: the exanthemata. 81 which are few in number, round, scarcely elevated, and soon fade away into the hue of the skin, to be replaced by another crop, and this continues for some time. Occasionally very minute vesicles appear, looking like drops of sweat (sudamina), chiefly on the neck, chest, or over the abdomen. Temperature.—The temperature affords very important information in enteric fever, and materially aids the physician in his diagnosis. In this form of specific fever the tempera- ture is gradually elevated, but in others it often abruptly rises. This gradual elevation of temperature is one of the diagnostic symptoms of typhoid fever. The temperature generally reaches 103.5° or 104° about the fourth or fifth day in this form of fever. Then antipyrin or antifebrin should be given so as to control the heat. The rash not occurring before the sixth, or sometimes not until the tenth or twelfth day, the diagnosis is somewhat difficult without noticing this gradual rise of temperature. It is also a means of prognosis. If the temperature varies, that is, if the tempera- ture is low in the morning and attains its maximum degree in the evening at the end of the second week, the attack will prove milder and of shorter duration; and if the temperature falls considerably in the morning, even though the rise may be considerable in the evening, the prognosis may still be favorable. But should the temperature remain continuously high during the second week then the attack will prove long and severe or fatal. One of the first indications of improve- ment in cases of persistent elevation of temperature is a decline in the morning temperature, notwithstanding the evening ele- vation may still be considerable. Sudden fall of temperature may result from diarrhoea or haemorrhage. The decline of temperature in enteric fever is more gradual than that of typhus. Complications.—Haemorrhage is one of the complications of enteric fever, and may occur at any period of the attack. If large vessels are involved the haemorrhage is apt to prove 6 82 the practice of medicine. fatal at once, and if it does not it so exhausts the patient that he has no power to bear up against the fever. Diarrhoea also may so exhaust the patient that he can not long survive. Ulceration of the bowels may progress until the coats of the bowels are perforated and cause fatal peritonitis. This may happen the second or third week, or during tedious and imper- fect convalescence. The symptoms of perforation of the bowels are pain and tenderness in the abdomen, with swelling, nausea and vomiting. Congestion of the lungs is a complica- tion that may occur; so may bronchitis. Treatment.—The treatment for the first few days should be antiseptic. Baptisia, in doses of from 3 to 5 gtt. (of the tincture) should be given every two or three hours. This remedy greatly modifies the disaese. Such remedies as aconite 0-1'1- ■ and veratrum exercise no influence over the disease in the out- set. No remedy will control the fever while the specific poison is affecting the system. Antiseptic treatment should be well carried out at first, not only by giving baptisia inter- nally, but the sulphite of sodium solution should also be used to thoroughly wash the body once or twice a day, tepid, if in cold weather, or cold if in very warm weather. Whenever the brain begins to manifest congestion, by intense headache or delirium, then drop doses of belladonna should be given every half hour, or 3 or 4 gtt. every two hours until this complica- tion is relieved. If there is a great nausea at any time in the attack, ipecac, in doses of one or two drops of a good tincture, should be given every half hour until this trouble is relieved. In cases where there is an extreme prostration, phosphoric acid (diluted) should be used in small doses, say 10 to 20 gtt., in half a glass of water, every two or three hours. Where there is restlessness, sleeplessness, and twitching of the mus- cles, then scutellarin*in 2 grain doses will relieve this trouble. And if there be slight haemorrhage from the capillaries, then sulphuric acid should be given, largely diluted in water, say *Antipyrin is much better Antifebrin is also valuable in this disease. fevers: the exanthemata. 83 two or three gtts. in a wine glass of water, three or four times a day. Towards the end of the second week, if the tongue becomes of a bright red color, then an emulsion of turpentine may be used, say 5 gtts., to a drachm of gum or elm muci- lage, to be given every two hours. After the zymotic poison is removed from the blood by antiseptics then aconite may be given in small doses every hour to control local inflammations or venous stasis of the blood in the bowels, lungs or brain. I usually add 20 to 30 gtt. to a glass of water and give a teaspoonful every half-hour or every hour. Where there is diarrhoea with meteoristic gurgling of wind in the intestines and a cadaverous odor about the body, then vegetable charcoal, in doses of 3 to 5 grains in water, every two hours should be given. The patient should have a nourishing diet all through the attack, such as rice water, chicken broth, and if there is rapid loss of strength boiled milk should be given. In cases of great pros- tration, with feeble circulation, wine-whey should be used as a diet. As soon as convalescence is fully established, the diet may then consist of beef tea or essence, toasted bread, rice and milk, but in small quantities at a time. Dilute nitric acid, in doses of 2 to 4 gtt. every two or three hours, in water, is very useful as well as pleasant to the patient. The hydro-chloric acid is also agreeable to the patient and cleans and moistens the tongue. These acids are indicated by a dry, brown or black tongue, with sordes on the teeth. The carbolate of iodine, made by adding carbolic acid, 3 1, to tinct. of iodine, 3 2; dose, 1 to 3 gtt. every three hours for the septic condition. If the patient is nervous and wakeful 10 grs. of chloral may be given twice a day until sleep ensues. In low muttering delirium, belladonna, in doses of 3 to 5 gtt. every six hours, has acted well for me. The diarrhoea should be controlled with 5 gr. doses of bismuth every four hours. Antipyrin will keep down the tempera- ture. 84 THE PRACTICE OF MEDICINE. Typhus Fever. Typhus is a specific form of acute fever, very highly infec- tious and contagious, and generally continues, under ordinary treatment, from fourteen to twenty-one days. It is attended with a confused lethargic condition of the faculties of the mind and a peculiar mulberry-colored eruption. It is often the result of over crowding, defective ventilation and priva- tion, hence called jail fever, ship and camp fever. Symptoms.—The precursory stage is usually short, causing the patient to take to his bed in three or four days. In this it differs from Enteric or Typhoid fever. The patient com- plains of soreness, fatigue, loss of appetite, frontal headache and disturbed sleep. He is often seized with a chill or rigor, usually succeeded by dry heat of the skin, thirst, quick pulse, dry, white, often tremulous tongue, scanty and high-colored urine, sometimes nausea and vomiting, heavy stupor, great prostration, and muscular pains (myalgia), irritability or restlessness, especially towards night, and if sleep occurs it is disturbed by dreams, and unrefreshing to the patient. The patient generally lies prostrate on his back, with a dull and weary expression of the face, his eyes appear heavy, and a dusky color is spread uniformly over his cheeks. In the ad- vanced stage of a severe attack he lies with his eyes shut, or half closed, moaning, and too prostrate to answer questions. If requested to protrude his tongue he does it with an effort, incompletely, and the muscles are trembling and half rigid. The mouth soon becomes dry, sordes form on the lips, gums and tongue, the skin becomes morbidly hot (color mordax) and dry, hearing grows very dull and is sometimes suspended for a time. During the first week the patient complains much of headache, noises in the ears, and finally becomes deaf, the conjunctivae are injected, the pupils contracted, eyes very sen- sitive to light and generally closed. He becomes irritable and fretful. And about the eighth or ninth day the mind passes from a state of excitement to one of delirium. This fevers: the exanthemata. 85 symptom is usually more severe, and appears earlier in per- sons of cultivated mind than those of a more common order of intellect. In the cultivated, the delirium may become wild and maniacal, or low and muttering. Sometimes there is sub- sultus tendiuum: but in favorable cases this symptom passes off in three or four days. Convalescence may set in suddenly. From the fourteenth to the seventeenth day the patient may fall into a long, deep, quiet sleep, and awake in twelve or six- teen hours quite refreshed. The powers of the mind gradu- ally begin to dawn again, the countenance to assume a more tranquil aspect, sleep becomes natural, and convalescence fully established. Diarrhoea may occur in this disease, but gener- ally the bowels are confined, and the discharges are dark (not yellow ochre colored as in enteric fever, but may pass invol- untarily. The Pulse.—The pulse in this fever is very rarely under 100 beats per minute, and very frequently we meet with cases where it runs up as high as 120, 130, or even 140 per minute. Where it runs up as high as 140 per minute, in adults, it in- dicates great danger. As a general rule, the pulse gradually increases in frequency up to the ninth or twelfth day, and in favorable cases then gradually or suddenly declines. If the pulse becomes more and more rapid after the ninth or twelfth day a fatal result may be prognosed. A falling pulse is one of the first and most reliable indications of convalescence; the decreasing temperature is also a reliable indication of amend- ment. If the pulse becomes slower, stronger and fuller we may know that the patient is convalescent. The fall of the temperature and the decline of the pulse often take place without marked perspiration, or critical diarrhoea, or altera- tion of the urine, or any very remarkable change otherwise. The Eruption.—The eruption appears between the fourth and seventh days, and consists of slightly elevated spots, of a mulberry color, which disappear on pressure ; they are often scattered and minute, or they may be numerous, and large, 86 THE PRACTICE OF MEDICINE. and two or more may coalesce. These spots usually appear first on the abdomen, then upon the chest and limbs. These spots remain with some changes of color, until the disease terminates. Pressure will temporarily obliterate these spots the first three days, but after that time they remain indelible, thus distinguishable from spots occurring in enteric fever, which disappear under pressure at any time during their ex- istence. In fatal cases the spots of typhus fever remain after death. There is always a characteristic odor about the typhus patient and his discharges ; it is pungent, ammoniacal, and very offensive. Nervous Symptoms.—The name typhus (rTxpoq in Greek) was applied on account of the characteristic nervous symp- toms. This peculiar poison operates chiefly through the nervous system. The ringing noises in the ears, restlessness, the low delirium or stupor, are the results of a profound im- pression upon the spine and brain. About the ninth day, in severe or fatal cases, the delirium merges into coma, or coma vigil. In this conditition the patient lies on his back with his eyes open, but indifferent or insensible to surrounding objects. His mouth may be open, his face is expressionless, and he is incapable of being awaked from his profound comatic sleep. The faeces and urine often pass off involuntarily. In fatal cases, the pulse becomes rapid and feeble, or imperceptible, and the patient gradually sinks and dies. Whenever the tongue becomes dry, brown, hard and tremulous in the early part of the attack, we may prognose an unfavorable issue. Causes.—I may mention defective ventilation, destitution, and want of cleanliness as prominent causes of this form of fever. It is common in hospitals, camps, jails and other over- crowded places ; generated first de novo, then transmitted by exhalations from the lungs and skins of those affected with it. Treatment.—It is believed by many writers that typhus fever must run its course, and cannot be cut short. However extensive this opinion, my experience amply proves to me that fevers: the exanthemata. 87 it can generally be either curtailed in its duration, or the vio- lence of its symptoms held in check, and convalescence hastened by proper means. When there is a thickly furred tongue, foul taste, thirst, pain in the head, exacerbations to- ward evening, the urine dark, restlessness, depression, wake- fulness and frightful dreaming in the sleep, then aconite will be of great service, in doses of J to ^ gtt. every hour, or half hour, according to the intensity of the symptoms above de- scribed. As an antipyretic remedy, baptisia stands at the head of the list. It may be given in doses of 1 to 5 drops, three or four times a day to arrest the fermentation in the blood. As soon as delirium supervenes, if it is of a wild and furious character, then hyoscyamus, in doses of 1 or 2 drops every two hours, will relieve the oppressed brain. But if there is great cerebral congestion, indicated by red, bloated face, staring of the eyes, partial paralysis of the tongue, great thirst, confusion of ideas, delirium, picking at the bedclothes and throbbing of the carotids, then belladonna, in doses of 2 or 3 gtt. every two or three hours, will be of material service. If there is low muttering delirium, stertorous breathing, pro- found stupor, hot and dry skin, or clammy skin, thick, brown- ish coated tongue, with great thirst, then small doses of tinct. of opium will do good service, say 1 to 5 gtt. every four hours, but it must not be given in large doses ; if it is it will do great harm. If the throat becomes sore and ulcerated, loss of muscular power, extreme dryness of the tongue, quick, feeble pulse, low delirium and cold skin, then muriatic acid, in doses of 3 gtt. every three hours, will do great good, and should be given. If there is a dark brown mucus on the tongue, thirst, bleeding of the nose, discharge of foetid urine, or involuntary, bad smelling discharges from the bowels, then rhus toxicodendron, in doses of 1 to 2 gtt. every three hours, will generally do good. If there is great prostration, sunken countenance, dry, cracked tongue, urgent thirst, and involun- tary discharges from the bowels, then Fowler's solution, in 88 THE PRACTICE OF MEDICINE. doses of 2 to 5 gtt. every four hours, will be of material service. The patient's clothing and bed-clothing should be changed daily, and his skin should be washed in a solution of sulphite of sodium, and occasionally in chlorate of potassium. The acids are often called for in this form of continued fever as in typhoid form. And antipyrin, or antifebrin, are also called for if the temperature runs high. If there is morbid vigilance, then chloral in small doses 5 to 10 grs., may be given. And the delirium must be met by belladonna, 5 gtts. If the delirium is mild, then hyoscyamus, 10 to 15 gtt. of the tinct. twice a day may be required. The bowels are some- times open enough, the discharges being mushy, but some- times the bowels are constipated, and then 3 1 of ex. fl. of Cascara will be required occasionally. Diet, milk or beef essence, etc. Measles. Measles is one of the infectious fevers, and is preceded by catarrhal symptoms, as sneezing, constant discharge from the nose, and not unfrequently more or less inflammation of the mucous membrane of the entire respiratory tract. This disease was formerly mistaken frequently for scarlatina; but it is quite distinct, and easily distinguished. It is not dangerous when properly treated, but by improper treatment a great many may die annually with this disease. Like other infectious fevers, it seldom attacks a person twice. Modes of Propagation.—A susceptible person cannot stay in the same room or same house with a subject of measles without a risk of contracting the disease. It is propagated in families, and is readily carried in clothes, and contaminates beds and even rooms where a patient has remained long with this disease. The contagion from measles ceases only after desquamation of the cuticle is completed, or about that time. Symptoms.—Measles has certain stages, such as a period of incubation, lasting from ten to fourteen days; then its precur- fevers: the exanthemata. 89 sory fever; then its eruptive stage, and finally its decline. The first symptoms may be mistaken for an attack of catarrh, for there are sneezing, red, swollen and watery eyes, free dis- charge from the nose, a hoarse, harsh cough, languor, fever, sometimes vomiting, and diarrhoea. These symptoms increase until about the fourth day, when the eruption makes its appear- ance, first on the face, then on the neck and breast, then gradually spreads over the entire body and limbs. The erup- tion is in the form of raised red spots, which soon multiply and coalesce into blotches of a more or less crescentic form, especially on the face, which is generally somewhat swollen and puffy. An abundant eruption is a favorable indication, but a scanty one is rather unfavorable. The eruption is two or three days in coming out, and then remains out about three days. The fever then abates and the eruption declines, be- coming browner as it fades away, and the epiderm. is thrown off in the form of a fine bran-like scurf. When the eruption declines, diarrhoea may occur. This, unless excessive, should not be interfered with, as it is eliminative of the peculiar poi- son, that, if it remains in the system, may produce other ovil effects. Temperature.—The average temperature is about 103° Fahr.; and if the bodily heat arises above this the case is one of great severity. If it is much below this, it may be regarded as mild. The maximum temperature is reached on the fifth day, after which it usually declines. The temperature distinguishes between the mild and more grave cases of this, as well as other eruptive fevers, and should always be noted. Sudden increase of the temperature, or the occurrence of rigors, with rust-colored sputa, indicates pneumonia or bronchitis. Pneumonia, bronchitis, or diphtheric inflammation of the larynx are the chief sources of danger in an attack of measles. Treatment.—Where the fever is well marked, give aconite, in doses of gtt. \ to 1 every one or two hours, according to the severity of the fever. If the lungs are deeply involved, one or 90 THE PRACTICE OF MEDICINE. two drops of veratrum viride may be given in alternation with the aconite. If the eruption is slow in making its appearance, or suddenly recedes, in the case of children, there is a liability to convulsions, in which case gelseminum should be given, in doses of from 3 to 5 gtt, according to age, until the effects of the drug are seen upon the muscles of the eyes. I usually give it every three hours, as its effects continue about that length of time. If the throat is very sore and the eyes highly inflamed, and there is severe headache, 2 or 3 gtt. of tincture of belladonna should be given twice or thrice a day. If there is nausea or vomiting, administer a few drops of tincture of ipecacuanha. If there is a bronchial cough with pain in the chest, bryonia, in doses of 2 to 5 gtt. every two hours will re- lieve this complication. For the cough, if excessive, I give drosera rotundifolia (13 to 41 of simple syrup), dose 13, every three hours. The sequelae must be met upon the pathological indications. Treatment of Sequele.—Diarrhoea is apt to continue after the entire disappearance of the other symptoms of this disease. If diarrhoea is very troublesome, the tincture of pulsatilla, in doses of 3 to 5 gtt., every two hours often will suffice for this complication. If the eyes are much affected by measles, and remain so after the main force of the disease passes off, and there is photophobia, then gtt. 3 of belladonna should be given every four hours, and that alternated with the tincture of euphrasia, in doses of gtt. 1 to 3. If there is an harassing cough left after the measles have passed off, then gtt. 10 to 15 of the tincture of sticta pulmona may be given, alternated with drosera rotundiflora. If the cough does not cease in a few days under these remedies, then from ^ to \ gr. of bichromate of potassium may be given three times a day, alternated with a grain of sublimed sulphur. For oedema, which often occurs in children who have been exposed too soon after measles, the acetate of potassium is useful in doses of gr. 2 to 3, every hour or two, until the kidneys act well, and if it fails to act, then gtt. fevers: the exanthemata. 91 5 or 6, of the tincture of apocynum cannabinum should be given every two hours. Scarlatina. Scarlatina, like the preceding diseases, is infectious and contagious. And such has been its mortality that it is much to be dreaded when in its most malignant type. It mostly af- fects children and young persons, and is not apt to attack them the second time. In point of mortality, scarlatina is second only to small-pox and typhus fever. In the year 1863, the mortality in London, England, was 4,982. In 1870, the rate of mortality in London alone was 108 per week. It is to be hoped the nature and cause of this dreaded scourge will be more thoroughly studied, and better understood, so that this alarming fatality among our children may be much curtailed at least. Varieties.—This disease may be properly divided into three varieties, or degrees of intensity, scarlatina simplex, scarlatina anginosa, and scarlatina maligna. These distinct degrees in the intensity of scarlatina depend doubtless, in part, upon the constitution of the patient. Exposure to the contagion of scarlatina simplex may produce scarlatina angi- nosa or mcdigna. Scarlatina simplex is a scarlet rash with redness of the throat, but without ulceration. This form will terminate favorably if properly treated. Scarlatina anginosa is a more severe form of the disease, with redness and ulcera- tion of the throat, and a tendency to abscesses in the neck. In this form the temperature is high and the circulation is very rapid. The danger arises from the complications in this form of the disease, such as ulcerations of the throat, and ab- scesses of the neck, etc. In scarlatina maligna there is an extreme depression of the vital powers, and great cerebral dis- turbance, added to the affection of the throat and skin ; the fever soon assumes a malignant type; the tongue has a brown coating; there is often low muttering delirium; the throat 92 THE PRACTICE OF MEDICINE. presents a dark livid or sloughly appearance; the eruption comes out imperfectly or irregularly, or first appears, and then recedes; and is of a dark color instead of a bright scarlet color. This form of the disease is very fatal. General Symptoms.—Scarlatina commences with a chill; this is succeeded by a hot fever, nausea, or vomiting, very rapid pulse, thirst, frontal headache, and sore throat. In about forty-eight hours after the occurrence of these symp- toms, the characteristic rash makes its appearance, first on the breast, and then gradually extends to the neck, face, trunk, and thence over the limbs. The eruption is of a bright scarlet color, and consists of numerous red points or spots. These spots diffuse themselves uniformly over the skin, or appear in large patches, more or less irregular, on the different parts of the body. The color of the skin disappears on pres- sure, but returns again. The tongue is characteristic; it is first coated, the tip and edges are red, the papillae are red and rather elevated, and after a time it becomes clean and rather raw looking. A diffused redness, sometimes of a dark claret color, covers the mouth, faces and throat, and disappears as the fever subsides. About the fifth day, the efflorescence gener- ally begins to decline, and disappears entirely about the eighth day, or at most, about the ninth day. In most cases, desqua- mation of the cuticle takes place in the form of a scurf from the face and trunk; but in large flakes from the hands and feet, the skin occasionally coming away entire like a glove or slipper. The disease, however, does not always pursue this uniform course. It sometimes occurs without the rash, or sore throat, and the eruption is livid and partial, and attended with such extreme prostration that the patient succumbs in a few hours under its violence. Distinctive Features.—The rash, already described.— The high temperature of the body, which is frequently 105° or 106° Fahr.—The prominent papillae and redness of the tongue, which is compared to the strawberry in color.— fevers: the exanthemata. 93 A peculiar glistening stare of the eyes, easily distinguished from the liquid eye of measles.—The sore throat, which is swollen around the soft palate and tonsils. These are the diagnostic peculiarities of scarlatina, but they vary in inten- sity in every epidemic visitation of the disease. Cause and Modes of Propagation.—The earliest source of scarlet fever is traceable to Arabia. The nature of the poison is subtle. It is doubtless transmitted by fomites in the clothes, bedding, carpet, or in dry goods, and physicians often convey it from family to family. Disinfection and thorough ventilation tends to destroy this poison, and a tem- perature of 205° Fahr. will kill it. The primary fever gives rise to the infection, which continues until complete des- quamation takes place. Treatment.—This disease requires very early and prompt treatment, the neglect of which by the physician gives rise to the worst cases we meet with. Cases of a mild type, left to themselves, may terminate in the mortification of the throat, nose, cheek, or sometimes the limbs. In scarlatina simplex, from 3 to 5 gtt. of belladonna should be given to adults every four hours, and 1 to 2 gtt. of tincture of aconite every one or two hours, according to the amount of fever. Digitalis answers well in many cases. For children, from \ to 1 gtt. of belladonna, and ^ to \ gtt. of aconite is sufficient. If there is burning and itching of the skin, it may be relieved by rub- bing it well with a salty bacon skin. If there is constant and violent vomiting, severe headache, intolerance of light, vertigo, very hot red face, rapid small pulse, ailanthus, in doses of 1 to 2 gtt. of the tincture every two hours, will be of material service. The above symptoms show a malignant tendency, which, if not arrested by the ailanthus, may be combated with baptisia, in doses of 1 to 5 gtt., according to the age, etc. In the anginose form, if there is rapid swelling of the throat and stinging pain, apismel in doses of 1 to 2 gtt. every two hours should not be forgotten. If there is great restlessness and a 94 the practice of medicine. tendency to convulsions, then gelseminum, in doses of 5 to 8 gtt., according to age, should be given three or four times a day. Where there is great prostration of strength, carb. of ammonium, in doses to suit the age of the patient, should be administered every two hours. If the throat is very sore, and the breath foetid, the patient should gargle with a solution of sulphite of sodium, and alternate with a tea-spoonful of cayenne tea every two hours. In the malignant form, small doses of belladonna must not be forgotten, say J to -| gtt. for children, and 1 to 2 gtt. for adults, every four hours, to pro- tect the brain and skin, and to aid in controlling the fever, as it exerts a controlling power over this disease. Where there is rapid prostration or emaciation, cold, clammy sweats, weak pulse, with burning heat, a few doses of Fowler's solution should be given, to aid in eliminating the poison through the kidneys. At times, from 2 to 5 gtt. of tincture of camphor, according to age, may be used to support the patient's waning strength. If typhoid symptoms appear, then rhus tox. should be administered in small doses. Potass, permang. as a wash. Small - Pox: Varioloid. These are highly infectious diseases, the infectious material being contained in the pustules as well as in the exhalations from the patient's body. All we know of this infectious virus is its effects upon the organism. It is readily reproduced again whilst it develops its peculiar phenomena, and thus prop- agates from person to person. Infection takes place by im- mediate contact with the patient, also by remote means. The virus is often carried in clothes or goods that have been ex- posed to the exhalations from the body of a small-pox patient. This infection is very persistent in its nature, and often re- tains its infectious power for several years, if it be excluded from the open air, and not exposed to intense heat. I knew a case in which small-pox was communicated to some persons engaged in cleaning out an old cellar, under a house where small-pox patients had been kept some two years previous. fevers: the exanthemata. 95 There appears to be no great difference between the virus of small-pox and that of varioloid, except in their intensity; either may cause the one or the other form of disease. This doubtless depends very much upon the susceptibility of the subject and the adaptation of the virus for a greater or less development of its effects under certain favorable or unfavor- able circumstances. Vaccination seems to destroy, to a great extent, the predisposition to the disease; if not completely, at least partially. Course and Symptoms.—After some nine days of incuba- tion, the first stage begins with a severe chill, or repeated chilly sensations, which are followed by a high fever, headache, sometimes delirium, a thickly furred tongue, generally white, a deep flush upon the face, a hard frequent pulse, a severe bruise-like pain over the body, especially in the back and loins, more or less pain and tenderness in the epigastric region; these are premonitory symptoms, and are very seldom absent. And when the pain and vomiting are excessive and continuous, they indicate that there will be a severe form of the disease. On the third or fourth day, the eruption is often so minute as to escape notice, it appears in the form of red spots, or small hard pimples, which feel like shot in the skin. This eruption appears first on the face, neck and wrist, then on the body, and finally on the lower extremities. Upon examination, the eruption may be seen upon the palate, and is sometimes found upon mucous membrane of the larynx, trachea, and bronchi, giving rise to soreness of the throat, salivation, cough, painful expectoration, and to great hoarseness of voice. These little pimples gradually increase in size until about the eighth day from the first invasion of the fever; the contents, at first watery and transparent, change to a yellowish matter as the pimples become ripened into pustules. These pustules are de- pressed in the centre, and are surrounded for a short distance by a rose-red areola. While the pustules are filling up, there is swelling of the eyelids and face, sometimes so much so as to 96 THE PRACTICE OF MEDICINE. deform or obliterate the features. About this time there arises from the patient a peculiar disagreeable odor, which is charac- teristic of this disease, so much so the disease might be known by this odor alone. There are always more papulae, compara- tively on the face than on any other part of the body, and when they are so numerous as to coalesce, they coalesce in the face; rarely, if ever, on the rest of the body. Variolar confiu- entes can only be seen on the face, whilst elsewhere the papu- lae are isolated—variolar discretce; or merely touch each other —variolce coherentes. In from nine to ten days from the first invasion the pustules are matured Simultaneously with this eruption on the skin, an eruption appears on the mucous mem- branes; that on the conjunctiva causes a flow of tears, photo- phobia, and in some cases a total closure of the eyes for several days, and sometimes total blindness. When the eruption is fully developed, the pains lessen, the fever decreases and the patient is much relieved. But in cases of variola confluens only, the relief is not marked. When the pustules are maturing they enlarge, the surrounding skin inflames and swells, and red areola forms around each pustule. The redness and swell- ing coalesce from all directions, and constitute a diffused ery- sipelatous appearance of the whole face, greatly disfiguring the patient. This process gradually spreads over the entire body, in the same order in which the eruption spreads. The patient complains of tension and burning of the skin, and the affections of the eyes, mouth, throat, larynx, and genitals in- crease in the same order. The heat of the body now rises again, and is frequently alternated with chilly sensations; it rises according to the intensity of the inflammation of skin, and does not abate until the dermatitis reaches its acme. This is the secondary or suppurative fever. It may assume a typhoid type. In other cases it may combine with a haemor- rhagic diathesis, the pustules become bloody, and bloody extra- vasations take place in the skin, or haemorrhages may take place from mucous membranes, constituting haemorrhagic 01 FEVERS: THE EXANTHEMATA. 97 septic small-pox; and finally portions of the inflamed parts may mortify, constituting gangrenous small-pox. There may be a localising of the virus in the serous membranes, producing stitching pains in the side, cough, bloody expectoration, pneu- monia, pleuritis, and other effects. In extreme cases, there are pericarditis, meningitis, suppurative inflammation of the joints, periostitis, abscesses, suppuration of the lymphatic glands, suppuration of the eyes, and croupous exudations on the larynx and trachea. About the twelfth day the pustules burst and discharge their contents, which dry and form hard, brownish crusts. The fever then gradually lessens, and all the painful symptoms disappear. The crusts of the pustules gradually drop off; they usually leave dark red, somewhat elevated spots, which after some time disappear. But where there have been deep-seated ulcerations, they leave uneven scars, which are at first red, but finally become white. In some grave cases of confluent small-pox the scars are larger and deeper, and resemble the scars of bad burns. This is the usual course of variola. Varioloid runs a similar course, but all the symptoms are much milder, its stages are much shorter, and its suppurative process is so mild, that it seldom leaves distinct scars. But even varioloid is milder at times than at others; like variola, it is influenced much by the diet of the patient, his peculiar condition at the time, and by the temperature and other atmospheric peculiarities at the time of invasion. Treatment.—At the beginning, if there is high fever, with alternate chills, dryness of the skin, rapid pulse, head- ache, nausea and vomiting, and pain in the back, aconite, in small and repeated doses, will do great good, 20 gtt. to 4 1 of water; dose, a teaspoonfull every hour through the course of the disease, when fever is prominent. If the pulse is very full and rapid, veratrum viride may be substituted for aconite. Digitalis, in doses of 10 to 15 gtt., and l-10th gr. sulphate of zinc, has answered me in many cases. In all cases in which 7 98 THE PRACTICE OF MEDICINE. there are a severe headache, delirium, and intolerance of light, I give a dose of belladonna, say 3 gtt. every three hours until these symptoms are subdued. When there is excessive swelling of the face and eyelids, with erysipelatous redness, stinging and burning pain, apis mel., in doses of 3 to 5 gtt. every one or two hours, will do good service in all cases. In those dangerous cases in which the swelling suddenly sinks in and the pustules suddenly dry up, showing a low state of the vital forces, tincture of camphor in doses of 5 gtt. every half hour or hour will aid in sustaining the patient. Where there is great soreness of the throat, with redness and itching, hydrastis is a valuable remedy. It is said to prevent pitting to a marked degree. The fluid extract may be given in doses of 5 to 10 gtt. every hour, or \ to \ gr. of hydrastis as often. Sarracenia—the pitcher plant, is believed to shorten the course of the disease considerably. It may be used freely in the form of infusion. Where there are glandular swellings about the neck, sore throat, and haemorrhages, the muriate of am- monium, in small doses, will aid in controlling these compli- cations. Where there is asthenia, with great debility, burn- ing heat, frequent small pulse, intense thirst, restlessness, irregularly developed variola, with a typhoid tendency, or a great tendency to haemorrhage, with a livid areola, then Fow- ler's solution, in doses of 2 to 4 gtt. every four hours, will aid in bringing such cases to a favorable termination; and this remedy should not be forgotten in such grave cases. Where there are other distinct typhoid symptoms, besides those above described, such as great fcetor of the body and breath, the pustules thick upon the palate, tonsils, uvula and in the nasal cavities, but very scanty upon the skin, profuse salivation, great prostration and excessive pains across the loins then baptisia will be of good service, in doses of 2 gtt. every three hours. This may be alternated with rhus tox. in doses of 2 gtt. of the tincture every three hours. Where there is great nervousness, with convulsions, or a tendency fevers: the exanthemata. 99 thereto, gelseminum, in doses of 8 or 10 gtt. every three hours will be demanded. The patient's diet must be strictly guarded until he is well. The patient's body should be sponged with a solution of glycerole of carbolic acid in water, 1 part to 60 of water. To prevent pitting, 20 gtt. of the tincture of cimici- fuga may be given thrice a day. If the eruption is tardy in its appearance, 5 gtt. of the saturated tincture of camphor may be given every two hours. Belladonna will keep the eruption out. If there is prostration, the ammonium car- bonate in doses of 5 grs. every two hours, will support the waning vital powers. Collodion is used over the face to pre- vent pitting. The carbonate of zinc powdered over the face aids in preventing pitting. The diet must be very light. Vaccinia. Vaccinia is a disease of the cow, which, by inoculation, was discovered by Jenner a century ago. It protects against small-pox generally. By vaccination the disease vaccinia is artificially introduced into the human system, for the purpose of protecting it against small-pox. According to statistics, in Sweden, forty years before Jenner discovered the prophylactic power of vaccination, about 2,050 persons died annually with small-pox; after vaccination only 158 died annually. In Ber- lin before vaccination was introduced, 3,422; but since vacci- nation was instituted, about 176 die annually. In Paris, prior to the introduction of this prophylactic measure, about 80 out of everyone hundred died of small-pox; since its introduc- tion about 14 to 16 die out of every hundred cases. The British army scattered all over the world, is, of course, greatly exposed to this disease, but it is so protected by vaccination, that one in one thousand is attacked, and less than one in ten thousand dies of the disease (See the London Lancet, August 15th 1863) Vaccination, to be protective, must be properly performed, and good, fresh lymphs from the cow or from a child free from any constitutional taint, must be used. It 100 THE PRACTICE OF MEDICINE. should be put in with a clean lancet or ivory point, which must make four or five scratches, so as to leave, at least, four good scars; this is important, as one or two scars are not a certain protection. Intermittent Fever. This type of fever is caused by a peculiar poison, which, under certain conditions, originates in marshy lands, swamps, low regions near rivers, newly settled places that are being cleared and cultivated, the vicinity of canals newly dug, and regions that seemingly lie dry, but contain a great deal of water underground; the drier the surface the greater the efflu- via from underneath the porous and cracked soil. This poison is usually called swamp-miasm or malaria. Its nature is un- known, and its effects differ according to certain atmospheric conditions at the time of its production. Although swamps and damp low regions are necessary for its development, yet these do not seem to be the only conditions that can generate this peculiar poison. Intense heat, decaying vegetable matter, and alluvia, do not explain the presence or absence of this poison, for there are sections of country where these conditions do exist where a sufficient quantity of this miasma is not pro- duced to generate fever; on the other hand, we find certain districts in which this fever prevails frequently, where there are no swamps or alluvium. Occasionally, there are sporadic cases of fever in places where there is no apparent cause of miasma. This fact is difficult to explain. One peculiarity of this poison is its general invasion. No age or sex is exempt from its influence; the liability to repeated attacks increases with every invasion, and persons that have had frequent attacks are subject to chronic enlargement of the spleen and malarial cachexia. In regard to the stage of incubation, it varies ac- cording to the intensity of the poison and the stronger or weaker resistive force of the constitution of the subject. In some cases the disease is developed at once, in others it seems fevers: the exanthemata. 101 to linger in the system some ten or fifteen days, or longer. There is generally a period of general malaise, and a disturb- ance of different functions, before the apyrexia and paroxysm of fever manifest themselves. This period of indisposition also differs in different individuals. This form of fever has three distinct stages, the chill, the hot stage—fever, and the sweat. The chilly stage may last but a few moments, or it may be prolonged three or four hours, or even longer. It is a stage of great depression, in which the blood seems to leave the surface and crowd the internal organs, and in which the venous blood is stagnated in the capillaries. This causes the chill. The skin is cold, shriveled—cutis anserina. The internal temperature is increased one or two degrees, or even more. The patient is apt during this stage to suffer from headache, thirst, pain in the back and limbs, and oppression. The hot stage—the stage of fever—comes on slowly, still accompanied by chilly sensations, until finally the whole surface is in a glow of heat, the temperature rising seve- ral degrees. This stage lasts from two or three to as many as eight and even to twelve hours in some rare cases. The third stage, that of sweat, finally ends the paroxysm, greatly to the relief of the suffering patient, who now feels comparatively comfortable. But this apyrexia is seldom free from all morbid feelings and manifestations. When an intermittent fever de- velops its regular paroxysms in these three well marked stages, and in regular order, it is termed intermittens completa; when one of these is wanting, it is called intermittens incompleta; and if the order of its stages is reversed, that is if the parox- ysm commences with the sweating stage, and ends with the chill, it is termed intermittens inversa. When the paroxysms come on every twenty-four hours, the attack is called a quoti- dian fever; if every forty-eight hours, it is called a tertian fever; and if every seventy-two hours, it is called quartan fever. When it occurs every seventh day, it is called intermit- tens septima. Sometimes it changes from one type to another, 102 THE PRACTICE OF MEDICINE. that is, a quotidian changes into a tertian, or a tertian into a quotidian. Causes of Intermittents.—Miasm Bacilli.—How does this bacillus miasmce or malarice produce the phenomena of fever ? Several years ago Prof. Henry F. Campbell wrote an admirable essay upon fevers, in which he states that the mode of action of this bacillus malariae is that of a nerve disturber; that the poison acts upon the cerebro-spinal centre, whose mor- bid manifestations are always paroxysmal. In accounting for the action of this poison, I conclude that this poison, from its molecular composition, per se, has the power to depress the nerve centres, especially the vaso-motor centres, and thus pro- duces the chill, which is evidently a spasm, or a profound de- pression of the vaso-motor nerves; and this vaso-motor depres- sion amounts almost to paralysis of these centres in the congestive or pernicious fever of the South. I conclude that this poison, like others, has an affinity for this part of the nervous system. We see that opium has its affinity, rhu- barb its affinity, ipecacuanha its affinity; all other active reme- dies have their affinities, and their specific power over some part, organ, or tissue of the body. And this fever poison is possessed of a specific poisonous influence, by which it pro- duces the phenomena of fever. It acts on a general law. The severity of the type is referable to the plus and minus resistive force of the patient, and to the intensity of the poison. I have seen an attack of what is called remittent or bilious fever converted into intermittent fever by bleeding and purging the patient, thus lessening his vital resistive force. The severity of the disease can be traced also in the swamps of the West by the nearness to the alluvium that is inundated in winter and spring, and dried off in the summer. The dis- ease is a very severe congestive fever near the swamps, gradu- ally becoming milder as we recede from the swamps. This is witnessed every year. This poison is received into the blood by absorption by fevers: the exanthemata. 103 the lungs and skin, and from the water we drink. It soon greatly impairs vital affinity, and affects the functions of the vaso-motor nervous system. The irritant effects of this poison produce the excitement peculiar to the febriculae, and the impaired tone of the tissues leads to congestion in the more vascular structures, as the spleen, lungs, liver, and mucous membranes. And, in the cold stage, the peripheral vessels are so affected that the skin is pale, shrunken and cold. But the very rapid accumulation of heat in the internal hyper- aemic structures soon raises the temperature to such a degree that the peripheral vessels are relieved of their contraction, and the heat is soon so increased over the body, that relaxa- tion takes place, which terminates in the sweating state or the intermission. If the relaxation is only partial, there is only a lowering of the temperature, which constitutes only a remis- sion between the paroxysms. But if the malaria, from its dense composition, has intense action, or if the debility of the subject is such as to give but feeble resistance to the action of the malaria, then we see the vital affinity so impaired as greatly to retard the molecular changes, and not only the vaso-motor function of the periphery, but of the whole sys- tem, is perverted, allowing a failure in the elaboration of heat, which allows a prolongation of heat, and such deficiency of innervation and secretion that death ensues. Such cases con- stitute the algid type of pernicious or congestive fever. When, with greatly impaired vital affinity, there is alteration of vaso-motor power, so there is paralysis or relaxation of the vessels of the mucous membranes of the alimentary canal, and of the cutaneous surface, giving rise to profuse serous discharges by purging and vomiting; it constitutes the choleraic variety of pernicious fever. Treatment.—While the preparations of cinchona are valuable in certain stages of this disease they are not specific against it, and had better be dispensed with in many cases, rather than be indiscriminately used in all instances as they 104 THE PRACTICE OF MEDICINE. have been. There are functional and structural lesions in many cases, which demand special treatment at the outset. Each of these lesions should receive its appropriate treatment at once. For the simple element of periodicity—as an antag- onist against the malarial poison, we may use the sulphate of cinchona or of cinchonidia, not in toxical doses, as has too often been done, but in moderate medical doses, or say gr. 5 to 8, in divided doses, of gr. 2 every hour. During the chill but little can be done, except to keep the patient as warm as possible with hot packs, etc. As soon as the hot stage sets in, the administration of the tincture of gelseminum, in doses of gtt. 10 to 15, every two hours should be commenced and continued until the fever subsides. If this does not produce a remission of the fever, after the second dose, one drop of aconite (tinct.) should be added to each dose of gelseminum. In some cases the tincture of ipecac, in doses of gtt. 1 to 2, may be given until the complication is controlled.* The above course will usually meet the indications at the outset of an attack of intermittent fever, but it often happens that the physician will have cases that have been maltreated, or neg- lected, and which have resulted in chronic intermittent fever, with general debility, prostration, anaemia and diarrhoea. In such cases the tincture of alstonia constricta, in doses of gtt. 5, every two hours, during the interval, is useful. In old chronic cases, in which the liver and spleen have become in- volved as they frequently do, I find that an occasional dose of euonymin and podophyllin, say gr. -| of the former and gr. ^ of the latter, every six hours, until a mild aperient effect is produced, is necessary. I find "that the euonymin is not only one of the most powerful stimulants to the liver, but is also a mild antiperiodic and tonic. When anaemia exists, I use iron and helonin, until the blood is enriched to its normal standard. In some cases of long standing, in addition to iron, I find Fowler's solution, in doses of gtt. 3 to 5 three times a day *See Author's Materia Medica. FEVERS: THE EXANTHEMATA. 105 beneficial; in fact, some cases are very slow to yield to any other remedy. As tonics, after the fever has been broken up, I find gtt. 20 of the tinctures of ptelea and sabbatia stellaris, three times a day, valuable in restoring the patient's strength. These drugs are also effective in some chronic cases in break- ing up the fever, as they are both mild antiperiodics as well as superior tonics. In some old chronic enlargements of the spleen, causing frequent relapses of this form of fever, I have given the comp. tincture of iodine, in doses of gtt. 5 to 6 three times a day, and have thus succeeded in making a final cure. Prof. Roberts Bartholow praises the antipyretic powers of resorcin. It is doubtless a valuable antifermentative, and as such will prove valuable in this and other diseases. The dose is, in ordinary cases, gr. 5 every two hours. Benzoate of sodium is also a valuable antipyretic, and has proved effective in this as well as in many other diseases. Dr. Klebs, of Germany, used this article as an antiseptic in several diseases. Pilocarpine is also highly extolled as a diaphoretic in elimi- nating the malaria. Apiol is also used by some writers. I have used eucalyptus in chronic malarial poisoning with good effect, in dqses of -J to 1 1 three times a day. The carbazo- tate or picrate of ammonium has been highly thought of as an antiperiodic* in doses of gr. J four times a day, or about one grain per day. In chronic cases I have often used ptelea trifoliata in doses of 1 3 three times a day with success, for keeping the liver and bowels regular in action. Euonymus atropurpureus is valuable.* Remittent Fever. Remittent fever differs from intermittent fever in this, that it has no apyrexia, but in place of it there is merely a re- duction of the fever, which is again succeeded by another ex- acerbation. In very grave cases the remission is so slight as often to be mistaken for continued fever. Remittent fever *See Author's Materia Medica. 106 THE PRACTICE OF MEDICINE. may be separated into three types, viz., the lightest form, the grave form, and the gravest form. The lightest form com- mences after the expiration of a stage of incubation, with a chill that is followed by a violent fever and some gastric symp- toms, enlarged spleen, in some cases more or less jaundice, herpes labialis, headache, pain in the limbs, dizziness, ringing in the ears, epistaxis, great debility, and sometimes bronchial irritation. This fever may last for three weeks, or it may change, as it often does, into the intermittent type, for these are but degrees of one and the same disease. The graver form is characterized by the remissions gradually ceasing and the fever becoming continuous, which causes the disease to re- semble typhus fever. The patient becomes delirious or lies in a profound stupor, his tongue becomes dry and his spleen is very much enlarged, and often tender upon pressure. This form lasts from ten to fifteen days. It may get better, and if so, it terminates in intermittent fever. If the disease does not get better the patient is apt to die in a comatose state, or diarrhoea or dysentery may set in. The gravest form is characterized by a very high degree of adynamia. The pa- tient rapidly sinks into a collapse. This form very soon gives rise to functional disturbances in almost all the vital organs. In some cases there is jaundice, in others, epistaxis, haemate- mesis, haematuria, or albuminuria, or suppression of urine; in in others there are discharges from the bowels resembling those of cholera. The liver and spleen are much enlarged, terminating sometimes in inflammation and suppuration. The serous tissues show exudations upon them, and the skin may become gangrenous and slough off in places. There is a form of malignant remittent fever now styled typho-malarial fever, which is the congestive fever of some of the old authors. This is, however, a new name for an old disease. This perni- cious intermittent is characterized by greater violence of symp- toms and longer duration. The stagnation of the venous cir- culation is greater, causing collapse, which resembles that FEVERS: THE EXANTHEMATA. 107 of cholera. This form prevails where there is great solar heat and an abundant supply of marsh exhalation, out of which is elaborated this intensely poisonous effluvium that is so de- pressing to the whole vital system. Treatment.—The treatment must be prompt to be suc- cessful. If there is a comatose condition, one or two drops of belladonna must be given every hour until this symptom is removed. In the adynamic form arseniate of quinia should be given in doses of gr. ^ every two hours, alternated with gtt. 5 of saturated tincture of camphor to support the vital powers. If these fail to arouse the circulation, then gtt. 30 of tincture of xanthoxylum should be given every hour, al- ternated with gr. 5 of cinchonidia. The skin should be well rubbed with mustard-water in which powdered cayenne is thickly sprinkled, to keep up the capillary circulation, thereby relieving the internal organs as much as possible; otherwise death may result. In the so called " typho-malarial fever " an antiseptic treatment should alternate with other indicated remedies. The sulphite of sodium, sulphurous acid and bap- tisia should be given at the outset, to counteract the septic tendency. If there is sordes on the teeth then muriatic acid, in doses of gtt. 1 to 2 every two hours, may be given in half a wine glass of water. If the faeces are slimy and very offensive, gtt. 5 of baptisia should be given every three hours, or gtt. 2 every hour until the stools cease to be offensive. In convales- cence, the patient's diet must be nourishing, but easy of di- gestion and unheating. In cases where the system is so pro- foundly affected by the poison that there is a want of reactive force, and hence the internal organs are liable to become con- gested, it is often necssary to apply strong washes of mustard and cayenne to the skin, to stimulate the capillary circulation. At the same time some internal stimulant may be given, such as the tincture of xanthoxylum fraxineum and nux vomica, say, gtt. 30 to 60 of the first named, and gtt. 5 of the nux vomica every two or three hours. In many cases that I treated 108 THE PRACTICE OF MEDICINE. in malarious regions, some years ago, I found it difficult to get a complete remission, in order to safely give the anti- periodics. In these cases I usually gave gtt. 1 of tincture of aconite and gtt, 25 to 30 of tincture of gelseminum, every three hours, until I procured the desired remission, then I proceeded to give quinia, or one of the other preparations of the bark, in doses to suit the patient's condition. I have found cinchonidia much less liable to affect the hearing and sight than quinia. I have also found the sulphate of cincho- nia a milder remedy than quinia, but slower to act. Yellow Fever. History.—It is stated by some writers that yellow fever first appeared in Africa, but Cortes found it in Mexico, and among the native Indians in San Domingo and other West India is- lands. It decimated some of the West India islands soon after the discovery by Columbus. It was unknown in Europe till after that period. The first appearance of the disease in America that we find is recorded by Noah Webster. He says that it prevailed among the Indians in New England in 1618, and again in 1746, and at other periods. Some writers affirm that it scourged Mexico many years before the Spanish Con- quest. It prevailed in Central America in 1596. It is not common in elevated localities. It is believed that this disease was imported into America, as it almost always prevails at some seaport before it attacks the interior towns or country. It is, perhaps, not indigenous to this continent. It can be carried from country to country in vessels, in clothing, bag- gage, merchandise, etc. It differs from paludal fevers in that it has but one paroxysm from twenty-four to seventy-two hours, and sometimes ninety-six hours, and it has a disproportion be- tween the rapidity of the pulse and the temperature of the body; after forty-eight hours, or longer, the pulse descends in yellow fever, but the temperature may keep the same, or even rise higher. The febrile stage of about seventy hours' dura- FEVERS: THE EXANTHEMATA. 109 tion, more or less, is succeeded by a period of complete cessa- tion of fever. The period of incubation may be set down at about two to five days. The poison is not like that of small- pox, in its very direct communicability, but the virus requires an appropriate nidus in which to germinate and develop. This nidus requires a certain degree of warmth and moisture to de- velop the germs so that they can migrate. And when de- veloped, they can be conveyed in baggage or merchandise (as fomites) for hundreds or even thousands of miles. Dr. Chopin, Health Officer of New Orleans (high authority), says that yellow fever is an exotic, and that its germ is a living organism, capable of rapid reproduction under proper condi- tions ; and that it multiplies itself, first on surfaces, then in the atmosphere, and thus soon becomes epidemic. He believes that, like scarlet fever, measles, small-pox and cholera, it will continue as long as the poison is in the system, and till it is destroyed by disinfection, or eliminated. The disease is always checked by cold, never prevailing below 32° Fahrenheit. It is aggravated in severity and multiplicity by filth of every kind. While humidity and a continuously high heat are re- quired to sustain an epidemic of yellow-fever, yet these do not of themselves generate it; for Constantinople has these, with filth, and has plague but no yellow fever; India has heat and the cholera, but never yellow fever. It seems that an atmos- phere very highly charged with ozone almost, if not entirely, exempts a locality from this disease. Visitations of Yellow Fever.—The first authentic ac- count of yellow fever is that of its presence in Central America in 1596; then among the Indians in New England in 1618; then in the Islands of St. Lucie in 1664, where 1411 died out of a population of 15,000; in 1665 it prevailed among the sailors, and 200 died out of 500; then in 1666 it prevailed in this Is- land and 5,000 died. It visited New York in 1668, and Bos- ton in 1617 and again in 1693. It visited Philadelphia in 1695, and also in 1699, and some 220 persons died. Charleston, 110 THE PRACTICE OF MEDICINE. South Carolina, was also visited by yellow fever in the year 1699. In 1702 it prevailed once more in New York, and 570 persons died. The same year in appeared on the Gulf-coast at Beloxi, Mississippi. It appeared at Mobile, Alabama, and Cadiz, Spain, in 1705; and again at Charleston in 1728; and at Cadiz, Spain, again in 1731; again in Charleston, S. C, in 1737; and at Cadiz it again appeared in 1733 and 1734, and the same year at St. Domingo, and one in five of the pop- ulation died. It appeared again in Charleston in 1734, and again in 1739; and in Philadelphia 1741, and the same year at New York; again both New York and Philadelphia were visited by the disease in the year 1742, and again in 1743; it appeared again at Cadiz, in Spain, and at Philadelphia, in 1744; at Charleston, South Carolina, in 1745, and at New York; it visited Albany in 1746; in 1747 it appeared at New York, Philadelphia and Norfolk, Va.; and in 1748 it revisited New York and Charleston, South Carolina; it visited Charleston again in 1753; again in 1755 and 1761; in 1762 it appeared at New York, Philadelphia and Charleston, South Carolina; it visited Nantucket Island, Mass., in 1763; and in 1764 it visited Pensacola, Fla., and Cadiz, Spain. It broke out in Pensacola, in 1765, and the same year it visited Mobile, Ala- bama, again, and again in 1766. It appeared again in Charles- ton in 1768; in New Orleans in 1767, and Charleston, South Carolina, in 1770. In 1790 it reappeared at New York. In 1791, yellow fever again visited New Orleans, New York and Philadelphia; in 1792, it visited Charleston, S. C, and New York, and in 1793 it appeared in New Granada among the sailors; it also visited New York, New Orleans, South walk/ and Kensington, also Philadelphia the same year, and some 4,041 persons died of it—that is, one in ten of the population. In 1794 it visited Katskill and New York city, N. Y., New Haven, Conn., Providence, R. I., Philadelphia, Norfolk, Va., Charleston, S. C, New Orleans, Baltimore, Md., and Havana, Cuba; also Sir Charles Gray's army, in the Windward and FEVERS: THE EXANTHEMATA. Ill Leeward Islands, and out of a population of 12,000, it carried off 6,012. In 1795 it appeared in West Neck, Suffolk county, N. Y.; also in New Orleans, Baltimore, Boston, Charleston, Norfolk, Va., and New York city. In 1796 it visited Chatham, Middlesex county, Conn.; and also New Orleans, Newburyport, Mass., Boston, Mass., New York and Gallipolis, Ohio; it also appeared at Philadelphia, Bristol, R. I., Charleston, S. C, Nor- folk, Va., Wilmington, N. G, and St. Nicholas, in the Island of San Domingo, with a mortality in the last place of one to two; it also visited the Island of Gaudaloupe, where out of a population of 20,000, it carried off 13,807; in same Island in 1796, out of 367 artillery-men it carried off 129. In the year 1796, it prevailed in New Orleans and Baltimore, Md.; and at the same time, at New Design, St. Louis county, twenty miles below St. Louis, Mo. It also prevailed this year at New York, Charleston, S. C, Philadelphia, Pa., in Norfolk, Va., Bristol, R. I., and at Providence, R. I. In 1798, it prevailed at Hart- ford, Conn., New London, Conn., on the Thames river, three miles from the ocean, and at Norwalk and Stonington, Conn., and on Long Island Sound; also in New Castle and Wilming- ton, Delaware. It also prevailed the same year at Baltimore, Md., Boston and Salem, Mass., at Portsmouth, N. H., and at Burlington, Port Elizabeth and Woodbury, N. J., Albany and Greenfield, Saratoga county, N. Y., Huntington and New York City, in the state of New York; at the same time at Chester and Marcus Hook, and also at Philadelphia, Westerly, R. I., at Charleston, S. C, Norfolk and Petersburg, and City Point, in Virginia; and St. Domingo, W. I., with great mortality. In 1799 it prevailed in New Orleans, Baltimore, New York, New Berne, N. C.; Bal Edge Valley, Nittany, Pennsylvania; Philadelphia, and the Island of Gaudalope, Charleston, S. C, Norfolk, Va., and on the ship Delaware, where it carried off half of the population. In the year 1800, yellow fever ap- peared at Hartford, Conn., New Orleans, Baltimore, Boston, New Bedford, Mass., New York, Washington, N. C, on Tar 112 THE PRACTICE OF MEDICINE. River in Philadelphia, Providence, R. I., Charleston, S. C, Norfolk, Va., Wilmington, N. C, and Vera Cruz. In Cadiz, Spain, 7,387 died—one in nine. At Seville, it prevailed the same year, with a mortality of 14,685, that is, one in five of the population, and in Havana it carried off 9.978 persons. In the year 1801, it prevailed at New Orleans, Baltimore, and New Bedford, Mass., New York, Queensborough, N. Y., Philadelphia Pa., Black Island, R. I., Long Island Sound, Norfolk, Va., Seville, Savannah, Ga., Norwich, Conn., Charleston, S. C, and Havana, W. I., where 2,366 died; Vera Cruz, Jamaica, St. Domingo, Medina, and Ledonia, Spain, and at Leghorn, Italy, where 150 died daily for months. In 1802 it appeared at Portsmouth, N. H., Wilmington Del., New Orleans, Balti- more, Boston, New York, Philadelphia, Charleston, S. C, Norfolk, Va. and St. Domingo, where 20,000 died, mostly sold- iers; at Martinique, where 2,891 died; at Gaudaloupe, where fifty-seven per cent of the French troops died; at Vera Cruz, and at St. Sebastian, where 1,500 died. In the year 1803, it prevailed at Alexandria, Va., New Haven, Conn., New York city, Lisbon, Pa., Philadelphia, Winchester, Va., Norfolk, Catskill, Gaudaloupe, where 2,700 died, Vera Cruz, and in the West Indies among the French troops, where 6,884 died, at Barcelona and Havana, where 4,766 died. In the year 1804 it prevailed at Cadiz, where 2,800 died; Ecija, where 3,802 died; Carthagena, where 11,445 died; at Malaga, where 11,464 died; at Alicant, where 2,471 died; in Spain, 124,000 died this year; at Gibralter, 5,746; at Leghorn, 055 died. It also visited New Haven, Conn., New Orleans, West Point, N. Y., Charleston, S. C, Norfolk, Va., Winchester, Va., and in the West Indies among the troops. In- the year 1805 it prevailed at New Haven, Conn., Baltimore, Boston, Gloucester, N. Y., New York city, Quebec, at Barbadoes, and Philadelphia__in the last named place, 3,400 died; at Westerley, R. I., Charles- ton, S. C, Norfolk,, Va., and at Havana, where eighty-five out of the hundred died. fevers: the exanthemata. 113 In the year 1806 it visited New York city, Newport, R. I., and Richmond, Va.—no report of deaths. In the year 1807 it appeared at St. Augustine, Fla., Savannah, Ga., New York, and Charleston, S. C. In the year 1808 it visited Savannah, Ga., New York, and St. Mary's, Ga., where half of the re- maining population died. In the year 1809 it appeared at New Orleans, Brooklyn, N. Y., Philadelphia, Charleston, S. C. In the year 1810 it appeared in New York, Philadelphia, Ha- vanna, where 4,305 died; at Gibraltar, Cadiz, and Carthagena, where it was very severe, In 1811 it appeared at Pensacola, Fla., New Orleans, St. Francisville, La., Perth Amboy, N. J., and Philadelphia, and the next year in Philadelphia again; also in New Orleans, Charleston, S. C, and at St. Christopher, West Indies; and again at Cadiz as an epidemic. In 1813 it visited Philadelphia, and also Spain. In 1814 it appeared at Philadelphia, and at Gibraltar and Cadiz as an epidemic. In the year 1815 it appeared at Philadelphia, New York and on the Island of Jamaica. In 1816 it visited New York, Phila- delphia, Martinique, and Barbadoes; mortality 1 to 2.5. In 1817 it appeared at New Orleans, Nachez, Miss., New York, Charleston, S. C, Mount Pleasant, S. C, and Baton Rouge, La., on the Mississippi river. In the year 1818 it visited New Orleans, New York, Martinique, and Trinidad, West Indies. In the year 1819 it appeared at Cadiz, Xeres, Seville, at Fort Claiborne, Ala., Fort Stephen, Ala., and at Mobile, Ala., also in New Haven, Conn., Savannah, Ga., Alexandria, La., New Orleans and West Feliciana Parish, La., Natchez, Miss., New York, Philadelphia, Charleston, S. G, Boston, Baton Rouge, La.; Jamaica, Bermuda, and Havana; in the last place 5,162 died. In 1820 it appeared at Middletown, Conn., Savan- nah, Ga., Bay St. Louis, La., New Orleans, Baltimore, New York, Philadelphia, Barbadoes, Xeres, Linguenza, and at Car- lotta. In 1821 it appeared at Mobile, Ala., St. Augustine, Fla., Baltimore, New York, Wilmington, N. C, Norfolk, Va., Ma- 8 114 THE PRACTICE OF MEDICINE. laga, and Tortosa, where 2,359 died; Barcelona, where 9,730 died—Adouard and Palma. In 1822 it prevailed at Mobile, Ala., Pensacola, Fla., Alexandria, and Baton Rouge, La., New Orleans, Baltimore, New York, and Charleston, S. C, com- mencing in June. In 1823 it appeared at Fort Smith, Ark., Ascension, La., New Orleans, Natchez, Miss., Brooklyn, the city of New York, Martinique, Port du Passage; in Europe, fatality 1 to 2.5. In 1825 it appeared at Mobile, Ala., New Orleans, New York, Charleston, S. C, and Key West, Florida, where 255 died. In 1826 it appeared at Mobile, Ala., Pensacola, Fla., New Or- leans, Natchez and Washington, Miss., New York, Charleston, and Martinique. In 1826 it appeared at Apalachicola, Fla., New Orleans, New York, Norfolk, Va., Gaudaloupe, 1 in 3 mortality. In 1827 it visited Mobile, Ala., Pensacola, Fla., Savannah, Ga., Alexandria,-Baton Rouge, Donaldson and New Orleans, Louisiana; Natchez, Miss., New York, Charleston, S. C, Jamaica, W. I. In 1828 it appeared in Mobile, New Or- leans, New York, Charleston, S. C, and Gibraltar; deaths 1,796. In 1829 it appeared at Mobile, Key West, Baton Rouge, New Orleans, and Opelousas, Louisiana; Natchez, and Rodney, Miss., and at Shieldsboro', on the St. Louis Bay. In 1830 it appeared at New Orleans, and at New York city. In 1831 it broke out Alexandria, and New Orleans, Louisiana. In 1832 it appeared at New York and New Orleans. In 1833 it appeared at New Orleans, New York, Columbia, Texas, Gaudaloupe, and Bassetere, W. T. In 1834 it visited Pensa- cola, New Orleans, New York, and Charleston, S. C. In 1835 it visited New Orleans, New York, Charleston, S. C, Sewanee, Florida; and in 1837 it visited Mobile, Alexandria, Baton Rouge, New Orleans, Opelousas, Plaquemine, and Washington, Louis- iana; Natchez, Miss., and Havana, W. I. In 1838 it visited St. Augustine, Fla., Mobile, Ala., New Orleans, New York, Charleston, S. C, Martinique, W. I., Barbadoes, Dominica, and Georgetown. In 1839 it broke out at Pensacola, St." FEVERS: THE EXANTHEMATA. 115 Augustine and Tampa, Florida; Mobile, Ala., Augusta, Ga., Alexandria, Franklin, New Iberia and New Orleans, Opelousas, Plaquemine, Port Hudson, West Feliciana Parish and St. Martinsville, Louisiana; Natchez and Vicksburg, Miss., New York city, Charleston, and Galveston and Houston, Texas. In 1840 yellow fever prevailed in New Orleans, and in Charleston, but was not severe or very fatal. From that date (1841) up to 1879 it prevailed in various towns and cities of the Southern States. In 1878 was the very fatal epidemic of Memphis, New Orleans, and between these places along the Mississippi valley. This epidemic was attended by great fa- tality. Of the 20,000 persons that remained at Memphis some 5,150 died; that is, one in four, or some seventy per cent, of the white population; and out of the 20,000 inhabi- tants some 17,600 had yellow fever. There were 14,000 ne- groes; out of this number 946 died; and of the 6,000 whites, 4,200 died. Some 200 whites escaped the fever, and most of these had suffered with it in previous epidemics elsewhere. It is estimated- that the population of New Orleans in 1878 was about 220,000, and the deaths something near 4,000. These statistics should humiliate the exclusiveness and arrogance hitherto displayed by the "regular" physicians, who have monopolized the medical service almost exclusively in the various epidemics of yellow fever. What we want is success in the treatment of disease, not aggrandizement of a sect or ism. Let us study the nature of cholera and yellow fever, so as to be able not only to cure them, but to prevent their visitations. If we can cure disease the people do not care whether we are Eclectics, Homceopathists or Regulars — orthodox or heterodox. This shameful exclusiveness of the self-styled " regulars " is not at all in keeping with the hu- mane, scientific profession they assume; nor does such un- christian exclusiveness inspire the people with confidence in the pretenders to the healing art. Men that enter the arena where struggling humanity is contending with the raging pes- 11(5 THE PRACTICE OF MEDICINE. tilence, should at once lay aside all prejudice and sectarianism, and labor to glean facts from all experience. Thus will their efforts be crowned with the desired success, and the people will confide in them as healers. The treatment, varied in each epidemic, and the great mortality of this fever show that but little is yet known of the pathology and nature of this disease. But from what is known of the cause now, the indications point out an active antiseptic course in the very incipiency of the attack. The excitability also should be as much lessened as possible. All local complications should be met, and the patient properly nourished to keep up vitality. The patient's room should be kept clean and of proper temperature, and his skin should be regularly sponged in a solution of some good antiseptic. The brain should be protected, Prof. N. S. Davis, of Chicago, in his recent work on the Practice of Medicine, recommends the tincture of gelsemium, and carbolic acid and veratrum. I think baptisia and eucalyptus globulus would be additions to the carbolic acid, the tincture of aconite would be preferable to veratrum viride, and belladonna would protect the brain; five drops of the tincture of belladonna should be given thrice a day. The tincture of arsenic is useful in the second stage, as well as in the third stage of the disease. The most strict sanitation should be instituted in a locality in which this disease breaks out. It is universally conceded that filth, especially decaying animal matter, including human excrement, is one of the potent, if not the prime, causes of the disease; but, doubtless, locality has much to do with the production, being a concurrent cause, and high temperature another concurrent factor in the development of the poison. Yellow fever obtains epidemically, but only during the hot season, and rarely, if ever, in localities over six hundred feet above the level of the ocean. It generally prevails in low, level land near the sea-coast, and mostly in very hot climates. It may break out on board ships, if they have been long at FEVERS: THE EXANTHEMATA. 117 sea and are in condition to favor its production, such as want of cleanliness, foul water, badly ventilated sleeping-rooms, easily decomposable freight, or excessive overcrowding with passengers. The virus producing this form of fever is alto- gether different from ordinary swamp miasma, as it is portable from person to person and from place to place, in ships, etc. Those most subject to this fever are the strong, young, full in habit, and such as are not acclimated. Whites are more liable than Creoles, and Creoles are more so than Negroes ; Indians are the least liable of all races. The stage of incubation is generally short, sometimes lasting only a few days, and again twelve or fourteen days. The disease itself runs an acute course, lasting from three to ten days. There are three dis- tinct stages of this fever : (1) The fever paroxysm ; (2) the period of remission, with icterus and slowness of pulse; (3) the apyretic stage, with haemorrhage, suppression of urine and collapse. The disease is generally ushered in suddenly by a chill, which is due to the depressing effects of the virus. This fever soon reaches a very high degree, to be followed by dry- ness of the skin or by sweat. This sweat, however, does not lessen the heat nor the hardness of the pulse. Violent head- ache and pain in the eyes attend this stage ; the eyes are red, watery, and of glassy appearance. There is also, at this time, severe pain in the lumbar regions and extremities. The patient is restless and has nausea, vomiting, and great thirst, with soreness in the epigastrium. The discharges from the bowels are retarded, and often of a light color, sometimes be- coming soft, profuse and bloody ; the urine also is scanty and of a dark red color. In some cases there is epistaxis. Mental dejection and physical prostration with the great restlessness are also symptoms. This stage may last but one or two days, or it may continue four or five days ; then follows the second stage. The patient now feels better. All the very distress- ing symptoms cease and the pulse falls to seventy or eighty per minute. In favorable cases this is the commencement of 118 THE PRACTICE OF MEDICINE. convalescence. In grave cases, however, the nausea and sore- ness in the stomach continue, and the skin and eyes begin to assume the characteristic icteroid hue. The pulse sinks below its normal standard, and the patient feels exhausted, and wears a stupid expression of countenance. These symptoms all in- crease in the third stage. In a day or two the soreness at the pit of the stomach turns into a severe burning sensation ; the tongue becomes dry, the thirst violent, and the nausea and vomiting grow more violent. At first there may be nothing thrown up but a sour fluid, but gradually the contents of the stomach become mixed with blood, and at last the vomit con- sists only of decomposed black blood (the characteristic black vomit). At the same time blood passes from the bowels, and, in some cases, from the nose, mouth, kidneys and capillary vessels under the skin, forming petechial spots upon the sur- face. The secretion of the urine is now scanty, or ceases entirely. The patient is in great agony ; there is either clear consciousness, or a state of delirium. This exhaustion in- creases very rapidly ; the skin becomes darker and the temper- ature of the body rapidly declines, until the patient either dies suddenly in a comatose state, with delirium and convul- sions, or retains his senses to the latest moment of extreme ex- haustion and agony, and dies gradually. This is the ordinary course of yellow fever, but there are cases that at first are so mild that the patient only feels unwell, and is not sick enough to take to his bed. Finally, all at once, he is seized with vomiting of blood, and rapidly sinks into a collapse. Treatment.—Treatment should begin with antiseptics. Baptisia, in doses of gtt. 2 to 5, should be given every two hours, as soon as the first symptoms appear, and continued throughout the attack. To control the fever, there is nothing better than small doses of aconite, gtt. ^ to 1 every hour. As soon as nausea and vomiting set in, Fowler's solution, in doses of gtt. 5 should be given every six hours, or gtt. 1 every hour. If there are meningeal symptoms, such as headache and pain FEVERS: THE EXANTHEMATA. 119 in the back of the neck, then gtt. 3 of tincture of belladonna should be given every three hours until they are relieved. If there are great depression and coldness of the surface and ex- tremities gtt. 2 or 3 of the saturated tinct. of camphor should be given every hour, until its stimulating effects arouse the circulation, and thereby prevent the collapse. In some cases in southern Georgia, pure alcohol, well diluted with water, given so as to stimulate the patient, has proven the most successful of any treatment yet tried. The alternation of moderate doses of aconite and belladonna, even in the stage of black vomit, has proved the best means of controlling headache, in- tense reaction, and the fever. Nitrate of silver in small doses is valuable in the stage of black vomit. Small doses of turpentine proved valuable in the hands of some physicians in the stage of black vomit. It is more than likely that it is the terebene in the turpentine that acts in yellow fever. If there are muscular pains, bryonia alba will relieve them promptly. CHAPTER X. DISEASES OF THE RESPIRATORY ORGANS. Bronchitis. THIS catarrhal inflammation is characterized by a hyperae- mic state of the mucous tissue of the bronchial tubes, giv- ing rise to excessive secretion, and, when long continued, caus- ing a gradual change of the texture. The mucous membrane appears ecchymosed, injected, infiltrated, opaque, swollen, and covered with abnormal secretion. The finest tubes are not un- frequently completely closed, so that the ingress of air into the air-cells is obstructed, and the blood as a natural conse- quence becomes poisoned with the uneliminated carbon. Especially is this the case when the disease attacks infants, or very young children who are unable to clear the obstructed air-tubes. In chronic cases, hypertrophy of the mucous membrane takes place, the muscular fibres lose their elasticity, and the bronchial tubes enlarge, sometimes evenly, or in other instances only in short sac-like tracks, a condition called Bronchiectasis. Inflammation may attack the larger bronchi only, or only the smaller ones. If the former be the case, there will be a tickling under the sternum, and a burning or sore feeling; whilst when the smaller tubes are affected, these symptoms do not exist. This disease is attended with more or less fever, whether the larger or smaller bronchi are involved. The fever in many cases is of a high grade. The disease is usually preceded by more or less chilliness, alternated with burning heat, without much increase in the thermometrical indications ; thus it maybe distinguished from inflammatory fever, which commences with an increase of thermometrical heat. This disease, like catarrhal fever, often assumes a 120 DISEASES OF THE RESPIRATORY ORGANS. 121 typhoid form, especially in weak children and in very old persons. The patient soon becomes delirious and comatose; the tongue is dry, pulse small and frequent, and an exhaust- ing perspiration comes on. There is a characteristic rattling in the trachea, caused by the inability of the patient to throw off the phlegm, resulting from paralysis of the muscular fibres of the bronchi. This is the so-called death-rattle ; and is a certain indication of a fatal termination. This form of bronchitis is called by old writers pneumonia notha. There is another form of bronchitis that attacks children, especially those at the breast. It involves the smallest branches of the bronchial tubes, and is called capillary bronchitis. This is a dangerous form of catarrhal bronchitis, and often termin- ates fatally under the best devised treatment. As the smaller air-tubes are attacked, they become impervious to air, and, consequently, the carbon is not expelled, and an insufficient supply of oxygen is inhaled. In these cases the respiration becomes very difficult, with hissing and rattling noises in the chest, and painful coughing spells, driving the blood to the face, and drawing up the lower ribs as in croup. When new- born infants are the subjects of this form of bronchitis, it soon develops itself into a higher stage. The child is too feeble to detach the accumulating mucus, the lungs become closed up, and the skin grows blue and gray in color ; the nose becomes pointed, the eyes dull ; the respiration quite superficial, and there is great danger of the disease terminat- ing fatally. Physical Signs.—Percussion reveals but little in this affection ; the sound is similar to that of health. Ausculta- tion shows a vesicular murmur, which soon becomes loud, harsh and coarse. The expiratory murmur (scarcely audible in health), now becomes louder than the inspiratory murmur. When the disease is confined to the larger bronchi, the vesic- ular murmur is hidden by the louder bronchial breathing. As soon as the mucous membrane becomes covered with the secre- 122 THE PRACTICE OF MEDICINE. tion, there is a fine bubbling, hissing and whistling sound. When the secretion is in the larnyx, trachea, or the larger bronchial tubes, the rattling noise is heard all over the chest, and, consequently, we cannot well judge of the extent of the secretion by the noise in respiration. If the finer bronchi only are involved, and the respiration is feeble, the rattling noise is not heard. In vigorous respiration, if the vesicular murmur is absent, it denotes either a large quantity of mucus in the bronchi, or else the closure of the finer tubes by the swelling, which prevents the air from passing into the air- cells. Bronchitis is generally not attended with severe pain, but is accompanied by a sore, raw, and sometimes burning sensation in the chest. The sputa may be slightly streaked with blood in cases of a grave type, but is not bloody as in pneumonia. We meet with every grade of this disease, from the most severe form to the mildest. It often prevails in a mild form, and is called catarrh, influenza or grippe. Again it appears in a grave form, attended with high fever, and proves fatal to old people and young children. It prevails epidemically in some localities, and these visitations generally prove severe in the southern parts of the United States. It is especially rife in localities infested with malarious diseases, and in such localities it is generally very severe. Treatment.—In the commencement of catarrhal bron- chitis, with high fever, dry skin, restlessness, headache, burn- ing and soreness in the chest, I have found aconite in doses of gtt. \ to 1 every hour for adults, and gtt. -1 to \ for children, according to their age, very useful. It has a controlling effect over all catarrhal fevers and inflammations, and should never be forgotten. In children, if the disease is attended with a hot skin, a tendency to perspire, a painful cough, caus- ing the child to cry, sleeplessness or starting in sleep, then administer a drop of belladonna once in four hours, until the child becomes quiet. In very young infants, gtt. \ to \ is DISEASES OF THE RESPIRATORY ORGANS. 123 sufficient for the dose. If the pain in the chest is severe, the cough dry and tight, or if there be pain at the epigastrium, in the pleura, or about the chest generally, then bryonia, in doses of gtt. 1 to 3, may be used with good effect. Where there is much rattling in the chest, convulsive cough, with vomiting of phlegm, dyspnoea or nausea, with pale face, then I give gtt. 1 tincture of ipecac, to children, and gtt. 3 or 4 to adults every half hour, until the symptoms are controlled. If there is croupous inflammation, a dry, hoarse, barking, hollow cough, then the tincture of sponge, in drop doses, every two hours, will be found effective. If there is great anguish, suf- focation, palpitation of the heart, oppression of the chest, difficult breathing from tightness of the chest, and spasmodic cough with thick yellow sputa, I prescribe digitalis in doses of gtt. 1 to 2, alternated with gtt. 2 or 3 of cereus grandi- florus, every one or two hours, according to the urgency of the symptoms. Adults may take gtt. 5 to 10 of digitalis, and gtt. 10 to 15 of cereus. In capillary bronchitis, with difficult respiration, rattling of mucus in the chest, short fits of coughing, and bright yellow thin stools, showing inaction of the liver, give a few drops of tincture of chelidonium every hour. If the sputa is very difficult to cough up, chelidonium may be alternated with gtt. 1 to 2 of tincture of sangumaria; gtt. 4 to 6 is the proper dose for adults, well diluted with simple syrup. I usually give the syrup of sanguinaria, made by adding 1 3 of tincture to 9 ? of simple syrup. The dose for children is from gtt. 8 to 12, and for adults gtt. 30 to 60 in water. This is one of the most certain and harmless expectorants we have, as in medical doses it does not irritate the stomach as squills and senega are known to do, but acts as a tonic. In the advanced stage, attended with excessive accumulation of phlegm, small doses of tartar emetic are in- dicated, gr. i to J. The hypophosphites are also valuable m this disease. 124 THE PRACTICE OF MEDICINE. Whooping Cough. This is also a species of bronchitis, but of a purely epi- demic nature, not a mere nervous affection, as has been stated by some old writers. In the incipient stage it is difficult to distinguish it from the ordinary bronchial catarrh ; but later on, the paroxysms of coughing are accompanied by the characteristic lohoop, which consists of a crowing inspiration caused by a spasmodic closure of the glottis, followed by quick, short, expirations in succession, which generally end in the ejection of masses of tough phlegm. These paroxysms come on as often as the phlegm collects in the bronchi. Res- piration is so much obstructed that cyanotic symptoms super- vene and swell the veins ; in some cases, the brain is so con- gested that convulsions take place. Occasionally epistaxis occurs, and the ears and mouth may also bleed more or less. Whooping cough has been divided into three stages : the catarrhal, the convulsive, and the critical. The catarrhal stage much resembles ordinary catarrh, the convulsive stage is sui generis, and the critical stage is similar to an attack of ordi- nary catarrh, and soon wears off. The disease, if properly treated, generally terminates in two or three weeks, but when neglected, may go on for several months, and then prove fatal. Its physical signs do not materially differ from those of bronchitis. It may terminate in pneumonia or emphysema, or, by its morbid effects upon the circulation, may bring about oedema of the brain and its membranes, and thus prove dangerous. This disease usually attacks children, and but once ; it is regarded as more or less contagious. Treatment.—If the disease is attended with congestion of the brain, red face, hot head, fever, drowsiness and disturbed sleep, with starting and jerking of the muscles, then bella- donna, alternated with small doses of aconite, gtt. 1 and gtt. ^ to \ for children, of aconite, every hour will be sufficient. If thev cough becomes very frequent, and there is a sense of DISEASES OF THE RESPIRATORY ORGANS. 125 constriction in the chest, then gtt. 5 to 10, of drosera rot. may be administered every hour or two, until the symptoms are completely relieved. If there be constipation, vomiting, gagging or choking spells, with bluish face, and severe pain in the umbilical regions, small doses of nux vomica will be of material service, and I give gtt. -| to 1 once every four hours in water. If convulsions supervene, let gtt. 5 or 6 of lobelia be given every hour, until the convulsions cease. The diet may be moderate. Recently the fluid extract of castanea vesca (chestnut leaves) has been used in whooping cough, in doses of gtt. 5 to 10 every one or two hours, according to the severity of the cough. To relieve the sudden, deep spas- modic cough attending some cases of this disease, the bromide of ammonium has proved a prompt remedy, in doses of gr. ^ to 1 every one or two hours through the day. Picrate of am- monium has shown itself to be very reliable in this affection. It is quite bitter, and is best given in the form of a saturated tincture, made by adding 1 3 to 1 1 of alcohol, and then gtt. 3 to 5 of that tincture may be added to 1 i of simple syrup. Give from -| to 1 teaspoonful of this mixture every two hours, in about an equal quantity of waier. Some writers highly commend sticta pulmonacea in whooping cough. Eriodyction is also highly extolled in whooping cough. Trifolium pra- tense (red clover blooms) has acquired considerable reputa- tion in whooping cough, given in the form of a saturated tincture, in doses of gtt. 5 to 10 every two hours. Infusion of mullin is also used with good effect. Syrup of alum is also a good remedy, in doses of 30 gtt. Asthma. Asthma resembles spasm of the glottis, and, like it, is caused by an irritation of the vagus nerve. It may be either cen- tral, peripheral, or a mere reflex from other nerves. Asth- ma, when purely nervous, exhibits upon post-mortem examina- tion no abnormal condition of the air passages. Irritation of the 126 THE PRACTICE X)F MEDICINE. vagus nerve causes a spasmodic contraction of the transverse muscular fibres of the bronchi, and, hence, the great difficulty of inspiration. How this irritation upon the vagus is pro- duced, however, we cannot tell. In some cases I have seen changes of weather produce it ; in others, dust will give rise to it. In some cases, indeed, I have seen asthma associated with heart disease, and in others associated with emphysema, and still again connected with lesions of the liver, stomach, and other organs, as the uterus, etc. Its exciting causes are various. In some persons it is produced and kept up by living in a certain locality ; in some by smelling certain drugs, especially ipecacuanha ; in some by sexual excesses and mental excitement, and sometimes it is difficult to trace it to any cause, save the impressionability of the patient's nervous system. It generally occurs in paroxysms every week, two weeks, or even every month. Treatment.—For relief of the paroxysms, several reme- dies are used, such as ipecac, lobelia, gelseminum, and the inhalation of nitrite of amyl, etc. I have frequently relieved paroxysms by having the patient breathe the smoke of soft brown paper steeped in a strong solution of pure nitrite of potassium, and then dried. This paper should be burned near the patient, in order that he or she may inhale the smoke freely. The curative treatment consists in giving such reme- dies as counteract the spasmodic tendency of the bronchial tubes. In old people, or when asthma is connected with emphysema or heart disease, arsenic is one of our chief remedies, and should be given in small doses, say gtt. 1 to 2 of what is called Fowler's solution, three times a day. This is a remedy also for asthma complicated with dyspepsia, as it tones up the stomach. I have used the bromide of lithium in some cases with good effect, alternated with gelseminum \ %, grindelia robusta 2 § , ptelea 2 1 , eriodyction Cali- fornicum 2 1 , silphium gummiferum 2 1, prescribed in doses of one or two teaspoonfuls every three hours, so as to DISEASES OF THE RESPIRATORY ORGANS 127 keep up the antispasmodic effect upon the nervous system. I use the saturated tinctures with good results. If continued long enough a cure may be effected. When the paroxysms occur very frequently, and are attended with a quick, small, and weak pulse, aconite in drop doses, three or four times a day, has often aided the above remedies in the radical cure of asthma. When connected with chronic bronchitis, the iodide of antimony, in doses of gr. 5 of the 2 dec. trituration, three times a day, has proved very successful in some cases. The cannabis indica (India hemp) in doses of gtt. 3 to 5 of the tincture has often given relief in extreme cases of this disease. Sumbul (musk root) in the form of a saturated tincture, in doses of gtt. 30 has proven a good remedy. Quebracho, in doses of gtt. 1 or 2 every ten or fifteen minutes, also gives prompt relief and is worthy of a trial as a curative remedy. When connected with diseases of the heart, I find gtt. 10 to 15 of cereus grandiflorus, every two hours, is necessary, in alternation with other proper remedies. In some instances I have found that the tincture of digitalis, in gtt. 5 to 6 doses, is necessary, alternated with anti- spasmodic remedies. Iberis, too, has proved very successful in some cases of asthma on record. Iberis amara is the " candy tuft" of the gardens. It may be administered in the form of a saturated tincture, in doses of gtt. 4 to 5. Pneumonia. This complaint consists of a hyperaemia of the pulmonary capillaries, with catarrhal or serous exudation. From the different morbid products of exudation, this disease has been divided into croupous, catarrhal, and serous pneumonia. Catarrhal pneumonia is acute bronchitis, which has been al- ready considered as an inflammation extending into the finest bronchial tubes, and hence, is called catarrhal capillary bron- chitis. It is mostly found in children, associated with whoop- ing cough, influenza or croup. It is usually an extension and 128 THE PRACTICE OF MEDICINE. aggravation of these affections. Serous pneumonia, or acute oedema of the lungs, is characterized by a serous exudation, and is generally a secondary disease, the result of croupous pneumonia, bronchitis, tuberculosis, heart disease, measles, and typhus or scarlet fever. Croupous pneumonia is the most common form, and consists of croupous or fibrous exudation, which is susceptible of being vitalized. It generally attacks the inferior lobes of the lungs, especially the right one; and rarely attacks both lungs. It does not often extend over one whole lung, but is confined to certain portions., which, in some cases, are too small to be detected at first by percussion. It does not often attack the central portion of the lungs alone, but generally extends to the surface. In the aged, and gener- ally in debilitated persons of any age, the disease attacks the posterior parts of the lungs. Pneumonia usually exhibits three stages: (1) The inflammatory stage, which is hyperaemia of the capillaries in the lung tissue with exudation of coagula- ble lymph; (2) hepatization, or infiltration of the lung tissue with coagulable lymph; and (3) resolution, or purulent infil- tration, which is the transformation of lymph into pus. These stages are recognized by their respective symptoms. The first stage sets in gradually with a chill, which is soon followed by high fever, the pulse running up to 120 or 130, according to the age of the patient. There is apt to be a red flush upon the cheek corresponding to the diseased lung, and the lips very often become covered with fever blisters. The respiration is much interrupted, being short and labored. There is cough and rusty sputum, which soon becomes mixed with blood. If the pleura be involved, there will be a sharp pain in the chest, and if there be a dull, heavy pain the bronchi are also involved. In severe cases there is delirium or stupor. The urine is scanty and highly colored, and gives a precipitate to nitrate of silver. The temperature is generally high. Physical Signs.—There is decreased mobility of the dis- eased side, and if both lobes are affected in depending portions, DISEASES of the respiratory organs. 129 the patient moves only the upper part of the thorax while breathing, and the abdomen remains quiet. Palpation shows an increase in the fremitus. The impulse of the heart is very much increased, but normal in position. Percussion yields a short, tympanitic sound over the engorged parts, as long as they contain air, but this condition ceases whenever the hepatization is completed: the sound is then very dull. Auscultation reveals a fine crepitant sound, like the rattling of parchment, or the pressing of hair between the thumb and finger, or like spitting forcibly against a silk cloth. The second stage is characterized by great dyspnoea, cough, pain, brain symptoms, albuminous urine, and strong vocal fremitus. Percussion now reveals a very dull sound over the part. Aus- cultation gives neither the crepitant sound, nor the vesicular sound, but a bronchial breathing—bronchophony and some- times pectoriloquy, unless the bronchi are closed up by mucus. If the bronchi be clogged with mucus, varied, rattling sounds will be heard. The third stage is characterized by a relaxation of the violent symptoms. The fever abates, the face becomes pale, the skin moist, the dyspnoea ceases, and the sputum be- comes copious, frothy, lighter and more easily expectorated. The urine grows clear, copious, and again throws down a pre- cipitate with nitrate of silver. On inspection, the thoracic walls will be seen to have regained their mobility. The per- cussion sound again becomes tympanitic, and upon auscultation the bronchial sound, the bronchophony, has become weaker; the crepitation sound then reappears, and finally yields to the natural vesicular respiratory sound. These stages, in the usual course of the disease, occupy about fourteen days. But, in some cases, we observe a new invasion of the disease follow- ing the first attack, and a portion of healthy lung becomes cedematous; that is, it becomes infiltrated by a serous exuda- tion, in which the dyspnoea increases eventually to suffocation. This fatal result is brought about by an increased quantity of carbon in the blood. In some instances, the disturbed circula- 9 130 THE practice of medicine. tion of the lungs causes a hyperaemic condition of the brain, and the blood not being sufficiently oxygenized, or being re- tarded in its return from the brain, causes stagnation and death, a form of apoplexy. Abscesses may form in the third stage, which, if small, may heal. But when the abscesses are large, and form large cavities, there will be pectoriloquy, or a metallic tinkling. In some cases, where the upper portions of the lungs are attacked, the hepatization may be transformed into tubercular infiltration. If this be the case, the fever does not leave altogether, but shows some increase at night. The dyspnoea, cough and dull sound of hepatization continue, and auscultation reveals bronchophony. In some rare instances, the hepatized lung becomes indurated, or cirrhosed, the inter- stitial tissue becoming tense, and rendering the air-cells impervious. In such cases convalescence is tedious, and for some time, upon percussion, we discover a very dull sound with bronchial breathing, and there is more or less depression in the thorax. It occasionally happens that gangrene takes place, which will show itself by sudden collapse, cadaverous odor of the breath, and by the expectorations growing very dark, and copious in quantity. Pneumonia, without treatment, or with poor treatment, may continue from twenty to thirty days, but with good care, it is possible to arrest it in either of the three stages. It may with proper treatment, be brought to a favorable termination in from 9 to 14 days in most cases, where there is no complication. Treatment.—Where the febrile symptoms are well marked, and the secreting functions are suspended or imperfectly per- formed, aconite is a most valuable remedy, in doses of gtt. J- to \, every fifteen minutes, or gtt. 1, every hour, when the inflam- mation does not run so high. If the respiration is short, labored, rapid, and attended with sharp pain in the side, with a very painful dry cough, give bryonia, in doses of gtt. 1 to 2, every three hours, or in very urgent cases, every hour or two. diseases of the respiratory organs. 131 If the chest is oppressed with excess of sputum, and there is great rattling of mucus, nausea, profuse expectoration, violent throbbing of the heart, and a sense of suffocation, gtt. 1 to 2, of the tincture of ipecac, and gtt. 1 to 3, of tincture of sangui- naria, may be given hourly. If cerebral complications arise, as indicated by nervousness, delirium, sleeplessness, picking at the bed clothes, flushed face, and congested eyes, then tinct. of belladonna, in gtt. 3 to 5 doses, every three hours, until the mind is entirely relieved, will be found invaluable. If the liver is involved, as indicated by pain under the scapula, then chelidonium, in doses of gtt. 10 to 15 four times a day, should be prescribed, until the complication is relieved. After hepa- tization takes place, the iodide of potassium may be alternated with the bromide of sodium, or with syrup of sanguinaria. If typhoid symptoms supervene, phosphorus, in the form of sat- urated tincture, in doses of gtt. J to |, every three hours will act well in sustaining the nervous system. If there is pleuro- pneumonia, the tincture of asclepias syriaca*, in doses of gtt. 20 to 30 may be alternated with aconite, every hour or two, ac- cording to the urgency of the symptoms. In pneumonia I have found hot compresses of much benefit, as well as of much comfort to the patient. They relax the skin, and distend the capillary vessels, thereby inviting a larger quantity of blood to the surface, and of course withdrawing that much from the engorged lungs. Compresses are much better than blisters. In the second and third stages, if attended by extreme dysp- noea, tough sputum, stitching pain in the chest, and quick, small pulse, the tincture of sanguinaria, in doses of gtt. 4 to 6, every hour, will aid the other remedies in bringing about a favorable termination of the disease. It may be used where the pulse very quick, full, hard and strong, but not otherwise; when needed I would use it in small doses, say gtt. 1 to 4 every two hours. *Asclepias tuberosa. 132 THE PRACTICE OF MEDICINE Phthisis. Phthisis, or consumption, is a condition having its remote origin in a peculiar scrofulous diathesis. In this deadly dis- ease certain morbid bodies, called tubercles, are deposited in the lungs, and in these bodies there is soon set up a process of suppuration and ulceration, looking to their discharge. The disease is not confined to any age or sex, but is most frequently developed in early life, say, from 18 to 30 years of age. When fully developed it is generally supposed to be incurable, but, in its early stages, remedial and hygienic measures may be brought to bear upon it'with much hope of success. An heredi- tary tendency or predisposition to this disease exists in many constitutions, but it is possible that an acquired debility of the system (which may be developed by various causes) may at times give rise to it. Indigestion, masturbation, chlorosis in females, acute eruptive fevers, typhus fever, whooping cough, pleuritis, pneumonia, and a humid atmosphere may all aid in developing this disease. Tubercles.—These morbid products are of various sizes, and consist of a yellowish, cheesy substance, which gradually degenerates into pus or an ichorous material, destroying more or less of the lung tissue. In this way are formed abscesses, which, when emptied, form cavities of vomicae. In new-born infants and young children, tubercles may form in the mesen- teric glands and at the base of the brain, causing, in the first case intestinal tuberculosis, and in the latter, tubercular men- ingitis, both of which are as fatal, generally, as phthisis. Symptoms.—The early symptoms are often obscure, and con- sist of cough, dyspnoea, irregular wandering pains about the chest, excessive susceptibility to cold, impaired digestion, loss of flesh, debility without any visible cause, haemoptysis, flushing of the cheeks, and acceleration of the pulse in the evening, followed by disturbed sleep, and morning sweats. It is not uncommon for the first symptoms noticed to be spitting or coughing up DISEASES OF THE RESPIRATORY ORGANS. 133 blood. As the disease advances, respiration becomes rather dis- tressing, the sputa becomes more purulent, and emaciation and exhaustion take place from imperfect digestion. The intes- tines may be implicated in the tuberculous deposit, and then there may be diarrhoea. The mucous membrane of the respira- tory organs becomes ulcerated or thickened, the voice grows husky or imperfect, and aphony results from ulceration. Aphthae of the mouth, pharynx and larynx often form, and the feet and ankles occasionally become ©edematous. The sub- clavicular region sinks in, the clavicles become prominent, and the thorax flattened and elongated. The respiratory motion decreases or ceases in these places, and in advanced cases, the respiratory motion is only seen in the lower portion of the thorax. Emaciation is rapid, the skin is loose, thin and pale, and the finger and toe nails become rounded, from deficiency of the hypophosphites in their composition. Palpation of the sub-clavicular region reveals stronger fremitus. There is more impulse in the heart's action. Percussion at the out- set of the disease affords no results, as the tubercles, while small, do not affect the sound; but when they become large, and in masses so as to lessen the amount of air in the lungs, the sound becomes very dull, especially in the infra-clavicular, acromial and supra-scapular regions. In the advanced stages, after the cavities have formed near enough to the thoracic walls to reflect sound, percussion over that part yields a metallic or tympanitic sound. Auscultation in the beginning of the disease gives an increased and rather prolonged expiratory murmur, and sometimes fine rattling noises. After the tubercles dissolve, a clicking sound is heard, and after the lung tissue has become infiltrated with tubercular masses we hear bron- chial breathing and broncophony, with various rattling sounds. Treatment.—In the incipiency of tuberculosis, use iodine in the form of Lugol's solution, gtt. 3 to 5, three times a day, alternated with pure creasote, say gtt. 25 to water 4 1—dose a teaspoonful three times a day. This aids in preventing indi- 134 THE PRACTICE OF MEDICINE. gestion and diarrhoea, and at the same time acts as an anti- septic, preventing decomposition. In some cases I have suc- ceeded with the phosphates, alternated with the tinctures of ptelia and euonymus atropurpureus, in moderate doses, twice daily. I use the compound syrup of the phosphites, as given by Churchill. After diarrhoea sets in, Fowler's solution, in gtt. 1 to 2 doses three times a day, is of great utility, often arresting the diarrhoea, and improving the digestion. Where the cough is very excessive, and attended with a purulent ex- pectoration and hectic fever, I have found Peruvian balsam, in small doses, to reduce it very much. In cases in which there is a very great tendency to decomposition, great dysp- noea, diarrhoea, utter prostration, and aphthae about the mouth or throat, I give iodide of arsenic in small doses of 1 gr. of the 3 dec. trituration three times a day. Cod-liver oil, salicin, quinia, pure salicylic acid, iodide of iron, iodide of manga- nese, carbolic acid, phosphoric acid, hypophosphorus acid, maltine, petroleum and crude mecca oil, have all been highly praised as antiphthisical remedies. Cod-liver oil has long been used, rather routinely, as a kind of specific, but has often failed, as other remedies have done, and always will do, until given in accordance with the pathological indications for the remedy. Given when the digestive system is feeble, it does great harm, as it increases the indigestion. This fact accounts for the great diversity of opinion in regard to the utility of this remedy. It will not do either, where there is an inflam- matory condition of the system existing, with tuberculosis, as it aggravates this condition, and so hastens the anatomatical lesions. In such a condition, instead of the cod-liver oil, I give gtt. 1 to 2 of aconite, three or four times a day, until the inflammatory symptoms cease. But where there are no actual inflammatory manifestations, I would advise 1 3 of the cod-liver oil, with 2 3 of pure maltine, three times a day. In most cases that I have treated, there has been more or less in- action of the liver, causing secondary indigestion. Where DISEASES OF THE RESPIRATORY ORGANS. 135 such is the case, I have found euonymus atropurpureus in doses of gtt. 20 or 30 of a saturated tincture, or gtt. 15 or 20 ofNthe fluid extract, one of our most trustworthy remedies. Petroleum possesses marked antiseptic properties, with which it arrests the blood poison, thereby lessening the tendency to disorganization of tissue. I have frequently combined ptelia trifoliata and euonymus atropurpureus with the hypo- phosphites, in the form of a syrup, by adding 4 % of each of the above remedies (in the form of fluid extracts or saturated tinctures) to 8 § of the hypophosphites as given by Prof. Churchill, of England. I have given a tablespoonful of this mixture, three or four times a day. It has a better effect (in the non-inflammatory form) than anything I have lately tried. I have a patient now under my treatment, who came from Franklin, Pa., in an advance stage of phthisis, who is now able to be up all the time, and is gaining strength and flesh under the above regimen. Some years ago, perhaps about 1862, I was called to a patient in Buford, Ga., whom I found in the advanced stage of phthisis pulmonalis, much emaciated, bed- ridden, in child-bed, with hectic fever, night-sweats, and a large vomica in the left lung. The larger portion of both lungs was filled with tubercles. This case presented all the symptoms of hastening dissolution, but I put her upon the hypophosphites, ptelia, and euonymus, and she mended from the first week or two. She finally recovered, and is now a living monument of the efficacy of the above remedies. These remedies possess the power of assisting the digestive appar- atus, and also of the assimilating functions, thereby elaborat- ing a protoplasm, out of which a much healthier cell-nucleus is formed. (I have recently treated several cases with like suc- cess. ) At the same time, doubtless, they stimulate the excretory organs to eliminate the aplastic or worn-out elements from the entire body. It must not be expected that these, or any other remedies, can control all cases, especially those in which the 136 THE PRACTICE OF MEDICINE. destructive metamorphosis has advanced too far to be arrested, for there is a point in this disease, as well as in many others, where a cure is impossible. Where there is a high degree of inflammatory excitement, the hypophosphites are contra-indi- cated. In this condition aconite should be given, in doses of gtt. 1 to 2, three or four time a day, alternated with mecca oil, or crude petroleum in moderate doses, from -§ to 13. Petro- leum is of much value in all caaes of catarrhal complications in phthisis, soothing the harrassing cough, and lessening the excessive expectoration that often attends this disease. It exerts no control, however, over the tubercular cachexia, and hence we must look to other remedies to prevent and control the primordial lesions of this disease. The phosphates, or phosphorus, in the form of the metalloid, alcoholic tinctures, or etherial tinctures cannot possess nutrient properties until they are vitalized so as to assume an organismal power; hence these forms of phosphorus are not assimilated until they are vitalized. There exists in the capillaries a tri-basic phos- phate of lime, magnesium, sodium, potassium, and iron, which is very similar to that found in the cereals. It is further noted, that those organic phosphates that are elabor- ated in vegetables are very active ailments, and readily assim- ilate in the form of pure maltine. Hygienic Treatment.— The patient's diet should be highly nutritious, but such as is easily digested. The tender parts of beef, mutton, game and fish, with stale bread, should constitute one or two meals a day ; milk, eggs, butter and oysters may be also used if the stomach will digest them easily. Cod-liver oil, in small quantities, emulsified with maltine, should be taken after each meal. From one to two teaspoon- fuls may be taken at each dose, provided it does not oppress the stomach. If digestion is feeble, pure pepsin, in doses of gr. 40 to 60, may be taken in water just after each dose. Daily exercise in the open air should be insisted upon when the weather is favorable. The skin should be bathed daily, DISEASES OF THE RESPIRATORY ORGANS. 137 and followed by a friction with a crash towel. If the weather is cool the water may be tepid at first and gradually reduced in temperature until it is cold. In the commencement of the disease (not after the system is too far debilitated to be benefitted) the patient should seek a high, dry and moderately warm climate, not a hot, humid atmosphere, filled with miasma, but one filled with ozone, which prevails in altitudes from eight hundred to one thousand feet above the level of the ocean. Many consumptives have improved rapidly by visiting Marietta, Ga., and similar places. The recent new treatment of phthisis pulmonalis, with carbolic acid and suphuretted hydrogen gases, does not ap- pear as yet to be any addition to the curative treatment. Some physicians claim that it improves the flesh for a time, but I see no reported cures as yet. The only cures I have ever made were made by the use of such tonics as euonymus and ptelia, alternated with the syrup of the phosphites, which I make myself of the hyperphosphite of lime, magnesia and and sometimes add the iron salt if the blood is wanting in red globules. Emphysema. This affection is an enlargement of the air-cells, either from a coalition of several of them into one, or from mere dis- tension of the cells. It may also be a transmission of air into the sub-pleural cellular tissue. In emphysema, post- mortem examination shows the lungs swelled out, and a want of that peculiar crepitation of the healthy lung when pressed between the fingers. The air-cells are widened, sometimes to the size of a partridge-egg, and even larger. I saw a very extreme case in the hospital at Philadelphia, Pa., in the year 1867, exhibited by Dr. Da Costa, which showed the air-cells as large as a walnut at the apex of each lobe of the lungs. This disease may be produced by violent inspiratory effort, as in asthma ; or it may originate in phthisis, pneumonia or 138 THE PRACTICE OF MEDICINE. bronchitis (from the tubes being blocked up with tough phlegm). Whooping-cough, playing upon wind instruments, and severe straining may also cause emphysema. It prevents the oygenation of the blood, surcharges it with carbon and lessens its percentage of oxygen. This deficiency of oxygen and excess of carbon gradually grows greater, until extreme dyspnoea takes place, causing the patient to strain the respira- tory muscles so much that the thorax becomes arched and very much dilated. As the air-cells become obliterated, so do the capillaries of the lungs. Consequently the blood from the right ventricle cannot find space within the lungs, and stagna- tion of the blood follows, causing hypertrophy of the right ventricle. This is followed by the usual consequences, which are, undulations of the right jugular vein, cyanosis of the face, varicosis of the vessels of the alee nasi and cheeks, swelling the liver, scanty urine and haemorrhoids. Diagnosis.—On inspection, the chest is found arched, barrel-shaped and dilated to the sixth rib. This condition, however, is not universal, for emphysema may exist without such marked alteration. Palpation generally reveals the fact that the heart has been forced lower down towards the pit of the stomach. Percussion gives the dull sound over the parts of the heart and liver covered by the distended lung, hence we have lung sound over the heart and liver. Auscultation affords but little information. If there is catarrh associated with emphysema, we should hear rattling and bubbling noises. The progress of the disease is slow, and its acute attacks are provoked by bronchial catarrh. It may end in general dropsy and death, or it may last for years. Treatment.—Like phthisis pulmonalis, emphysema is very difficult to cure. When the dyspnoea is very great, and the face cyanotic, tinct. of arsenic in doses of gtt. 2 or 3, three times a day, generally affords signal relief. If the circulation is much disturbed and there is headache, dizziness, palpitation of the heart, and fulness of the abdomen, gtt. 3 or 5 of tinct. DISEASES OF THE RESPIRATORY ORGANS. 139 of belladonna, three times a day, will give relief to these symptoms. If there are attacks of suffocating dyspnoea, attended with cold sweats over the body, coming on regularly every morning, I then prescribe small doses of arseniate of quinia. The 1st centesimal is as strong as it can be used, as it is highly toxical. The dose of that trituration is gr. ^ to 1, three times a day. In old cases, where there is hypertrophy of the heart, digitalis, in small doses, say gtt. 5 to 10, every four hours, often brings relief. This may be alternated with cactus, gtt. 10 to 15. If there is a dry, spasmodic cough, and the sputum is tough and difficult to raise, small doses of the tincture of ipecacuanha and sanguinaria, will produce easy expectoration ; gtt. 1 to 2 of ipecac, and gtt. 5 to 6, of sangui- naria, is sufficient. If that fails, the tinct. of lobelia and syrup of senega may be used. Pleurisy. In pleurisy, post-mortem examination reveals the fact that the inflammation results in an injection of the pleura, with pink- ish stripes and spots here and there. These consist in enlarge- ment of the capillary vessels; and in some cases there are irreg- ular, ecchymosed patches of dark and red extravasation in the pleura. The surface of this membrane appears dull and swollen, and sometimes, rough, villous, and granulated. This is so in many instances, but in some cases, in addition to the above pathological conditions, there is a scanty fibrinous ex- udation, like a soft, croupous membrane, covering the pleura. Where there is recovery, this exudation may be dissolved by fatty metamorphosis, and thus be absorbed; but the fine gran- ulations, and new cells that lie underneath, frequently give rise to adhesions of the pleural surfaces. This fibrinous ex- udative pleurisy also accompanies most cases of croupous pneumonia. In some cases a large quantity of a greenish yellow serum, and coagulated fibrinous masses, may collect, float in the serum, and finally adhere to the pleura like croupous 140 THE PRACTICE OF MEDICINE. membranes. There are always more or less pus-globules con- tained in this secretion, and so there may be bloody exudation. In cases that recover, this secretion may be gradually ab- sorbed, and between the adhesions there may be left a yellow cheesy material, the residue of unabsorbed pus-globules and fibrinous substances. As absorption advances, the lungs regain their normal volume, provided the air-cells be not closed by fibrinous deposits. In some cases the exudation is purulent (that is, so full of pus-globules that it forms an opaque, yellow, thick fluid, called empyema,) and it constitutes pyo-thorax. But even in these cases absorption may take place in time, and a cure be the result. If the pleura itself become involved in the suppurative process, it causes soften- ing and finally perforation of its tissues, and the pus escapes outside, either through the thoracic wall, or the bronchial tubes ; is then coughed up and the patient recovers. Symptoms.—In the first form of pleuritis, in which there is no exudation, there are no well marked symptoms. But in the secdnd form in which there is fibrinous exudation, when it is attended by pneumonia or tuberculosis, there is sharp pain, which prevents deep inspiration ; and sneezing and coughing give rise to increase of the pain. If not complicated with either of the above diseases, there is but slight cough attend- ing it. The third form, with abundant sero-fibrinous exuda- tion, usually commences with a chill, followed by high fever. The chill may be repeated, giving rise to the suspicion that there is a complication of intermittent fever. This, like the second form, is accompanied by a violent pain in the side and chest. This pain is usually attended with dyspnoea as long as the fever lasts, and when there is extensive exudation com- pressing the lung, there may be a cough. Pleurisy reaches its climax in six or eight days, and may then begin to decline. The fever, pain and cough cease, and absorption of the exuda- tion commences, progresses slowly, and finally, in a few weeks, the fluid is removed. DISEASES OF THE RESPIRATORY ORGANS. 141 Physical Signs.—Upon inspection the thorax is discovered to be enlarged from the exudation. The intercostal spaces ap- pear level with the ribs, or may in some cases bulge out between them. The respiratory motion is much lessened. Palpation.—This reveals the absence of the vocal fremitus, which is the result of the fluid between the thoracic walls and the lung. The heart and liver are also found to be moved out of their normal place. Percussion. —This yields a duller sound, but if the exuda- tion be moderate, so as not to compress the lung and drive all the air out of it, there will be a tympanitic sound. Auscultation.— This reveals an absence of the natural respiratory murmur over the part covered with the exudation. In the fourth form, which goes by the name of empyema or pyo-thorax, there are similar physical signs, as above stated. When pus is about to make its way through the thoracic walls there will appear an cedematous swelling, between the fourth and fifth ribs, that soon grows hard and tense, and protrudes between the ribs. Finally this tumor becomes soft, and, if not opened, will burst and discharge the pus. When it breaks through the bronchial tubes, it may do so suddenly, causing violent paroxysms of coughing, the patient throwing up large quantities of sero-pus or pus. The patient may suffocate or sink under the pyaemic poisoning of the blood, or the pus may make its way down through the diaphragm into the abdominal cavity, causing peritonitis, and death ; or it may escape exter- nally through the intercostal spaces. Pleurisy is distinguished from pneumonia by the repeated chills as its outset; catarrhal sputa; pain; enlargement of the throax; dislocation of the heart and liver, and by the friction sound. In pneumonia, there are rust-colored sputa, and dull, or no great pain unless the bronchial tubes are involved. There is increased vocal fremitus also, and a crepitant sound, but no dislocation of the heart and liver. Treatment.—Where there is great thirst, high fever, 142 THE PRACTICE OF MEDICINE. quick pulse, dry skin, pain in the side and chest, inabilily to lie on the right side, and dry hacking cough, aconite in doses of gtt. 1 to 2 should commence the treatment. The dose need not be repeated oftener than every hour. Perhaps a better plan would be to give gtt. \ or \ every fifteen minutes until the pulse and fever are both reduced, and then at longer in- tervals. If the tongue is coated with a white fur, the pain in the chest severe, and there is great thirst, bryonia should be alternated with the aconite, in doses of gtt. 2 to 3. There is pleuro-pneumonia in some cases, in which we have bloody or rusty sputa and severe cough, which may be treated with tincture of sanguinaria gtt. 3, or gtt. 20 or 30 of the syrup of sanguinaria with the same quantity of wine of antimony, given every two hours at the outset, and alternated with tinct. of aconite. Where the skin is dry and harsh, I find the tincture of asclepias, in doses of gtt. 20 or 30 every hour, or in severe cases, frequently repeated, to be one of the safest and most prompt diaphoretics. Warm compresses (made by soaking flannel clothes in hot water, and wringing them sufficiently), applied to the chest, will aid in the relief of the pain, and the internal congestion, by bringing the blood to the surface. HEMOPTYSIS. When the capillary vessels of the bronchial tubes become rup- tured and the blood, either thin or coagulated, is coughed up in large quantities of a bright dark color, the condition is called haemoptysis, or blood-spitting. When abscesses, tubercular cavities, etc., cause the rupture of larger vessels and a profuse flow of blood from the lungs it is called haemorrhage of the lungs or pneumorrhagia. Sometimes the blood is not brought up; in that case it collects in the parenchyma of the lungs, and forms the so-called hcemoptoic infarctions, that appear black and shining, have an uneven granulated appearance, and are of various sizes, from that of a pea to that of a walnut; they con- tain no air and sink in water. When the infiltration takes DISEASES OF THE RESPIRATORY ORGANS. 143 place and the parenchyma of the lung gets torn, the blood fills the opening and in this way produces pulmonary apoplexy. This pulmonary apoplexy gives a very dull sound upon per- cussion. When haemorrhage of the lungs results from tuber- culosis and disorganization, it is an alarming disease, as it is apt to recur again and again, greatly to the distress of the patient. It often proves fatal, unless arrested. The disease may arise from disease of the heart, caused by obstruction in the ostium venosum, and by insufficiency of the mitral valve. Treatment.—There is quite a number of remedies recom- mended for this haemorrhage, but I have found only a few that are reliable in urgent cases. Among them is the tincture, or infusion of lycopus virg. or bugle weed. This plant posesses not only sedative powers by which it controls the capillary circulation, but is also astringent, and so lessens the calibre of these minute vessels, and consequently reduces the flow of blood in proportion. It is much safer than digitalis, as it is not like it, cumulative in its action. So positive is its action in haemoptysis, that I have seldom had to use any other remedy to check ordinary cases of this affection. In the absence of the lycopus, aconite in small repeated doses, alternated with the fluid extract of ergot, in doses of gtt. 15 to 20, every one or two hours, according to the urgency of the case, acts ad- mirably. Vegetable charcoal, properly prepared, in small doses, is of utility in cases of slow pulse and cold skin at- tended with paroxysms of cough and hoarseness. If the haem- orrhage is associated with piles, collinsonia in doses of gtt. 20, three times a day, will be found useful. Where there is anaemia, iron should be used in connection with other remedies. If the haemorrhage is from the venous capillaries, hamamelis, in gtt. 5 (doses) every half hour, is very positive in action. Pneumothorax. Pneumothorax consists of a collection of air or gas within the pleural sac. Air alone does not constitute the disease, but 144 THE PRACTICE OF MEDICINE. pus, blood or serum are usually found with it, hence it is called either pyo, haemato, or hydro-pneumothorax. Pneumo- thorax is known by the enormous extension of the thoracic wall of the affected side and by the bulging out of the inter- costal spaces. When it affects the left side it pushes the heart to the right side, and this presses the liver down into the abdominal cavity. The gas consists mostly of carbonic acid and nitrogen, with a small percentage of oxygen. If, however, decomposition has taken place, there is sulphuretted hydrogen gas. The substances may be limited to a small space or they may fill the pleural cavity. The entrance of air into this cavity is occasioned by a perforation of the pleura pulmonum, allowing the air to enter from the air-cells of the lungs; or it may origi- inate from a perforation of the thoracic wall, permitting the air to enter from without. Gaseous substances may, too, re- sult from decomposition in pyrothorax. The disease makes itself known by dyspnoea and by the patient being com- pelled to sit up and keep the sound lung free from pressure. The worst cases occur in connection with tuberculosis, gan- grene or cancer. Physical Signs.—Upon inspection enormous enlargement of the diseased side of the thorax will appear, and there will be a bulging of. the intercostal spaces and a want of respira- tory movement. The breathing is suspiratory. Palpation reveals an absence of vocal fremitis, the liver and spleen are displaced downwards, and the heart is found much out of place, towards the middle or the right side of the thorax. Percussion reveals a tympanitic sound, unless the thorax be greatly distended, when it becomes non-tympanitic Very often the upper part of the lung is so compressed that there is a dull sound. If there be effusion the sound of the lower portion of the thorax is dull when the patient is erect, and changes when he shifts his position. Auscultation reveals a full resonant percussion sound, with a metallic, tinkling sound when the patient coughs, talks, or inhales deeply. Over the DISEASES OF THE RESPIRATORY ORGANS. 145 compressed lung there will be broncophony and bronchial breathing. Differential Diagnosis.—This disease differs from em- physema by its dyspnoea coming on suddenly and growing worse regularly and steadily. The one-sided distention of the thorax, the great bulging of the intercostal spaces, the absence of fremitus, the absence of vesicular murmur, and the pres- ence of a tinkling sound, also serve to distinguish between the two diseases. Treatment.—Where the dyspnoea is sudden and very dis- tressing, I use small doses of tincture of arsenic, gtt. 2 or 3, every three hours. If the disease be the result of external wounds or injuries of the chest, aconite in doses of gtt. ^ to 1, in alternation with gtt. 1 of arnica mon., every two or three hours, will give relief. After the inflammatory symptoms are under control by the aconite, give delphinium staphisagria, in doses of gtt. 2 every two hours. If these remedies fail to arrest the morbid process, then resort must be had to the aspi- rator. As a general rule the aspirator should be made to en- ter just above the sixth rib, unless the pus be thick, when it may be better to let it out at the anterior portion of the chest. It may be necessary also to puncture this part, and keep the wound open for some time, as the discharge will be kept up probably for nine months. In the anterior portion of the chest, there is less danger of the aperture closing. This is the case too when the opening is made in the side. Hydrothorax. Hydrothorax consists of a collection of serum in the chest —within the pleural sac—without marked inflammatory symp- toms in that locality. It generally occurs on both sides of the chest at the same time, although one side sometimes contains more fluid than the other. The color of the serum differs in different cases ; sometimes being clear, at others, yellowish, reddish, or greenish. It never contains fibrinous substances, 10 146 THE PRACTICE OF MEDICINE. as is always the case in a pleuritic exudation. There is often, however, albumen present. The pleura exhibits no signs of inflammation, but is of a pale and dull color. This disease often follows organic disease of the lungs and heart, which cause obstruction of the venous circulation within the lungs ; or it may be the result of some morbid condition of the ven- ous or arterial system, causing the blood to become thin and watery, as in the case in Bright's disease. It may also follow disease of the liver and spleen, and as a result of anaemia and cachexia. It is most frequently, therefore, attended by general dropsy. Its symptoms are various, according to the complications attending it. Symptoms.—Dyspnoea, which is always worse when lying down, is one of the most prominent symptoms. When the patient is sitting up the fluid gravitates to the lower part of the thoracic cavity, and thus allows space in the upper part of the thorax for a partial expansion of the lungs, while in the reclining position the lung is compressed by the fluid. Where there is a large collectidn of serum, the patient is compelled to sit up all the time, or he suffocates. On inspection the chest presents an enlargement visible to the eye Palpation shows absence of vocal fremitus, and displacement of the heart, liver and spleen. Percussion gives a dull sound as far as the fluid reaches. Auscultation shows absence of the vesicular breathing over the space occupied by the fluid, but there may be bronchial breathing about the spine where the lungs are compressed. Treatment.—The treatment must be in accordance with the existing complications. If there is irritability of the stomach, suppression of the urine, and very short breathing, I usually commence the treatment by giving gtt. 10 to 30 of apocynum cannabinum every three hours, and alternate that with gr. 10 to 15 of nitrate of potassium in half a glass of water. If these fail, I then give digitalis, gtt. 15 thrice daily. The DISEASES OF THE RESPIRATORY ORGANS. 147 kidneys are frequently hard to manage, and it requires very active diuretics to produce the desired effect. Where the hydrothorax accompanies heart disease, asparagus, in the form of a strong infusion, often acts admirably. I have found the polytrichum juniperum (haircap moss) to be one of our best diuretics. It may be given freely in the form of infusion. I use pipsissewa, in connection with the above, with good effect. If the stomach and bowels are affected, and there is great dyspnoea, thirst, and palpitation of the heart, tinct. of arsenic is a valuable remedy; it should be given in drop doses, every meal. If there is heart disease that should be treated also, or a cure cannot be effected. If the liver and spleen are diseased, they should receive due attention. After the fluid is removed it requires the best treatment to prevent its reaccumulation. I usually put my patients upon iron, alternated with helonias dioica to enrich the blood, and restore the lost balance between secretion and excretion. If the stomach and liver are at fault, bryonia, in doses of gtt. 2 to 5 times a day, will aid digestion, and regulate the bowels. Asclepias syriaca is also a valuable remedy in all forms of dropsy, given in the form of sat. tincture. This asclepias syriaca may be given in doses of 30 to 60 gtts., every two hours with 10 to 15 gtts., of apocynum canna- binum, until the kidneys act freely. This form of dropsy is often very obstinate. The kidneys are sometimes hard to move in this form of dropsy, as well as in other forms, and one remedy will act on some, while it will not on others. I had some patients under my care, whose stomachs would not tolerate some remedies ; in such cases I have found the acetate of potash to act well, in doses from 5 to 10 gr., given every two hours; in some cases diuretic tea, as parsley root, acted well. Squill acts on some patients very well, but it soon proves too irritating to the stomach and bowels in full diuretic doses. But if the powdered squill be carefully parched, without burning, until it is brown, then it can be given in diuretic 148 THE PRACTICE OF MEDICINE. doses, say 5 to 10 grs., every three hours. This is especially a good diuretic in hydrothrorax connected with disease of the heart. It may alternate the eupatorium purpurium, which is especially applicable in renal dropsy. The dose of a satu- rated tincture is 30 to 60 gtts., every two hours. CHAPTER XI. DISEASES OF THE HEART. THE Heart.— Its Examination by Auscultation.— In order to understand the diseases of the heart, it is necessary to become acquainted with the healthy or normal, and the unhealthy or abnormal sounds of this organ. There are four divisions of the heart, to wit: two auricles and two ventricles— which from their respective positions, are called right and left auricles, and right and left ventricles. Into the right auricle the venae cavae empty the blood that has been used by the body for its sustenance. From the right auricle, there is an aper- ture leading into the right ventricle, called the auriculo-ven- tricular opening. This opening has three triangular folds, opening inward, which are called the tricuspid valves. The right ventricle has an opening leading into the pulmonary artery, which carries the deoxygenized blood into the lungs. This opening is guarded by a set of valves called the semi- lunar valves, which open outwards. This arrangement is also repeated in the left auricle and ventricle. The left auricle re- ceives the oxygenated blood from the lungs through the pul- monary veins. From the left auricle there is a like opening leading into the left ventricle, which is also guarded by valves, consisting of two segments. These are called bicuspid or mitral valves, and open inward. The left ventricle has also an opening, which leads into the aorta, through which the heart pumps the blood to every part of the body. There are likewise, in this opening, a set of valves of the semi-lunar varie- ty, which open outward. The following is the modus operandi of the heart as soon as the ventricles become fully distended: They simultaneously begin to contract, and on account of the 149 150 THE practice of medicine. direct relation of the several valves to those two cavities of the heart, the blood, under great pressure from the contraction of the ventricles forcibly shuts the tricuspid and mitral valves, thus closing the auriculo-ventricular openings, and the same action opens both sets of semi-lunar valves for the escape of the blood. As before stated, the pulmonary artery carries the dark blood to the lungs, from which the pulmonary veins return the blood (oxygenated) to the left auricle, thus forming the pulmonary circulation. Then through the aortic valves and artery, the red blood is propelled through the entire body, whence it is returned through the venae cavae to the right auricle, forming the systemic circulcdion. As the two ventri- cles contract the two auricles dilate, and vice versa. This contraction of the ventricles and simultaneous dilatation of the auricles, constitute the heart's systole, and the forcible closure of the auriculo-ventricular valves, produces the first sound of the heart. The dilatation of the ventricles and simultaneous contraction of the auricles, is known as the heart's diastole, which by forcibly closing the two sets of valves (semi-lunar) produces the second sound of the heart. The first sound then, is caused by the shutting of the tricuspid and mitral vah'es; the second sound by the shutting of the semi-lunar valves. Being acquainted with the position and character of the normal sounds of the heart, the physician is prepared to study the abnormal sounds of the organ in disease. For instance, the normal first sound, heard most clearly at the apex of the heart, is proof that the mitral valves close completely, not allowing any blood to regurgitate into the auricle; and that the aortic valves and orifice offer no obstacle to the direct passage of the blood out of the left ventricle. If then the mitral valves be deficient so that they cannot shut perfectly during the rush of the blood against them, the stream of blood not stopping there, re-enters the auricle, causing a noise, but not the characteristic tick. If the aortic valves be stiffened or roughened, or the aortic opening constricted, so that the stream DISEASES OF THE HEART. 151 of blood, in its onward course, is interfered with, it then rubs against this obstacle, and thereby causes a noise or murmur, at the same time when the closure of the mitral valve would give the first tick. And if the mitral valves be deficient, and, at the same time, the aortic valves stiffened and roughened, or the aortic opening constricted, then the stream of blood must inevitably regurgitate through the auriculo-ventricular open- ing, and also rub against the obstacles in the aortic opening and cause a noise, but not the characteristic tick. An increase of the second or diastolic sound of the pulmonary artery is almost always attended with insufficiency of the mitral valves. And an increase of the second sound of the pulmonary artery, and a noise over the aorta, shows that there is insufficiency of the mitral valves and a constriction of the aortic artery com- bined. If we hear a murmer or noise, instead of the second sound, over the aorta, we may know there is insufficiency of the aortic valves. And in case there is a thickening of the mitral valves, or constriction of the auriculo-ventricular opening the blood accumlating in the lesser circuit, causes hypertrophy with dilatation of the right ventricle. In case the auriculo- ventricular valves be insufficient, and, at the same time, the auriculo-ventricular opening be constricted, then there would be a see-saw sound. Valvular diseases are rare on the right side of the heart, and when they do occur, it is mostly in con- nection with diseases of the left side. An anozmic murmur is a soft sound, like the blowing of a pair of bellows, but it is sometimes like that of filing or sawing, and is heard over the aortic valves. Pericarditis. The internal layer of the pericardium is a serous mem- brane, like that of the pleura, and hence, when inflamed, it presents similar post-mortem appearances. These are injec- tion, exudation, and swelling. During the inflammatory pro- cess the injected capillaries may become ruptured, which 152 THE PRACTICE OF MEDICINE. causes bloody exudation. If pus globules should form in great abundance the exudation becomes purulent, and should the exudation undergo decomposition, it exhibits a foetid, dis- colored, ichorous appearance, as in empyema. A serous exuda- tion is readily absorbed again, but if it be of fibrinous charac- ter it gives rise to adhesions between the heart and the peri- cardium. If there be very large quantities of this fluid the heart is pushed back from the thoracic walls, its movements are interfered with, and at the same time the lung is very much compressed. Congestion of the lungs, brain and liver may result ; also oedema of the lower extremities. Pericarditis may be the result of injuries, or it may originate from taking cold, or from acute rheumatism. Pleurisy, pneumonia, or ulcerative processes of the ribs, vertebrae, oesophagus, stomach, liver or lungs, may also cause it, or it may follow Bright's disease, tuberculosis, disease of the valves, cancer, and fevers. Chronic pericarditis may result from abuse of spirit- uous liquors, violent exercise, and gouty affections or it may follow the acute form of pericarditis, especially in rheumatic habits Symptoms.—It is attended with fever, sometimes com- mencing with chills, and followed by heat and rapid pulse. There is also a sharp cutting pain in the region of the heart, which is increased by motion, deep inspiration, and also by external pressure. Dyspnoea is generally present; sometimes to such an extent as to prevent the patient's lying down with- out an extreme sense oP impending suffocation. In some cases there is a short, dry, hacking cough, and if the patient can lie down at all, can only lie on the left side Physical Signs.—After two or three days we may hear the friction sound, which takes place as soon as a deposit of fibrin is formed within the pericardium. This friction sound is seldom synchronous with the sound of the heart, but precedes or follows it. Inspection.—In young persons there may be a perceptible DISEASES OF THE HEART. 153 bulging out of the praecordial region, from the quantity of ex- udation distending the chest. Palpation.—In the beginning of the disease palpation re- veals a strong impulse of the heart at its normal place; but later this becomes weaker and finally ceases. When the loud friction sound takes place it feels like the purring of a cat. Percussion.—At the outset percussion reveals nothing. As soon, however, as exudation takes place the dull percussion sound of the heart extends over a large space, but if the lung happens to cover the filled pericardium, we fail to get the sound at all. In the beginning exudation is confined to the base of the heart and to the origin of the arteries, and hence, we look for the dullness of the sound at these points. Later the dullness of the sound may be found over the long diameter of the heart, and, if the effusion is considerable, in the trans- verse diameter. The pericardium contains two or three pounds of fluid, and the sound becomes dull from the second left costal cartilage to the lower border of the thorax, and from the right edge of the sternum to the middle of the left lateral region. Where the pericarditis is a mere complication of some other disease, the course is less uniform, although the phys- ical signs are similar to those mentioned above. When the disease is not complicated, it is quite easily cured, but when it is complicated with rheumatism, phthisis pulmonalis, gout, chronic bronchitis, and confirmed cases of dyspepsia, it is quite difficult to manage. Our prognosis should always be in accordance with the complications existing in each individual case. Treatment.—At the outset, treat the fever, the pain in the heart, and the dyspnoea with aconite, in doses of gtt. 1 every hour, until the pulse is controlled. If, after the fever is mod- erated, there still remains pain in the region of the heart, bryonia in doses of gtt. 1 to 3, every three hours, will gener- ally give relief. If there be a sensation of stricture in the heart, preventing its mobility, and a sense of suffocation, faint- 154 THE PRACTICE OF MEDICINE. ness, cold perspiration on the face and palpitation, then cereus grandiflorus is one of the main remedies, and I usually give it in doses of gtt. 10 to 20. every fifteen minutes until it brings relief, and then in doses of gtt. 5, every hour for some days after. If there be rheumatism connected with pericarditis, a a copious exudation of serum, irregular, intermittent pulse, and a brick-dust colored sediment in the urine, I find digitalis required, in doses of gtt. 10 to 15 of the saturated tincture. I carefully watch its effects, for it is liable to produce dangerous sedation in some subjects. I prescribe it every two or three hours, until it controls the action of the heart, and acts upon the kidneys. As soon as the friction sound is heard, give small doses of spigelia in tincture. Hydropericardium. This disease consists of a collection of serum without fibrin. A fibrinous exudation never takes place without an inflamma- tory process preceding it. The serum in hydropericardium is clear and of a yellowish color, but if mixed with blood, is brownish or reddish and of alkaline reaction. A small quan- tity of such fluid is generally found in post-mortem examina- tions, and when dropsy of the pericardium exists several ounces of it are found within the sac. The pericardium is much dis- tended, is without luster, and of a dull whitish color. The fat upon the heart is also gone, and the cellular tissue cedema- tious, while the the heart becomes compressed, and the chest enlarged. This disease takes place generally in consequence of an hydraemic condition of the blood, or in consequence of some other disease that causes a general dropsical tendency in the system. Such are enlarged spleen, Bright's disease, cancer, anaemia, dilatation of the right ventricle, and hyper- trophy of the heart, etc. It may result also from obstruction of the circulation (as in emphysema), cirrhosis of the lungs, defects of valves of the heart after pleurisy or pneumonia. DISEASES OF THE HEART. 155 Hydropericardium generally follows or originates from some other disease. Symptoms.—The symptoms are rather obscure until there is a large collection of serum in the pericardium, when there is dyspnoea. This prevents the patient from assuming a re- clining position, attempting to do so causing a sense of suffoca- tion at once. There is apt to be a collection of dropsy in other parts of the body, and the jugular veins enlarge. As the dropsical accumulation invades the other portions of the body, the respiration is impeded, the circulation is much re- tarded, and the patient finally falls into a stupor, which ends in his death Physical Signs.—There is an absence of friction sound, and a distention of the praecordial region in young persons. The impulse of the heart is weak or absent; and percussion sounds are dull and wider in circumference than in a healthy state. Treatment.—This form of dropsy should be met with the remedies advised in hydrothorax. I have found small doses of digitalis, alternated with apocynum cannab. to be effective in stimulating absorption, and the acetate of potassium suc- cessful as a diuretic to remove the fluid. In some cases that I have recently treated from my dispensary, I have been quite successful with large doses of infusions of pipsissewa, poly- trichum juniperum (hair-cap moss), and apocynum canna- binum, alternated with nitrate of potassium, in doses say of gr. 2 to 3, three times a day, in a large quantity of water. This nitrate acts powerfully upon the kidneys, in moder- ate dose, but if given largely it purges, and is likely to irritate the stomach and bowels. In one or two instances, after using other diuretics for some time unsuccessfully, I have given gtt. 30 to 60 of tincture of senecio aureus with each dose of the diuretics, and have succeeded in rapidly removing the serum. In this form of dropsy, like all other forms of the 156 THE PRACTICE OF MEDICINE. disease, to effect a radical cure we must enrich the blood after removing the serum. To do this requires not only iron, but also such other remedies as directly tend to stimulate the blood-making functions. In this class helonias dioica stands at the head of the list. I give it alternated with iron. If hydropericardium has followed some disease exhausting the blood, I give tincture of cinchonia, in small doses. Huxham's tincture is also a good preparation for this purpose. Insufficiency of the Mitral or Bicuspid Valves. If there exists a deficiency in the mitral or bicuspid valves, the blood regurgitates into the left auricle during the systole, thus checking the full flow of the blood through the pul- monary vein. This deficiency causes an undue accumulation of blood in the lungs, causing the blood to be forced backwards into the pulmonary artery, widening its volume and producing a louder second-tick. The increased second-tick of the pulmonary artery is the characteristic symptom of valvular insufficiency. Check of the pulmonary circulation also causes dilatation and hypertrophy of the right ventricle. Finally, this increase of power in the right ventricle diminishes again, the veins of the lungs become overcharged with blood, the venae cavae are also surcharged, and, in consequence, the liver, spleen and kidneys become hyperaemic, a condition that finally leads to general dropsy. This stagnation of the pulmonary circulation may also lead to dyspnoea, bronchitis, periodical haemorrhages of the lungs, hyperaemia of the brain, and cyanosis. If valvular in- sufficiency exists, the diastolic sound will be replaced by a noise at the point where the apex strikes the thoracic wall. The diastolic sound of the pulmonary artery is much increased, and the natural dull percussion sound of the heart extends further in breadth, on account of the dilatation of the right ventricle. DISEASES OF THE HEART. 157 Constriction of the Left Auriculo-Ventricular Opening. Constriction of this aperture prevents a due quantity of blood from passing through the left ventricle, and so causes an accumulation of blood in the left auricle, and there is a check to the flow of blood in the pulmonary vein. This causes an over-filling of the lungs, and a greater pressure backward into the pulmonary artery. The necessary consequences are detailed in the treatment of mitral valves. The deficiency of blood circulating through the aorta and the left ventricle causes the aorta to become narrowed, and the left ventricle to grow smaller. The sound at the heart's apex is like the purring of a cat, the diastolic sound of the pulmonary artery is louder, and the dull percussion sound is heard further to the right side of the chest. Defective Aortic Valves. The aortic valves are liable to become so defective that they do not close up completely, and consequently the blood is driven into the aorta during the heart's systole, but rushes back into the left ventricle, and causes an undue quantity to accumulate there. The blood accumulated in the thickening causes it to make a greater effort to expel this blood. This overaction produces dilation and thickening, and so gives rise to eccentric hypertrophy of the left ventricle. The defective aortic valves are counterbalanced by the increased size of the left ventricle. And for a time there may be neither dropsy nor cyanosis. But there is apt, however, to be more or less congestion of the brain, as shown by dizziness, noise in the ears, flickering before the eyes, headache, red face, and at times hallucinations. Signs.—The diastolic sound is louder and more distinct, and there exists great extension of the dull percussion in the heart's long axis. The impulse is lower down, the pulse is short, jerky and wiry, and there is strong pulsation in the carotids. 158 THE PRACTICE OF MEDICINE. Constriction of the Aortic Opening. One of the first indications of constriction of the aortic opening is deficient circulation, followed by paleness, small and thread-like pulse, fits of fainting, coolness of the skin and extremities, and anaemia of the brain, etc. As the disease ad- vances the veins become overcharged with blood, dyspnoea sets in and not unfrequently cyanosis supervenes, accompanied by other symptoms of diseased heart. Physical Signs.—Systolic murmur is one of the promi- nent physical signs, and can be heard in the carotids. There are dull percussion sounds, somewhat extended towards the longitudinal axis of the heart, and, in consequence, dilatation and hypertrophy of the left ventricle follow. The displace- ment of the apex of the heart outside of the nipple line, and the small, wiry, irregular and thread-like pulse are all com- mon signs of this affection. Defective Tricuspid Valves. This defect allows the blood to flow back into the right auricle when the heart contracts. The retrograde stream of blood flows into the venae cavae and jugular veins, and im- parts pulsation to these veins simultaneously with the arterial pulsation. This flow of blood causes overfilling of all the veins, and this is followed by hyperaemia, cyanosis, and, finally, either partial or complete dropsy. Physical Signs.—In this disease the systolic murmur is heard in the right ventricle; and there will be pulsation and enlargement of the jugular veins. Dull percussion sounds will now be heard in the direction of the breadth of the heart, due to the right auricles having become enlarged. Their affection often results from disease of the other valves, and consequently it is attended by all the physical signs and disturbances given above. Treatment of Valvular Diseases of the Heart.—The DISEASES OF THE HEART. 159 treatment will have to be varied to suit each individual pecu- liarity and complication. Simple disease of the valve may point to certain remedies and other complications must also be met by proper treatment. The diet must not be stimula- ting and all stimulants, as coffee and tobacco, must be avoided. The most effective remedy for defective valves is tinct. of arsenic, in doses of gtt. 1 or 2, three times a day. To quiet the heart, small doses of lycopus and cereus grandiflorus may be administered every two hours through the day, and, in ex- treme cases, at night also. In some instances, in addition to this remedy, I have used small doses of belladonna, three times a day, with good results. My usual dose is from gtt. 5 to 15, in alternation with convallaria maj. Where there is anaemia, I give the pyrophosphate of iron, in doses of gr. 1 to 2, in the form of syrup, three times a day. If there be evi- dent signs of congestion of the lungs, the tincture of phos- phorus, in doses of gtt. 1 to 2, three or four times a day, will be found invaluable. These valular diseases are generally so soon complicated with others that it is impossible to lay down any positive guide for their treatment. If dropsy supervene a special course of therapeutics will be necessary. If the heart becomes enlarged, that, too, will require special treat- ment. The disease also is liable to end in dilatation, hypertro- phy and softening of the heart's walls, all of which must in time receive due attention. Endocarditis. In this disease post-mortem examination shows the lining membrane of the heart injected, reddened, swollen and covered with fine fringe-like substances. These finally change into papillae and wart-like excrescences, which consist of softened endocardium. The chordae tendinae and valves are often torn loose by this softening process, and in some cases the endo- cardium itself is torn at the place where it covers the heart muscles, and the blood rushing into it, and so distends 160 THE PRACTICE OF MEDICINE. and softens the heart muscles that it constitutes an acute heart aneurism. Adhesion of the chordae tendinae and points of the valves, either between themselves or to the walls of the heart, and myocarditis may also result from an extension of the inflammation. Emboli may result from particles of coagulated fibrinous exudation being driven with the stream of blood into the arteries. These emboli may cause abcesses, apoplectic clots, or, should they block up the larger vessels of the lower extremities, they may cause gangrene. Endocar- ditis is generally found in the left ventricle, in consequence of matastasis during an attack of acute rheumatism of the joints. Especially is this the case where several of the joints are affected at the same time. It may be associated with pericar- ditis, myocarditis, with the acute form of Bright's disease, or it may even follow scarlet fever, puerperal fever, typhus fever, and measles. Its invasions during these affections, may be unnoticed; for the patient seldom complains of pain in the region of the heart when thus attacked, except in cases of rheumatism. Symptoms.—Palpitation of the heart, and a soft, compress- ible and small pulse are the early indications of this disease. Dyspnoea is a marked symptom, and is severe in proportion to the amount of complication with the respiratory organs. If the lungs are much involved in the morbid process, there may be quick and unequal respiration, fainting, congestion of the brain, headache, delirium, sleeplessness, stupor, or even coma. Physical Signs.—The sounds of the heart are heard over a larger space than in health, and are stronger than natural at the outset of the disease. In place of the first tick, we hear a murmur from the diseased valves, and the arterial tick is increased. Percussion.—This at first, reveals nothing to guide us in the diagnosis, but after a few days there will be a dull sound over a greater space than there is in health, by reason of the dilated condition of the right ventricle, from impeded circula- DISEASES OF THE HEART. 161 tion. This disease can be successfully treated, thougn it may leave behind diseases of the valves, such as thickening, adhe- sions, or perforation, and in consequence there may be dilation and hypertrophy of the heart. It is a serious disease. Treatment.—If rheumatism be connected with it, and pain in the praecordial region, causing great anxiety, palpita- tion, with irregular, intermitting pulse and dyspnoea, then small doses of the chloride of gold, three times a day, will act well. The dose need exceed gr. yi^. Follow this with gtt. 5 to 10 of the tinture of spigelia every two hours, or gtt. 5 of the tincture of convallaria. If the pain in the region of the heart is of a cutting or cramp-like character, gtt. 10 to 15 of tinc- ture of cereus grandiflorus should be given every ten or fifteen minutes, until the pain is more or less relieved. If there be stagnation of the pulmonary circulation, then the carbonate of ammonium is required. Give aconite if there be high fever, until that is subdued. Hypertrophy and Dilatation of the Heart. Hypertrophy of the heart consists of an increase of its muscular mass, or of thickening of the walls, whereby the capacity of the organ is diminished. This is the case in what is called concentric hypertrophy. There is still another form, in which the muscles are increased in thickness, and at the same time the inner cavity is enlarged. This is called eccentric hypertrophy. Sometimes only one half of the heart is enlarged or dilated. If the left ventricle is hypertrophied, the heart will be longer, and reach further down the left thorax, but if there is eccentric hypertrophy of the right vent- ricle, the heart will be broader, and will extend further over into the right thorax. Diseases of the valves and arteries, or obstruction of the circulation in the capillaries of the lungs are prime sources of both hypertrophy and dilatation of the heart. Pericarditis and myocarditis, mental excitement, alco- ii 162 THE PRACTICE OF MEDICINE. holic spirits, excessive use of tea or coffee, may all aid in its production. Signs.—Percussion, in hypertrophy, gives a dull sound, transmitted in all directions; and the heart's impulse is so greatly augmented that the chest is shaken by it. The apex of the heart is lower and towards the left nipple line. Dilata- tion and hypertrophy of the left ventricle gives similar re- sults. The percussion sound does not extend so far towards the right thorax in hypertrophy and dilatation of the left ventricle as it does in complete dilatation and hypertrophy. In hypertrophy and dilatation of the right ventricle the dull percussion sound is further towards the right side. The jugular veins swell and undulate, and very soon cyanosis takes place, accompanied not unfrequently by bleeding of the lungs, and dropsy. Treatment—For hypertrophy of the heart from obstruction of the portal circulation, gtt. 3 to 5 of nux vomica, three times a day give good results. If the disease is from valvular insufficiency, give collinsonia, in doses of gtt. 10 to 20, three times a day, alternated with gtt. 2 to 3 of tinct. of arsenic every three hours. To control the palpitation of the heart, I have used cereus grandiflorus and lycopus virg., in doses of gtt. 10 to 15 every two hours. If the disease is associated with rheumatism, gtt. 2 to 3 of kalmia latifolia may be given three or four times a day. If the hypertrophy and dilatation are from mitral insufficiency or aortic constriction, and there is an irritable heart, then digitalis, in doses of gtt. 5, every three hours, will give tone to the muscles of the heart. If there be valvular disease preceding hypertrophy, the iodide of arsenic is a valuable remedy, and may be given in doses of gr. 1-20. If the disease has followed acute, or exists with, chronic rheumatism, I then use tincture of colchicum, in doses of gtt. 10 to 15 every three hours, until the pain at the heart is subdued. Should this fail I would employ carb. or benzoate of lithium. If there be a sharp pain in the region of the diseases of the heart. 163 heart, bryonia, in doses of gtt. 2, every two hours, alternated with gtt. 5 of spigelia, will be apt to give relief. If the patient suffers from a cramping pain like a band around the heart, I have always found that the tincture of cereus grandiflorus would give quick relief. This is also the remedy for simple nervous palpi- tation of the heart. If there be a tight cough, congestion of the lungs, over-sensitiveness to external impressions, palpitation from emotions, great debility, fatty degeneration of the heart, dyspnoea, and these in dilatation following endocarditis, then gtt. 1 to 2 of the tincture of phosphorus, three times a day has a good effect. If dilatation and hypertrophy of the left ventricle, dyspnoea and very frequent spells of palpitation exist, very small doses of the acetate of lead may be given three times a day, gr. ^ to \; gr. ^ is enough in most cases. If anaemia, or chlorosis show itself in young girls, I advise the pyrophosphate of iron with other proper remedies. In many cases that I had at my dispensary, haemorrhage of the lungs was quite frequent, and I have found lycopus virg. one of our most trustworthy remedies. I usually give the infusion, or saturated tincture, according to age. Nervous Palpitation of the Heart. This form of palpitation does not occur regularly, but as occasional paroxysms it often attends organic disease of the heart. During the attack the face may be red, and the pulse full and large, or the face pale, and the pulse small and irreg- ular. Some have dizziness and roaring in the ears, headache, flickering before the eyes, fainting spells, and great dyspnoea. Causes.—One of the most frequent causes is anaemia or chlorosis. It also often occurs in women about their clima- teric period; also in hysterical women, especially if any uterine disease or irregularity exists. It results often from sexual excesses, or it may be the result of spinal irritation, or reflex nervous irritation from worms. Occasionally it sets without any apparent cause. In our examination, we should 164 THE PRACTICE OF MEDICINE. not depend upon sounds during a spell of palpitation, but ex- amine the heart in the interval between the spells, as there are unusual sounds during palpitation, which do not exist at other times. We must therefore be careful in our examina- tions, or we may be deceived. Treatment.—Generally, in cases of young persons, after excitement or fright, aconite in gtt. ^, doses every half hour, will allay the attacks of palpitation. In women, after sup- pression of the menses, or in the case of those that are hyste- rical, medium doses of the tincture of asafoetida are generally all that are required, with such other remedies as the general constitutional conditions point out. If there are coldness of the skin and extremities, paleness of the face and great dyspnoea, then use gtt. 3 to 5 of the tincture of camphor, every ten minutes, until relief is afforded. If this affection follow long continued nursing, or loss of blood, small doses of the tincture of bark will often be required. In cases of tremulous palpitation following unusual exertion or mental emotion, cocculus indicus, in doses of gtt. 3 to 5, every two hours, will frequently relieve the spells. If the patient be anaemic, then pyrophosphate of iron should be given for some time. If the affection occur in young girls from sup- pressed menses, I administer gtt. 10 to 15, of pulsatilla, until the menses are restored to their normal quantity. Angina Pectoris. This is a pressing, aching pain in the middle of the sternum, which comes on suddenly, and almost suspends the breathing. It gradually increases in violence, and spreads from the middle of the sternum towards the left plexus brachialis, to the hands and feet; but seldom attacks the right side. The patient suffers great pain and dyspnoea; the counte- nance becomes pale, the front part of the head is covered with a cold perspiration. These paroxysms may terminate in about half an hour, with eructations of gas from the stomach, DISEASES OF THE HEART. 165 and may, or may not, return again. In some cases the heart's action is increased, and in others diminished. The spells may occur only occasionally, or they may occur daily. They are generally associated with some organic disease of the heart, such as aneurism of the aorta, fatty degeneration of the heart and ossification of the coronary arteries. This is always a grave disease. Treatment.—For the relief of the paroxysm the inhalation of gtt. 5 of nitrite of amyl every few minutes, for two or three doses, is invaluable. At the same time the patient should take gtt. 20 of cereus grandiflorus every ten or fifteen min- utes, until he is relieved. This remedy seldom fails to quickly relieve the paroxysm. I gave a gentleman in the city of Atlanta three or four drachms in the course of a few hours one night, and it relieved him of one of the worst cases of angina pectoris I ever witnessed. After relieving the patient we should carefully examine him to ascertain what organic heart affection gave rise to the angina. Then, when our diagnosis is made out, we should treat whatever disease of the heart may exist. If it be ossification of any of the arterial trunks, our treatment can be only palliative. I usually give a course of Fowler's solution, alternated with the carbonate of potassium. If there be fatty degeneration of the heart, the prognosis is very grave, and a spare and low diet should be prescribed. Diaphragmitis. The tendinous tissue of the diaphragm is seldom prima- rily affected; but as the serous lining on its upper surface is a continuation of the pleura and pericardium, and that on its lower surface of the peritoneum, it frequently suffers from participation with affections of the pleura, the pericardium, or the peritoneum. Symptoms.—Dyspnoea is one of the direct indications of this disease; also singultus, yawning, risus sardonicus, pain 166 THE PRACTICE OF MEDICINE. in the shoulders, vomiting, great difficulty in swallowing and a feeling of extreme tightness, etc. Therapeutics.— Where there is a hard, quick, feverish pulse,thirst,anxiety, restlessness, painful cough, great dyspnoea, and pain and heat in the region of the diaphragm, I use gtt. 1 or 2 of aconite, every hour, until the pulse is slower or softer, and then half the quantity to keep down the inflammation. If there still be great pain, I give gtt. 1 or 2 of bryonia every one or two hours until the pain ceases. If the pain be of a rheumatic character, gtt. 1 to 2 of rhus tox., should be given every two or three hours, until the patient is relieved. If these remedies fail, 20 to 30 gtts. of asclepias tuberosa should be given every two hours; at the same time cloths rung out out of hot water may be regularly applied to keep up the capillary activity, and thus relieve internal congestion. CHAPTER XII. DISEASES OF THE DIGESTIVE ORGANS. Dyspepsia. T NDIGESTION is a common disease of the age. So common -*- is it, indeed, that almost the entire population is dyspeptic. The disorder includes every grade of severity, from a mild type to the extreme, torturing, soul-beclouding, life-embitter- ing disease that converts the bright sunshine of life into the dark shadows of the grave. It sits like an incubus upon the very soul of man. Indigestion may result from anatomical changes in the digestive organs, as inflammation, catarrh, thickening of the coats of the stomach, ulceration, eruption of the mucous tissue, cancer of the stomach, or softening, etc Again, it may be caused by a deficiency of gastric fluid, or of the chemical constituents of that fluid. It may also originate from a want of pancreatic fluid, or of biliary secretion. An abnormal condition, of the nervous system may give rise to it, or it may be the result of using stimulating drinks, or of improper food. The use of tobacco is a great factor in the production of this disease. Sedentary habits and excessive mental application may also combine to produce it. Symptoms.— The symptoms are so various that it is diffi- cult to enumerate them. I shall therefore only give such as are most prominent and common. In some cases there is a want of appetite and in others a morbid one, with a craving for sour articles of diet and drink. Palpitation of the heart accompanies the disease, especially in those cases character- ized by the accumulation of gas upon the stomach. Many cases are accompanied by great and rapid accumulation of acid upon the stomach; the patient having more or less rancid 167 168 THE PRACTICE OF MEDICINE. eructations, pyrosis or heart-burn, and water-brash every day, In some cases of long standing, the patient's digestion becomes so much impaired that nothing seems to digest, and he may have vomiting or diarrhoea in consequence. There is often tenderness over the pit of the stomach, which seems to the patient as if it were full, and sometimes very much swollen. The mind is depressed, incapacitating the subjects for mental or bodily work; they become morose and irritable, and are dis- turbed at night by dreams. The expression is relaxed, tired, weary, and sad, with dull sunken eyes, and lips generally pale. The flesh diminishes rapidly, the hands and feet are generally cold, and the whole body becomes very sensitive to cold changes. The teeth often decay from excess of acid in the blood, and the patient suffers often from toothache and neuralgia about the face and head. The bowels are either loose or constipated. Patients very frequently complain of pain over the region of the stomach and in the neighborhood of the liver, which some- times radiates to the left scapula. There is occasionally also roughness in the throat, causing the patient to hawk up a tough phlegm. If the liver is implicated, which is often the ease, there will be a hacking cough. The tongue is furred very frequently, red at the tip and edges, and there is a bad taste in the mouth. Treatment.—One of the first things to be done is to put the patient upon a proper diet. He should be confined to such articles of food as are best suited to his particular case. If he use tobacco he must be informed at once that it is violent poison and the most powerful relaxant in nature. It is the prime factor in the production of dyspepsia, and he should be advised to relinquish it at once, thus doing much towards curing the disease. He should also be prohibited from the use of large quantities of drinks. A glass of fresh sweet- milk is most suitable for the majority of patents. Some can use no other diet than bread and milk, while others can take a small quantity of fish, fowl, tender beef, mutton, or kid, DISEASES OF THE DIGESTIVE ORGANS. 169 without injury. Whatever the patient digests with the greatest ease should be partaken of in great moderation. As much of the cure depends upon the proper kind and quantity of food, as upon medicine, and without strict dieting no cure can be accomplished. Among the vast list of tonics I have tried, but few are available in this disease. In recent cases, or in acute dyspepsia, especially when it occurs in summer, and is caused by high living, or excessive use of acid fruits; and where, too, the tongue and mouth are inclined to dryness, and where there is yellowish coating on the tongue, accompa- nied by aphthae, bitter belching, great soreness of the epigas- trium, nausea, distension of the bowels, sensation of fullness in the stomach, water-brash, jaundice, congestive headache, obstinate constipation, and disgust for food, bryonia, in doses of gtt. 1 or 2, one hour before meals, will give appetite, tone up the stomach, and act on all the secretions concerned in the digestive process. In some cases where eating is followed by keen pain (which is generally due to ulcer of the stomach,) I give oxide of bismuth, in doses of gr. 3 to 5, one hour before meals; should this fail, I use gtt. 2 to 3 of the tinct. of arsenic in a wine glass of water, before meals. If the bowels are not reg- ulated by the use of bryonia, I give gtt. 3 to 5 of the tinc- ture of nux vomica, one hour before each meal. Where the mouth is dry and clammy in the morning, and there is heart- burn, berberis vulgaris is a valuable remedy, and has been frequently successful. In females that are feeble, and whose catamenia are irregular or deficient, where there is nausea, disgust of food, vertigo, slow digestion, constipation, flatulence and sleeplessness, aletris farinosa is a valuable remedy, in doses of gtt. 25 to 30 of the fluid extract every three or four hours. If the tongue is white, dry, streaked, narrow and pointed, and there is an aching, gnawing pain in the stomach, with a sense of constriction, aggravated by pressure, a desire for milk and hot food, colic and wind in the bowels, constipa- tion, morose disposition, and pain in the side, radiating to the 170 THE PRACTICE OF MEDICINE. left scapula, chelidonium, in gtt. 10 to 15 doses, three times a day, will soon restore the biliary secretion and relieve the above aymptoms. Should this fail the tincture of euonymus atro- purpureus, may be given in doses of gtt. 20 to 30, three times a day between meals. This drug acts finely upon the secre- tory organs. Cornus circ. is a valuable remedy when there is constant nausea, a bitter taste in the mouth and aversion to all kinds of common food; the dose is gtt. 30 to 40 of the tincture before meals. When dyspepsia is attended with prostration, nervous headache, flat taste, craving for certain articles of food, regurgitation and painful bloating after meals, small doses, say gtt. 1 to 2, of ignatia amara may be given before meals. Where there is great lassitude, exhaustion, obstinate constipation, dull headache, frequent desire to urinate, wind in the bowels, large, flabby, slimy tongue, sour eructations, dyspnoea, palpitation of the heart, pyrosis, stitches in the epi- gastrium, chronic mucus discharges and great weakness, gtt. 10 to 15 of hydrastic canadensis, before each meal, will aid digestion. If anaemia exists (as is often the case), with prostration and albuminuria or diabetes, helonias dioica, in doses gtt. 2 to 5, every three hours, is one of our best reme- dies. When there is nausea and vomiting pain in the umbil- ical region, yellow, watery, corrosive stools, and a burning sensation in the rectum, iris versicolor in gtt. 1 to 2 doses, three times a day, will bring relief. Should the patient have a sweet taste in the mouth, or an acid and putrid taste, with constant flow of saliva, excessive thirst, aversion to animal diet, sensation of emptiness in the stomach and drowsiness, muriatic acid in doses of gtt. 2 to 3 before meals, diluted with cold water, will do good service; I have used it frequently with happy results. In cases attended by nervous prostration from the loss of vital flu ids, phosphoric acid (pure acid phos- phate), in doses of gtt. 20 to 30, is always valuable. For ex- cessive acidity of the stomach, if the above acids do not give relief, robina in gtt. 5 doses, should be tried, as it lessens this DISEASES OF THE DIGESTIVE ORGANS. 171 tendency very much. Where there is a craving for acids, a changeable appetite, putrid taste, foul breath, dryness of the mouth and throat, white fur on the tongue, pyrosis, sour eructations, regurgitation of the food, vomiting, with canine hunger, constipation, headache, prolapsus of the rectum after stool, morning diarrhoea, and great depression of mind, tincture of podophyllum, in doses of gtt. 1 to 2. four times a day, will very materially aid in the cure. Tincture of the seed of lappa major is a remedy highly praised by some writers. Where there is a bitter, slimy taste, a feeling of tightness after meals, epigastric pain, want of appetite, bitter vomiting, flatulence; and when bread disagrees with the patient, where there is water-brash, hiccough, colic and pains in the bowels, gtt. 1 to 2 of tincture of pulsatilla, three times a day, generally gives immediate relief. The hypophosphites of lime, sodium, and magnesium in the form of compound syrup, have done me good service in several cases. Many cases of this disease are the results of an exhausted condition of the nerve centres, and continued use of the phosphites is required to restore proper nervous tonicity. When the gastric, pancreatic and salivary fluids are deficient, I have found lactopeptine of essen- tial service, when given just after meals. Various tonics have been known to effect a cure, but the above mentioned drugs have proved most successful in my hands. Acute Gastritis. Catarrh of the stomach, in the acute form, is similar, in a pathological point of view, to catarrhal inflammation any other mucous tissue. There is swelling, redness, and often a tough transparent, or grayish white slime over the mem- brnne after death: the mucous membrane is so softened as to b.- **siry scraped off like a mushy covering of the tissues. Causes.__Cold or wetting may cause this inflammation, or very cold or very hot food and drinks may produce the same results; so too, with alcoholic drinks, ice cream and ice water. 172 THE PRACTICE OF MEDICINE. Symptoms.—In the outset there may be a chill, accom- panied by paleness of the face and cold extremities. Later, the chillness alternates with flushes of heat, and the face becomes red and hot with high febrile reaction. The patient then complains of soreness, fullness, and a burning pain in the stomach. The appetite is suspended, but the patient is apt to crave water, and, if this be indulged in, will vomit. Thera is constantly a belching up of gas, although the stomach still feels full. If the bowels are implicated, the stools become foetid and mushy. Treatment.—Where there is great thirst and pain in the stomach, with burning nausea and vomiting, gtt. 25 of aconite in f 4 of water, in doses of a teaspoonful, may be alternated with drop doses of tincture of arnica every two hours. Sub- nitrate of bismuth is a good remedy in doses of 5 grs. If, however, the tongue is dry, without thirst, and there is constipation, gtt. 10 or 15 of bryonia should be added to 1 4 of water, and given to the patient in doses of a teaspoonful every two hours. If constant sour and rancid belching exists, with a bloated condition of the stomach and bowels, vegetable charcoal in small doses, every hour, acts admirably. When there is a bitter taste in the mouth, vomiting of green bile, constant rumbling in the bowels, nervousness, sleeplessness, with an impatient, fretful frame of mind, chamomilla (gtt. 8 or 10 of the infusion in a glass of water), taken in doses of a teaspoonful every two hours, will generally easily correct these symptoms. If the disease is caused by eating sour, unripe fruit, and attended with constant vomiting, followed by diarrhoea, then small doses of ipecac should be given, say gtt. 1 to 2 every hour or oftener, in urgent cases. If the disease be attendant upon the use of alcoholic stimulants, I have found nux vomica one of the best remedies, the dose not ex- ceeding gtt. 2 or 3, every two or three hours. I use the saturated tincture of this as well as of most other remedies. diseases of the digestive organs. 173 Chronic Gastritis. A chronic form of inflammation of the stomach often follows badly managed attacks of the acute form of the disease, but it is also produced sometimes by the abuse of spirituous liquors, excessive use of coffee, tea and tobacco. It often follows glut- tony and sedentary habits ; or it may be secondarily produced by gout, anaemia, chlorosis, Bright's disease, marasmus, tuber- culosis, cancer, and haemorrhoids. Especially is this the case in impressionable constitutions, and in young persons. Symptoms.—One very common symptom is belching of an acid character after eating, attended with heart-burn. Another quite common symptom is a full feeling in the stomach, with actual distention of the organ. The appetite is frequently very poor, and the tongue coated red at the tip and edges, with constant pain in the stomach, which is worse after meals. The mind is gloomy, morose, irritable and hopeless, and the skin dry, hard and pale. The patient becomes emaciated and very feeble, and often has palpitation of the heart with great dysp- noea. The disease generally progresses slowly, and most commonly terminates in softening of the stomach, which may end in death. It may, on the other hand,' end in ulceration of the mucous coat, which finally proves fatal if not met by timely treatment. Treatment.—In the treatment or chronic gastritis I have found the subnitrate of bismuth to have an almost specific effect when given in doses of gr. 5 of the powder, or I use liquid bismuth in doses of gtt. 30 to 60 every three hours. After failure with the bismuth, in occasional cases, I have found the tincture of arsenic, in doses of gtt. 1 to 2, three or four times a day, effective in relieving the pain. If there be constant sour stomach, I have found nux vomica, alternated with robina, gtt. 5 each, to give relief. In some cases, I have been successful with gtt. 5 to 10 of tincture of capsicum, repeated three or four times a day. Should the patient have 174 THE PRACTICE OF MEDICINE. much mucus in his mouth and stomach, pulsatilla, in doses of gtt. 4 to 5, before meals, has generally done well. If there is nausea and vomiting of bile, gtt. 1 to 2 each of ipecac and chamomilla, every three hours, will afford relief. Hydrastis canadensis, gtt. 5 of the tincture, every four hours, has answered well in many cases that I have treated. Nausea, headache, painful burning in the stomach, intense thirst, red tongue, and dryness of lips, should be treated with gtt. 1 to 2 of tincture of sanguinaria. The dose may be repeated every two hours, until it relieves. In some cases in which there is great tendency to sour belching, podophyllum, in doses of gtt. ^ to 1, has acted well. I use the saturated tincture of the fresh root. Strict dieting is neccessary. Gastralgia. Gastralgia is a paroxysmal and painful affection of the stomach, without structural change of tissue. It is sometimes associated with anaemia, chlorosis, tuberculosis or great loss of vital fluids, and may occur with chronic inflammation of the or- gan. It has also been known to attend cancer and ulcer of the stomach. It may attend irregular menstruation in women, and often occurs from chilling the stomach by drinking ice water or eating ice cream while the body is heated ; lemonade or acid fruits, hot cakes, and other articles of food difficult of digestion, may also produce it. It is generally sudden in its attack, the pain being pressing, drawing, burning, boring, gnawing, and cramplike, and sometimes so intense that the patient faints ; his face appears collapsed, his hands and feet are cold, and his pulse threadlike and small. The pain may extend to the larynx, causing choking, or to the bowels, caus- ing colic. The attack may end in belching of wind, vomiting of sour fluid, or in diarrhoea. Occasionally the stomach is greatly distended with gas, and the belching up of the gas is followed by relief from pain. Some persons are very prone DISEASES OF THE DIGESTIVE ORGANS. 175 to attacks of this kind and will have it whenever they use acids, cabbages, cucumbers, or other watery vegetables, or pickles. Treatment.—To relieve the attack, I have found the ethereal tincture of asafcetida, one of the most prompt remedies. Sometimes I give the tincture of dioscorea, in doses of gtt. 15 to 30, every fifteen minutes, alternated with gtt, 30 to 60 of the essence of peppermint. If there be indigestible food or acids in the stomach, an emetic of lobelia, or lobelia and ipecac, should be given at once, and if the cramp does not cease, any of the above remedies will do. To ward off attacks, the patient should avoid acids, acid fruits, watery vegetables, ice water, and large quantities of very cold water ; and, in addition, he should take small doses of the tincture of nux vomica before each meal for some time, to tone up the digestive apparatus. If the liver is inactive, he should take small doses of euonymin, celandine, or podophyllin, once or twice in the day, until the organ is restored to a normal state. The excessive use of tobacco often leads to this affection. In case it has been pro- duced by the use of tobacco, ignatia amara is one of the best remedies we have ; it may be given in doses of gtt. 3 to 4, an hour before each meal. If the pain is cutting, and extends to the bowels, I have found gtt. 2 or 3, of the tincture of colocynth, to check it readily. The patient should be careful in his diet. Perforating Ulcer of the Stomach. The pyloric portion of the stomach is the most common seat of this form of ulcer. It may appear also in the duode- num. There may be one ulcer, or there may be two or three. Sometimes they are small, again they are large. In shape, they are generally round or oval. They are small on the out- side, and large on the inside, and rather funnel-shaped where they perforate the stomach. As soon as the ulceration reaches the serous membrane of the stomach, it gives rise to perito- neal inflammation and fibrinous exudation, which may cause 176 THE PRACTICE OF MEDICINE. adhesions to the pancreas, liver, omentum, and even to the colon. Violent haemorrhage occurs in some cases from ulcera- tion of exposed vessels. It is possible to cure this form of ulceration of the stomach, in all of its stages; when it heals, granulations are formed, and a flat, radiating cicatrix is left instead of the ulcer. This process may contract the pylorus, so that the exit of food into the intestines is much impeded. Virchow believes that the ulcer has its origin in obstructions of arterial vessels, in consequence of which the mucous mem- brane is deprived of its wonted nutriment, and dies off, becom- ing deeper and deeper. Symptoms.—Gastralgia, or pain like gastralgia in the pit of the stomach, coming on in paroxysms, after meals, and some- times ceasing after the vomiting of a slimy, tough, clear, taste- less or sour fluid, is the early indication of this form of ulcer. The face assumes a pale or yellowish color in a short time, and patient falls away in flesh more rapidly and becomes more morose and sad, than in nervous gastralgia. Vomiting some- times occurs, and again may not occur very often. This ulcer always interferes with the process of digestion. The appetite may be impaired, or it may be good for a time, but eating gen- erally causes pain, and digestion is always very slow. Milk and the tender parts of meat are the most easily digestible substances. The patient is very subject to pyrosis, nausea, and water-brash, and the bowels are generally constipated. When perforation takes place, there will be peritonitis imme- diately. The patient experiences a sharp, cutting pain in the stomach and bowels, which is followed by a chill and violent vomiting. His features become distorted, pale, collapsed, and expressive of extreme suffering and despondency. The abdo- men soon becomes greatly distended and very painful, so that the respiration is superficial and short. Singultus and violent action of the heart set in, the pulse becomes small and skin cold, and this condition is followed by fainting spells and great prostration. DISEASES OF THE DIGESTIVE ORGANS 177 Diagnosis.—This condition may be readily confounded with chronic catarrh of the stomach, but can be distinguished from it by the red, clean tongue, and the more frequent vom- iting that occurs in ulcer. It is liable also to be mistaken for nervous cardialgia; but the rapid loss of flesh, the pale yellow- ish face, and the vomiting between the spells of pain, serve to distinguish between the two diseases. Ulcer of the stomach and cancer of the stomach are often confused, but differ in the ulcers coming on earlier in life than cancer. Moreover, cancer causes more rapid loss of flesh, and is known by its hard swell- ing in the pit of the stomach, which never takes place in ulcer of the stomach until it heals up. Treatment.—Very small doses of the tincture of arsenic, well diluted with water, is the most trustworthy remedy, and may be alternated with conium to relieve the pain. Atropine may be occasionally given instead of conium. After giving Fowler's solution for a few weeks, if no improvement appear, small doses of the bichromate of potassium should be tried. The diet must be fluid. Cancer of the Stomach. This disease may be divided into three forms, viz: (1) scirrhus, which is a fibrous growth, and generally originates in the sub-mucous cellular membrane; (2) carcinoma medullaris, which is a marrow-like growth, sponge-like in its development; and (3) carcinoma alveolaris, which is a soft growth, resem- bling jelly, forming upon the sub-mucous cellular tissue, but often penetrating to the peritonium. These three kinds of cancer may exist in the same case. They affect the pylorus oftener than other parts, and if the disease exist long adhe- sions to other organs are apt to form, especially with the pan- creas, liver, kidneys, and sometimes the colon The stomach becomes greatly enlarged, especially where the pylorus is strictured There is chronic inflammation of the mucous membrane near the seat of the cancerous growth, and decom- 178 THE PRACTICE OF MEDICINE. position of tissue often causes violent haemorrnage of the stomach. The cause of the disease is not known. Symptoms.—The symptoms are very similar to those of ulcer of the stomach. The pain is more violent and radiating, however, than in ulcer; the skin is ashen colored, and cancer comes on in old age, generally after forty years of age. Treatment.—The treatment can only mitigate the symp- toms. When there are violent pains in the stomach, subni- trate of bismuth will relieve them as quickly as any other remedy, and may be given in gr. 2 to 4 doses. If the pain, however, be of a burning character, no remedy is so positive in its effects as the tincture of arsenic in doses of gtt. 2 to 3 every three hours. Hydrastis canadensis is a very valuable remedy, and may be given in the form of powder gr. 1 to 5, or a fluid extract gtt. 5 to 10, three times a day. I have seen this drug influence the disease in a very prompt manner, and as it is a direct tonic to the digestive powers, it should always constitute a part of the therapeutics of this hitherto intractable disease. The American Indians, says Rafinesque, used this remedy in the treatment of cancer before it was known to the white race, and the testimony of some physicians is that there is no remedy that changes the condition of the patient so quickly as hydrastis. It acts upon the dyscrasia at once, causing rapid improvement. As it is harmless, it should be continued until health is restored, or as long as there is any hope of its doing good. H.EMATEMESIS. Haemorrhage of the stomach consists of an extravasation from either the arteries, veins, or capillaries of the organ. Causes.—There are two causes, viz.: an increased and abnormal tendency of blood toward the vessels of the stomach, as in cases of congestion or catarrhal inflammation of the mucous membrane of the stomach, Diseases of the vena portae and liver, and those that interfere with free circulation, DISEASES OF THE DIGESTIVE ORGANS. 179 constriction of the vena cava, in heart and lung diseases, and diseases causing a greater pressure of the blood in the mucous membrane of the stomach all come under the first head. The haemorrhage may be capillary only, or it may be profuse, provided the pressure is great enough to rupture the larger blood vessels. Such conditions follow suppression of menstruation in females, and the development of haemorrhoidal tumors. The second cause consists in impairment of the texture of the coats of the vessels, either from chemical or mechanical influences. Among such are alkaline or cor- roding chemicals, pointed mechanical substances within the stomach, violent straining in vomiting, or the effects of a contused wound from a fall or knock upon the pit of the stomach. Certain pathological conditions may give rise to this form of haemorrhage, as varicosis and aneurism of the arteries. Scurvy, yellow fever, and some acute exanthematic fevers produce it; as also do ulceration of the stomach, cancer and haemorrhagic erosions. Pathological Conditions.—The mucous membranes are found injected, or pale and anaemic, and sometimes the mucous membrane is softened and easily detached. After profuse haemorrhages, clots of blood will be seen, but where these haem- orrhages are slow, the blood is generally altered by the gastric juice into a mass like coffee-grounds, as in yellow fever. Symptoms.—Where the blood flows freely enough to pro- duce vomiting, there is no difficulty in the diagnosis, but where it does not produce this result, there will be a sense of warmth and fullness felt in the stomach, with paleness, small pulse, cold extremities, great depression, anxiety, ringing in the ears, flickering before the eyes, fainting and dizziness. Sometimes there is no blood thrown up, in which cass it passes from the bowels, giving the faeces the appearance of tar. It may be distinguished from haemorrhage of the lungs in vari- ous ways. In the latter disease there is generally cough, and the blood is coughed up. Haemoptysis, too, is preceded by lung 180 THE PRACTICE OF MEDICINE. or heart disease, and is always attended by cough. Haemate- mesis, most commonly, is preceded by disease of the stomach, and attended by nausea and vomiting. The blood coughed or spit up in haemorrhage of the lungs is bright and frothy, while that from the stomach is dark and often rather decom- posed. In haemorrhage of the bowels, the blood is generally in masses unmixed with the faeces, but when ejected from the stomach, it is always mixed with them, when it passes into the bowels. Treatment.—In many cases that I have had, I have been successful in arresting the haemorrhage with small doses of Monsel 's salts, in gr. 5 doses, dissolved in a wine glass full of water, and given every half hour, or according to the severity of the disease. If this drug is not at hand, the tincture of the oil of erigeron in doses of gtt. 20 to 30, every fifteen minutes, in water will produce a favorable result. If this cannot be pro- cured, use tincture of hamamelis in gtt. 5 to 10 doses, every two or three hours, and if this is not effective, alternate with ipecac, in doses of gtt. 1 to 2 in water, or, gr. 4 or 5, of vege- table charcoal, every half hour in water. Ergot is recom- mended, but is not as certain as the iron or erigeron. Lycopus often does well; dose ■£ 3 to 1 3. Gastromalacia. In this disease, the coats of the stomach are found, upon post-mortem examination, to be changed into a mass which is easily detached with a scalpel. There are no signs of in- flammatory, catarrhal or ulcerative processes in the mucous membrane of the stomach, and the softened portion seems to pass off gradually into the healthy tissue, without any sharply defined border. Symptoms.—One of the most noted symptoms is constant vomiting, and later in the disease there is diarrhoea. I at- tended a man at Hamilton, Ga., who had been troubled with symptoms of gastromalacia for some time, and finally was DISEASES of the digestive organs. 181 taken with vomiting and haemorrhage of the stomach. He vomited up large sheets of mucous membrane, which were very much thickened and easily broken up into a mushy sub- stance. He died in a few hours from very free haemorrhage of the stomach. Treatment.—Nothing can be expected from treatment but a temporary suspension of fatal results. With this in view, give small doses of creasote, say gtt. 1 to 2, in a half glass of water, to be sipped occasionally by the patient. If the creasote does not relieve the haemorrhage, gtt. 1 to 5, of tinc- ture of hamamelis, may be given every ten or fifteen minutes, or Monsel 's salt in doses of gr. 5, every hour. Lycopus virg. in doses of 30 to 60 drops of the fluid extract, or saturated tincture, will stay the haemorrhage sometimes. CHAPTER XIII. DISEASES OF THE INTESTINAL CANAL. Intestinal Catarrh. THE acute form of this disease presents the same appear- ance as is generally seen in catarrhal inflammation of the mucous membrane. These are injection, swelling and in- filtration of the sub-mucous tissue of the intestines. Causes.—It may be produced by overloading the stomach, excessive use of drastic purgatives, patent pills, taking cold, and by mental emotions. In some cases it accompanies cancer, tuberculosis, typhus fever, puerperal fever, pneumonia, denti- tion in children, and extensive burns. Symptoms.—A catarrhal inflammation of the small intes- tines is generally associated with catarrh of the stomach, and is known by obstruction of the gall-ducts, with jaundice as its result. Catarrhal inflammation of the colon generally involves the rectum, and then it is known by the spasmodic pains it produces in the sphincter ani and intestines, and the burning sensation at the anus. In all cases diarrhoea is a prominent symptom, unless the upper portion of the small intestines alone is diseased, in which case constipation will prevail. The stools may be watery, acrid, slimy, containing undigested food and even bloody mucus. The frequency of the stools varies in proportion to the amount of inflammation. In severe cases there are fever and headache, and evacuations are preceded by sharp cutting pains in the abdomen. Treatment.—Where there are frequent scanty and loose stools with tenesmus, aconite and gelseminum are the remedies for the early stage. I usually order aconite gtt. 30, gelse- minum 3 lij, aqua pura 1 2-|; dose, gtt. 30 to 50 according to 182 DISEASES of the intestinal canal. 183 the urgency of the symptoms. If the disease occur in the summer, from the sudden changes, or after free indulgence in acid fruits, the tincture of bryonia in gtt. 1 to 2 doses may be given every two hours. If the disease follow chilling of the stomach with ice water or ice cream, and there is great pros- tration and thirst, administer gtt. 1 to 2 of tincture of arsenic every four hours. If it occur in little children, and is attended by painful diarrhoea, bloated, hard abdomen, watery discharges and green, slimy or undigested discharges, then chamomilla will give the best results. This must not be given in larger doses than gtt. 5 to 10, in half glass of water; and a teaspoon- ful given every hour or two is sufficient. If the stools are dark or yellow, with griping and tenesmus, nervous excitability and dullness, followed by flushes of heat and sweat, use cornus circinatus, in doses of gtt. 5 to 10 of the tincture every two hours until relief is obtained. If the disease occur in children during dentition, and is accompanied with diarrhoea and vomit- ing, or spasms, gtt. 2 of ipecac, in 3 4 of water, should be given by the teaspoonful every fifteen minutes until relief is afforded. If there are painful greenish discharges, and burning in rec- tum, the tincture of iris versicolor, in doses of gtt. 1 to 2, every two hours, will correct that condition. If the diarrhoea changes constantly in color, at first green, then yellow and slimy, and now whitish, small doses of the tincture of podophyllum, say gtt. 1 every two hours, will often give relief. The dose must be small. If the catarrh occur during dentition, and is char- acterized by a peculiar sour smell of the child and its dis- charges, and if these discharges are fermented, green, brown, and attended with great pain, rhubarb, in the form of com- pound powder, or syrup, or the simple tincture, in small doses will frequently cut short the disease. If the disease be attended by cramps in the stomach and bowels, or with flatulence, then dioscorea, in doses of gtt. 10, alternated with gtt. 2 or 3 of colocynth will act well. 184 the practice of medicine. Chronic Intestinal Catarrh. In this affection the mucous coat of the intestines appears of a brownish-red, livid gray, or slate color, and is also some- what swollen and thickened. Its follicles are hypertrophied, and its surface is covered with a jelly-like slime of various colors. In some cases all the coats of the bowels are hyper- trophied, and small excrescences bestud the outer coat. The mucous membrane sometimes appears pale and anaemic, and there is infiltration of the submucous cellular tissue. This may appear only on the small intestines, or it may be diffused over the entire track. Causes.—The chronic form of intestinal catarrh may be the result of repeated attacks of the acute form, or may origi- nate from cancer, tuberculosis, typhus fever, cirrhosis of the liver, organic diseases of the heart and lungs, or obstruction to the portal circulation. Symptoms.—Diarrhoea and constipation alternate. The stools are thin and of various colors, mixed generally with slimy mucus, which is tough and jelly-like. There may also distention of the bowels, from gas accumulated in them. The mind is gloomy, hypochondriacal, and irritable, and emaciation gradually supervenes. The most frequent location of the disease is in the small intestines, in which case the patient complains of pain in the umbilical region, and there is most commonly constipation of the bowels. Treatment.—If the disease be attended with burning pain, and the discharges are very offensive, thin and lumpy, and excoriate the anus; and if there be great thirst, restlessness, exhaustion and emaciation, with crossness and despondency on the part of the patient, then tincture of arsenic in doses gtt. 1 to 2 every three hours, will aid other proper remedies. Where the stools are dark and offensive, and mixed with some blood, and there_is nausea, colic, tenesmus, pain in the hepatic region, and a typhoid tendency, baptisia in doses of gtt. 1 to 5 every diseases of the intestinal canal. 185 three hours, will allay the symptoms. If the pain in the bowels be cutting, with loose discharges of a dark brown or black color, and great prostration, I find gtt. 5 of tincture of camphor every hour or two very useful. Where there is con^ stant distention of the bowels with gas, a few drops of tincture of dioscorea villosa will do away with this trouble, I usually give gtt. 20 to 30 in mint water, or essence of mint and water. If the stools are green, and there is nausea and vomiting, ipecac, in doses of gtt. 1 to 2 of the tincture of the fresh root, will be an appropriate remedy. If severe griping and colic exist, with muco-gelatinous stools, and here and there shreds of yellow or green muscus, or if there are pro- fuse, frequent stools, gushing out suddenly, gtt. 5 of tincture of podophyllum in 3 4 of water, giving one teaspoonful every three hours, is the best remedy. Typhlitis and Peri-typhlitis. The symptoms of the above inflammatory affections are so very nearly alike, that a diagnosis between them is almost impossible. Typhlitis, or inflammation of the mucous mem- brane of the caecum, either in consequence of hardened faecal accumulations, cold or hard substances, as cherry or plum- stones, may spread over the ascending colon, and to the vermi- form appendix, and invading the muscular coat of the bowel, cause ulceration and perforation, and end in peritonitis, and finally death. Peri-typhlitis is an inflammation of the loose areolar tissue around the caecum, caused by typhlitis, or begin- ning separately. It is likely, if not checked, to end in abscesses in the right iliac fossa. These abscesses may break through the parietes of the abdomen, near Poupart's ligament, or they may discharge themselves into neighboring viscera, and, should they find no outlet, end in peritonitis and death. Inflammation of the appendix vermiformis may be caused by hardened faeces or by foreign bodies lodging there. The latter being the case, it may cause the obliteration of the pro- 186 THE PRACTICE OF MEDICINE. cess; or if its opening is closed, a slimy, serous fluid may block up its walls, and form what is called dropsy of the appendix. It may also terminate, if not opened in time, in abscesses, and, finally, in peritonitis and death. Symptoms.—External swelling in the right or ilio-inguinal region of the abdomen, is one of the first noted symptoms in these forms of intestinal inflammation. The swelling is immovable, smooth, and of various degrees of consistency. The pain usually commences suddenly, and is sharp, lancinat- ing, and increased by any motion of the body. The swelling is sensitive to the touch, and generally confined to the right iliac fossa, or else may extend to a larger surface, as the inflammation does. .Constipation generally accompanies this affection of the bowels, but may alternate with a slimy kind of diarrhoea. Vomiting is liable to occur at any stage of the typhlitis, and the upper bowels and stomach are filled with gas, giving rise to quite a troublesome hiccough. Pain is frequently felt in the testicles, accompanied by contraction of the cords, difficulty in urinating, and numbness of the right leg from pressure upon its nerve. This pressure may in turn produce oedema of the right leg, in consequence of pressure upon the crural and iliac veins. There may be considerable fever at this stage of the disease, and the whole system may evince signs of sympathetic participation in the morbid condi- tion of the intestines. Hectic fever may finally set in, and the patient become exhausted and succumb. Differential Diagnosis.—This disease is liable to be confounded with abscesses of the psoas muscle, were it not that in this affection of the psoas muscle the swelling lies deeper, nearer Poupart's ligament, and more towards the mid- dle line of the abdomen. The right leg is kept in a bent posi- tion, motion is impossible, and the action of the bowels is not disturbed. Abscesses of the psoas muscle are associated with caries of the vertebrae or the bones of the pelvis, and when pus is discharged through the abdominal walls it has no odor of DISEASES OF THE INTESTINAL CANAL. 187 faecal matter. It may be distinguished from intussusception or invagination of the intestines by the absence of diarrhoea in psoas abscess; whereas, in intussusception diarrhoea precedes that disease, but after the invagination has taken place there will only be bloody and slimy discharges. In intussusception there is generally stercoraceous vomiting, hiccough, etc. Treatment.—If there is great pain in the ilio-caecal region, nausea and vomiting, and high fever, small doses of bella- donna, alternated with aconite, should commence the treat- ment. If, in the prognosis of the disease, a hard, painful swelling should appear in the right side of the abdomen, which compels the patient to lie on his back, with his knees drawn up, I give small doses, say gtt. ^ to 1 of rhus toxico- dendron every two hours. After the abscess forms, silicea is required in doses of gr. 1 to 2 of the first dec. trituration three times a day. Proctitis. This form of disease of the rectum occurs in the acute and chronic form. In its pathological peculiarities it resembles other catarrhal inflammations of mucous membrane, exhibiting swelling, injection of vessels, and thickening of tissue, which may result in large excrescences. Proctitis may be produced by abuse of purgative medicines, strongly-medicated injec- tions, and by worms and hard faecal matter lodging in the folds of this part of the large intestinal tract. It may be asso- ciated with syphilitic, cancerous or tubercular ulceration. It may arise from disorders causing an obstruction in the abdom- inal veins, as diseases of the liver, vena portae, heart, lungs, or even from haemorrhoids when these are improperly treated. Symptoms.—The affection is characterized by pain of a tearing, throbbing, stinging character which grows worse at stool; and by tenesmus, tormina, and, in severe cases, reten- tion of the urine, painful urination, dripping of the urine, drawing up of the spermatic cords, and in females white 188 THE PRACTICE OF MEDICINE. swelling. The upper bowels are generally constipated, and if any faecal discharges pass, they are covered with mucus, tinged with blood. The tenesmus and tormina often cause prolapsus ani. The chronic form is not attended with fever, but with frequent slimy discharges. Treatment.—In acute proctitis, if the fever is high, I use tincture of aconite, gtt. 30, aqua 3 4; dose, a teaspoonful every hour or every two hours, according to the urgency of the symptoms. I alternate with gelseminum, 3 ^, aqua § \, in doses of a teaspoonful every three or four hours. When I have moderated the febrile or inflammatory symptoms writh the above remedies, I give every hour a teaspoonful of ipecac. (tincture of the fresh root), 3 1; aqua 3" 4; and alternate with tincture of podophyllum, 3 1, aqua 3 4, in doses of a teas- spoonful every three hours. These remedies, in moderate doses, have direct affinity for the mucous membrane, and lessen congestion by controlling the capillary circulation of that tissue; but, in large doses, they produce their toxic effect, and do more harm than good. In many cases that I have treated, I have found it best to keep the upper bowels open with the very mildest cathartics, such as Rochelle salts, in doses of 3 1 to 2, cream of tartar, or Epsom salts, in small doses. The disease is often confounded with dysentery, the difference being that the latter occurs epidemically, while proctitis appears sporad- ically at any season of the year, and generally receives the title of "sporadic dysentery." It is a much milder rectal disease than epidemic dysentery, and is seldom fatal. Dysentery. This is an inflammation of the mucous membrane of the large intestines, and usually commences at the valve of the caecum, and spreads rapidly over the colon and rectum. Its greatest intensity is in the bends of the affected bowels. The mucous membrane is reddened and swollen, and the epithelium peels off, and is sometimes raised into blebs by exudation. In DISEASES OF THE INTESTINAL CANAL. 189 the advanced stages of the disease, the mucous tissue becomes covered, in patches, with a yellowish gray or red substance, which finally assumes a brownish or greenish color. If it is scraped off with the scalpel, the mucous membrane beneath is seen reddened and softened; and there are serous infiltra- tions in the cellular structure, giving the surface an uneven appearance. The solitary follicles are also found ulcerated and swollen. In extreme cases, the mucous coat has been found much decayed or changed into a dark, soft mass, which is sometimes finally thrown off and discharged. If the patient lives, ulcers will appear in the colon, which are liable, finally, to perforate the bowels. Besides these changes in the intes- tines, there is always more or less peritonitis, enlargement of the mesenteric glands, and enlarged and inflamed liver. Dys- entery generally prevails epidemically, and is doubtless pro- duced by a peculiar miasmatic poison in the atmosphere. It often attacks camps, hospitals, and crowded cities. It is most prevalent in Summer and Autumn, especially when the days are very hot and the nights very cool, and spares neither age nor sex. It is believed to be contagious to some extent, par- ticularly where care is not taken in houses to keep up free ventilation. Symptoms.—This disease often commences with free, loose stools, of a rather diarrhoeal character, but which soon change into the characteristic dysenteric stools. At the outset there is apt to be more or less jelly-like slime in the stools, which is often dotted or streaked with blood. This jelly-like mate- rial increases, and is charged with much tormina and tenesmus. As these mucus and bloody discharges increase in quantity and frequency, the faecal discharges diminish, and finally altogether cease. The mucus discharges frequently assume a dirty, reddish, or gray color, like the scrapings of flesh, and are seen swimming in a thin bloody serous fluid. The quan- tity of blood varies from a mere tinge to pure fluid. Where whole shreds or pieces of tough mucus slough off from the 190 THE PRACTICE OF MEDICINE. bowels, and where the discharges assume a brownish choc- olate-like color, and have a cadaverous odor, it indicates an ichorous ulceration of the mucous membrane of the bowels. When faecal matter reappears in the stools, the inflammation gradually declines, although there may still be tenesmus and tormina, and more or less mucus in the discharges for several days. If the proper treatment is carried out, the patient will soon regain his health. In severe cases, the fever may run very high in young and vigorous subjects, and the patient may at first suffer with nausea and vomiting. Prognosis.—Copious haemorrhages and ichorous, choco- late-colored and cadaverous-smelling stools, are indications of a fatal termination. Extreme prostration, frequency and smallness of pulse, cold skin, cold, clammy perspiration, livid face, collapsed abdomen, paralysis of the sphincter ani, in- voluntary discharges, peritonitis, perforation of the bowels, shaking chills, delirium and convulsions, all indicate approach- ing dissolution, as does also paralysis. Treatment.—In the most active form, in which there is high fever, a dry skin, and frequent, painful, and bloody stools I have found gtt. 1 to 2, of tincture of aconite, with gtt. 15 to 30, ofJgelseminum, useful, given every hour until the effects of the aconite are felt upon the frequency of the pulse, and the effects of the gelseminum are seen upon the muscles of the eyes. After this give them at longer intervals. If, however, the disease has progressed far, and the symptoms are grave, I use antiseptic treatment. If there are violent colic-like pains before and after stool, great tenesmus, and discharges of offensive or pure blood, containing very little mucus, I give gtt. 3 to 5, of baptisia every two hours, until the stools cease to have a disagreeable smell. If large quantities of blood are passed, then hamamelis, in doses of gtt. 1 to 5, should be given every hour until the haemorrhage stops. If nausea and vomiting set in, with bloody stools and much tenesmus, small doses of ipecac, alternated with the tincture of podophyllum, DISEASES OF THE INTESTINAL CANAL. 191 in doses of gtt. 1 to 2, each, will frequently put a check to the disease. If the upper bowels are bound up, then a mild aper- ient, as cream of tartar, Rochelle salts, or a small dose of Epsom salts, should be given every day to keep up the action of the upper bowels. This always aids in the cure. The sul- phate of sodium in small doses, gr. 2, every two hours is valuable in this disease. In many cases in which there are frequent, bloody, and watery stools, violent tenesmus, and much flatus escaping with the stools, gtt. 1, of the tincture of aloes will be likely to do great good. This medicine has direct affinity for the colon and rectum, and its effects are produced, like all other remedies, in doses too small to give a toxic effect. The toxic effect is to gripe and purge, while its medicinal effect is to soothe and quiet the excited mucous membrane; whence its good effects in dysentery. Very small doses of colocynth have the same effect when there are griping and twisting pains in the bowels. I have had under my care, for the last thirty-eight years, a great many cases of this disease, and have tried all forms of treatment, from drugging with calomel, opium, and castor-oil to the milder treatment with cream of tartar and opium, but they have all signally failed This season I have generally aborted the disease (in all cases that I saw in time) with aconite and gelseminum. If I do not see the patient in time to do this, I resort to small doses of baptisia, alternated with the tincture of the green root of podophyllum. I seldom give opium now, as the gelseminum relieves the tenesmus and the tormina; if not I give McMunn's elixir. Cholera. This disease produces serous, tough exudations upon the linning of the intestines. The small intestines are found flabby; their serous lining, in consequence of hyperaemia, appears pinkish; their mucous tissue is injected; and the solitary glands, and generally Peyer's too, are enlarged, and filled with serum or a solid exudation. 192 THE PRACTICE OF MEDICINE. The characteristic rice-water fluid fills the small intestines, or their walls are lined with a paste-like substance. The coats of these intestines are swollen and cedematous. The villi have lost their epithelium, and consequently the surface of the mucous tissue appears raw and skinned. The colon and rec- tum do not, generally, present any unusual appearances. The characteristic rice-water discharges, take place in this way: the villi being denuded of their covering, give rise to a copious transudation of serum into the small intestine, which discharge may be passed up or down. By the loss of the epithelium, these villi are unable to absorb the fluid the patient takes as drink, and so he or she rapidly loses fluids in all the tissues of the body. This accounts for the thickness and dark color of the blood, and also for the cessation of secretions, as sweat, tears, saliva, urine and bile. The blood thus constantly loses its serum, and in consequence thereof the capillaries become impaired. As this takes place in the muscular structure of the heart it causes a paresis of that organ, which is followed by feebleness of the heart's sounds and impulses, cyanosis, and blueness of the skin and tongue, so characteristic of this disease. The respiration is also so impaired, that the blood is imperfectly oxygenated, and causes the great prostration so noticeable in this dangerous disease. Spasms, or tonic cramps, are pains doubtless originating from central irritation, which is the result of the loss of fluids of the blood, which contract the muscles in round hard knobs, and render cholera so pain- ful. This is the picture of Asiatic cholera pathologically. Causes.—This affection is caused by some very deadly emanation, the nature of which has never been defined. It first appeared in Asia, and hence is yet called Asiatic Cholera. It is generally very fatal if not checked, or, if it does not prove so, in a short time the disease changes into some kind of typhoid inflammatory condition, such as pneu- monitis, pleuritis, bronchitis, parotitis, splenitis, or diphtheritic DISEASES OF THE INTESTINAL CANAL. 193 exudation in the intestines, pharynx, or bladder, which is apt at last to carry off the patient. Treatment.—In the premonitory stage, where there is nausea, diarrhoea, sweat, or pain in the hypogastrium, conges- tion of the mucous membranes, cold limbs, blue nails, and tendency to collapse, gtt. 1 of aconite, alternated with gtt. 5 of the saturated tincture of camphor should be given every hour, or gtt. ^ of aconite and gtt. 5 of camphor every half hour where the symptoms are grave. If this fail to produce a favorable change in three or four hours, and there is great prostration, intense thirst, incessant vomiting and purging, a cold clammy sweat covering the skin, burning pain in the bowels, frequent scanty discharges, containing dark or yellow- ish water, small, feeble, tremulous pulse, and tonic spasms of the extremities, the best remedy is from gtt. 3 to 5 of tincture of arsenic, every two hours, or gtt. 1 to 2 every half hour, in alternation with the tincture of camphor. When spasms seize upon the whole muscular system, including even the whole diaphragm, and muscles of the heart, and there is very severe colic, with constant nausea and vomiting, collapse, blue ■ ness of the skin, delirium, and deathly prostration, I give small doses of sulphate of copper in alternation with veratrum album, say gr. 1-20 of copper, and gtt. \ or \ of tincture of veratrum. The veratrum album is a splendid remedy in this stage, if given in small doses. Some German writers, as Rademacher, use acetate of cop- per, while other writers recommend the ammoniated sulphate of copper, especially where there is excessive thirst, vomiting of large quantities of fluid, and violent cramps in the limbs. Some have (especially where there is excessive thirst and vomiting) found euphorbia corollata a valuable adjuvant in this disease, especially where there are large quantities of mucus and water vomited up, or where there is faintness or exhaus- tion. When the disease assumes a typhoid variety, and there is coma, with quick, full pulse, then belladonna, in doses of 13 194 the practice of medicine. gtt. 2 to 3 every two hours, will be of material service. If the ejections are yellow or corrosive, with burning in the stomach, bowels and rectum, small doses of tincture of iris versicolor will give relief. It has been ascertained that the air in those localities where cholera prevails is destitute of the usual amount of ozone, and from that fact I would recommend that the patient's drink be sufficiently impregnated with ozonized water, and his room kept filled with ozone. This may be done by evaporating a solution of permanganate of potassium slowly in the apartment. Iodized starch paper kept lightly heated in the room will also generate ozone, as will also a stick of phos- phorus in water, when occasionally agitated briskly. Cholera Morbus. This disease is accompanied by nausea, vomiting, watery purging, spasmodic pains in the abdomen, frequent cramps in the lower limbs, rapid loss of strength, and coldness of the surface. It generally comes on suddenly, and often in the night. There is usually thirst and constant vomiting, and purging of a matter at first thin, foetid, and bilious, but soon changing in color, and finally becoming like rice-water, with- out fcetor. The disease prevails mostly during summer heat, although it may occur at other times, and is caused generally by improper food. Causes.—It seems to follow exposure, checked perspira- tion, drinking ice-water, and eating ice-cream and watery, indigestible fruits, such as cucumbers, raw onions, cabbage, green apples and plums, etc. It resembles Asiatic cholera, but is less severe, and is not, like it, caused by a specific poi- son ; hence it is neither so violent nor so epidemic as cholera. Treatment.—For the violent vomiting there is nothing so prompt in its action as ipecac, in doses of gtt. ^ to 1 every ten minutes, until the vomiting ceases. If the ejections from the bowels are sour, profuse, frequent and watery, the tincture of iris versicolor should be given after every passage until this DISEASES OF THE INTESTINAL CANAL. 195 symptom is checked. If the ipecac, fail to check the vomit- ing, euphorbia cor. may be tried; and if it fail, too, try small doses of the 1st dec. dilution of creasote, or of gtt. 1 to 2 in doses every half hour. Where there is great prostration and coldness of the skin, gtt. 5 to 6 of camphor, given every hour until the symptoms cease, act well. If there is much fever, with green and watery stools, I prescribe gtt. 1 of aconite in alternation with the tincture of chamomilla (German chamo- mile.) every one or two hours, according to the severity of the symptoms. Should painful cramps of the stomach, bowels, and extremities set in, let gtt. 10 to 15 of dioscorea (tinct.) be given every ten minutes until the cramp ceases. In all instances in which the disease manifests great severity, and prostration takes place very soon, I would recommend cam- phor, as in cholera. It is a valuable remedy. Cholera Infantum, or Summer Complaint, as it is called, is very similar to Cholera Morbus. It is frequently characterized by greenish stools, with frequent vomiting. It is often associated with teething. I have found ipecac, or euphorbia the best reme- dies for vomiting, and compound syrup of rheum for the purg- ing. If the dejections from th^ bowels are green, then small doses of tincture of chamomilla answer well. If the stools are offensive, small doses of borax are required, or sulphite of soda. Chronic Constipation. Constipation may originate from various causes, such as sedentary habits, dissipation, improper quantity and quality of food, exclusive use of fine flour, mental anxiety, inaction of the liver, poisonous effects of lead in paints, or the use of hair dyes that contain acetate of lead, inertia of the coats of the bowels, mechanical obstruction to the contents of the bowels, and inflammatory affections of the bowels, brain, spinal cord 196 THE PRACTICE OF MEDICINE. or their membranes. Many people, however, superinduce the disease by impairing the tone and susceptibility of the mucous coat of the bowels, by taking patent pills or other harsh purgatives every time they are feeling unwell. Constipation, being generally the result of certain pathological conditions of the general system and of certain organs, is not to be cured by purgatives. Treatment.—If it be associated with indigestion, gtt. 5, of nux vomica, at meal time, or just before, will often relieve it. Cascara sagrada is also a reliable remedy. Where it re- sults from inaction of the liver, and the stools are hard, dry, and light colored, gtt. 1 to 2, of bryonia, three times a day, will generally relieve it. If it be associated with haemor- rhoids, and the dejections are painful—like sharp sticks in the rectum, I give gtt. 5 or 6, of aesculus hippo., which should be used twice a day, alternated with whatever remedy the other symptoms may indicate. Constipation from the poison of lead, or from inertia of the rectum, in which the stools are hard, knotty and scanty, should be treated with small doses of alum. Where constipation is attended with prolapsus ani, and weakness and soreness of the back, small doses of podo- phyllin, at night, should be alternated with a dose or two of rhamnus purschiana in the day. When it occurs in aged persons, who lead a sendentary life, and where the stools are hard, gtt. ^ to \ of tincture of aloes at night, may overcome the the trouble. If constipation exists, with pressing pain in the rectum, and the discharge contains only mucus and much wind, small doses, say gtt. 10 to 30, of asafoetida, three times a day, may overcome the disease. When associated with pain in the region of the liver, with stools in balls, and of a pale color, caused by portal congestions, gtt. 20 to 30 of chelidonium, must be alternated with gtt. 20 of tincture of collinsonia, and will relieve the constipation and regulate the biliary action. If the affection is from indigestion, as is often the case, then hydrastis and euonymus (in tincture) are the best remedies DISEASES OF THE INTESTINAL CANAL. 197 in doses of gtt. 10 to 15, of each. They may be alternated, and given a few hours before each meal, if desirable. If great acidity of the stomach be the cause, then gtt. 2 to 5, of robina is the remedy wanted, or 5 gtts. of sulphuric acid, three times a day. Intestinal Hemorrhage. This condition is often the result of obstruction of the portal circulation, as in cases of cirrhosis of the liver, diseases of the lungs and heart, compression of the vessels by large abdominal tumors, and erosions or degeneration of the coats of the blood vessels, from typhus fever, yellow fever, and scurvy. It may also be the result of cutting substances pass- ing along the bowels, and is sometimes caused by suppression of haemorrhoids or of menstruation. Severe haemorrhage of the bowels is associated with paleness, coldness of the limbs, weak pulse, collapsed features, chilliness, and discharges of blood through the rectum. If the discharges be from the upper bowels, they are dark, and generally mixed with faecal matter; but from the lower bowels they are red and fluid. Its exact seat, however, can not be determined, as it may come from the stomach as well as any portion of the intestines. If the blood is turned black, and the stools are the color of tar, the passages thrown into water turn red if they contain blood, but if bile, and not blood, the color will be green or greenish yellow. Treatment.—Vegetable charcoal is a reliable remedy, as is also hamamelis in passive haemorrhage. I have always had best success, however, with small doses of Monsel's salt of iron. Ipecac, does well in doses of gtt. 4 or 5 of the tincture every hour. HiEMORRHOIDS. This disease consists of an enlargement of the veins of the mucous membrane outside and inside the sphincter muscles of 198 THE PRACTICE OF MEDICINE. the anus. When the tumors appear outside the sphincter ani, they are called external piles, and when they occur inside, they are called internal piles. They are doubtless produced by various causes in persons that have a constitutional tend- ency to a varicosed condition of the veins, and especially of the rectum. When one or more of these varicosed veins are ruptured, they are called bleeding piles, and when they do not rupture and bleed, they are called blind piles. When a catarrhal condition of the mucous membrane of the rectum exists, and a slimy mucus secretion passes from the anus, they are called white or slimy piles. The size of the haemor- rhoidal tumors varies from that of a pea to that of a cherry or even walnut, and sometimes they cover the whole anus. Espe- cially is this the case in pregnant females. When the piles are pressed out through the sphincter muscle, they become strangulated by its contraction, and assume a purple or bluish color. This turgescent state of the haemorrhoidal veins is not always continuous, but subject to frequent changes. There are intervals, shorter or longer, when the patient is always free from pain, attendant upon the disease. Repeated attacks of the turgescence result finally in a thickening of the coats of these varicosed veins, and the tumors become paler and harder. The tumors are gradually elongated by each evacuation of the bowels, and are finally developed into soft bags outside of the sphincter ani, which very often become inflamed by slight pressure upon them, or from attacks of dysentery. Causes.—The predisposing cause of haemorrhoids seems to be the position of the rectal veins, they being the lowest branches of the abdominal vessels, and in the want of valves to sustain the returning column of blood in its course towards the vena portae. It is plain that any retardation or stagnation in this backward moving column—the weight of which presses downwards upon the lowest branches of the vessels, overfilling and enlarging them—is calculated to produce varicosity in these vessels. This obstruction of the blood in the veins DISEASES OF THE INTESTINAL CANAL. 199 may arise from tumors within the cavity of the abdomen pressing upon the veins of the rectum, or from the impreg- nated uterus pressing upon the same vessels. Diseases of the liver obstructing the portal circulation, may produce the same effect. Diseases of the heart that more than fill the veins with blood, may lead to the same result. The use of wine and alcoholic drinks over-stimulates the capillary circu- lation, and naturally leads to haemorrhoids. Symptoms.—These are plain, and need not be mistaken. Besides the appearance of the tumors, the patient will often complain of disturbed digestion, costiveness, dull pain in the small of the back, and more or less headache. There may also be complaint of much pain at the stool, and of frequent haemorrhages, and if they are suddenly checked by cold or otherwise, constitutional troubles may follow, such as conges- tion of the head, lungs, stomach, liver or kidneys; or there may be bleeding at the nose, and from the lungs and urinary organs. Sometimes, in old people, there is a varicose condi- tion of the veins of the neck and bladder, and in females, of the uterus and vagina, which causes haemorrhages of these organs. Sometimes the haemorrhoidal tumors inflame, sepa- rate and form fissures of the anus, resulting finally in con- tractions of the sphincter ani, or prolapsus ani. All these ill consequences may arise, and ofttimes various others. I have seen piles so often precede phthisis pulmonalis, that I am of the belief that, in constitutions predisposed to it, they may develop that disease. Treatment.—If constipation exist with piles, or occur in those addicted to intoxicating drinks, nux vomica once or twice a day, in doses of gtt. 3 or 4, alternated with small doses of sulphur to regulate the bowels, j.will often produce improve- ment in a few days. The application of an ointment of Mon- sel's salt, say 3 1 to \ 1 or 2 of lard, and the internal use of aesculus hippo., or aesculus glabra, in doses of gtt. 2 to 5 of the tincture three times a day, will often cure the disease. A 200 the practice of medicine. solution of Monsel's salt is better. In cases attended with profuse haemorrhages, aconite, in doses of gtt. 1 three times a day, alternated with gtt. 1 to 2 of the tincture of hamamelis, will generally check the haemorrhages and aid in the final cure of the haemorrhoids. I have successfully treated a number of cases, some of them where the tumors were large, with the tinctures of collinsonia and aesculus hippocastaneum, in doses of gtt. 10 of the collinsonia and gtt. 5 of aesculus hippo., three times a day. At the same time I applied a strong solution of Monsel's salt to the tumors. In my own case I have effected a cure five times in my life, and each time I had the disease very severely from riding. Injecting the tumors with the tincture of ergot and carbolic acid, in equal parts, with a syringe made for the purpose, is a good plan for internal piles. In persons of sedentary habits with blind piles, and plethoric persons with constipation or indigestion, gtt. 3 to 5 of nux vomica, alternated with gr. 2 to 5 of sublimed sulphur, will generally give relief, if it does not cure them. If the liver is inactive and the bowels rather bound, podophyllin gr. ^ three times a day may be given, or gr. ^ of podophyllin and ^ gr. of aloes, three times daily, until the action becomes normal. Then give aesculus hippo., in doses of gtt. 5, three times a day until the cure is completed. When haemorrhoids are attended with tenesmus and diarrhoea, gtt. 1 to 2 of tincture of capsi- cum, every two or three hours, will generally bring prompt relief. When the tumors are very large, hard, and extremely painful, small doses, say gtt. 1 to 3, of muriatic acid, three times a day, are very valuable remedies. Should the tumors be inflamed, raw, and very painful, use the unguentum gallae, alternated with the oint. of the leaves of stramonium or hyos- cyamus. The diet should be strictly regulated, and the bow- els kept loose. The patient must avoid stimulants in either food or drink, indigestible food, full meals, and too much meat. Injection of cold water occasionally, before stools, is a good prophylactic. Surgical operations are seldom necessary. diseases of the intestinal canal. 201 Peritonitis. The pathological peculiarities of peritonitis are like those of pleuritis, meningitis, or pericarditis — injection of the capil- laries, followed by exudation. This exudation is either of a serous character, and then profuse and distending the abdo- men, or the exudation is of a fibrous character, coagulable lymph predominating. This is apt to cause adhesions, that thus fasten one portion of the intestines to another, giving rise to strangulations of portions of the intestines Sometimes the exudation is more or less mixed with bloody globules, and then it is called haemorrhagic exudation, and is mostly found in scurvy, typhus, and other haemorrhagic diseases. Again, the exudation may be converted into pus or ichor, and is then called purulent or ichorous exudation. This last, however, rarely takes place, except in cases in which the blood is greatly depraved, as in puerperal fever, pyaemia, or in which urine passes into the abdomen. It is apparent, then, that the simple cessation of inflammatory symptoms is not an evidence that the disease is cured, but of the exudation being still pres- ent and giving rise to much trouble. It may even, at last, terminate fatally. Peritonitis does not always involve the whole peritoneum — that is, it is not always general or dif- fused peritonitis, but is frequently partial, attacking only cer- tain portions of the membrane, as, for instance, the parts which cover the liver, spleen, kidneys, uterus, or portions of the bowels, they being more or less complicated with inflam- mations of the respective organs or parts. Causes.—The causes are various. In many cases the dis- ease is caused by injuries, such as blows, falls, and penetrat- ing wounds, either accidental or from surgical operations. In some instances it may be the result of cold. It may also fol- low inflammation of the liver, spleen, womb, bladder, caecum, and stomach. Ulceration and perforation of the bowels may 202 THE PRACTICE OF MEDICINE. follow child-bed fever or suppressed menstruation. A cold suddenly taken may also be responsible for its appearance. Symptoms.—The disease exhibits a variety of manifesta- tions, owing to the diverse causes of the peculiar affection. Pain is a common symptom, is lancinating and sharp, and is increased by motion, touch, or the slightest pressure. The patient breathes only with his thorax, avoiding the action of the diaphragm, and lies with the limbs flexed to prevent the tension of the abdominal muscles, which is painful. Nausea and vomiting are likely to supervene in a few hours, and the vomiting frequently becomes stercoraceous if there is obstruc- tion in the bowels. Singultus often sets in about the second or third day, especially if the lining of the diaphragm is involved in the inflammatory process. Constipation is fre- quently troublesome, and where there is ulceration, or in cases of puerperal peritonitis, there is often diarrhoea. The bowels are generally distended with gaseous accumulations, from the passive state of their coats. If the serous lining of the blad- der is involved, there will be a constant desire to urinate, with tenesmus of the bladder and retention of urine. There is always fever, and sometimes it is intense, according to the sur- face involved. When caused by taking cold it is not very dangerous, when properly treated, but when the attacks follow wounds it is sometimes fatal. When the pain gradually abates it may be regarded as a favorable sign, especially if the pulse rallies. If the pain ceases, and the pulse grows weaker and weaker, it is a bad sign. If the features collapse, the pain very suddenly ceases and the pulse becomes flickering, then we may look for a fatal termination. When this affec- tion becomes chronic, it often terminates in marasmus. Treatment.—Aconite < is the remedy for peritonitis in the first stage of inflammation, in doses of gtt. 1 every two hours. In the second stage, when the fever abates, and effusion threatens, bryonia, in doses of gtt. 1 or 2 every hour, acts admirably. Bryonia should be given from the commencement diseases of the intestinal canal. 203 of the peritonitis when it follows mechanical injuries. Should the inflammation attack abdominal organs, and there be colic- like pains in the bowels, I give small doses of colocynth, say gtt. 1 to 2, of the tincture, every hour, alternated with bryonia alba. For tubercular peritonitis, gtt. 1 to 2 doses of tincture of arsenic, every three hours, alternated with the carbonate of lime, or the carbo veg., in doses of gr. 2 to 3 every two or three hours, is very effective. If there be headache or any disturbance of the brain, gtt. 2 or 3 of tincture of belladonna should be given every three hours, until the symptoms are relieved. If tympanites is very great, tincture of oil of erigeron should be given in doses of gtt. 3 to 5, every two hours, until it gives relief. If the pain should become sharp and stinging, and the limbs look puffy or ©edematous, I prescribe gtt. 2 to 3 of tincture of apis mel., every two hours, until the symptoms disappear. Hot fomentations should be applied at first. Enteralgia. By colic is to be understood neuralgic pains in the bowels coming on in paroxysms. These may occur without any pathological lesion, or may be the result of various morbid processes, or of changes in the bowels. Colic is often caused by improper food, or by an undue quantity of healthy food. Again, it may be caused by gas accumulating in the bowels— wind colic; or by impacted, hard faeces, stercoraceous colic. Occasionally it exists in children from the irritation of worms (colica verminosa); from certain metals, as lead, when it is called colica saturnina, and from copper, when it is called colica aeruginosa. It may be caused, either primarily or second- arily, by disturbed nervous action. In the secondary form— consequent upon diseases of other organs, it is caused by reflec- ted nervous irritation, as when the liver is diseased; or in uterine diseases, or diseases of the kidneys. Wind colic is also of this order, for here we have reflected nervous irritation thrown back upon the nervous center, resulting in spasms. 204 THE PRACTICE OF MEDICINE. Structural changes in the intestines, such as dysentery, hernia, intussusception, strangulation, and typhlitis, cause colic. We meet, too, with rheumatic colic, produced by cold feet, or by the patient suddenly taking severe cold. Symptoms. —The pain is of a crampy, griping, or twisting character, and comes on in paroxyms. Its seat is generally in the umbilicus or in the side of the abdomen, and sometimes it shifts from one place to another. Pressure gives relief in some cases, and in others increases the pain. The application of heat gives relief in most cases, but it generally increases the pain. Sometimes there are irregular contractions of the bowels, which move the fluid and gaseous contents, and cause a hard knot in the colon, which can be felt by examination with the hands. In lead colic, there is generally a large col- lection of gas in the bowels. Frequently constipation, nausea vomiting and belching, are attendant symptoms, and the pulse is often small, and the skin and extremities are cold with per- spiration. The patient is generally very restless, constantly changing his position. These spells, if unrelieved, may last for some hours, or for a day or so, or even terminate fatally. In wind colic, the pain ceases as soon as the gas is discharged, Colic from indigestion or overloaded stomach ceases as soon vomiting takes place, or it may be relieved by diarrhoea. Treatment.—In flatulent colic, a few drops of chloric ether, in mint water, will usually relieve the paroxysm. Gtt. 20 to 30, of the tincture of dioscorea villosa, in a teaspoonful of essence of mint, with water, generally gives prompt relief. Then, gtt. 2 to 3 of nux vomica, three times a day, will relieve the indigestion upon which, in almost every case, the colic depends. If the pains are twisting, cutting or griping in character, small doses, gtt. 1 to 2, of the tincture of colocynth, have generally acted well with me. In flatulent colic, iris ver- sicolor, in doses of gtt. 1 to 2 of the tincture every one or two hours, often cures when all other remedies have utterly failed. In some cases of this disease in children, caused by DISEASES OF THE INTESTINAL CANAL. 205 worms, santonine, in gr. |- to ^ doses, will give good results. In that form in which colic is attended with vomiting of bile, dioscorea, in doses of gtt. 10 every hour, will give relief. Where it occurs in children, causing them to scream out suddenly, chamomilla, in doses gtt. 1, every one or two hours, will be useful. In severe cases of spasmodic, flatulent colic, gtt. 1 to 2 of nux vomica (saturated tincture), has proved one of the most positive remedies we have, and if continued will ward off attacks. Ascites. This disease consists of a collection of fluid, within the peritoneal sac, and is of a yellow or yellowish green color, or, if there be blood mixed with it, is of a reddish color. This, when carefully examined, contains a great deal of albumen, saline matter, and some flakes of coagulated lymph, floating in it. The quantity of fluid contained within the peritoneal sac differs in each individual case, the sac some- times containing thirty or forty pounds. The peritoneum becomes opaque, loses its luster, and thickens considerably. The liver and spleen are pale, and in some cases smaller than natural. The kidneys, too, are anaemic; and the pressure of the fluid drives the diaphragm up into the thorax. This is never a primary disease, but always follows some other, as disease of the lungs, heart, larynx, blood-vessels, liver, spleen, kidneys, cancer, cachexia, or some form of fever, as measles, scarlet fever, typhoid or typhus fever, or even long continued and neglected chills and fever. Impediment to the circulation may cause it, especially obstructions to the vena portae; and it very often results from cirrhosis of the liver, tumors of that organ, cancer, and tuberculosis, excessive salivation. Symptoms.—One of the first symptoms noted is enlarge- ment of the abdomen. When the patient is erect the hypo- gastric region is most swollen; but when in the reclining posi- tion, the most dependant portion of the abdomen protrudes. 206 THE PRACTICE OF MEDICINE. This is the distinguishing point between ascites and other swellings of the abdomen, such as pregnancy and distention. Palpation shows a distinct fluctuation over the abdomen. The kidneys are also apt to be torpid, and the patient is troubled with dyspnoea and palpitation of the heart. Percussion reveals a dull sound while the patient is reclining. Treatment.—In cases in which the urine is dark colored and scanty, and in which there is great soreness of the abdo- men, stinging, burning pains in the body and dyspnoea when in a reclining position; when it follows scarlet fever, uterine tumors, and any inflammatory disease of the bowels, I advise the tincture of apis mel., in doses of gtt. 2 to 5, three or four times a day. If the pulse is small and feeble, the tincture of digitalis, in doses of gtt. 10 every two or three hours, aids other remedies in reducing the accumulation of water in the cavity. Apocynum cannabinum, in infusion, is one of the most trust- worthy drugs, and may be given in doses of gtt. 60 of a strong aqueous infusion every hour, until the kidneys respond, or until it begins to purge. Then prolong or lessen the dose one-half. If the dropsy is from cirrhosis of the liver, small doses of tincture of croton tiglium, made by adding 3 1 to 3 9 of alcohol, may be of material service. The dose is gtt. 3 to 5. If it purges too much, lessen the dose. Should these remedies fail, I use the infusions of polytrichum juniperum and chima- phila umbellata, in doses of 3 1 to 2 every hour, until the kidneys act well, when I prolong the intervals between the doses. Recently, I have used the tincture (in gin) of the actinomeris helianthoides* in doses of one or two teaspoonfuls every one or two hours, until the kidneys act well. This medi- cine acts with great force upon the kidneys. If I fail to cause action of the kidneys, which is sometimes the case, I give the compound powder of jalap and cream of tartar, with about gr. \ of podophyllin to each dose, until I move the bowels *See Author's Materia Medica. DISEASES OF THE INTESTINAL CANAL. 207 freely, which will generally start the kidneys to action. The fluid will be then rapidly removed. In the successful treatment of dropsy of any part, we must always correct the torpid state of the kidneys, and also that of the blood, and remove any diseased condition of the liver, spleen or stomach; for upon these organs most cases of dropsy depend. Some cases are caused by diseases of the heart, and some of these affections of the heart are incurable ; con- sequently, the dropsy caused thereby is likewise fatal. I frequently at the commencement of the treatment, put my patient upon iron and tonics alternated with diuretics, and if not then, I do so as soon as I get the kidneys in working order. The syrup of the carburet of iron is a reliable prep- aration of iron, and as a tonic and blood-maker helonias dioica in doses gtt. 30, three times a day, is very valuable. I have been obliged to administer the nitrate of potassium in doses of from gr. 5 to 10 three times a day, before I could remove the water from the blood. If it acts well and does not purge it should be continued, given in a large quantity of water to prevent irritation of the stomach and bowels. The acetate of potassium also acts well on the kidneys of some individ- uals. The best of diuretics fail to cure some patients. Iron is needed to renew the blood. Intestinal Worms. Intestinal worms often trouble young people and children, and are occasionally found in older persons. Symptoms.—The symptoms vary in different cases; but the most sure and unmistakable sign of their presence is their occasional passing off with the alvine discharges. The other symptoms vary according to the kind of worm produc- ing them. There are five species of worms described as in- habiting the human intestines, but there are only three that are commonly found. (1) Oxyuris Vermicularis, the thread or seat-worm, mostly called the ascaris vermicularis, which is 208 THE PRACTICE OF MEDICINE. found in the lower bowels, generally in the rectum. This worm is from two to five lines in length, white, slender, pointed at one end, and very active. The head is club-shaped, and the tail curved in males, and straight in females. The females are the most numerous. The symptoms of this worm are irritation and tickling in the anus, and sometimes they produce a sticking sensation, as if a pin or other sharp-pointed sub- stances were lodged in the part. They cause so much irritation some cases as to give rise to catarrhal inflammation of the mucous coat of the rectum, blennorrhcea and swelling, with tenesmus. They frequently produce headache. In the females, they may leave the rectum and lodge in the vagina, causing intolerable itching and inflammation, and may so excite the parts as to give rise, in young girls, to the habit of masturbation. Treatment.—When I was young I saw in Prof. Eberle's practice the following prescription used, viz.: Proto-sulphate of iron, gr. 2; aqua pura, f 4; dissolve, and inject into the rectum. This has always proved successful. I was once giv- ing an old lady the powdered bark of the root of the apocy- num cannabinum, in pills, in doses of gr. 4 or 5, as a cathartic for headache, and while relieving the headache (which was doubtless caused by the ascaris), she passed a large number of these worms, and was given immediate relief from her head- ache. Injection of a strong infusion of the apple-tree bark has frequently removed them for me in children, and although it is not as certain to remove the worms as the iron, it is not as irritating. I use cold water injections. (2) The Ascaris Lumbricoides, the round, long worm, is of a cylindrical form, rather pointed at the extremities, from six to twelve inches in length, and about the thickness of a goose-quill, thus resembling a large earth-worm. Its body is transparent, and of yellowish color. The females are most numerous, and are the largest. This worm inhabits the small intestines, but sometimes migrates and ascends into the stom- DISEASES OF THE INTESTINAL CANAL. 209 ach, finally into the oesophagus, and then is discharged through the mouth. They have been known to get into the larynx, wind themselves up, and thus cause suffocation. There is a case of this character on record in the surgical museum at Washington, D. C. Symptoms.—These worms as a general thing give rise to griping pains in the umbilicus, secretion of slime, diarrhoea, vomiting, and irregular appetite; or they may cause reflex irri- tation, itching of the nose, anus and genitals, enlargement of the pupils, squinting, salivation, restlessness at night. Start- ing and grating of the teeth in sleep also result from it. The child may look well, or it may be cachectic, with blue rings around the eyes; enlarged abdomen may also result from large quantities of these worms. In children of a highly impressi- ble nervous system there may be irritation of the brain, con- vulsions or fits of an epileptic character, or they may only produce headache, swelling of the upper lip, etc. Treatment.—I have had success by giving gtt. 30 of tinc- ture of spigelia, and from gr. -J to J of santonin, in sweetened water, ter in die. (3) Taenia Solium.—Common tape-worm. This species of tape-worm inhabits the small intestines. It consists of a head, upon the front part of which there are four sucking cups, and in the middle of each a nozzle or snout, which is encircled by a double row of hooks; a neck, that is slender, flat, and about half an inch in length, but has no segmentation; and a body, consisting of a long row of segments, each of which has a rectangular shape, and contains both a male and a female organ, the orifices of which are joined together at the apex of the lateral papilla. These papillae are so arranged that each following segment has the orifice on the opposite side, so that they run along alternately from side to side. The size of the segments increases gradually towards the caudal extremity, becoming broader and broader; for the para- site is nourished and grows from its head, the newly created 14 210 THE PRACTICE OF MEDICINE. segments pushing those already formed before them. The caudal extremity, consequently, is the oldest portion of the worm, and its segments alone contain ripe eggs. There may be eight hundred or a thousand segments, and the worm may measure ten or thirty feet in length. The oldest segments are said to fall off from time to time, and are discharged. If these discharged segments happen to fall into a suitable soil, into the body of a dog or pig, for instance, the eggs develop themselves into cysticercus celluloses of the pig, or into the tape-worm in the dog. The cysticercus celluloses of the pig, by transplantation into the stomach of man, becomes again tape-worm in him. Only one is generally found in one per- son, but as many as five have come away from an individual at one time. Eating raw pork will cause them. The Taenia Lata, or the Bothriocephalic Lotus, is another kind that, instead of four mouths, has only a pair of fissures on its head; and its sexual organs lie in the centre of each segment. Its neck is not distinct, and the segments of its body are broader than they are long. They are found in Poland and Russia, and also in the eastern part of Prussia, and in Switzerland. Symptoms.—The symptoms are obscure in some individ- uals. Others complain of a pain of the stomach, have some nausea and vomiting at times, great hunger, and sometimes fainting spells. There may be also bloating of the abdomen, itching of the nose, headache, dizziness, dark spots before the eyes, and noises in the ears. Some have chorea or epilepsy. Treatment.—Among the remedies that have proved suc- cessful may be first mentioned the tea of the pomegranate root bark, made strong, and drunk freely in the morning, on an empty stomach. In the evening purge off quickly with jalap and senna. Koosso, the flowers of the brayera anthelmintica, in doses of 3 2 to 3, in a tumbler of water, is a useful remedy, if it be always taken well stirred up. This should be prepared in the evening, and in the morning the patient should take a cup of coffee, to prevent nausea. One-half of the solution DISEASES OF THE INTESTINAL CANAL. 211 should be taken, and the rest half an hour afterwards. If the patient is nauseated he should sip lemonade to allay this symptom. In one or two hours the worm will begin to be discharged, which may be encouraged by a brisk cathartic The oil of aspidium filix mas,—male fern, in doses of gtt. 3 to 5, three times a day, followed by a brisk cathartic, is highly recommended by some writers. Kamala is used with good effect in some cases. Cucurbita pepo, in emulsion, is much used sometimes, but does not answer with me. Some recom- mend moderately large doses of turpentine, but I think that gtt. 10 or 15 repeated four times a day, with oil to purge, is more successful. Oxide of zinc, in doses of gr. 8, every two hours has had success. Pelletierine, the alkaloid of Granatum, is by far the most certain remedy for the tape worm; it should be repeated after a week for a second worm, as others may infest the patient's bowels, for as many as three have been expelled from one patient. Chloroform is a very effective taenifuge, 1 3 to 1 1 of mucilage, on an empty stomach, followed in one hour by § 1 of castor oil, for adults, less for children. If convulsions occur from worms, 2 gtts. of ignatia may be given three times a day. CHAPTER XIV. DISEASES OF THE LIVER. Hyperemia. IN the very warm climates, hyperaemia or congestion of the liver frequently exists, but is not as frequent in temperate climates as is generally supposed. Where it occurs there is enlargement of the organ, which is overfilled with blood. Its surface is smooth, tense, firm, and of a glistening appearance, and if cut into black blood oozes out, and the parenchyma appears very dark. It is most usually caused by obstruction to the circulation of the blood, either from disease of the heart or the lungs. Diseases of the mitral and tricuspid valves of the heart, pneumonia, pleuritic effusions, and emphysema of the lungs, may also cause this disease. Intermittent, typhus, puerperal, and exanthematic fevers, may often result in this affection of the liver, as may also scurvy. Suppression of the menses, or of haemorrhoidal discharges, may bring it on. Symptoms.—These are heaviness, tension, pressure in the right hypochondrium, frequent derangement of the stomach, with nausea, vomiting, headache and depression. Palpation and percussion reveal an enlargement of the liver, and there may or may not be jaundice. The bowels are often consti- pated, and the stools clay-colored. Treatment.—If there are vomiting, a bitter taste in the mouth, white tongue, dryness of the mouth, thirst, costiveness, and soreness over the liver, from gtt. 2 to 5 of the tincture of bryonia, should be given every three hours. Where there are fullness, stitching pain and swelling of the liver, yellow color of the skin, great irritability and costiveness, gtt. 5 of tincture of nux vomica, every four hours, will regulate the action of 212 DISEASES OF THE LIVER. 213 the liver and improve the digestion. For enlargement, I give tincture of chionanthus in doses of gtt. 60, every four hours. * This is a valuable remedy, and it is especially called for if there is jaundice with the enlargement. Euonymin, in doses of gr. J to ^, may be given in alternation with chionanthus. If there be' constipation, I order podophyllin, in doses of gr. \ every four hours, until the bowels are regulated. Should jaundice exist, and be the result of catarrh of the biliary pas- sage, the sulphate of manganese, in small doses, every three hours, will aid in the relief. Hydrastis is also a good remedy in jaundice from catarrh of the bile ducts. If the disease is of malarial origin, iris versicolor (tincture), in doses of gtt. 2 every three hours, is "effective, as is also centaurea benedicta. Torpidity of the Liver. For the functional torpidity of the liver there is a great deal of maltreatment in this country. Routine physicians, who usually treat without diagnosing cases of supposed liver inaction, ruin many fine constitutions, by the wholesale ad- ministration of mercurials for what they merely suppose is liver trouble. If we consider what the functions of the liver are, we shall then see how to treat their interruptions. The liver performs three distinct functions: (1) The storing up glycogen; (2) the oxidation of albuminoids; (3) the elabora- tion of bile. Indigestion often disturbs the liver. The sugar taken up by the portal vein is converted by the action of the liver into glycogen, which is an insoluble form of sugar. And but for the functional action of the liver the blood would be overloaded with sugar; but the liver stores it up in this insol- uble form, and then gives it off as it is needed. If this function be performed torpidly, and the rehydrating of sugar into glycogen is imperfectly accomplished, then it must find its way out by the kidneys, and constitutes one form of glycosuria. It may be thrown off in small quantities without * See Author's Materia Medica. 214 THE PRACTICE OF MEDICINE. causing any alarm, but if in very large quantities, then it pro- duces the symptoms of diabetes mellitus. Diabetes results from the disturbance of this first function of the liver, that is, the glycogenic function of this organ. The second function of the liver is the oxidation of the albuminoids. It converts the albuminoid constituents of the food into peptones, by the aid^ of the pancreatic juices and gastric juices. These peptones then feed the tissues as de- manded, and any surplus is broken up by the liver into glyco- gen and nitrogenized waste, as leucin and taurosin, which, by still further oxidation, are converted into uric acid and urea. The liver also burns up worn-out blood corpuscles and debris from the tissues. Dr. Murchison says that from the " func- tional disorders of the liver there are found considerable quantities of lithates in the urine." And in cases in which large portions of the liver are destroyed, the amount of urea is proportionally diminished. We see then that functional tor- pidity of the liver causes defective oxidation of albuminoids and its consequences. If we observe a large sediment in the urine, we may know that there is imperfect oxidation of albu- minoids; that is the patient is taking a large surplusage of food. The lithates are likely to be present in such cases of over-eating, especially if the food be largely composed of nitrogenous matter, such as meats, rich in composition. The third function of the liver is the secretion of bile. Just what the action of the bile is, is not fully settled by physiologists. It has some effect upon sugar and fat, and it also aids the pancreatic juice in its action upon albuminoids. It has likely some effect upon the proteids in their transit through the intestines, aiding the pancreatic juice and the succus entericus in dissolving and converting the proteids into peptones. By the aid of the bile the starch is converted into sugar, and the sugar is partly further converted into lactic acid. The fats are emulsified and partially saponified. These DISEASES OF THE LIVER. • 215 appear to be the uses of bile. Bile also lessens the tendency to putrefactive fermentation, and stimulates peristalsis. Hepatic disturbance demands careful attention, whether it be the result of the above named causes, or the effects of such medicinal agents as may injuriously affect the liver. Many cases of hypertrophy, jaundiced and other diseased conditions of the liver, are the results of disturbing the functional action of the liver by agents that produce congestion of this organ. The functional action of the liver should be promoted by the administration of euonymus atropurpurus, leptandrin, or bry- onia alba. These will act gently, with none of the injurious aftereffects caused by mercury. Hepatitis. This is inflammation of the substance of the liver. It sel- dom, if ever, invades the whole organ at once, but parts only here and there, which are soft and yellowish in the centre. At their periphery they show hyperaemia, with swelling and, soft- ening of the liver tissue. In advanced stages of the inflamma- tion, small pus globules form in the centre of the inflamed spot, increase in number, finally unite and form a small abscess, which may again unite with other abscesses, and these in the course of time may involve the greater part of the liver in the suppurative process and prove fatal. The right lobe is more subject to this form of abscess than the left. If these abscesses reach the periphery of the liver, they break through and discharge their contents into the abdominal cavity. Where, from previous inflammation, the surface of the liver has formed adhesions with adjacent organs, they perforate these organs and discharge themselves either through the abdominal walls, or into the thoracic cavity, stomach, gall- bladder, or intestines. This is primarily a very rare disease, and is mostly produced by external wounds, as a fall, a blow, or a contusion, etc. Secondarily, it may originate from irrita- tion, produced by hardened concretions within the gall-ducts. 216 THE PRACTICE OF MEDICINE. It may also be caused by ulcerative processes within the stom- ach and the intestines, which perforate and spread upon the surface of the liver. In very hot climates it may exist with dysentery. It may also originate from pyaemia, in conse- quence of wounds of the body. Symptoms.—Hepatitis, from a fall, blow, or other mechan- ical injury, is attended with pain in the right hypochondrium, which is sometimes very severe, especially where the lining portion of the peritoneum is inflamed. It also causes pain in the right shoulder, and, on tension, sometimes in the right straight abdominal muscle. The liver is generally swollen also, and the skin more or less yellow, with fever, etc. Secondary hepatitis, from ulceration of the stomach and intes- tines, commences with chills, fever, pain in the region of the liver, jaundice, and swelling of the liver. These are the symp- toms of this disease when caused by'pyaemia, and abscesses may form on the convex surface of the liver, causing it to bulge out. This is easily detected by palpation. If the abscess forms on the concave surface, it compresses the portal vein, and results in enlargement of the spleen and ascites. Small abscesses may terminate without marked symptoms. Perforation through the abdominal walls is the most favorable termination, as in this case the pus is discharged outside. Should the perforation be through the pleura into the pleural sac, it causes pleuritis; if into the lungs, the pus is coughed up; and if into the pericardial sac, it causes pericarditis, which proves fatal. If the stomach is perforated, the pus is vomited up, and if the intestines, it is discharged per rectum. In view of these facts, it is evident that this disease generally ter- minates fatally. Treatment.—In the acute stage, gtt. 1 of belladonna, alternated with aconite, each every two hours, will be apt to control the fever, and then bryonia should be given in doses of gtt. 2 every two hours. If there is a cramp-like pain at the inner angle of the right scapula, a shooting pain in the liver, DISEASES OF THE LIVER. 217 bitter taste in the mouth, nausea, palpitation of the heart, quick and irregular pulse, and constipation, euonymin, alter- nated with tincture of chelidonium, should be given four times a day in small doses. If the tongue present a yellow coat, and there be nausea and vomiting, brown urine, and black stools, leptandrin, in doses of gr. -§ to 1, may be given every six hours. If the pain in the liver is throbbing or stitch-like, gtt. 5 of nux vomica may be administered" every six hours, to relieve this pain and the congestion of the organ upon which it depends. In cases in which abscesses are found, recourse should be had at once to aspiration of the abscess. The sul- phide of calcium, in doses of gr. ^ to 1, should be given as soon as suppuration is apparent, and continued until it ceases. This drug materially lessens suppuration, and should not be forgotten. If a green, slimy diarrhoea sets in, gtt. 2 or 3 of Pulsatilla every two hours will have a good effect. If there is vomiting of black masses, a burning pain in the liver, violent thirst, passage of dark stools, and a very quick pulse, tincture of arsenic in doses of gtt. 1 every hour is the best remedy. In slow cases, complicated with pneumonia, gtt. 2 of lycopus, in tincture, every three hours, should be used, with such other remedies as are indicated in each individual case. When there is an inactive state of the liver, with inflammation, I have found nux vomica, alternated with bryonia, the very best rem- edies. They act well both upon the liver and upon the digest- ive functions. They should be administered in small doses of say gtt. 2 to 3, three or four times a day. The diet must be very light. Cirrhosis of the Liver. This is a chronic inflammation of the areolar tissue of the liver, which is of a fibrous texture, and forms a capsule over the whole organ, entering the liver, as Glisson's capsule, with the portal vein, and lining all its ramifications. Inflammation causes exudation of coagulable lymph, which forms a new areo- lar tissue, and also adhesions between the ramifications of 218 THE PRACTICE OF MEDICINE. minute vessels. • This compresses the secreting cells of the liver, and forms larger and smaller granulations, which are compared to hob-nails. In the progress of the disease the new formation compresses the biliary ducts and blood vessels, and causes the liver to shrink and become hard, pale, anaemic, and tough, and, when cut through, to be seen tinged with bile. Causes.—The most frequent cause is over-stimulation of the liver. It also results from the use of alcoholic drinks or may follow fever (especially remittent), or chills and fever. Symptoms.—In this disease, during the stage of exudation, the liver is enlarged, but in the stage of granulation, it is so much lessened in size that the left lobe may disappear entirely. This affection is often connected with hypertrophy of the spleen, following obstruction of the circulation of the blood in the portal vein and its branches, which lessens the free circu- lation of the blood]through the vena lienalis. Ascites often takes place from this obstruction of the portal circulation, and oedema of the feet may follow. If there be meteorism, there may be also greater or less dyspnoea, palpitation of the heart, nausea, etc. The patient loses flesh and strength, and jaundice is apt to supervene. Diagnosis.—It may be distinguished from stricture of the gall duct by the colicky spells in biliary stricture and by the absence of swelling of the spleen in that condition. It differs from nutmeg liver in the absence of the enlargement of the spleen, and of lung and heart disease. The latter always exist in nutmeg liver. It may be distinguished from cancer of the liver by absence of enlargement of the spleen, and by the potato-like shape of the liver in this hob-nail condition. Our prognosis may be favorable in the first stage of the disease, but after granulations have formed, a cure will be uncertain. Treatment.—In the treatment of cirrhosis of the liver resulting from the use of alcoholic drinks, the patient must first abandon drinking, and then take nux vomica, one of the DISEASES OF THE LIVER. 219 best antidotes to tobacco and whiskey, in doses of gtt. 5, three times a day. If the digestion is affected, in addition to nux vomica, let him take gtt. 3 to 5 of the tincture of pulsatilla, alternated with nux vomica. Should digestion be much affect- ed, and should there be pain in the stomach, of a burning character, gtt. 2 of tincture of arsenic may be ordered just be- fore each meal, well diluted in water. If inaction of the liver exists, which is often the case, gtt. 3 of tincture of bryonia should be given three or four times a day, until the organ acts as usual. I am of the opinion that the tincture of chionanthus in doses of gtt. 25 or 30, three times a day, would do well alternated with the other remedies. It is a very positive remedy in jaundice, and doubtless, like chelidonium, has a direct affinity for the liver. In the second stage of the disease we must be guided by the peculiar symptoms of each indi- vidual case. There are no remedies that promise any great remedial effect, though some may mitigate symptoms. Acute Yellow Atrophy of the Liver. Yellow atrophy of the liver causes diminution of the organ in all its diameters4 in consequence of its parenchyma becom- ing greatly degenerated. This substance is infiltrated with bile, which gives the liver a deep yellow color. The exterior surface becomes wrinkled, and the gall-bladder shrivelled, the latter having but a small quantity of bile. If the parenchyma be examined under a microscope, the secreting cells of the organ will be found mostly destroyed, and fat-globules and decayed remnants of the cells in their place. This disease is not very common, but follows excess in venery, poor living, mental emotions, and may exist in the last months of pregnancy. It runs a rapid course, frequently terminating in from twenty- four to forty-eight hours, but sometimes runs on from five to eight days. Symptoms.—Jaundice is always a result. It may appear at the outset, or it may set in later. Headache, dizziness, 220 THE PRACTICE OF MEDICINE. and stupor are very common accompaniments. There may also be grating of the teeth, spasmodic actions of the jaws, and dilated or contracted pupils. In some cases there are involun- tary discharges of the faeces and urine, and in others no dis- charge at all. In the latter case the catheter is necessary, and cathartics are required. Occasionally, instead of stupor, there may be violent agita- tion, delirium, and spasms and tremors. More or less fever sometimes sets in with a chill. There is nausea, and vomiting sometimes of bloody secretions from erosions of the stomach, with bloody faeces. The liver will be found very small by per- cussion. The diagnosis is very difficult, as it may be mistaken for typhus. Treatment.—If it commences with a chill, followed by , fever, aconite in doses of gtt. 1 every two hours, alternated with gtt. 2 to 3 of tincture of bryonia, will be the proper rem- edy. If head symptoms make their appearance, gtt. 3 or 4 of belladonna should be given three or four times a day, until the brain is cleared. Should there be nausea or vomiting, I use ipecac, in doses of gtt. 1 to 2 of the tincture of the fresh root every ten or fifteen minutes, until this symptom is controlled. If there is coldness of the extremities, dark stools, and a thickly coated tongue, with a dark streak in the centre, gtt. J of leptandrin, or gtt. 10 or 15 of the tincture should be given every four hours, until the discharges are changed to a natural color. For the jaundice I do not think there is any remedy equal to chionanthus and berberis vulgaris, in doses of gtt. 30 to 60 each. Cholecystitis. Gall-stones of various sizes form in the gall-bladder and occasionly are found also in the larger biliary passages; the ductus choledochus, hepaticus and cysticus. Their size varies from that of sand to gall-stones as large as a hen's ego-. They are oval, or round, when found singly; but more angular and DISEASES OF THE LIVER. 221 serrated when there are many together. They vary in color, being black, yellow, brown, green, red or bluish, hut most com- monly they are black or dark brown. Stones are generally very bright, will swim in water, and are also very easily crushed between the fingers, and when dried, crumble. They are composed of cholesterine, a chalky mixture with the pigment mucus around a nucleus of lime and pigment. Their cause is not known. It has been conjectured, however, that they are caused by a surplus of gall-fat or cholesterine, and, again, that they are the result of a surplus of calcareous materials in drinking water, especially in the lime regions. It is more likely that they originate from inflammation of the gall-ducts, obstruction of the gall-ducts, cancer, and the like hepatic diseases. I once saw an extreme case connected with valvu- lar obstructions in the aortic valves of the heart, and tuber- culosis. Here there were two large gall-stones. Symptoms.—In some cases, the symptoms are very ob- scure, and large gall-stones may lie for years in the gall- bladder without any marked symptom whatever. But should they once become incarcerated within the gall-ducts, they produce violent pain, which is called gall-stone, colic, or hepatic colic. This frequently commences all at once, with extreme pain in the right hypochondrium and epigastrium, radiating to the navel, back towards the spinal column, upwards into the chest, thence to the scapula, and sometimes down the arms to the fingers. In severe cases, there is nausea and vomiting, cold perspiration, sunken features and eyes, pointed nose and cramps in the feet and hands similar to cholera. Jaundice soon sets in, and is apt to continue as long as the gall-stones remain in the gall-bladder or duct. This disease, however, may not occur where the gall-stones are incarcerated within the ductus cysticus, from the fact that the bile still passes into its proper place, the duodenum. Pain may continue for days, or if the stone happen to get out of the duct, ceases. The stone may pass out into the duodenum, and then be discharged with the 222 THE PRACTICE OF MEDICINE. stools. There was a case of that kind near Marietta not long since, in which several stones passed. All cases do not termi- nate so well. Sometimes the gall-stones perforate either the gall-bladder or gall-duct. In such cases peritonitis is almost sure to ensue, and frequently death. One case occurred near Marietta, in which some stones, as large as the end of the finger, made their way outward, and by suppuration were finally discharged over the hypochondrium. Again, the calculi have been known to find their way into the stomach or the intestines, or through some portions of the abdominal walls. If the stones obstruct the gall-ducts, they cause abcess within the liver, and the consequences detailed under the head of suppuration in hepatitis. The total obstruction of the doctus hepaticus, or choledocus, may cause the blood to become so overcharged with the biliary secretion, that we have cholaemia—intense jaundice, which may be followed by deli- rium, or convulsions, and finally death. Diagnosis.-—If the gall-stones pass off in the stools, the diagnosis is quite easy, but otherwise quite difficult to make out. Jaundice is one of the characteristic signs of gall-stones, and its persistence, notwithstanding the remedies given regularly, is also strong evidence of their existence. The paroxysms of hepatic colic are also diagnostic signs. Treatment.—The treatment has not been as successful as might be desired. To relieve the paroxysms of pain, berberis vulgaris has been used with some success. Chloroform has been praised for the same purpose. The carbonate of lime has proved very succesful in relieving the pain. But chelidonium (celandine of England) in doses of gtt. 5 to 10 of the satu- rated tincture, has been reported as curative by some English writers. The tincture of the best cinchona bark is praised as a preventive of gall-stones, and some writers believe that it aids in dissolving the stones. Podophyllin is also useful in the expulsion of the stones. For the spasmodic condition of the system produced by the passage of gall-stones, gelseminum DISEASES OF THE LIVER. 223 in doses of gtt. 30 to 40 may be given twice a day, until they pass, or a drop or two of tincture of nux vomica every hour, for the same purpose. I think that chionanthus will be found one of our best remedies, and may be ordered in doses of gtt. 10 every half hour. Nitro-muriatic acid may do as much good towards the cure. Euonymin, in doses of gr. ^ to ^ is also worthy of a trial. If there be fever and great pain in the liver aconite, alternated with berberis vulgaris should be given, and warm compresses may be applied over the liver to relieve the pain. Jaundice. This is not generally a disease in itself, but only a symp- tom of some morbid condition of the liver. It is manifested in the white race by the color of the skin and white of the eyes, and in the colored race, by the yellow color of the whites of the eyes. This color is from a deposit of the biliary pig- ment, biliphaein, or cholepyrrhin in the skin and eyes. It may also be found in the hair, nails and even in the enamel of the teeth. After death, it has been seen in the mucous mem- branes, brain, nerves, etc. This yellow or icteric color varies in degree from slight yellow, to a greenish or blackish color. How this coloring matter gets into the blood again, so as to be thus deposited in the skin and whites of the eyes, and else- where is not known. Leibig, Lehman, F. C. Schmidt, Strieker, Blondlot, Bernard and Frerichs, have endeavored to solve this difficult question. A common conclusion is, that the bile, in consequence of obstruction of the biliary ducts, is re-absorbed by the blood in the liver, whence it is distributed to the vari- ous parts of the system. This is a plausible conclusion, for jaundice follows many diseases of the liver that obstruct the biliary ducts, and disappears when this obstruction is removed. This may not explain all cases, for an autopsy reveals no ob- struction in many cases of jaundice. These cases are gen- erally associated with pneumonia, pyaemia, puerperal fever, 224 THE PRACTICE OF MEDICINE. rare cases of intermittent fever, yellow fever, with the toxical effects of mercury and other drugs, the bites of snakes, and chloroform inhalations. In this form of the disease, the most reasonable conclusion is that it is caused by an inflammation of the portal veins, clogging up the blood, and preventing it from entering the liver, and so, as it circulates through the system, with the biliary constituents still in it, by some un- known process, these elements are deposited in various tissues of the body. There may be in addition to the jaundice, itch- ing of the skin in small spots, all over the body, and in some cases so severe as to prevent sleep. The circulation is very slow, except in those cases connected with suppurative diseases. or some other acute disease. Xanthopsia is one of its results in which white appears yellow to the eye. Hemeralopia, or night- blindness may also occur in cases in which the gall-ducts are obstructed by granulation. Jaundice often produces certain brain symptoms, as depression, coma, soper, tremors, paralyt- ical affections, dizziness, headache, delirium, wild excitement, convulsions, or both of the last in alternation. The urine gen- erally contains the coloring elements of the bile, giving it a deep yellow or brown color. When it is tested by nitric acid it is colored green, which soon changes into violet, blue, red and orange color. The faeces are of a whitish or grayish color in these cases, resulting from obstruction of the ductus chole- dochus. The disease occurs in new-born children, and is called icterus neonatorum. It is supposed to result from an accumu- lation of mucus in the gall-ducts. Sometimes a more grave form is produced by an inflammation of the umbilical vessels, and consequently pyaemia. The disease may occur in females in the last months of pregnancy. Treatment.—I have generally succeeded with the tincture of chionanthus, in doses of gtt. 30 to 60, every three or four hours, where the disease is not caused by obstruction of the bile-duct, where it is, other remedies will have to be used., Where there is pain in the liver, in addition to the chionanthus DISEASES OF, THE LIVER. 225 I give the tincture of chelidonium, in doses of gtt. 5 to 10, every four hours. If the disease is from catarrh of the bile- ducts, the tincture of hydrastis, in doses of gtt. 5 or 6, every three hours, may be given with good effect. In chronic form, nitro-muriatic acid, in doses of gtt. 3, three times a day, will often prove curative. If jaundice is from induration of the liver, nitric acid, in doses of gtt. 3, every four hours may readily give relief. If there is a deficiency in secretion of bile, euonymus (tinct.) in doses of gtt. 30, every four hours, has proved effective with me. Where constipation exists, in addi- tion to the other remedies indicated, tinct. of nux vomica in doses of gtt. 4 to 5, every four hours, will restore the peristal- tic action and aid in restoring the functions of the liver. Berberis vulgaris has cured some chronic cases. If the stools are black, leptandrin, in doses of gr. \ to 1, three times a day, will be apt to give relief. If this fails, recourse should be had to bryonia, giving gtt. 5, of the tincture every four hours. I have recently succeeded in producing a good effect upon the liver with bryonia. Centaurea has made many cures and is worthy of a trial, dose, gtt. 4 to 5. When caused by ob- structions by gall-stones, this drug is one of our most reliable remedies. Where it is from mercurialization, the comp. tinc- ture or simple tincture of iodine, in doses of gtt. 3 to 5, three times a day, alternated with the tincture of chionanthus, has proved very successful with me in many grave cases. Podo- phyllin, in doses, of gr. J to J, three times a day, often aids where there is obstruction of the gall-ducts by gall-stones. If there be febrile excitement, aconite should be given in doses of gtt. 1, three or four times a day. This is a special remedy where there is inflammation of the liver or its appendages. Where there is a dark coating of the tongue, myrica cerifera, in doses of gtt. 10, of the tincture, has acted well in many in- stances. In cases connected with diseases of the heart, whero the tongue is clear and there is induration of the liver, digita- lis, in doses of gtt. 8 to 10, three times a day, will do good 15 226 THE PRACTICE OF MEDICINE. service. In chronic jaundice, from cirrhosis of the liver, gr. 1-100 to 1-60 of chloride of gold, three times a day, has made some remarkable cures. It must not be given in larger doses than the above, for it is highly toxical; the 1-200 is the dose. Euonymus atropurpureus is a very valuable remedy for func- tional affections of the liver. Its cathartic action is very similar to that of rhubarb. But in small doses of the tincture or fl. extract, it acts as an efficient cholagogue, in doses of 5 to 10 gtt. Euonymin is also used in doses of \ to 5 grs. Hydrastis canadensis, in the form of fluid extract, in doses of 20 to 30 gtt. four times a day, is of much benefit in jaundice from catarrh of the ducts. And small doses of arsenic have been successful in the same condition of the ducts, and in catarrh of the duodenum. Nitro-hydrochloric acid has also been used with success in some cases. But in cases of catarrh of the gall-ducts, sodium phosphate has proved a very reliable remedy; doses 3l every four hours. The sulphate of manga- nese is also recommended by O. L. Potter in jaundice from catarrh of the biliary passages. Rhubarb and aloes both act in cases of this character. Ammonium iodide, in doses from 1 to 3 grs., in water, every two or three hours, proves an active remedy in catarrhal jaundice. Ammonium chloride has also a similar effect under like conditions. Iris versicolor is a valu- able remedy in malarial jaundice, dose 3 to 5 gtt. of the tinc- ture, three times a day. Potassium sulphate is the most useful saline cathartic, in moderate doses. Chloroform is also highly praised by some writers as a solvent of the gall-stones. Some have recommended olive oil, taken, and the patient to lie down with his chest and head lower than his feet, so as the oil will enter the gall-ducts. Chloral hydrate is one of the safest remedies to relieve the pain of gall-stones. One or two ounces of pure olive oil taken at night, and followed next morning with 3 or 4 seidlitz powders, have been efficient in aiding the expulsion of the gall-stones. The diet should be carefully regulated. The patient should avoid all sugars, starchy food DISEASES OF THE LIVER. 227 and fats, also all malt liquors and spirits. He or she should take regular but moderate exercise daily. His or her diet may consist of lean meats, fish, eggs, fruits and succulent vege- tables, and a bath, with 10 or 20 drops of nitro-hydrochloric acid in 1 gal. water, may be taken. CHAPTER XY. DISEASES OF THE SPLEEN. PHYSICAL Examination.—As a usual thing the adult spleen, in health, is some four or five inches in length, about three inches in breadth, and one and a half inches in thickness. On percussion, it yields a dull sound. It lies posteriorly against the eleventh dorsal vertebra; is bounded in front by a vertical line drawn from the anterior border of the axilla to the free end of the eleventh rib, superiorly by the ninth rib, and inferiorly by the free end of the eleventh rib. In percussion, the patient must be placed upon his right side, and the stomach must be empty. If there be fluid in the left thoracic cavity, gas, or tumors of the liver, omentum, kidneys, etc., it is very difficult to define the size of the spleen. Ordin- arily, an enlarged spleen can be easily detected by percussion, and is so much enlarged as to reach to the os pubis, and almost fill the abdomen. The enlargement can be felt when- ever the spleen reaches below the eleventh rib, which is very often the case. The spleen is wedge-shaped, and its surface is smooth, except when invaded by cancer. Its notch, which corresponds to its middle line, and which is more distinct when enlarged, distinguishes it. But little is known of the functions of the spleen. It seems to be related to the elabora- tion of the white blood corpuscles, but we do not know how it is thus connected with the blood-making power. Splenitis. Splenitis consists of the blocking up of the smaller splenic arteries by fibrinous globules or coagula, which have formed in the left ventricle of the heart, in consequence of endocar- 228 DISEASES OF THE SPLEEN. 229 ditis. These coagula are carried by the blood through the splenic arteries into its smaller branches, where they lodge. This condition may take place in consequence of long exposure to malaria, from typhus, septicaemia, and acute exanthematic fevers. In such cases it seems to originate from a stagnation of the circulation within the splenic veins. An abscess may form, and suppuration go on until the entire organ becomes a mass of suppuration, or it may produce pyaemia, or burst and discharge the pus into the peritoneal sac, producing periton- itis. Again, the pus may be discharged into the cavity of the stomach, colon, or pleura. Symptoms.—The symptoms are very often rather obscure. If the enlargement is associated with endocarditis, it may often be more than double the normal size. In still other cases the enlargement can not be detected. The enveloping membrane, or the adjacent organs, give rise to more or less pain, which is of a dull character, and is increased by deep inspiration, percussion, or quick motions of the body. If the pain be sharp, it denotes that the inflammation is in the peri- toneal covering. If suppuration is taking place, there will be chills, alternated with some fever. Dropsy and scurvy may also set in. If there be suppuration and perforation, there will be peritonitis. Chronic swelling and hypertrophy may cause many symptoms not found in splenitis, such as cough, anxiety, dyspnoea, nausea, vomiting, and sometimes dizziness and clouded vision. Treatment.—If the disease be from malaria, or from sim- ple engorgement, gr. 2 of cinchona, or gr. 2 of sulphate of cinchonidia, may be administered every two or three hours, alternated with gtt. 15 to 20 of the tincture of the leaves and stems of ceanothus Americanus. If hypertrophy exists with- out active inflammation, I use the biniodide of mercury gr. 2, iodide of potassium 3 2, and aqua f 8; dose, a teaspoonful ter in die. Where there is active inflammation and fever, gtt. 1 of aconite should be given every three hours. Should there 230 THE PRACTICE OF MEDICINE. be active inflammation of the capsule, accompanied by stitch- like pains, gtt. 2 or 3 of tinct. of bryonia should be given until the pain is subdued, and then ceanothus until all enlargement subsides. In chronic splenitis, ceanothus is the best remedy we have. Iodine may be used locally at the same time, or an ointment of uvedalia may be applied over the spleen, while small doses of ceanothus may be given internally. If there is anaemia, the phosphate of iron should be alternated with the above-mentioned remedies in small doses. Where there are violent stitches in the spleen, and pain in the left hypochon- driac region, increased by coughing, with diarrhoea, gtt. 2 to 5 of the tincture of sanguinaria every two hours may be used. It is claimed by some writers that the silphium perfoliatum (Indian cup plant) is a valuable remedy for this disease of the spleen. It may be given in alternation with ceanothus Americanus. The polymnia uvedalia and ceanothus both have a direct affinity for the spleen, and I have always found those remedies best whose affinities were the most direct for an organ or tissue. Hence, in splenitis or hypertrophy the cean- othus and uvedalia are the most reliable remedies we have. Sometimes, where there is anaemia, iron and helonias may be required to build up the blood, but in the simple disease of the spleen they are not necessary. Euonymus atropurpureus is a valuable remedy, in doses of 30 gtts. every three hours. CHAPTER XYI. DISEASES OF THE PANCREAS. THIS conglomerate gland is analogous to the salivary glands, and is situated behind the posterior surface of the stomach, discharging its secretion by a main duct into the duodenum near the opening of the ductus choledochus into that intestine. The physiological function of the pancreas, un- til recently, was not well understood. It is now believed that the pancreatic juice transforms amylon into sugar, and, in conjunction with the bile and intestinal secretions, dissolves the fatty constituents of the food. Pathological changes in this gland are not of as frequent occurrence as of other glands of the body. Acute and chronic inflammation are the most common affections to which the pancreas is generally liable, Inflammation of this gland may terminate in suppuration, hypertrophy, atrophy, cancer, or fatty degeneration. The symp- toms of the disease of this gland are very obscure. The causes also are obscure, and are perhaps always of a secondary nature; that is, disease of this gland generally originates from that of adjacent organs, such as the liver and stomach. The lungs and heart also, may so influence the function of the pancreas as to cause disease. Pancreatitis. This inflammation is characterized by redness, swelling, and softening of the areolar tissue of the gland. If the inflam- mation be intense, the gland becomes hard, and when thus firm and hard is apt to suppurate, or the inflammation may result in induration of the areolar tissue, and the obliteration 231 232 the practice of medicine. of the glandular structure of the pancreas. This inflammation may also end in hypertrophy of the gland. Treatment. — If the inflammatory symptoms are well marked, gtt. ^, of aconite may be used every hour, alternated gtt. 1, of belladonna. After inflammatory symptoms are sub- dued, I give pulsatilla, gtt. 5, alternated with gtt. 1 of iris versicolor, every two hours, and if these do not restore the functional activity, then small doses of the carb. of lime should be given, alternated with euonymus, in doses of from gtt. 10 to 20 of the tincture, every two hours. If the inflammation is connected with disease of the liver, and there is jaundice, which is often the case, chionanthus, in doses gtt. 20 to 30 of the tincture, and gtt. 20 to 25 of the tincture of berberis vul- garis, should be given three times a day, until the jaundice disappears. The chionanthus doubtless has the same effect upon the pancreas as it is known to have upon the liver in jaundice. CHAPTER XVII. DISEASES OF THE KIDNEYS. rpHE kidneys being the organs that secrete the urine, it is -*- apparent that any morbid changes in the physiological products of those organs, point with more or less certainty to disease. The examination, chemical and microscopical, of the urine is very necessary in the diseases of the kidneys, and in those of other parts or organs as well. Its reaction is deter- mined by simply dipping blue litmus paper into the urine, and if that fluid be acid, the paper turns red as soon as it dries. This acidity of the urine varies even in the normal urine. It is greater before meals, decreased after meals, and dur- ing the process of digestion is somewhat augmented by any acid taken into the system. An alkaline condition of the urine may result from alkalies taken into the system, such as sodium, potassium, lime or magnesium. In such cases yellow test paper is turned red when dipped into the urine. If the urine remains alkaline all the time, it denotes nervous depression, and exhaustion by mental labor, or spermatorrhoea. Lemon and orange juice may produce alkaline urine, and so may mucus and pus. Diseases of the mucous coat of the bladder also gives rise to this alkalinity of the urine, and so does long retention of the urine. If there be an anaemic, chlorotic condition of the system, and specially after hysterical paroxyms, the urine is pale. In diabetes mellitus, the quantity and specific gravity are much increased. Should the urea be much increased in amount, the urine will be a deeper, darker color, but is generally clear when first voided. Urea is the principal product of the decomposition of nitrogenized sub- stances, and consequently its amount may be taken as an index 233 234 THE PRACTICE OF MEDICINE. of the waste and repair of the tissues of the body. It is very abundant in cases of high living, from the fact that all the nitrogenized substances can not be assimilated. Active exer- tion of the body increases this waste in the form of urea; acute febrile diseases, profuse perspiration, and diarrhoea generally do the same. If there is blood in the urine it will be opaque. Blood is found in the urine in haemorrhage, from the kidneys or bladder and during menstruation. If from the kidneys, it will be uniformly mixed with the urine, and if from the blad- der or womb, it is apt to be in clots. If there be bile in the urine, it will be very yellow, and white paper or cloth is turned yellow by it. Nitric acid dropped in a thin layer causes a play of colors, viz.: commencing with green or blue, then pass- ing to violet, red, and finally to yellow and brown. Bile is found in the urine in jaundice, pyaemia, yellow atrophy of the liver, and in some cases of. pneumonia of the right side. Cer- tain drugs color the urine, such as santonin, rhubarb, senna, turpentine, madder, beets, tar and creasote. If the urine be turbid when first voided, it is an evidence of the presence of epithelium thrown off by catarrhal processes from the mucous linings within the urinary apparatus. Leucorrhoea and gonor- rhoea produce whitish flakes in the urine. In Bright's disease casts of the uriferous tubules are found in the urine, which soon settle at the bottom of the vessel as a downy sediment. When pus settles as an opaque, creamy or clayey mass, (which is converted to a dense gelatinous cloud by the addition of potassium, and has a foul, ammoniacal smell,) it is evidence of suppuration, or shows that an abscess has opened into some portion of the urinary organs. In chronic catarrh of the blad- der, pus forms a layer of grayish-white sediment at the bottom of the urinal. Uric acid, when the urine gets cool, settles in little red crystalline granules. The urates settle in a pinkish or whitish sediment. The urine containing the urates gen- erally shows an acid reaction, and, if a few drops of nitric acid be added, the mixture slowly evaporated over a lamp to nearly diseases of the kidneys. 235 a dry mass, and a drop of ammonia added, a purple color will be produced. This play of color occurs in accute rheumatism, in leukaemia, and in acute inflammations and fevers. The phos- phates of the urine are combinations of phosphoric acid, sodium, lime, and magnesium, and such urine is always alkaline in reaction, yields when cold, a white sediment, and is rendered clear by adding acetic acid to it. The phosphates are found with pus, in chronic catarrh of the bladder; and in hyperaemia, or paraplegia. In such cases the urine generally has an ammoniacal odor. The phosphates may exist in excess during convalescence from acute diseases, in nervous debility, mental anxiety, sper- matorrhoea, and in acute inflammatory diseases of the nervous structure. They may also occur in fractures of the skull, especially when inflammation takes place in the brain. They may result from acute rheumatism, and from the use of animal food. If grape sugar be present, the urine soon becomes semi-liquid, viscid and inspissated, and the specific gravity will be higher in proportion to the amount of sugar in the urine, ranging from 1030 to 1040. If such urine be mixed with caustic potassium and then boiled, it turns reddish brown by degrees, and emits the odor of molasses, especially upon the addition of nitric acid. If there be albumen in the urine it foams when agitated. Heat detects the albumen by quickly coagulating it, and nitric acid causes a white precipitate. Large amounts of albumen cause albuminuria. Among the sediments of the urine are light, flocculent and cloudy deposits of mucus, epithelial cells and spermatozoa. A yellow, orange or pinkish deposit generally proves to be urates. A dense, white deposit, dissolving in acetic acid, usually consists of the phosphates. If the deposits be crystalline, of a reddish color, and small in quantity, it is uric acid, blood on the con- trary, causes a dark, sooty, dingy-red color. The quantity of urine varies considerably in health. In diabetes it is greatly increased; but fevers always decrease the quantity. 236 THE PRACTICE OF MEDICINE. Diabetes Mellitus. Diabetes mellitus consists of a peculiar diseased condition of the vagus nerve, causing excessive secretion of urine which contains grape sugar. There is also a form of diabetes insi- pidus which is an excessive flow of urine, without sugar, but which contains other substances akin to sugar. Some writers, as tuberculosis is a common complication of diabetes, attrib- ute the formation of sugar to the lungs. Others, again, believe that the liver elaborates this sugar in such large quantities that the lungs can not transform or destroy it, and so it soon comes into general circulation, and is excreted by the kidneys. Bernard has shown that this sugar is fabricated by the liver. We do not know why the liver forms it in such excessive quantities, nor do we know why the lungs do not transform it into heat. It may be that some morbid condition of the brain gives rise to the disease. Bernard found that the piercing of a certain part of the brain of animals produced sugar in the urine, and I have seen it produced in students at school, where they studied too intensely. Symptoms.—These are well marked. The excessive quan- tity of urine is noticed by the patient before other symptoms make their appearance. Then there is great thirst and hunger, dry skin, constipation, with dry, hard stools, want of natural warmth, constant wasting away of the flesh, loss of sexual desire and power, mental depression, etc.; finally phthisis supervenes, and ends the scene, or dropsy ensues. Treatment.—I have treated a great many cases with such old remedies as helonias dioica, lycopus virg., trillium, nitrate of uranium, nux vomica, etc., but with only partial relief to the patient. Recently, by the advice of Dr. J. S. McClanahan, of Boonville, Mo., I have treated this disease very success- fully with rhus aromatica, in doses of gtt. 30 of the tincture or gtt. 20, of the fluid extract, given every two or three hours through the day. One of my first patients was an old man DISEASES OF THE KIDNEYS. 237 some 74 or 75 years of age, who was very weak, and was pass- ing a large quantity of urine, the specific gravity of which was 1040. Upon evaporation upon a slip of glass, over a lamp or candle, this yielded a large percentage of molasses, I put this old gentleman upon lycopus and nitrate of uranium, which treatment he continued for one month; it reduced the quantity of the urine, but not the quantity of the sugar. I then put him upon the fluid extract of rhus aromatica, gtt. 30, three times a day, which he continued for one month, with a great decrease in the quantity of urine and sugar, I now took the specific gravity of the urine and found it to be 1032. I continued the prescription another month, at the end of which he appeared much better, and said he felt well. He was gaining flesh and strength rapidly, and I advised him to continue the treatment for another month; at the end of this time he reported himself perfectly well, and so continues up to last accounts. The rhus is reported to be as good in diabetes insipidus as in diabetes mellitus. By thus quoting an extreme case of diabetes mellitus, in an old man of 74 or 75,1 desire to show that the rhus aromatica is the most reliable remedy that has hitherto been used. The old gentleman had been visited by two of his brothers, both old and reputable physicians, both of whom pronounced his case incurable. He lives yet as a proof of the power of the rhus arom?tica over diabetes. HEMATURIA. When there is haemorrhage from any part of the urinary organs, the urine is colored more or less, according to the quantity of blood passed, and, upon cooling, a sediment more or less thick forms at the bottom. Causes.—It may arise from injuries, inflammation, typhoid and exanthematic fevers, Bright's disease, irritating drugs, calculi, and ulcers, etc. In scurvy and yellow fever, haemor- 238 THE PRACTICE OF MEDICINE. rhage seems to be the result of a general dissolution of the blood. If the haemorrhage be from the kidneys, the blood when passed will be thoroughly mixed with urine, and will be accompanied with pain in the kidneys, dysuria, and sometimes slight albuminuria. Should the blood be from the ureters, there will be spells of severe colicky pains, like those caused by calculi. If the haemorrhage be from the bladder, there will be only streaks of blood in the urine, which are discharged at the close of urination, with pain in the bladder and more or less strangury. Occasionally there will be a discharge of mucus or pus. Haemorrhage of the bladder is not very pro- fuse, but if it continue long it may cause anaemia and great prostration of the whole system. Treatment.—If caused by external violence, small doses, say gtt. \ to 1, of arnica every two hours may be alternated with other proper remedies. The rhus aromatica has proved itself to be valuable in this disease, as well as in diabetes. It may be given in doses of gtt. 30 to 60 every hour or two, according to the severity of the disease. If constant strangury is present, drop doses of tincture of cantharides may be given every hour until this symptom is relieved. Where there is a great deal of slimy mucus passing with the urine, an infusion of uva ursi may be used freely until the urine is clear. If the haemorrhage be from the kidneys, and there be great pain in that region, small doses of terebinthina may be given every hour, say gtt. 3 to 5, in mucilaginous drinks, as gum arabic or ulmus. Where I have had cases connected with anaemia, I have found the muriated tincture of iron, in doses of gtt. 15 to 20 in water, a very positive remedy. If haemorrhage occur with catarrh of the bladder or calculi, I use lycopus alternated with capsella bursa pastoris (shepherd's purse), or chima- phila umbellata. The equisetum hyemale is also a good rem- edy. If the haemorrhage is passive, trillium is a valuable drug, as is also the tincture of erigeron. DISEASES OF THE KIDNEYS. 239 Acute Bright's Disease. This consists of enlargement of the kidneys, with hyperae- mia of their papillae. The uriniferous tubules, especially those of the cortical portion, are filled with coagulated cylin- drical fibrin, which is discharged with the urine in connection with epithelial cells and blood corpuscles. Causes.—It may follow exposure to cold and external inju- ries, or it may be caused by irritating drugs, such as canthar- ides, copaiba, or turpentine. It may also result from scarlet fever, measles, typhus, typhoid, and sometimes remittent fever. Symptoms.—The acute form generally commences with a chill, followed by fever, nausea, vomiting, and pain in the region of the kidneys, extending along the course of the ure- ters. There is constant desire to urinate, but the quantity passed is small, and is of a dark, dirty reddish, or brownish color. This soon forms a flocculent, reddish, or yellowish sediment, containing the above-named cylindrical casts, with epithelial cells and blood corpuscles. If such urine be boiled, and nitric acid added, it yields large quantities of albumen. oedema of the eyes, face, and extremities soon takes place. Treatment.—When attended with dropsy, tincture of apis mel., alternated with tincture of arsenic, may inaugurate the treatment. Asclepias syriaca has also proved valuable in such cases. I have used the tincture of apocynum cannabinum, in doses of gtt. 5 to 20 every three hours, with the best effects, and at the same time have given the tincture of euonymus atropurpureus, in doses of gtt. 25 to 30, every three hours. The chloride of gold and sodium, in doses of gr. 1-100 to 1-200, has proven effective in some cases. It may be given three times a day, but never in larger doses than the above. The nitrate of uranium has lately been introduced as a remedy in this disease; the dose is gr. 1-10 to 1-20, three times a day. Pilocarpin has also been lately recommended for this disease. Prof. J. M. DaCosta reports a case cured by him in the Penn- 240 THE PRACTICE OF MEDICINE. sylvania Hospital. Many flattering reports come from Belle- vue Hospital of the efficacy of jaborandi. If there is great debility, helonias dioica will aid other indicated remedies in restoring the strength. If there be a want of nervous tone, phosphoric acid (pure diluted) or the hypophosphites may be given with the very best effect. The benzoate of ammonium may be ordered where the urine is smoky and there is pain in the kidney, and when the head is heavy and stupid. Turpen- tine is a good remedy. Chronic Bright's Disease. This disease may be divided into three stages; (1) hyper- aemia and exudation; the kidneys in this stage are enlarged and the uriniferous tubules of the cortical substance contain a fibrous exudation. The epithelial cells are not much changed. (2) In the second stage the exudation is changed into a fatty mass, and the kidneys become still more enlarged, owing to the fact that the uriniferous tubules become filled with epithelial cells which swell, causing the cylindrical casts of the fibrim, which soon collect therein, to undergo a fatty degeneration or transformation. (3) In the third stage atrophy takes place, caused by discharge of the destroyed epithelial cells, exuded cylindrical casts and fatty substances, and by the final de- struction of the uriniferous tubules. Causes.—Exposure to cold and wet may cause this disease; hence it is found more in low, damp, cold climates than in the warmer and drier localities. The abuse of acrid diuretics, such as cantharides, copaiba, turpentine and other like articles, may produce the disease. The use of alcoholic drinks is also a fre- quent cause of this affection. It may result from caries and necrosis of bones, long continued suppuration, and a cachectic state of the system. It may also be the result of certain dys- crasiae: such as gout, rachitis, scrofula, syphilis and malaria. Symptoms.—There is generally more or less pain in the kidneys. The skin and mucous membranes are pale, and the DISEASES OF THE KIDNEYS. 241 patient complains of being very feeble and anaemic. The urine may at first be diminished in quantity, and afterwards increased, but is always loaded with albumen. It is of a pale yellow color, and foams readily when shaken, the foam remaining longer than in any other urine. If heated, and if a few drops of nitric acid be added, it coagulates. Dropsy generally soon shows itself, first in the eyelids, face and feet, and finally upon the upper extremities, scrotum and abdomen. The fluid may fill the cavities of the chest and surround the heart. This af- fection may be complicated with pleuritis, peritonitis, pericar- ditis and meningitis; or follow catarrhal bronchitis, catarrh of the intestines, and hypertrophy and valvular obstruction of the heart. Should the secretion of urine be greatly interrupted there may be uraemia, vomiting, stupor and convulsions. The disease may last for years, or may soon terminate. Treatment.—If caused by exposure to cold, I begin the treatment with small doses of dulcamara, say gtt. 10 to 15, three times a day. If it be the result of using acrid drugs, gtt. 5 of nux vomica three times a day will do good service. Should it rise from the abuse of alcoholic drinks, tincture of arsenic alternated with pulsatilla will be the proper treatment, and a milk diet is necessary. If it follow a cachectic state of the system, or suppuration, I give the chloride of gold in doses of gr. 1-100 three times a day, alternated with the phosphate of lime. If debility exist, I prescribe helonias dioica in doses of gtt. 10 to 20 every three hours, alternated with gtt. 5 of Phytolacca. Euonymus atropurpureus, in the form of a tinc- ture or fluid extract, will aid in regulating the action of the liver, and increase assimilation. If there is excessive flow of urine, rhus aromatica in doses of gtt. 15 to 30 of the tincture three times a day, will regulate the action of the kidneys. Where there is deficient action, and a tendency to dropsy, the apocynum can. in doses of gtt. 10 to 15, may be used every two hours, alternated with the tincture of chimaphila, or moder- ate doses of the tincture of eupatorium purpureum. It requires 16 242 THE PRACTICE OF MEDICINE. strict attention to cure this disease. Turpentine should be tried. Interstitial Nephritis. * This disease has its seat in the uriniferous tubules, and nephritis vera attacks the interstitial tissue which connects these tubules and the capsules of Malpighi. In nephritis the kidney is enlarged, softened, and of a dark red color; and its capsule is injected, thickened, and easily separated. If cut and pressed, it exudes a thick bloody fluid; as the disease advances, the par- enchyma assumes a dirty grayish or brown color; finally suppurating and forming abscesses in various places, which may at last unite. When the collection of pus becomes very great it may be discharged, either into the renal pelvis, the abdomi- nal cavity, intestines or externally. Causes.—External injuries are the most common cause of this affection. It may also result from renal calculi, pieces of bone (sequestra of caries of the spine), inflammation of adja- cent tissues, exposure to cold and wet, or infection of the blood by ichor. Symptoms.—It commences with a chill, followed by more or less fever, and pain in the affected kidney, when only one kidney is affected, or in both kidneys when both are. Pres- sure aggravates the pain, and so does motion, coughing, sneezing and deep inhalation. The pain soon extends along the ureters to the bladder, thigh, and upward into the shoulder of the affected side, There is also a painful desire to void the urine, which usually only passes off in small quantities, and is thick, dark, and mixed with blood. If both kidneys are highly inflamed, there is generally suppression of urine, a condition which is soon followed by coma, delirium or convul- sions. Nausea and vomiting are always present. If chills return at the height of the disease it denotes suppuration. This form of inflammation may also end in rupture and perfor- diseases of the kidneys. 243 ation with their various consecutive symptoms. The prognosis depends upon these different complicated conditions. Treatment.—In inflammatory conditions, aconite in doses of gtt. 1 every hour is the indicated treatment. In the advanced stage, if there be much desire to urinate, small doses of tinc- ture of cantharides, every hour, acts admirably. Pulsatilla in gtt. 1 to 2 doses, may be alternated with the cantharides. If delirium or sopor supervene, hyoscyamus in doses of gtt. 5 should be ordered every two hours. If suppuration takes place, the sulphide of calcium may be used in 1 or 2 grain doses every two hours. This lessens the suppurative process more than any other remedy. Renal Colic. This is an extremely painful affection, being usually caused by the passage of the fine calculi through the ureters into the bladder, which are finally discharged through the urethra. These calculi form in the calices of the pelvis of the kidneys. Occasionally calculi of considerable size pass down into the ureters, but they are generally small. Sometimes they cause the most excruciating pain as they pass along into the bladder, giving rise in males to contraction of the spermatic cords. The pain is thus distinguished from that of all other affec- tions of the abdomen. Symptoms.—There is often vomiting, cold perspiration, cold extremities, small, quick pulse, and collapsed features, in- dicating extreme agony. The pain ceases as soon as the stone enters the bladder, except in rare cases, where the calculus happens to become incarcerated, when it plugs up the ureter, and causes either bursting of that tube or uraemia. The latter is apt to prove fatal. Coagulae of the blood may cause similar painful spells; and so may parasites. The pain is most severe in highly nervous constitutions, owing to the fact that the calculi cause very great spasmodic contraction of the ureters—nephralgia. 244 THE PRACTICE OF MEDICINE. Treatment.—Where the pain is very severe, and of a spasmodic character, I find gtt. 1 to 3 of belladonna very use- ful, given every hour until the mouth becomes a little dry, and if that does not afford relief, give gtt. 20 of gelseminum every hour, until the specific influence of the medicine is manifested upon the eyelids. The cannabis indica in doses of gtt. 5 every hour or two, alternated with the bromides, will give great relief. If the urine be dark colored, and the pain extend to the bladder, the tincture of coccus cacti (cochi- neal) gives good results, in doses of gtt. 5 to 6 every hour. Berberis vulgaris, is doses of gtt. 10 to 20 every hour, also relieves the pain, and so will gtt. 5 or 6 of chloroform. The carb. of calcium is a valuable medicine for the same pur- pose. To cure the disease the citrate of lithium is the best remedy, administered in gtt. 5 doses every hour or two, until relief is obtained, and then three times a day, until the urine is rendered alkaline. Ozonic ether is also effective in doses of 3ss three times a day in water until the calculus is dis- solved. If the calculi be phosphatic, the benzoate of ammo- nium is the proper remedy, or the carbonate of lithium in doses of gr. 5 every two or three hours. If these are not on hand, the citrate of potassium may be given in large doses, every three hours. The prevention of the formation of renal calculi requires a change in the patient's diet, regular exercise to promote digestion, and avoidance of nitrogenous articles of diet. Arnica, in doses of 1 to 3 gtts. will frequently relieve the nephralgia—- renal colic. Piper methisticum is a valuable remedy, dose 10 to 30 gtts. every two hours. Eupatorium purpureum has relieved many, and aids in preventing the formation of the calculi by the dilution of the urine, thus preventing crystal- lization. Lithia carb. 15 grs., three or four times a day has done well for me in many cases. Benzoate of ammonia and borax are very good. CHAPTER XVIII. DISEASES OF THE BLADDER. Cystitis. TNFLAMMATION of the bladder may have its seat in the -L mucous coat, in the serous covering, or it may affect the entire structure of this organ. Where it is confined to the mucous coat it is called catarrhal cystitis, and is characterized by redness, swelling, and an increase of mucus secretion. If it assume a chronic form, the mucous coat may become softened thickened and infiltrated, and covered with a purulent secretion of grayish color. Causes.—Exposure to cold and wet is a fruitful source of this disease. It may also follow injuries, irritating drugs, such as cantharides, turpentine, and balsam of copaiba, irritat- ing calculi, retention of urine, and inflammation of adjacent organs. Symptoms.—There is severe pain in the region of the blad- der, which is aggravated by pressure. The pain may finally extend into the kidneys and through the urethra. In addition to the above mentioned symptoms, there is painful micturition, the urine being voided drop by drop, with a sense of scalding of the urethra. The urine is highly colored and sometimes mixed with blood. The fever finally becomes high, and then there is vomiting, prostration, singultus, and cold perspiration over the body. In chronic cystitis there is not such excruciat- ing pain, but very frequent desire to void the urine, which is turbid, and yields, upon standing, a heavy, bright, thick, viscid sediment, and has an ammoniacal odor. In some cases the bladder becomes so dilated as to prevent the patient from com- pletely emptying it. Paralysis of the sphincter results from 245 240 THE PRACTICE OF MEDICINE. this condition, and the urine passes off involuntarily. In advanced age, the chronic form is subject to frequent acute attacks from anything that irritates the bladder. Treatment.—In the acute form of cystitis, in which the fever is high, the patient should have gtt. 1 of aconite every half hour, or hour, until the fever is reduced, and for the pain gtt. 2 to 3 of belladonna, every two hours. If there be vio- lent burning in the bladder, tincture of arsenic should be given in doses of gtt. 1 to 2 every two hours, instead of the belladonna. If there be tenesmus and burning, drop doses of the tincture of cantharides should be ordered every hour until symptoms are relieved. If cystitis be caused by a fall or blow, drop doses of arnica every hour will give much relief, and should alternate the aconite. In the chronic form, tincture of actinomeris helianthoides is the remedy, in doses of 3 1 every hour, with drop doses of cantharides. In the chronic form the urine should be examined with a good microscope, and if there be calculi, the citrate or carbonate of lithium, gr. 3 to 5, should be given, three or four times a day, until the urine is cleared of the calculi. If there be much mucus in the urine, buchu and uva ursi may be administered in the form of in- fusion, or tincture. I have often found that the tincture of chimaphila will readily arrest mucus discharge. If the ure- thra and glans penis be painful, pareira brava, in the form of tincture or fluid extract, should be given in doses of gtt. 30 to 60 every two hours until the symptoms are relieved. In old per- sons with chronic cystitis the turpentine emulsion in small doses often acts well. If there be great strangury, the tinct. of camphor, in doses of gtt. 5, every two hours often gives relief. The tincture of erigeron is also a valuable remedy, in doses of gtt. 20 to 30 every two or three hours. Santonin, in doses of gr. | to 1 every four hours has given good results. Recently, the actinomeris helianthoides has proved, with me, one of the most trustworthy remedies. Where there is much mucus, the tincture of hydrastis canadensis has wrought a rapid diseases of the bladder. 247 cure, as has silphium perfoliatum. Equisetum hyemale also is a good remedy. Vesical Calculus. The calculi vary in size from those the size of an egg or larger, to those that are only visible with the microscope. They vary also in shape. Some are round, some oval, and some rough and some irregularly shaped. They consist of a combination of uric acid and ammonium, magnesium or lime, etc. Some are hard, heavy, brown, yellow or grayish-white. Those composed of the phosphates are brittle, light, crumbly, and of a grayish-white, or sometimes, of a yellow color. Some are composed of the oxalate of lime; these are the heaviest and hardest of the calculi found in the bladder, and are of a dark brown or blackish color, and uneven outside. Some consist of the carbonate of lime, cystine and xanthic oxide, but these are encountered but rarely. Those composed of mixtures of urates, phosphates and oxalates are of the most frequent occurrence. In these mixtures a nucleus of the oxalate of lime is usually first formed, and then the other earthy salts gradually accrete around this nucleus. The calculi may be few or many. They may first form in small particles in the kidneys, then work their way down the ureters into the bladder, and gradually in- crease in size. If they are formed in the bladder first they are solitary. Symptoms.—In some cases the patient feels the calculus in the bladder, as if it were a heavy substance moving about as he moves. If the stone be not impacted, there will be pain in the neck of the bladder when walking, standing, at stool, and riding in a carriage or on horseback. At rest, or lying on the face or back, the pain may be much less, or altogether cease. Severe exercise is likely to cause a discharge of the bloody urine, and more or less catarrhal inflammation. Sometimes the pain is chiefly felt along the urethra and glans penis. In many cases there is severe strangury, just as the last of the 248 THE PRACTICE of medicine. urine is passing, which continues for some time after urination. Sometimes the calculus, if not impacted, is liable to fall down into the neck of the bladder, producing pain and sudden stop- page of the flow of urine. Occasionally the calculus becomes wedged in the neck of the bladder, causing constant pain, and difficulty in voiding the urine. It may often cause spasm in the vagina in females, or in the testicles in men, and in the kidneys, perinaeum and legs. Examination with the metallic sound reveals the calculus as a hard body, which, on being struck, gives the characteristic metallic sound. Treatment.—I think that lithia carb. alternated with the carb. of potassium, in moderate doses, not only relieves pain in urination, but aids the solution of the calculi. By giving these remedies for several days, then following them by full doses of fluid ex. of eupatorium purpureum and hydrangea arbo. the calculi may be expelled, if not too large for solution. It should always be faithfully tried before resorting to an opera- tion, as that is frequently fatal. The pain can be much miti- gated by the use of mullein tea used freely. This tea should be made of the plant and root. If the stones are large and hard, they can not readily be dis- solved, and belong to the domain of surgery. In the early stage however, something may be done to prevent the forma- tion of calculi, especially if they be of the soft kind, as phos- phates. I am confident that the carbonate and citrate of lithium in gr. 5 doses, have a great tendency to check the formation of these calculi, and I believe that they aid in dissolving them. I feel sure that the actinomeris helanthoides, in strong tinc- ture, aids in preventing their formation, and perhaps, as is affirmed by Dr. Turk, of N. C, in dissolving calculi already formed. Sarsaparilla is believed to have the same effect, and so is hydrangea arborescea, given freely. Chimaphila, erigeron, eryngium, eupatorium aromaticum, and corydalis have all been recommended as efficient remedies, although their lithontriptic powers may not be so positive as has been supposed. I have DISEASES OF THE BLADDER. 249 never entirely dissolved the calculi when large, but have often carried them away when small, by giving carbonate of potassium alternated with chimaphila and hydrangea in large quantities in the form of infusion. If upon examination with the micro- scope, I find small calculi in-the urine, I give the carbonate of lithium in doses of gr. 15 three times a day until it gives re- lief, or the benzoate of ammonia in alternation, in doses of 6 to to 8 grs. The tincture of liatris spicata is a very positive remedy in this disease, dose 10 to 30 drops. CHAPTER XIX. DISEASES OF THE MALE ORGANS OF GENERATION. Gonorrhoea. THIS is a catarrhal inflammation of the genital organs of a specific character, acquired by coition with an individual already contaminated. It is first seated, in the male, in that portion of the urethra lying back of the glans penis, the inflam- mation extending sometimes back to the bulbous and the membranous portion of the urethra, and finally to the neck of the bladder. In females the inflammation extends over the vulva, vagina and urethra, sometimes spreading back even to the neck of the uterus. In this last case it is quite trouble- some. Symptoms.—The stage of incubation is generally from three to eight days, although I have seen cases in which the disease showed itself in some thirty-six or forty-eight hours. These cases, however, are rare, for it generally takes six or eight days for the virus to produce its specific effects, and it may take two or three weeks. One of the first symptoms is a tickling sensation at the orifice of the urethra, and with males, in the fossa navicularis. Very soon there is an increased secretion of mucus in the urethra, which causes its lips to stick together. The tickling soon changes into a burning sen- sation, and the mucus, which was at first transparent, grad- ually grows thick, yellowish, greenish, or even bloody. The orifice of the urethra becomes highly inflamed and swollen, and tender when pressed between the thumb and finger. A rather tensive pain extends along the urethra into the testes and inguinal regions, and micturition becomes very painful and frequent In some cases the glands in the inguinal 250 DISEASES OF THE MALE ORGANS OF GENERATION. 251 region becomes swollen and sore, like a bubo, but unlike it do not suppurate. If the patient exercises freely, or indulges in highly stimulating food or drink, the testicles become inflamed and swollen, and the spermatic cords sore and enlarged. In what is called synochal or phlegmonous gonor- rhoea, the inflammation extends into the parenchyma of the glands, which becomes dark and swollen. It may also extend into the corpora cavernosa, with exudation, forming hard nodes in the penis. This gives rise to chordee, which, during an erection, draws the organ sideways or downwards, giving great pain to the patient. Occasionally the urine can only be passed in a small stream, or drop by drop, with great strain- ing and pain. In this case the discharge may become dark, bloody, or ichorous. The prepuce may contract, and phimosis may result; or contraction may occur behind the glans penis, and paraphimosis may set in, which renders the suffering still greater. In some extreme cases the inflammation spreads back to the neck of the bladder and the adjacent areolar tissue, giving rise to abscesses which form and break through the perinaeum, forming fistula urinae. Again, the disease may be of an indolent character, giving rise to but little pain, and lit- tle inconvenience, except a profuse mucous discharge. Some- times there is an erysipelatous gonorrhoea, in which the glans penis becomes greatly inflamed and swollen, and there is a watery, ichorous discharge. The disease, if left to itself, gen- erally runs into a chronic form, called gleet. When this hap- pens there is no pain, except a fixed pain in the fossa navicu- laris, and the discharge is generally thin and watery. Some- times, however, it is thick and yellow, now passing freely, and now in small quantities. This form may continue for years, in spite of all treatment that is instituted. In females the symptoms are very similar to those above described, but the disease is less painful to them than to men. In high degrees of inflammation, and when it extends to the urethra, the clit- oris, and labia, it may become painful. In such cases the dis- 252 THE PRACTICE OF MEDICINE. charge is quite profuse and deeply colored, excoriating the internal parts as it passes off. It may produce condylomata on the inside of the thighs, on the labia, and around the anus, causing much suffering. Excoriations and ulcers often occur upon the os uteri, and sometimes the disease extends into the womb and ovaries, producing chronic catarrhal affections that are very difficult to cure. A non-specific form of catarrhal inflammation very much resembles gonorrhoea, and it requires a very thorough knowledge of the characters of each to distin- guish between them. Non-specific or benign affections of the genital organs are milder than gonorrhoea, and run their course in a few days without treatment. It is often very dif- ficult to distinguish between gonorrhoea in a female and an acrid case of leucorrhcea, but it must be remembered that acrid leucorrhcea may produce a discharge in a man that has not had intercourse with a woman affected with gonorrhoea. The peace of families depends upon the proper diagnosis in such cases. Treatment.—I have found that gtt. 1 of aconite and gtt. 20 to 25 of gelseminum every three or four hours, and a wash of the sulphate of zinc gr. ^ to 1 to the ounce of water, are all that is required in the first stage of the disease, and often abort it. If the inflammation is high and the discharge scanty, gelseminum should be continued until the inflamma- tion is materially lessened or subdued. An injection of 3 1 of tincture of yerba reuma to 3 3 of water, is a very valuable remedy; so also is boracic acid, sat. As soon as the inflamma- tory symptoms are subdued, gtt. 5 of cannabis sativa should be given every three hours. This and the cannabis indica are valuable remedies. In the subacute stage I give an injection of hydrastis canadensis, 3 1 to aqua § 8. If there are painful erections, chordee, and inflammation extending into the blad- der, drop doses of cantharides should be given until these symptoms are subdued. Should the disease produce orchitis, small doses of pulsatilla, say gtt. 3 every hour, and a poultice DISEASES OF THE MALE ORGANS OF GENERATION. 253 of mullein leaves, will give excellent results. In the advanced stage, in which the discharge is profuse and thick, gtt. 10 to 15 of copaiba three times a day will aid in the cure. I have found the tincture of the oil of sandal wood (1st dec. dilution) to do better, indeed, than copaiba. Recently the eucalyptus has been highly praised as a curative in this disease. I have had much success lately, in several severe cases, with piper methys. (the kava kava), given in doses of gtt. 30 to 40 three times a day. Some writers also speak highly of the silphium gummiferum. I have succeeded in aborting the disease by using gr. 5 of permanganate of potassium to the ounce of water, as an injection, twice daily for three days, and then using gr. 1 to 2 of it to § 1 of water. If the discharge becomes very thin and profuse, an injection of gr. 5 of alum to the § 1 of water will usually check the flow. An injection of the tincture of yerba reuma 3 1 to 1 3 of water, is also pos- itive. Echinacea is a valuable remedy. Sequels.—One of the most common complications is orchitis. Very often one testicle swells, and the swelling extends to the other. At first this may be soft and elastic, but it soon becomes hard, painful and red, and is attended with more or less fever. Orchitis follows strong injections, too free use of astringents, undue exercise, and taking cold. It is very apt to supervene when the gonorrhceal discharge is too suddenly suppressed by injections. Treatment.—Orchitis caused by taking cold should be treated with small doses of clematis and dulcamara, and poul- tices of warm, fresh, green mullein leaves. As an internal remedy I have found gtt. 2 to 3 of pulsatilla, every two or three hours, very successful. Tussilago may be used if the above fails. Rhus tox., in doses of gtt. \ to 1 every three hours, will aid in the cure. If the prostate gland is involved in the inflammation, thuja acts well in gtt. 2 to 5 every two hours, alternated with tinct. of pulsatilla nut (the anemone). Equisetum hyemale is a good remedy. 254 THE PRACTICE OF MEDICINE. Vesical Gonorrhoea. If the disease be transmitted to the bladder by suppress- ing the discharge with astringent injections, there will be vio- lent pains in the region of the bladder, perinaeum, and anus, with a constant desire to urinate, only a few drops passing at a time. The treatment is similar to that of cystitis. If there is a burning sensation in the bladder, the tincture of canthar- ides, in doses of gtt. 1 to 3, may be given every one or two hours until this pain ceases. Copaiba in small doses may then be prescribed for a few days in the form of tincture. Bubo. The inguinal glands are liable to inflame in this as well as in other diseases of the genital organs. It is possible for the virus, by absorption, to produce this affection of the glands, but it is most commonly superinduced by over-exertion or suppression of the discharge. As soon as the glands are dis- covered to be enlarged, indurated and sore, they should be painted with an ointment of iodoform, and the comp. tincture of iodine given in doses of gtt. 3 every three hours. Stricture of the Urethra. This consists in a fibrous hardening of certain portions of the urethra, whereby the organ becomes so narrowed that the urine can pass through only with difficulty or perhaps not at all. The main seat of the stricture is in the membranous por- tion of the urethra and the fossa navicularis, though other parts may also become diseased when involved in the inflam- matory process. The first symptom is the difficulty in making water. The stream of urine will be small, twisted, split and jerky in its flow. Very often, from the bladder's not being completely emptied, there will be dribbling of the urine for sometime after micturition. The strictures that follow this disease are generally caused by over strong injections, such as diseases of the male organs of generation. 255 nitrate of silver, sulphate of zinc and copper, or any other strong substance. Treatment.—Clematis may aid in the removal of this trouble, and so may digitalis. Dulcamara and pulsatilla are also valuable remedies. Rhux tox. will also sometimes give excellent results. Occasionally the introduction of bougies, of the proper size, will overcome the stricture ; if not it requires a surgical operation. Syphilis. The chancre is the primary lesion of syphilis. The term chancre is derived from the word cancer, which means a cor- rosive ulcer, with hard bottom and callous edges. This des- cription of the chancre frequently corresponds to that of the syphilitic ulcer. It commences usually upon the genital organs where the virus generally first infects the patient. In males, the glans penis, prepuce, fraenum, front part of the urethra, external parts of the penis, scrotum, and sometimes the groins are primarily infected. In females, the labia, vagina, urethra, and even the neck of the uterus are first attacked. In rare cases, it is possible for the virus to be transferred to such portions as are liable to be infected by it, as the lips, tongue, nipples, denuded parts of the fingers, and other portions of the body. It is an unsettled question as to whether chancre is ever merely a local affection, or always constitutional. The latest opinion, of at least a majority of writers, is the follow- ing:—there are two kinds of virus; one, which they think never causes anything but a local complaint, consisting of an ulcer, where the virus is inoculated into the skin, and some- times more or less suppuration of adjoining lymphatic glands. The other virus invariably produces a local ulcer and consti- tutional disease, which extends its destructive disturbances to the whole nutritive system. The following characteristic differences are given: the simple chancre develops itself out of a macula or papula, the surface of which continually peels off 256 THE PRACTICE OF MEDICINE. until the skin appears excoriated; or else we see at first a small vesicle or pimple, which finally bursts. We may also observe a chafed spot, which does not heal, but soon becomes covered with a dirty exudate finally forming an ulcer, which in differ- ent cases may present quite a variety of aspects. It may rapidly decompose the parts in which it is located, spreading in various directions, having well defined edges, and the base being covered with a dirty looking fatty substance, which is called diphtheritic chancre, or the ulcer may be rather superficial, and only look like an excoriation of the skin, spreading grad- ually in circumference, but not in depth. This is the superfi- cial chancre. Again, the disease may develop itself in a sebaceous gland, in which case it shows a very small circumfer- ence, but appears comparatively deep. This is the follicular chancre. All these forms of simple chancre may assume a phagedaenic or even a gangrenous character, but they have no induration at their base, and consequently are called soft chancres. The ability to distinguish between the soft chancre and other ulcers is not always easy, unless the history of the case decides it for us. Some writers advise the inoculation of the secretion of the ulcer upon the thigh of the patient, and say if this takes, it proves to be a soft chancre. The constitu- tional chancre may be known by the following characteristic: a hard papule or knot, which may be the size of a pea or bean, or even as large as an acorn. This induration consists of cells and granules, without any characteristic peculiarities, which are imbedded in the normal tissue. Constitutional Syphlilis. Syphilis may sometimes cause nothing but a swelling of some of the lymphatic glands; but generally gives rise to a train of unmistakable symptoms. As soon as the primary ulcer heals, there may be a truce for several weeks before condylomata, exanthemata, or other signs of the syphilitic infection show themselves. Then, after these disappear, still another period of DISEASES OF THE MALE ORGANS OF GENERATION. 257 comparative good health may be enjoyed, when a second series of syphlitic symptoms appear. There are cas.es, however, in which the periods of apparent health do not supervene, but the secondary symptoms develop themselves whilst the recent chancre yet exists, although, as a rule, the secondary symptoms do not appear before the expiration of eight or ten weeks after the first infection, and about the same length of time elapses between the secondary and tertiary symptoms and aggravations. The order in which constitutional symptoms develop themselves is not always uniform. Generally indolent buboes appear, then condylomata, exanthemata, superficial ulcers of the mucous membranes, and iritis, all of which are considered as secondary affections. Later syphilitic lupus, periosteal nodes, induration of the subcutaneous, submucous, and interstitial tissues, and affection of the muscles and inner organs set in, and are called tertiary affections. Sarcocele seems to stand between these two stages, and there are cases in which destructive processes take place at first in the bones, before any constitutional symptoms are developed. This last is believed to be conse- quent upon the abuse of mercury. Febrile symptoms precede the outbreak of constitutional affections. Syphilitic cachexia seems to be produced by a mercurial treatment, the excessive drain attendant upon it, combined with ulceration, thus gradually undermining the constitution, and retarding the nutritive functions in their normal operation.* The induration of the chancre may be very thin, and if this be the case, it is called the superficial constitutional chancre. Again an excoriated surface may appear, elevated above its surroundings, secreting a very scanty, thin fluid; or, perhaps, nearly dry with deep induration underneath. This is called the elevated constitutional chancre It may be that the ulcer has not only a hard basis, but has raised, hard and callous edges; this form is known as Hunter's constitutional chancre. The stage of its incubation is from three t6 four *See Headland on the Action of Medicine. 17 258 THE PRACTICE OF MEDICINE. weeks. If its secretion be inoculated upon the thigh of the patient, it does not take; thus showing that the virus is already in the whole system. It resembles small-pox virus in this particular. The indurated chancre differs also from the soft one, in that it is indolent, not painful, and generally ap- pears alone, except in cases in which the virus entered the system at different points at the same time. % This chancre scarcely ever leaves a cicatrix when it heals, whilst the soft chancre always does. Infection with one form of chancre does not hinder the infection with another form; hence we may have both the soft and the hard chancre in the same case. Coitus with an infected person is the common source of this disease. Clothes, utensils and sleeping apartments, may be soiled by the virus, which, if brought in direct contact with any denuded surface on the body, may produce syphilis. The constitutional poison is carried by the lymph-vessels, and a healthy child may become infected by vaccination, provided the vaccine matter be taken from an infected person. The first sign of healing in a soft chancre is cleansing of the dirty looking base, and the springing up of new granulations upon its surface. By these the ulcer closes, and finally heals, leav- ing a well marked cicatrix. In healing, the indurated chancre gradually softens, just about the time that secondary symp- toms appear. The hard chancre leaves behind a discolored spot, of a brown, red or copper color, which remains on the body as long as the virus lurks in the system, and disappears with it. Treatment.—In view of the double nature of the virus producing indurated, or hard chancre and soft chancre, a some- what different treatment from that formerly given, is pointed out. Formerly, before mercurial preparations were depended upon, we used remedies in each stage of the disease according to the nature of its manifestation That the use of mercury has done great harm no sound pathologist and experienced, un- prejudiced therapeutist will deny, and that the indiscriminate use of mercurials, in massive doses, often produces many of the DISEASES of the male organs of generation. 259 so-called tertiary symptoms is established by the best authori- ties, such as Headland and Ringer, of England, and many others in the United States. It is apparent, from the success with which it meets, that the compound iodide is the remedy in cases of indurated chancres, indolent buboes, and indurated glands, and after the abuse of mercury. I use echinacea with iodide of potassium, 3 2 echinacea § 8; dose a teaspoonful three time a day. This will not at all injure the constitution. The mercurials when surcharged with iodide (for which it has a most powerful affinity) will do less harm in the iodine than if given alone, and can not leave any baneful effects if given in proper doses. In cases of long standing, after the abuse of mercury, when there are painless ulcers, with gray everted edges, which bleed easily; or where there are superficial ulcers, with zig-zag elevated edges, or ulcers with callous, hard edges, under which is an ichorous secretion; or where there are mucous, moist condylomata, or inflamed buboes, nitric acid, in doses of gtt. 1 to 3, three times a day, often manifests a cura- tive power. Where the ulcers are round and deep, a strong solution of bi-chromate of potasium applied on lint will have a good effect, say gr. 5 to f 1 of water. If the case goes on to the tertiary form, and there are still deep ulcers with hard edges, or if in the secondary form there be hard buboes, pain in the bones, and falling out of the hair, iodide of potassium will do good service, and should be given in moderate doses. At the same time the tincture of stillingia and corydalis, in doses of gtt. 30 each, three or four times a day, will aid the iodide of potassium in its cure. In the primary stage, if the chancre assume a gangrenous aspect, Donovan's solution, in doses of gtt 3 to 5, three times a day, may be given, and the chancre dressed with permanganate of potassium, gr. 5 to the Z 1 of pure distilled water, or with an ointment of iodoform, gr. 10 to the 3 1 of lard. Primary chancre should be touched with a pine stick first dipped into nitric acid, and after it dries 260 TH*E PRACTICE OF MEDICINE. be dressed with dry calomel, which will heal it. Stillingia and iodide of potass|um are the remedies for the tertiary form, especially for ulcers upon the palate; they should be given in moderate doses. In the tertiary form the chloride of gold, in doses of gr. y^- to ■£w three times a day, acts well, espe- cially when there is sarcocele, osseous affections, lupus, ozoena, or any other syphilitic inflammation. For condylomata I have found thuja an excellent remedy, and I give gtt. 3 to 5, three times a day. I apply the tincture the same number of times daily to the parts affected with fig-warts, and it causes them to disappear under its external and internal use. For buboes, indolent or not, I have found iodoform one of the best applica- tions. I melt gr. 5 to 10 in 3" 1 of alcohol. Where the ulcers in any stage, do not yield to the application of nitric acid, I use a solution of chloride of zinc, gr. 2 to 3 to § 1 of water, and apply on lint. I never could accomplish much with sar- saparilla, the old remedy for this disease, I believe that the rhus venenata, if properly used, would prove a valuable rem- edy, especially in the tertiary form. Its dose is not more than gtt. i| to 1, as it is highly toxical. I have recently treated some cases of secondary and tertiary syphilis, after all the old remedies had failed, with the fluid extract and tincture of the berberis aquifolium, and succeeded admirably. This root has general tonic powers and very active cataleptic properties, both of which render it one of our best remedies in the tertiary form of syphilis, especially in cases of long standing, very much reduced by a course of mercury. I have recently tried caroba (fluid ex. of the leaves made by Parke, Davis & Co.) and find it to be a very active anti-syphilitic, especially in the tertiary form. I have also tried, recently, in a case of some standing that had resisted the ordinary treatment cascara amarga, aceitillo bark, and the caroba leaves (in the form of fluid ex.) all combined, and cured a case of the tertiary form in a very short time. The young man had had the usual mer- curial course, and then the iodide of potassium in the tertiary DISEASES OF THE MALE ORGANS OF .GENERATION. 261 stage, but all to no purpose. He came to me with extensive ulceration of the soft palate and mucous membrane of the mouth, both of which disappeared in a few weeks under the above treatment. Recently I have been testing echinacea angustifolia and have found it a most potent remedy. I make saturated tincture of the fresh root, crushed, and give 30 to 60 gtts. three times a day. This has proved with me, one of the most active antisyphilitics, and will give satisfactory results. CHAPTER XX. DISEASES OF THE TESTES. Hydrocele. THERE is a serous membrane that encloses the testicles and epididymis, in the form of an enclosed sac, consisting, like the pleura, of two blades, the tunica vaginalis propria and the tunica vaginalis reflexa. This, like, other serous tissues, is liable to exudation, and when that occurs, it constitutes hydro- cele or dropsy of the scrotum. This may exist with general drop- sy, in consequence of hydraemia, as found in old age, or it may be the result of tuberculosis or of other chronic affections; some mechanical irritation of an inflammatory nature may also give rise to it. It is sometimes found in young and healthy per- sons. Like peritoneal and pleuritic effusions also, it may become chronic, and the enlargement may thus be very great. In such cases, the scrotum appear smooth, tense and glisten- ing; and the testicles, being compressed, becomes atrophied, and sometimes gradually disappear entirely. In this case the scrotum becomes like a transparent bladder. Perhaps the undue irritation may cause enlargement of the testicle, which becomes indurated and forms cysts; and the exuda- tion may coagulate and become mixed with blood and pus globules, and cause adhesions. In ordinary cases of hydro- cele, the testicle lies in the upper and posterior portion of the scrotum, the lower portion of the scrotum being filled with the fluid. If, however, previous inflammation has existed, adhesions may arise between the testicles and lower part of the scrotum, so that the testicles will be confined low down in the scrotum, and the fluid gathered above. Hydrocele may be mistaken for scrotal hernia, but may be distinguished from it 262 DISEASES OF THE TESTES. 263 by carefully comparing the history of both these affections. The neck of a hernia is traceable into the abdominal ring, while hydrocele only exists in the scrotum. Treatment.—If this disease originate from an injury, such as a blow or fall, gtt. 1 to 2 of arnica, alternated with gtt. 2 of pulsatilla, every three hours, often cures the disorder in the early stages. In sporadic cases the chloride of gold and sodium in doses of gr. 1-50 to 1-100 three times a day may be tried, while the diluted tincture of iodine is used locally. In old chronic cases an operation is required to effect a cure. Orchitis. The testicles themselves are the seat of the inflammation here. Orchitis may either follow external violence, or it may be an extension of the inflammatory process from other organs related to the testes, such as the prostate, the neck of the bladder, or the urethra. Again, it may be the result of syphilis. There is a form that is caused by a metastasis in mumps. Orchitis may cause a serous exudation, especially when it at- tacks the epididymis or tunica vaginalis, and is then exceed- ingly like acute hydrocele. Again, orchitis may cause a fibrous, plastic exudation, which causes.infiltration, swelling and finally induration of the epididymis. It may also result in a serous haemorrhagic exudation, in cases of acute specific orchitis. It may arise from a purulent exudation into the parenchyma of the testicle itself. Plastic exudation commonly results in chronic enlargement of the epididymis. Purulent exudation may be reabsorbed, or it may cause abscesses, which gradu- ally break through the scrotum. Such abscesses are very hard to heal, and are apt to form fistulous openings. A case of orchitis very much resembles a case of incarcerated hernia of the scrotum. The pain is very severe, running along the spermatic cord, and causing nausea, vomiting and colicy pains. In such cases we must have the previous history of the case, and must know where the swelling commenced. In a case of 264 THE PRACTICE OF MEDICINE. orchitis the swelling starts from below and goes upwards; but in scrotal hernia it comes from above and advances downwards. This is the most characteristic diagnostic symptom. I have known many physicians to make grave mistakes from the want of the previous history of the case. Treatment.—At the outset, there is no remedy better than aconite, which may be given in small doses, repeated every ten or fifteen minutes, say gtt. 10 in four ounces of water, in doses of one teaspoonful every ten minutes. At the same time the scrotum shouTd be bathed frequently in a strong infusion of mullein leaves. After the circulation is controlled by the aco- nite, gtt. 1 to 3 of pulsatilla should be given every two hours. This has a direct affinity for the testicles, and is a remedy for the advanced stages of orchitis. If the inflammation follow gonorrhoea, cannabis indica may be given in doses of gtt. 2 to 5 every three hours, alternated with gtt. 2 of clematis, or pul- satilla every two or three hours. If the skin is a bright red color, gtt. 1 to 2 of belladonna should be administered every two or three hours. In chronic cases iodine is the best remedy, gtt. 1 to 2 three times a day. Varicocele. This affection consists of a varicose enlargement of the veins of the spermatic cord, and gives rise to a knotty swelling, which feels like the convolutions of earth-worms. It is much larger in the erect position than in the horizontal one. It usually forms on the left side, and its causes are rather obscure, as it seems to have no connection with varicoses of other parts. If it be slight it causes no great inconvenience, but otherwise it is very troublesome, causing an unpleasant dragging sensa- tion, which extends down into the leg, especially when walking. It also gives rise to weakness, prostration, paleness, and great dejection of spirits. Treatment.—I have generally treated it in the first stage with hamamelis, gtt. 1 to 2, four times a day, and lint moist- DISEASES, OF THE TESTES. 265 ened with the tincture applied frequently to the parts. Fluoric acid (of the 3d dec. dilution, in doses of gtt. 1 every three hours) is recommended. Collinsonia is a valuable remedy, and it may be ordered in doses of gtt. 3 to 8, every two or three hours, alternated with hamamelis. I have always found this drug one of the most trustworthy, and with it, used as above directed, I have cured several recent cases. If the disease is of long standing, it will require the aid of surgery to cure it. Impotence. This disability for sexual embrace may be transient, or a total want of virile power may exist. Mere partial or transient impotence may be the result of a feeble state of the sexual or- gans, or arise from spermatorrhoea. There may be the power of erection of the penis at the proper time, or there may be total inability to erect. There may be relaxation in the midst of sexual embrace, and again in old masturbators, the semen is ejected immediately upon the introduction of the penis, and in some cases before the introduction. Total impotence has its origin in some functional debility of the genital organs, in which case erection is impossible. In some cases the testes are unusually small, atrophied, and soft, the scrotum is relaxed and pendent. The penis, too, is small, shrivelled, and inclined to be colder than natural. In some cases the causes may lie in the spinal cord and brain. It is occasionally connected with diabetes, and I have known a great many cases that resulted from excessive venery in youth. A large majority occur from early excess in venery. Treatment.—If impotence be the result of excessive in- dulgence, rest and nux vomica, alternated with the hypophos- phites, will generally relieve it. As a tonic, helonias dioica has a good effect in debility of the sexual organs. Stillingia also has a tonic effect upon these organs, and may be used with benefit in many cases. One of the best remedies for impotence, resulting from excessive indulgence in the sexual appetite, is 266 THE PRACTICE OF MEDICINE. damiana. I have given it in a great many instances with the best results, in doses of 3 1 to 2, three times a day. If there is any spinal deficiency, or lack of nervous tone, the hypophos- phites alternated with nux vomica are required. A current of electricity run through the brain and spinal column thrice a day will doubtless also do much good. Diet may aid materially, if properly selected. I prescribe eggs, fish, oysters, meats, milk, and graham bread. The patient should take moderate exercise in the open air, but not fatigue himself. He should also take a cold hip or shower bath every morning unless too great debility exists. CHAPTER XXI. DISEASES OF THE PROSTATE. Prostatitis. r I iHIS is an inflammation of the prostate gland. Primary -L prostatitis is not of very frequent occurrence, but may occasionally follow injuries, blows, riding on horseback, or result from sudden suppression of perspiration, excesses in venery, and freqeuntly from masturbation. Secondary forms are of frequent occurrence, and generally consist in the exten- sion of the inflammation from adjacent organs; as from ure- thritis, stone in the bladder, gout, rheumatism, etc. One of the most frequent causes is gonorrhoea, and also the abuse of irritating medicines, as cubebs, balsam of copaiba, turpentine, and strong injections. Symptoms.—The most noted symptoms are pain at the neck of the bladder, heat, pressure, throbbing in the perinaeum and rectum, and frequent stitches from the perinaeum into the pubic and lumbar regions, and down the thighs into the legs. Constant pains around the corona glandis. The urine flows slowly, drop by drop, a quantity often remaining in the blad- der, and consequently, micturition fails to give relief. In severe cases there is retention of urine. Defecation is also attended with pain. If the finger be introduced into the rectum, the gland will be felt as a hard substance. In favor- able cases prostatitis may end in resolution; but badly treated cases may suppurate and form abscesses, which perforate, either into the rectum, bladder, or urethra, and discharge ac- cordingly. Some cases assume a chronic form, and in conse- quence of exudation, infiltration, and deposition of tubercles and cysts of calcareous substances, produce a permanent en- 267 268 THE PRACTICE OF MEDICINE. largement of the prostate. This hypertrophy may reach the size of the fist, and may even be larger, or it may only affect single lobes of the glands, in which case it is not so large. Sometimes only the lateral lobes are enlarged, caus- ing irregularities in the direction of enclosed parts of the urethra, compressing it more or less in places, and so forming a kind of zig-zag passage. Again the posterior part of the enlarged lobe presses into the bladder, and, in this way, from without, shuts the neck of the bladder inside, or gives it an oblique direction. Enlargement of the middle of the lobe or isthmus, which is the deformity most frequently found in old age, is apt to cause a partial or entire closing of the neck of the bladder, thus either obstructing the passage of the urine, or entirely preventing its passage. For this reason old men frequently have to use the catheter for years previous to their death. In such cases the prostatic fluid passes off at stool sometimes. Treatment.—This affection is diagnosed simply by intro- ducing the catheter into the urethra. If there is obstruction in the prostatic portion and the patient experiences difficulty in urinating, or if there is dribbling of the urine, and frequent discharges of prostatic fluid when at stool, enlargement may then be expected; and if the finger be introduced into the rectum the enlarged gland can be felt. Where there is frequent desire to urinate, a dull pain in the region of the neck of the bladder, and spasmodic pains in the bladde* after urinating, pulsatilla should be used in doses of gtt. 2 to 3, every two hours, until the symp- toms are relieved. If this fail in two or three days, I find gtt. 10 to 15 of tincture of digitalis, given three times a day, or gtt. 3 to 5, every two hours, very useful, in alternation with the pulsatilla. Where there is a frequent discharge of the pros- tatic fluid, ignatia amara in the form of tincture, is one of our best remedies; the dose is gtt. 2 to 3. Prof. E. M. Hale recommends barosma crenata, chimaphila, iodide of barium, populin, senecio aureus and turnera aphrodisiaca (this is a i DISEASES OF THE PROSTATE. 269 good remedy) in this disease, especially for hypertrophy of the gland. Where it follows gonorrhoea, thuja occidentalis, in doses of gtt. 2 to 5, is one of the best remedies we have. Ergot, in doses of gtt. 15 to 20, is also effective. Iodide of barium is a valuable remedy. Onanism. This dangerous, sinful and destructive habit is often con- tracted in early youth, and not infrequently in childhood. Among the many instances which show the contagiousness of vice, none are more striking than this. The baneful influence of the bad example of other children at boarding schools often spreads this worst of vices among the younger members of the school, who are not aware of its real turpitude, or its des- tructiveness of mind and health. It may also be self-invented in early childhood by children whose virile powers are very active, and whose moral faculties are not well cultivated. It is, however, oftener learned from some vicious companion who has long been a victim of this unnatural, wicked and self-des- troying vice, more ruinous to health and morals than any other in the dark catalogue of crimes. It is spreading stealthily, and almost without an effort to stay its onward progress, and bids well ere long to sap the strong foundations of religion and morality, unless its inundating tide be rolled back and forever stayed in subjection. It is becoming alarmingly prev- alent everywhere, both in town and country, and reigns as the scourge of our youth, as well as the grand cause of the deterior- ation of our race. The human family is on the increase all around us, generation after generation, and this evil should fill the mind of every christian philanthropist with gloomy fore- bodings as the future physical degeneracy approaches. This damnable vice, the destroyer of mind, health, and morals,^ is not confined to the male sex, but has also made its destructive inroads within the secret precincts of female chastity. That universal thirst for fictitious reading in females is leading to 270 THE PRACTICE OF MEDICINE. this as well as to other vices of a degenerate age; and the voice of the minister of God, and the pen of the philanthropic physician should never cease until the progress of these twin vices is forever stayed. I was criticized in a review, in the first edition, by an unchristian misanthropist, but I care not for his attempted sneers. Some, I know, will sneer at the idea above put forth and will hurl upon me their anathemas; but truth and duty compel the revelation, although I incur the displeasure of many of the fair votaries of what is vulgarly called polite literature. The unreal, fanciful trash, that is flooding the country and being devoured by the young instead of solid science, is exerting a destructive influence upon the morals of our eountry, and its evil consequences should be depicted to the mind of the young of both sexes. The sensa- tional sketches found on almost every centre table, breathing love and passion in every line, are cultivating a vitiated taste, and are inflaming the young mind with an uncontrollable passion for the sexual appetite. The powerful impression made upon the mind by the trashy and abominable books that are flooding the country are impressed upon the nervous sys- tem, and through it upon the sexual appetite, as the legitimate sequence of cause and effect. However early this detestable habit may be contracted, the victims but too frequently succeed in concealing it from parents and others interested in their wel- fare until its destructive effects tell upon their physical sys- tem in a peculiarly pallid countenance, sunken eyes, and downcast and gloomy look. Or perchance it manifests its ruinous influence upon the mind by an impetuous irascibility that renders them unfit for the companionship of others. It may also enfeeble the intellectual faculties by degrees, until it produces the lowest state of: imbecility, or even raving and incurable insanity. But, before it ends in insanity, the ner- vous system and physical powers become shattered, the diges- tive and assimilative organs prostrated, the patient grows feeble and anaemic, the joints are weakened and there is not DISEASES OF THE PROSTATE. 271 unfrequently spinal curvature. In females, it gives rise to chlorosis and chorea, and in either sex there is often epilepsy, neuralgia, rheormatism, nervous headache, chilliness of the body, especially, of the extremities, and finally inability for intellectual or physical pursuits supervenes. If the victim has fallen a prey to this destructive vice in early years, growth is stunted, and there will be enlargement of the lymphatic glands. Not unfrequently there may be tubercular deposits in the lungs or other viscera; or perhaps scrofula will be developed. Many cases of this disease and of consumption are attributable to onanism. It is now a well attested fact that these diseases have their foundation in an enfeebled condition of the molecular vital forces, which, of course, soon deterio- rates the blood and deprives it of its wonted pabulum —the blastoderm of healthy tissue, and consequently, an unhealthy tissue is formed, or one of such low vitality that it is incapable of sustaining organic life, and tubercle is the result. When such a result is about to take place, there will be contraction of the chest, rounding of the shoulders, great weakness of the joints, a sunken appearance of the eyes, which lose their lustre and the countenance becomes pale and the patient shy. A dark circle forms around the eyes, the vision often becoming impaired, and not unfrequently destroyed; the hair falls out more or less; there are pains in the back and limbs, and an aversion to sitting still; and headache, with often an inability to sleep soundly, from frightful or lascivious dreams. Other symptoms then supervene, such as great loss of color, pallor and softness of the gums, and fcetidness of the breath. The countenance becomes dusky and very much dejected, and some- times there are sores on the face. In females, leucorrhcea, scanty or painful menstruation, spinal irritation, and hysteria take place. All the functions become disordered, and special forms of neuroses follow, as epilepsy, palpitation and some- times disease of the heart, melancholia, mental wretchedness, palsy, enlargement of the spermatic chords, testes, and pros- 272 THE PRACTICE OF MEDICINE. tate glands in males, urinary diseases, consumption and insanity. The digestive and assimilative organs are very much impaired at this stage and constipation is persistent. The sexual organs themselves now become greatly disordered, the frequent unnatural excitement they have been subjected to causing an increased secretion in men or boys, with inflam- mation and hypertrophy of the glands, irritation of the vesi- culae seminales, and finally atrophy of the testes, followed by involuntary emissions, particularly at night. The patient, in spite of his fears, that are now awakened by his alarming symptoms, can not control his habit. If he resolves to reform, he either masturbates in his sleep or has lascivious dreams with emissions of semen in spite of his strongest efforts to refrain. Habit has now asserted her dominion over him, bound his moral faculties in her own iron fetters, and he is the unwill- ing slave of the deadliest and most detestable vice that ever shocked the sensibility of humanity. This sinful and health- destroying habit is often contracted in much earlier years than the non-professional suppose it to be. At school one may see boys that were once sprightly and buoyant, becoming sad, thin, irritable and bashful; their features too, assume a haggard aspect, their eyes become sunken, their countenance wear a cadaverous expression, and their downcast faces evince consciousness of their guilt. Though some children are naturally timid, yet a large majority of them are made so by self-pollution. Such boys may be known by having cold, moist hands, short, unrefreshing sleep, marasmus, nervousness, spasmodic contractions, and convulsive affections of the mus- cles. There are yet other visible signs of this destroyer of youth. When the little culprit, who formerly evinced consid- erable intelligence, and possessed a retentive memory, begins to show greater difficulty in acquiring his lessons than before, the cause may be found in the formation of this detestable habit. If it is not now abandoned at this stage, the victim's DISEASES OF THE PROSTATE. 273 health soon fails, and he too soon finds out the full extent of the ills of the workers of iniquity. If this vice be indulged in only to a limited extent before puberty, it may be sup- pressed by timely instruction; by instilling into the young mind virtuous principles, properly portraying the hideousness of the vice, and depicting its evil consequences. If, however, it pass that age and becomes confirmed, it is exceeding hard ever to reform the victim. I have often been consulted by young men, in whose careworn countenances and pallid faces, I traced the visible marks of this ruinous practice. Upon questioning them they would reluctantly confess that they had long been guilty, but said that they now craved, above all things, to wrest themselves from this deadly habit, and had failed to accomplish this object. What a miserable state? A young man came to me several years ago, frankly confessing his guilt, and asked me if I could do anything for him. He said that he had formed the habit of masturbation in early youth, before he was old enough to know the evil of the vice, and when he arrived at more mature years, and his moral feelings were shocked at such a crime, he tried every expedient to break himself from the habit, but all his efforts had proved in vain. He told me that while when awake he refrained, but when asleep he either had lascivious dreams, with emis- sions, or he masturbated in his sleep. His health was gone and his mind so fast failing that he had stopped his education, and was racked with neuralgia and rheumatism, and so nerv- ous that he could not well confine himself to anything. He was gloomy, petulant, indisposed for society, refrained from com- pany, and sat for hours at a time in melancholy musing, brood- ing over his sad, and to him hopeless condition. He excited my keenest sympathy, and I told him that though his condition was a deplorable one, there was yet some hope of his final re- covery if he would take my advice, and abide by my prescrip- tion This he readily agreed to do, and I had the very great 18 274 THE PRACTICE OF MEDICINE. satisfaction of reforming him and restoring his health, and he is now married and a happy father and husband. I was visited some years ago by a young man from an adjoining State, in whose countenance were the unmistakable evidences of long masturbation, although he did not confess it, but consulted me in regard to various diseases. He had an affection of the seminal duct and prostate gland, irritability of the bladder, and dyspepsia in its most aggravated form. All these troubles I could readily trace to masturbation. To be certain in my opinion I examined his urine miscroscopically, and there detected his guilt. I treated him, and soon re- stored him to his wonted vigor. I was recently called on by a young man to prescribe for his brother, who he said was very dyspeptic and fast losing his mind. I questioned him very minutely, but could not arrive at the cause, and so told him to bring his brother to see me. When he came I at once saw the well recognized expression of a confirmed masturbator. I at once plainly told him the cause of all his mental aberra- tions and bodily suffering. He frankly confessed it, and said: " I wish I could have known the evil of this vice in time, and then I would have escaped all its ill consequences." He strongly pressed me to try and aid him in breaking himself of the habit. I put him under both medical and hygienic treat- ment, and had the pleasure of seeing him restored to health in mind and body. This is only one out of hundreds of sim- ilar cases. This evil habit could be counteracted if timely care were taken to warn the young in their tender years by pointing out the protean evils resulting from it. Parents should kindly, yet solemnly, enjoin upon their children to refrain from this most baneful and detestable vice. They should plainly tell them that their future health and happiness are at stake, and then portray the many physical ills and mental woes that this habit always visits upon the unhappy subjects of this life, and the ruinous consequences that it will inevitably entail in DISEASES OF THE PROSTATE 275 the awaiting future. The young minds can and should be in- spired with an utter detestation of this damnable and most loathsome practice. As soon as they can read let them have some treatise that points out the evils, mental and physical, of this violation of the laws of God and of life. The young mind is easily impressed with good as well as with evil; and while the vicious make masterly efforts to deprave the rising generation, let the Christian philanthropist be equally vigi- lant in instilling the principles of virtue and piety into the minds of the young. Why have not appropriate works upon this subject been disseminated long ere this? Why has not the mental anguish, experienced in this violation of the laws of chastity, been pointed out to the young long since? It is true that a few treatises upon the subject have been written, but they have been so large, and consequently so costly, that they have not reached the general reader. Let the veil be re- moved, and let this dark crime appear to the young mind in all its frightful hideousness, and the deadly blight of virtue and health will be much lessened. Let the young know that the sexual desire, only imparted to man to " multiply and re- plenish the earth," must' be restricted by the sternest laws of virtue, and that those who violate these laws by illicit inter- course of the sexes will be visited by the severest penalty; much more so, those who violate the same laws by self-pollu- tion. Many victims of onanism drag out a miserable exist- ence for years, and then die a painful death, rather than dis- close the cause of their suffering. Yet more die within the walls of an asylum for the insane, and the cause of their in- sanity remains unknown save by the attending physician. This should not be the case, but the crime should be exposed, even if the criminal rest forever in profound concealment. The medical philanthropists should take the unhappy victims kindly by the hand, with all the soothing sympathetic lan- guage of compasssion, and point out to them the awful conse- quences of this violation of virtue. Thev should plainly tell 276 THE PRACTICE OF MEDICINE. those that are gifted by natural endowment, and so fitted to become the pride and glory of their parents, and an ornament to society, that ere long this vice will produce such moral and physical degradation as will ring the hearts of parents and friends, and that with the last remnant of mind, will haunt them them daily with the thought that their hopeless wretch- edness is the invevitable result of their own misconduct.* There are such tormenting horrors in the mind of the victims of this deplorable vice, that it often produces a disposition to commit suicide, especially in those of a melancholic disposi- tion. Many of the suicidal cases that occur in colleges, and are generally attributed to study, are the result of onanism. Nor are imbecility, insanity and suicide the only grave se- quences of this vice of youth, but phthisis pulmonalis, with all its justly dreaded horrors, is a very frequent result of this great drain on the electrical, or life forces. It is estimated by reliable authority, that 18 per cent, of consumptives die from this practice. Perhaps there is no disease, that does not reside directly in the nervous system itself, that so quickly enfeebles all the vital powers, or sooner leaves its sad impress of imbecility upon the mind, and but few persons have any just conception of the enfeebling nature of this vice, until painful experience has taught them its destructive tendencies. Very few men in the medical profession know why masturbation is so much more destructive of health than excessive venery. It is because the electricity of the person addicted to it, is parted with, and no compensation received, as is the case to some extent, in or- dinary sexual intercourse. Spermatorrhoea. Self-pollution is soon followed by spermatorrhoea, another destructive drain upon the molecular life forces. This is an involuntary flow of sperm, and recurs so frequently, when once *A young man came to consult me some time ago, and though I encour- aged, he committed suicide. DISEASES OF THE PROSTATE. 277 debility of the seminal system is superinduced, as to destroy the health of body and mind in a short time, especially where the quantity emitted is large. But few of the victims of this vice ever listen to the note of alarm at an early period; they remain unmoved until a train of physical and mental evils of dreadful import come upon them. Spermatorrhoea occurs generally in the night; when the mental and moral faculties are wrapped in profound sleep. The impression is transmitted from the excited or diseased vesiculae seminales, through the recurrent system of nerves to the brain, and the discharge is in accordance with a physiological law, converted into a patho- logical condition, which demands moral and medical treatment. The remarkable curse of Onan,—the first man that we read of in the early ages of the world, who dared to waste his seminal power upon the ground, should be pointed out to the young. God was so displeased with the wicked inventor of this un- natural crime that he slew him ; see Genesis 38th chapter, 9th and 10th verses. Yet even now, in almost every village, ham- let and city, and in every section of our land we may see a partial verification of the same anathema of Jehovah, not in the immediate destruction of the wicked offenders, but as that law is unchangeable, and remains in full force through all gen- erations, he that violates it, whether ignorantly or knowingly, must sooner or later suffer the fatal consequences. If imme- diate death be not inflicted, as it was in the case of Onan, pre- mature decay, lingering diseases, spermatorrhoea, enlargement of the prostate glands and testes, loss of muscular powers, con- sumption, impotency, dyspepsia, and a long train of maladies, at sight of which, humanity shudders, religion weeps, philan- throphy grows pale, and angels pity, prey upon health and life. Treatment.—Under this head may be included nocturnal emissions as well as real spermatorrhoea, both of which have their origin in excessive sensibility of the testes, spermatic cords, seminal vesicles, ejaculatory ducts and prostate gland. The first thing to be done is to relieve the cause. For the 278 THE PRACTICE OF MEDICINE. great irritability of the seminal organs, the drug gelseminum, in the form of tincture, may be given in doses of gtt. 15 to 25, three or four times a day, until it allays excitement. Should this fail, in a few days it may be alternated with small doses of tincture of nuphar, two or three drops ter in die. Where there is nervous prostration, and pain and tenderness in the testes, diluted phosphoric acid, in small doses, may be given with good effect. Staphisagria has with me proved a valuable rem- edy in many cases. I use the tincture in small doses of gtt. 1 to 2. In some cases of nocturnal emissions "the bromide of camphor, in small doses acts admirably. I have used cannabis indica, in doses, of gtt. 5, three times a day, with good results. For many of the evil results, such as im- potency and great relaxation of the seminal organs, I have found turnera aphrodisiaca the best remedy, as prepared by Parke, Davis & Co., Detroit, Mich. And in connection with electricity, small doses of the tincture of diascorea vilosa may be given every three or four hours. If there is irritation of the stomach, the tincture of arsenic should be given in doses of 3 to 5 gtts., three times a day until this is removed. If there are nocturnal emissions, and great prostration, the tincture of staphisagria, in doses of 2 gtts., three or four times a day, will be required to aid the cure. If the genitals are relaxed, cold, and the emissions of semen take place at stool, then 5 gtts. of tinct. of gelsemium, every four hours are necessary. Collin- sonia will also aid the above. Spermatorrhoea being generally the result of a disordered state of the sexual system, its final cure may be much aided by the judicious use of electricity to give tone to the exhausted organs involved. To use electricity, place the sponge electrode attached to the positive pole at the perinaeum, manipulating the sacro-lumbar region, epigastrium, and pubes for fifteen minutes daily, until there is marked im- provement, then treat less frequent. If it is a case of long standing, the current should be very light at first. Showering the genitals also aids to control excitement CHAPTER XXII. DISEASES OF THE FEMALE GENERATIVE ORGANS. Ovaritis. INFLAMMATION of the ovaries has its seat in the Graafian follicles, in the parenchyma, or in the peritoneal covering of the ovary. When seated in the Graafian follicles they are enlarged and filled with a bloody fluid, and their surfaces are injected. If, in the parenchyma,. we find the areolar tissue of the ovary hyperaemic, cedematous and infiltrated (this form terminates in suppuration in rare cases, much oftener in indur- ation and shrivelling of the ovary). Inflammation of the peri- toneal covering is either a primary affection, or it is a continu- ation of a parenchymatous inflammation. In both cases we find the ovary covered, as in all inflammations of serous mem- branes, with a fibrinous exudation, which may cause subse- quent adhesions between the ovaries and the Failopian tubes, or the broad ligaments of the uterus. Causes.—Ovaritis may originate from cold, getting wet at the menstrual period, onanism, or it may be the result of inflammatory processes of adjacent organs, as of the peritonaeum or uterus. It is most frequent in females who have much rough work do to, such as washing, scrubbing, etc. Prosti- tutes and lewd women are also very subject to this disease, and women who had once had an attack are more subject to it again. It very rarely attacks both the ovaries at the same time. Symptoms.—If the parenchyma alone is the seat of the inflammation, there will be violent, sharp, colicky pains, vomit- ing and fever. If the Graafian follicles should become rup- tured, there will be some fever. If the ovary is pressed upon 279 280 THE PRACTICE OF MEDICINE. by introducing the finger into the rectum, it will be found painful. If the inflammation spreads to the adjoining organs there will be pain in the urinating, and in the evacuation of the bowels, and there may also be a utero-vaginal blennorrhcea, or a numbness of the affected side. The inflammation may subside in twelve or twenty-four hours, or it may last eight or ten days. It may become chronic, if not well treated, and form serous cysts, and cause induration of the ovary, or it may terminate in suppuration. Treatment.—Aconite is the best remedy in this disease; it may be given in doses of gtt. 1 every hour, until the pulse is controlled, and then every two hours, until the force of the inflammation subsides. If there remain induration, tensive pain, restlessness, stitchlike pain from the ovary down to the thigh, with anasarca, the tincture of arsenic should be given in doses of gtt. 1 to 2, every three hours. If there is indura- tion, with lancinating pains in the ovary, or burning, sore, aching pains, conium, in drop doses, three times a day, may aid the cure. If there are hysterical symptoms with rheuma- tism, and suppressed, painful or profuse menstruation, gtt. 10 to 15 of cimicifuga, given every three hours, in alternation with such other remedies as may be indicated, will give good results. If there be chronic congestion, with leucorrhcea, dropsy, or induration of the ovary, and pain in it, I use iodine in doses of gtt. 2 to 5 of the compound tincture, three or four times a day. If, with the induration, there is dragging pain extending down into the thighs, bryonia, in doses of gtt. 2, three times a day, should alternate the iodine. If rheumatic stitches are felt in the side and in the ovary just before and during menstruation, which are increased by changes of weather, gtt. i to 1 of rhus tox. should be given three times a day, in alternation with staphisagria. If the pain is much increased during the menstrual flow, the tincture of thuja occidentalis, in doses of gtt. 1 to 2, should be prescribed daily DISEASES OF THE FEMALE GENERATIVE ORGANS. 281 until relief is afforded. If there is an intermittent pain, shooting down into the legs, ustilago is the proper remedy. Ovarian Dropsy. It is frequently the case that the Graafian follicles become degenerated, and so distended with a clear, yellowish, serous, or thick, limpid fluids, as to attain to the size of a child's head or even larger. There may be one, or several of such cysts, and the fluid be as above described, or it may be thick, and jelly-like in consistency. I tapped a case some years ago, that was of this character, and I had to make an incision through the linea alba before the gelatinous mass would pass off. This jelly-like fluid was in strata of various colors; some of it was yellowish, and some red, and mixed with bloody serum in large quantities. The alveolar degeneration of the ovary destroys all the original structure, its whole substance becoming trans- formed into larger and smaller cavities, which are separated by a fine tissue. By the extension of some of these, the ovary assumes an uneven shape. The contents of the cysts are frequently a yellowish, tough substance, resembling syrup or honey, or sometimes they are filled with a thin fluid. This degeneration of the ovaries is frequently associated with can- cer of these organs. Some rare cases have occurred under my notice, where, instead of fluid, these cysts contained hair, teeth and bones, and their interior walls presented a structure similar to cutis, having an epidermis with sudorific and seba- ceous glands. Such cysts are called dermoid, and vary in size from that of the fist to that of an apple or an orange. Symptoms.—The symptoms of ovarian dropsy do not differ very much from those of the first stage of ovaritis, but when the cysts attain considerable size they press upon the bladder and rectum, causing difficult urination and defecation, and upon the posterior wall of the lesser pelvis, causing pain in the small of the back, or pain and numbness in the lower limbs. When they press upon the veins in the pelvis, they 282 THE PRACTICE OF MEDICINE. cause oedematous or varicose swellings of the lower limbs. Sometimes the mammae sympathize with the diseased ovaries, and in consequence become enlarged and tender. The stomach may also sympathize with the ovaries and cause vomiting, thus simulating the commencement of pregnancy. As the cysts enlarge, they rise out of the pelvic cavity, and their pressure upon the pelvic organs ceases. When, however, they attain a very great size, they press against the diaphragm and compress the abdominal organs. This pressure upon the abdominal organs may cause shortness of breath, vomiting, palpitation of the heart, catarrh, disturbed secretion of the urine, deficient nutrition, anaemia and hydraemia, which may terminate in general marasmus. The size of these ovarian cysts increases at the menstrual period, and decreases after menstruation is over. If thev should burst their contents are discharged in the abdominal cavity, and consequently produce peritonitis, or in some rare cases, in consequence of previously formed adhe- sions and inflammatory processes the fluid may gain entrance into some other abdominal organ, and be discharged thereby. Diagnosis.—While the cysts remain in the pelvis, examina- tion per vaginam or rectum will reveal a well defined swelling moving of the uterus out of its place. As it rises in the abdo- men, it appears well defined over the horizontal ramus of the pelvic bones; and later it may rise higher, and appear as a large tumor, yielding more or less sense of fluctuation. Percussion yields a dull, flat sound, where the tumor impinges on the parietal walls; the percussion sound being dullest where the swelling is most prominent, thus differing from ascites, which is just the reverse of the above. Treatment. This disease is generally overlooked by the sufferer until the enlargement is too great to be overcome. If there'are sharp, stinging pains, with constipation, scanty urine. pale skin, pain in the back, oedema and numbness of the lower limbs, the treatment should commence by giving gtt. 3 to 5 of apis mel., every three hours. If there is acrid leucorrhcea DISEASES of the female generative organs. 283 that corrodes the parts, and a sensation of pressing down towards the genitals, and constipation, I use the iodide of arsenic in doses of gr. 1-50 to 1-30 every three hours, well diluted with water, else it will corrode the stomach. I gener- ally use the 1st dec. trit. adding one or two grains to § 4 of water, and giving a teaspoonful of this mixture. If there is a burning pain in the ovary, and scalding of the urine, the tinc- ture of cantharides, in doses of gtt. 1 to 2 every three hours, should alternate with the other indicated remedies. If the affection is accompanied with general dropsy, great debility, urgent thirst, and burning pain in the ovaries, tincture of arsenic in doses of gtt. 1 to 3, may be given every four hours, largely diluted with water. If the cysts have become very large, all that can be done with medicines is to improve the general health, and leave the rest to operative surgery. LEUCORRH03A. Leucorrhcea may be produced by all disorders that cause stagnation of the proper circulation of the blood, as heart and lung diseases, chronic constipation, direct irritations, excesses, masturbation, pessaries (these are very fruitful sources of leu- corrhcea), general debility, typhus, cholera, small-pox and other infectious diseases and chlorosis, scrofulosis and tuberculosis. Excessive child-bearing and too long-continued lactation may also give rise to it. Pathology.—This disease consists of hyperaemia of the mucous membrane, characterized by swelling, dryness, in the early stage, and afterwards increased secretion of rnucu^. As it becomes chronic, the mucous tissue becomes thickened and hypertrophied, and its surface is frequently found studded with small excrescences. This tissue is of a slate color, and the secretion finally becomes more or less purulent. The vaginal follicles become swollen on account of the obstruction in the excretory ducts, whilst their secretion is going on inside and little round bodies of the size of hemp seed form, which 284 the practice of medicine. are called ovula Nabothi. In some advanced stages of long standing there are diffuse catarrhal erosions for the most part on the posterior lip of the os uteri, or follicular ulcers that are caused by the bursting of the ovula Nabothi. Occa- sionally granulating ulcers form. Symptoms.—A drawing pain in the small of the back and in the inguinal region, a feeling of fulness and heaviness of the pelvis, together with dysuria and tenesmus, characterize this disease. Pressure over the uterus gives pain, and in acute cases there is more or less fever. In some three or four days the characteristic leucorrhoeal discharge begins, which at first is transparent and sticky, staining the linen a grayish color. As the disease advances this discharge becomes opaque and more or less purulent. In chronic cases it sometimes com- mences more gradually, and the discharge may be scanty at first. If the discharge is corrosive it is generally evidence that it is from the vagina. The longer this disease exists, the more the mucous lining is changed in its character, which changes influence the menses, causing either excess, pain or deficiency in the discharge. If conception takes place there is great liability to miscarriage. Chronic catarrh may be endured a long time, but it produces debility, relaxation, anaemia and hydraemia. It leads also to hyperaesthesia, neuralgia and spasmodic complaints, such as hysteria. Again, it may lead to metritis, displacements of the uterus, closure of the cervical canal, and sterility. Treatment.—Where there is great debility, defective nutri- tion and anaemia, it is advisable to commence the treatment with aletris farinosa, one of our best tonics for females. It may be given in doses of gtt. 10 to 15 three times a day. If there is great pain in the back and hips, constipation and piles, aesculus hippocastaneum may be given in alternation with the aletris farinosa, in doses of gtt. 5 to 6, three or four times a day. If there is great distension of the abdomen, and the discharge is like the white of an egg, muriate of ammonium in doses of grs. diseases of the female generative organs. 285 2, three times a day will aid materially in the cure. If the discharge becomes acrid and corroding and passes off when the patient stands on her feet, tincture of arsenic, in doses of gtt. 2 to 3, will have a happy effect upon the disease. If the dis- charge be acrid and foetid and is attended by ulceration of the os uteri and vagina, baptisia, in doses of gtt. 1 to 3, should be ordered three times a day, and the vagina syringed out with a solution of permanganate of potassium, gr. 5 to the § 1 of water at first (to be gradually reduced in strength to gr. 2). If there is pruritus accompanying the leucorrhcea, gtt. 10 or 15 of tincture of collinsonia should be administered every three hours. Pulsatilla is also an invaluable remedy in doses of gtt. 3 to 5, three times a day. The fluid extract of hydrastis canadensis applied locally is a valuable remedy in vaginal leucorrhcea, and the sulphate of hydrastin, in a saturated solu- tion in water and glycerine, ^s also a good topical application. Cimicifuga is effective in uterine leucorrhcea, and may be given in doses of gtt. 20 three times a day. For vaginal leucorrhoea, with severe catarrhal inflammation of the mucous membrane, tinct. of yellow marigold, with water and glycerine in equal parts, is valuable for external use. I usually apply it on lint or a soft sponge, renewing the application twice or thrice a day in grave cases. For muco-purulent leucorrhoea, the balsam of Peru in aqueous solution acts very well when locally applied. Where the discharge is very acrid and foetid, I use carbolic acid as a wash, diluted in water, 1 part to 10 or 20 parts of water, according to the sensibility of the parts. Carbolic acid 3 2, glycerine \ 1, rose water § 7, is also a good combination for this purpose. A wash of a saturated solution of boracic acid is also advisable in vaginal leucorrhoea. A strong solution of alum in an invaluable application where the discharge is thin and very profuse. In leucorrhoea of long standing, with inflammation and ulceration, sepia * and pulsatilla are the proper remedies.______________________________ *Sepia is made from cuttle fish, and must be used caref illy. * 286 THE PRACTICE OF MEDICINE. Acute Parenchymatous Metritis. In this disease, the uterus is hyperaemic, ©edematous, enlar- ged, and presents a dark, red color, often containing exudates of blood, or bloody serum. In the chronic form, the redness is not so apparent, as from the exuberant growth of the inter- stitial tissue the small blood vessels become compressed, so that only a few of the veins become varicosed on account of the obstruction to the circulation in the organ. The substance of the uterus itself appears pale, dry and tense, and very much thickened. This condition of the parts, either in acute or chronic metritis, is always more or less complicated with inflam- mation of the mucous coat of the uterus, catarrh of the uterus, or an inflammation of the peritoneal coat of the organ, as in puerperal peritonitis occurring after delivery. Causes.—The causes are the* same as those producing uterine catarrh, except in the case of puerperal peritonitis, which follows delivery, abortion or miscarriage. Symptoms.—This form of inflammation, like most others, sets in with a chill, followed by fever and pain in the back, etc. There is generally pain in the inguinal region; pressure in the pelvis; and great soreness over the uterus. If it takes place during the menstrual flow, this suddenly ceases, or may burst forth as metrorrhagia. Metritis is almost always com- plicated with uterine catarrh, and, consequently, is attended with similar characteristic discharges. Prognosis.—In favorable cases the disease may terminate in eight or ten days, Puerperal metritis, however, is a graver form of the disease, and often proves fatal, especially if not well treated. The most frequent causes of this form of metri- tis are operative manipulations during parturition, mental excitement or depression during the puerperal state, improper diet, taking cold, and doubtless, there is at times a condition of the atmosphere favorable to it. The epidemic form is usually called puerperal fever, which is a peculiar dissolution DISEASES OF THE FEMALE GENERATIVE ORGANS. 287 of the blood similar to, but not identical with, that of typhus fever. This disease generally commences after delivery, while the uterus is still in a state of hyperaemia. It sets in with a a chill, followed by a high fever, extreme tenderness over the uterus, great thirst, nausea, and often vomiting, suppression of the lochial discharge and a great tendency to putrescence. This last symptom is evinced by a very offensive odor about the patient and her bed. The disease is often complicated with phlegmasia alba dolens, milk leg, which is a metastatic inflammation of one or more of the large veins of the thigh, causing a shining, white and very painful swelling of the whole limb. The chronic form of metritis is characterized by a heavy feeling often mistaken for prolapse of the uterus. At the outset the menses are generally very profuse; but later, as the exuberant interstitial tissue compresses the blood-vessels of the uterus, menstrual discharge becomes scanty, or perhaps ceases, and leucorrhoea takes the place of the menses, Treatment.—In the acute form of metritis, I find aconite invaluable, in doses of from gtt. -§ to 1 every half hour or hour, according to the severity of the disease. Belladonna may be given in doses of gtt. 3 every four hours, in alternation with the aconite. Both of these remedies oppose the inflammatory process by their direct influence over the capillary and gen- eral circulation. They are both especially applicable in the puerperal form of inflammation of the uterus and its append- ages. If there is constant nausea and vomiting, small doses of ipecacuanha should be given, say gtt. 1 to 2 of the tincture of the fresh root, every half hour until the Symptom is relieved. If the fever runs very high in puerperal metritis, and the pulse is full, strong, and quick, veratrum viride, in doses of gtt. 2 every two or three hours, has acted well for me in many cases. If there is great soreness over the uterus, I usually apply a cloth wet in spirits of turpentine over the spot. In cases of an adynamic type, in which there is great prostra- tion, a bruised feeling all over, foetid odor from the body and 288 THE PRACTICE OF MEDICINE. excretions, and a dry, red or brown, parched tongue, baptisia, in doses of gtt. 2 to 5, may be given every two hours until this condition is corrected. The above is the proper treatment for the acute form of metritis ; the chronic form requires other remedies. In,chronic metritis, where there is constant desire to urinate, and constipation exists, nux vomica often does much good in doses of gtt. ^ to 1 every two hours. If the disease comes on in a subacute form, from getting the feet wet during the menstrual period or just after confinement, pulsatilla, in doses of gtt. 2 to 3 every two or three hours, will aid in the cure. If, instead of obstruction of the menses, there is haem- orrhage, sabina may be prescribed, in doses of gtt. 1 to 2 of the tincture every three hours, with good effect. If the disease is attended with putrescence of the uterus and ulceration of the os uteri, gtt. 1 to 2 of the tincture of secale cornutum should be administered every two hours until this state is cor- rected. Should there be constant tenesmus in the bladder, gtt. 1 to 2 of tincture of cantharides may be given every hour until the symptom is relieved. Chronic Parenchymatous Metritis. This is areolar hyperplasia of the uterus, and is one of the most intractable diseases of females. This complaint seems to consist in a diffuse growth of connective tissue, constituting induration. The whole uterine connective tissue sometimes proliferates, usually without accompanying increase of muscu- lar substance, or, if this does occur, the connective tissue pre- dominates. This condition is generally called hypertrophy of the uterus, or enlargement of the cervix, by some authors sub- involution of the uterus, and by others chronic enlargement of the uterus and cervix. Causes.—Any impairment of the vital forces may tend to the development of this disease, and a tuberculous tendency of constitution may also have this result. Too frequent par- turitions, prolonged nervous depressions, attacks of puerperal DISEASES OF THE FEMALE GENERATIVE ORGANS. 289 inflammation, displacement of the uterus, endometritis, cardiac disease and neoplasms, and excessive sexual intercourse, may also cause it. Symptoms.—Where the cervix alone is involved, there is pain in the back and loins, pressure on the bladder and rec- tum, irregular menstruation, nervous disorder, pain with the sexual embrace, dyspepsia, and leucorrhcea. If the body of the uterus is affected, there will be a dull, heavy, dragging pain in the pelvis, which is increased by motion. Defecation and sexual intercourse are also attended with more or less pain, and the monthly courses are preceded by a dull pain in the back and uterus. There is apt also to be pain in the mammae just before and during the menstrual flow; the areolae around the nipple become darker. In some cases there is nausea and vomiting, and the pressure in the rectum fre- quently results in haemorrhoids. The uterus is perceptibly enlarged, and is tender to the touch. Treatment.—Local depletion, either with leeches or the scarificator, may do good in some cases. I have depleted with tampons of sponge saturated with glycerine, applied at night, and then renewed in the morning. This treatment should be continued for several days, and is of special utility in cases of enlarged cervix uteri. Phytolacca in small doses, gtt. 5 every three hours, will aid in lessening the enlargement. Sepia has done good service for me in several cases, when given in doses of gtt. 1 to 2 three times a day. After using the glycerine a few days, I administer gtt 10 of Lugol's solution to 3* 2 or 3 of glycerine and water. This may be alternated with a solu- tion of the tincture of polymnia uvedalia, gtt. 10 to 20 of which may be taken internally three times a day. It may be applied by adding equal quantities of pure glycerine, or glyc- erine and water. Puerperal Fever. This is a most serious disease in females. Its frequent causes are, operative manipulations during parturition, great 19 290 THE PRACTICE OF MEDICINE. mental excitements or depressions during the puerperal state, faulty diet, and taking of cold, etc., during that period. There is a very grave form of puerperal fever, similar to typhus fever, due to a severe septic condition of the blood. This form of puerperal fever always commences in the first days of the puerperal state, even before the uterus regains its normal posi- tion and size. It usually sets in with chills, followed by high 'fever, great tenderness over the abdomen, urgent thirst, vom- iting, suppression of the lochial discharge, and a very marked tendency to putrescence and decomposition. Phlegmasia alba dolens, or milk leg, is a frequent complication of this form of fever. This seems to be a metastatic inflammation of one or several large veins of the thigh, causing a white, shining, very painful swelling of the whole limb, together with great enlarge- ment of the diseased vein. Parenchymatous metritis, acute and chronic, often occurs, in which there is an hyperaemic, cedematous enlargement of the substance of the uterus. If this state be attended with a great tendency to putrescence and decomposition in the acute form, it is apt to prove, in most cases, intractable to all kinds of treatment. Treatment.—If there is a great tendency to putrescence, antiseptics should be given at the outset, alternated with arte- rial sedatives. I have found the tincture of veratrum viride, in doses of gtt. 2 or 3 every two hours until the rapidity of the pulse is moderated, then in smaller doses, alternated with aco- nite in doses of gtt. 1 every two hours, answer well in most cases. If there is an offensive odor about the patient, a solu- tion of grs. 2 to 5 of permanganate of potassium to the ounce of water, used with a syringe, and thrown up against the os uteri every two or three hours, is effective. I also give from gtt. 3 to 5 of the tincture of baptisia every two hours. If the inflammation is the result of injury from manipulations during parturition, I then administer gtt. 1 of tincture of arnica four times a day. If there is headache or delirium, I use gtt. 3 to 5 of tincture of belladonna three times a day. If there is par- DISEASES OF THE FEMALE GENERATIVE ORGANS. 291 tial paralysis of the lower limbs, restlessness, dry tongue with red edges, red rash on the breast, and any other marked typhoid symptoms, rhus toxicodendron, in doses of gtt. 1 to 2 every three hours, will be found to act well. If there is' con- stipation, and great distention of the abdomen, headache and thirst, I give gtt. 2 to 3 of bryonia every two hours. If there is a very great tendency to gangrene, gtt. 5 of turpentine every hour or two act admirably. Anteversion of the Womb. Anteversion consists in a displacement, in which the fundus of the uterus falls forward, and leans upon the bladder and pubis. This condition may be the result of hypertrophy of the anterior wall of the uterus, of peritoneal exudates or tumors within the abdominal cavity pressing it forward, and of muscular efforts. Symptoms.—There are no very distinct symptoms, except pressure upon the bladder and rectum. Upon introducing the index finger into the vagina, the portio vaginalis will be felt inclined backwards. Retroversion of the Womb. Here the fundus of the womb inclines back towards the os sacrum, or is even pressed down beneath its promontory. This condition may exist in the early stage of pregnancy, and mav be produced by the same abdominal conditions that cause anteversion. Its symptoms are pressure upon the neck of the bladder, sometimes causing great difficulty in passing the urine, and pressure on the rectum, causing constipation, and pain in defecation. Upon examination, the neck of the uterus will be felt high up, towards the pubic arch, in a position just the opposite of that of anteversion. The examination should always be made while the patient is in the erect position, as reclining changes the position of the misplaced uterus. 292 THE PRACTICE OF MEDICINE. Prolapse of the Womb. The uterus may descend, more or less, into the pelvis; from a slight bearing down upon the upper portion of the vagina, to a protrusion of the womb out of the vagina—pro- lapsus completus, or what is called by some writers prociden- tia uteri. The womb is kept in its normal position by the peritonaeum and the broad ligaments, but can descend when there is a relaxed state of this apparatus. Undue pressure from above, straining and lifting, or standing too much on the feet while the body is hot, may also cause it to descend. All debilitating diseases favor this malposition of the uterus, as leucorrhoea, excessive menstruation, chlorosis, anaemia, poor diet, etc. Symptoms.—There is a peculiar sensation of heaviness in the pelvis, and a feeling of great weight, as if everything within the abdomen would pass through the vagina. This sensation is worse in walking, after standing long on the feet, and after severe exercise. Pressure upon the bladder and rectum, causing constant desire to urinate and defecate, and generally more or less leucorrhoea exists. Upon examination with the index finger, the os uteri will be felt near the outer opening of the vaginal orifice, together with a fold of mucous membrane. Treatment of Uterine Displacements.—In anteversion, the use of pessaries accomplishes but little, except in some exceptional cases. The uterus should first be reduced to its proper position with a uterine sound, and then Thomas' retro- version pessary should be introduced to keep it in its normal position until the muscular tone of the parts is toned up. After replacing the uterus, which can be done with the sound both in cases of anteversion and retroversion, and after cor- recting the malposition, the patient should have such direct tonics as have a special affinity for the uterus, as sepia, in very small doses, say gtt. 1 to 2 of the 3d dec. solution, for it DISEASES OF THE FEMALE GENERATIVE ORGANS. 293 must be remembered that this drug has powerful toxical effects. Helonias and cimicifuga are both good uterine tonics, as are also lilium tigrum, in doses of gtt. 2 to 5 three times a day, aesculum hippo., and ustilago, doses of either gtt. 3 to 5 every three hours, and aletris. Nux vomica often does well, in small doses, as does aletris, in 5 gtt. doses. The medicinal treatment in this affection consists in the administration of such medicines as will relieve the patholog- ical conditions upon which the deformity depends. The dis- ease often exists with chronic congestion of the uterus, which will generally yield to the chloride of gold and sodium, in very small doses of gr. 1-100 to 1-200 three times a day. Very often even this dose will prove toxic. Sepia will also often correct malposition of the uterus, and should always be tried, in small doses. Nux vomica has a direct tonic effect upon the muscles of the uterus, as it has upon all the muscles of the body, and should be used if sepia fail. Cimicifuga, in doses of gtt. 15 three or four times a day, has proved itself valuable in my hands, and so has lilium tigrum. If there be conges- tion, ustilago and belladonna are the best remedies; dose of the former gtt. 3 to 5, and of the latter gtt. 1 to 3. iEsculum and helonias are as applicable in prolapsus as in other malpo- sitions. The use of corsets and heavy skirts must be prohib- ited ; and, as temporary support until the uterus can regain its usual tone, the soft rubber pessary may be worn. (Dr. Jack- son's elastic soft rubber pessary is to be preferred.) In cases of procidentia, the uterus must be replaced before any other treatment is commenced. Some writers recommend amputa- tion of the enlarged and elongated cervix, but I never had a case in which I deemed this necessary. In addition to the above tonic treatment, I use an astringent wash, composed of Monsel's salt 3 1 to aqua 3 4, or Monsel's solution 3 1 to 3 2 of water, thrown up with a glass syringe against the os uteri, and retained there ten or fifteen minutes by elevating the hips. This last is the most powerful astringent in the list, 294 THE PRACTICE OF MEDICINE. and may be used stronger and stronger, until its astringence begins to contract the muscles of the part so that it produces great soreness, as it will often do. I would rather have this than all the washes in the Materia Medica. AVith it, and proper internal tonics, I can effect a cure when all the pessa- ries have utterly failed. I treated a case not long since that had worn a pessary for months, until it had produced such violent ulceration and leucorrhoea that the woman stank dread- fully. I threw away the pessary, and used for the foetor and ulceration the solution of iron as above, alternated with a solu- tion of permanganate of potassium gr. 5 to the ounce, with proper interna! tonic treatment. I succeeded so well with this treatment, that I have abandoned the pessary entirely in almost all cases. Polypus of the Womb. Uterine polypi are soft tumors, growing from the mucous surface on a pedicle or stem, and are generally within the womb, though there are interstitial fibroids that are imbedded in the parenchyma of the uterus. They seldom exist in females under thirty years of age, and can be diagnosed only by a physical examination. The mucous polypi consist of an exuberant growth of the uterine mucous lining. They are usually pediculated, and either consist of distended mucous follicles, or are mere vascular bodies. They frequently cause violent haemorrhage, and always excessive leucorrhceal dis- charge. Treatment.—The phosphate of lime, in doses of gr. 3 to 5. three times a day, has much reputation, as has sanguinaria used externally and internally. Staphisagria, in doses of gtt. 1 to 2, three times a day, is recommended by some writers; and powdered tannin, locally applied, will sometimes destroy a soft polypus. Rhux toxicodendron, gtt. 1 to 2, every four hours, is highly recommended by some, as is iodine. This affection properly belongs to the domain of surgery. The DISEASES OF THE FEMALE GENERATIVE ORGANS. 295 tumors may be removed by ligature, or torsion, and then the roots destroyed by application of diluted nitric acid. This acid should be so diluted that it will not corrode the sound flesh, which may be protected with oil. Cancer of the Womb. Cancer of the womb is generally of the medullary variety, scirrhous and alveolar cancers occurring less frequently. The disease generally begins at the vaginal portion of the uterus, and very rarely extends to the fundus. It is very apt, however, to spread down the vagina, over the bladder and rectum, caus- ing the most extensive destruction of these organs. Symptoms.—One of the first symptoms noticed by the patient is severe pain in the small of the back, loins and groins, becoming more and more violent At first there will be haemor- rhages at the monthly periods, but as the disease advances, they may occur at any time A copious leucorrhoea sets in, which becomes more and more offensive and watery, corroding the parts it happens to touch. Cauliflower excrescence is a cancroid hypertrophy of the papillae at the mouth of the womb, which often attains very great size. It is usually in the shape, of a cauliflower. Its color is a bright red, it bleeds very easily, and is very prone to cancerous degeneration. The constitution soon becomes prostrated from the pain and loss of blood. It is similar to cancer of the womb in its symptoms, and can only be certainly diagnosed by the introduction of the speculum, as is the case with cancer of the uterus. They are both apt to prove fatal, even under surgical treatment. Treatment.—The cloride of gold and sodium is one of the best remedies in this disease. It is indicated when there are very offensive discharges, and stinging, cutting pains in the uterine region. As soon as the disease has exhausted the vital powers, and the pains become burning, sharp, and worse at night, and the discharges grow acrid, corroding, offensive and dark colored, I find arsenic, or the iodide of arsenic, very 296 THE PRACTICE OF MEDICINE. useful in small doses. I give gtt. 1 to 2 of tincture of arsenic, or gr. 1-30 to 1-40 of the iodide of arsenic four times a day. If the pain is intense and stitching, and there is nausea and vomiting, small doses of conium should be administered, and the cancer dressed with an ointment of the same drug. In cauliflower excrescence, where the menses are irregular and offensive, graphite (plumbago * or black lead) in doses of gr. 1 or 2 three or four times a day, will have the most excellent effect. At the same time, the excrescence should be washed in a solution of glycerine, water and creasote, 1 1 of glycerine, 3 1 of creasote, and f 7 of water. Where the tumor is inclined to bleed easily, the tincture of thuja 3 1 to water 3" 3, may be applied on lint, and renewed every three or four hours. Miti- gation of the patient's sufferings is all that need be expected in this disease. Metrorrhagia. I This disease consists of a more or less profused haemorr- hage from the womb, between the menstrual periods. It may occur in the non-pregnant state, and seems to result from an abnormal flow of blood to the womb or from morbid groAvths in the uterus. It is very frequently produced by the peculiar physiological changes consequent upon the so called "change of life "—cessation of the menses. Some of the worst cases that I have ever treated occurred at this period. This form of haemorrhage may also set in in during the pregnancy. Some women menstruate several times after conception, without apparent injury; but in most women a haemorrhage during pregnancy indicates abortion. A severe haemorrhage, four or five months after conception, indicates placenta praevia, or miscarriage. In cases of abortion, the haemorrhage may be very profuse, and generally occurs from imperfect contraction of the uterus. Metrorrhagia is frequently preceded by a chill, and the haemorrhage comes in gushes, or in a continued flow * Carbon. DISEASES OF THE FEMALE GENERATIVE ORGANS. 297 of bright red or dark blood. The face soon bleaches, the hands and feet grow cold, and there may be laborlike pains or colic. After great loss of blood, the patient becomes anaemic, faint, nervous, and very impatient. Treatment.—Ipecac, in doses of gtt. 1 to 2 of a saturated tincture of the fresh root, has often done good service, especially where the haemorrhage is of a bright red color, and is accom- panied by nausea and vomiting. It may be repeated every twenty-five or thirty minutes until the haemorrhage is arrested. If this fail, gtt. 3 to 5 of the tincture of cannabis indica should be ordered every half hour until the flow ceases. If the flood- ing occurs with great relaxation in feeble cachectic women, I give secale cornutum, in doses of gtt. 10 to 80 of a good tinc- ture of fluid extract, every one or two hours, as required. In robust, florid women, in whom the haemorrhage originates from uterine congestion, or inflammation (in which case the dis- charge is of a bright red color), the tincture of sabina in doses of gtt. 1 to 3, should be administered every two or three hours, or repeated oftener in smaller doses. Should this fail to stop the haemorrhage, the oil of erigeron should be alternated, in doses of gtt. 8. There are still other remedies recommended, as apocynum cannabinum, in doses of gtt. 1, every ten or fif- teen minutes. I have succeeded well with tincture of trillium pendulum, and also with gr. 5 doses of pure berberine sulphate, every hour. Menorrhagia. This is a profuse flow of blood from the uterus at the regu- lar menstrual period. These periods may come too soon, or may last too long; and, in some cases, the menses are not only to profuse, but come on too early, and last too long, hence proving very exhausting to the women. Causes.—Morbid growths in the uterus, structural changes etc., may give rise to this haemorrhage, or it may result from stagnation of the blood in the uterine veins, and lung and 298 THE PRACTICE OF MEDICINE. heart diseases. Preternatural determination of blood to the uterus, sexual excesses, sexual excitement, or onanism, may also cause it. Sometimes it results from a haemorrhagic diathesis, as in purpura, scurvy, small pox, typhus fever, measles, etc. The blood in this form of haemorrhage of the womb, is either fluid or coagulated, and differs in color, in each case. Treatment.—The treatment is similar to that detailed above for metrorrhagia. If the discharges be of bright red color, and there be nausea and vomiting, ipecacuanha is the most reliable remedy, in doses of gtt. 1 to 3, every half hour or hour, according to the severity of the flow. If this drug does not control the haemorrhage in due time, tincture of sabina may be used in alternation, every two or three hours. This latter is a most valuable remedy. Should the uterus be relaxed, ergot, in doses of gtt. 30 to 60, every one or two hours, will aid the above remedies in stopping the haemorrhage; or it may alternate with oil of erigeron. I have often succeeded well with cannabis indica, in doses of gtt. 5. Tincture of rue is highly praised by some writers, but I have never tried it. If the discharge is black and lumpy, I find the tincture of crocus sativus (saffron ) very useful in doses of gtt. 2 or 3, every two hours, or in smaller doses every half hour. Where there are cardiac complications, and the flow is of a dark color and thick, tincture of cereus grandiflorus may be administered in doses of gtt. 1 to 5, every hour, in alternation with charcoal in small doses or with the tincture of chamomilla, in doses of gtt. 1 to 2. In cases of vascular excitement, with flushed face, throb- bing of the carotids, full, bounding pulse, nausea, etc., gtt. 3 to 5 of belladonna, every three hours, will aid other remedies, and is most valuable in alternation with ipecacuanha. Some- times small and repeated doses of the bromides have done well especially in rather passive forms. In this form, the tincture of hamamelis, in doses of gtt. 5, every fifteen minutes, has proven very efficient, and so has trillium pendulum. Ustilago DISEASES OF THE FEMALE GENERATIVE ORGANS. 299 maidis is also an invaluable remedy. In the interval I give tonics and senecio aureus. The best tonic is helonias dioica, or aletris. Amenorrhea. This may occur at any time between the ages of puberty and the climacteric. After puberty, females should menstru- ate regularly, except during pregnancy and nursing. Non- appearance of the menses at the age of puberty may be from chlorosis, scrofula, rachitis, tuberculosis, etc. It may also arise from degeneration of the ovaries, but is oftener due to catarrhal affections of the womb. It has occurred from spinal diseases, occlusion of the os uteri, and imperforate hymen. Metritis is a common cause of this obstruction. Sometimes vicarious menstruation will take place. This is a flow of blood, at the monthly period, from some other mucous mem- brane, as the nose, eyes, bowels or ears, or from wounds. With this obstruction there may be headache, dyspnoea, dys- pepsia, sadness, sleeplessness, oedema, palpitation of the heart, and haemorrhages of various parts, as above stated. Treatment.—If delayed menstruation occur in rheumatic subjects, or from getting the feet wet at the time menstruation should take place, aconite in doses of gtt. ^ to 1 three or four times a day, alternated with cimicifuga, will often bring on the flow. Delay of first menses, in mild dispositions, should be treated with gtt. 3 to 5 of pulsatilla three times a day. If there is anaemia, however, helonias and iron will be necessary, alternated with cimicifuga. If the delay or obstruction should be the result of an atonic condition, the chloride of gold and sodium will arouse the dormant energies of the system, and aid in bringing on the menses. If with obstruction there exists indigestion and constipation, nux vomica, in doses of gtt. 2 to 5 three times a day, will have excellent results. If, in the interval, there exists cerebral irritation, belladonna in doses of gtt. 2 to 3 may alternate other indicated remedies; 300 THE PRACTICE OF MEDICINE. or should there be leucorrhoea instead of the menses I give sepia in very small doses, gtt. j to | three times a day, and not oftener, for it is highly toxical. If there be congestion of the head and delirium, or a tendency to dropsy, the tincture of apis met, in doses of gtt. 3 to 5, may alternate with aconite or belladonna every three or four hours, according to the urgency of the symptoms. I have frequently succeeded well with gtt. 30 of senecio aureus three times a day. If obstruction is due to rheumatic exposure, I order bryonia in doses of gtt. 2 to 3 of a saturated tincture, three times a day. The sitz-bath should be used always at and near the menstrual period. In functional inactivity apiol has been highly praised by Prof. Bartholow. Where chlorosis or anaemia exists, iron, aletris farinosa, and helonias dioica are proper remedies, and will always aid in the cure. Dysmenorrhea. Dysmenorrhoea is usually attended by unusual pain, which may continue only a day or two, or the entire menstrual period. It is generally caused by one of four things, viz.: (1) structural changes, or flexions of the uterus (the mechan- ical dysmenorrhoea of writers) ; (2) congestion of the uterus (commencing with signs of congestion of the pelvic organs, as strong action of the heart, and congestion of the head with fever, which is believed to be produced by a thickening of the peritoneal lining of the ovaries, and the consequent difficult perforation of the Graafian follicle); (3) the formation of an exudation between the mucous coat and the parenchyma of the uterus (membranous dysmenorrhoea, in consequence of which portions of the loosened membrane are thrown off and discharged); and (4) a morbid sensibility (hyperaesthesia) of the nervous system controlling the uterine organs, called neu- ralgic dysmenorrhoea. In this form the menses are attended with extreme pain in the uterus, back, and limbs, and some- times with neuralgic pains in various parts, cramps, etc. DISEASES OF THE FEMALE GENERATIVE ORGANS. 301 Treatment.—In the congestive form, in which the dis- charge is of a bright red color, aconite in drop doses every hour or two, alternated with gtt. 3 of pulsatilla, will be apt to give relief. If it is of the inflammatory order, the above rem- edies should be relied upon at first, but if they fail, the ace- tate of ammonium should be administered in doses of § | to 1 every two hours. If dysmenorrhoea is complicated with haem- orrhoids, and there be pelvic congestion, collinsonia in doses of gtt. 10 to 15 every two hours may be alternated with other appropriate remedies. If the discharge is scanty, I use sepia (juice of cuttle-fish) in doses of gtt. 1 given every two hours. In the spasmodic form we have several very positive medi- cines, as xanthoxylum fraxineum (tincture of the bark and berries), which I give in doses of gtt. 30 every half hour. If this fails in two hours, gtt. 15 to 20 of tincture of gelseminum will be effective. If this does not stop the spasms, tincture of viburnum prunifolium may be used in doses of 3 1 every half hour. If this can not be obtained, the tincture of viburnum opulus may be substituted in the same sized dose. Cimici- fuga, in doses of gtt. 10 to 15, often readily relieves the con- gestive form. I have also relieved it with gtt. 30 to 60 of the ammoniated tincture of guaiacum every two or three hours. Cannabis indica is the best remedy where the discharge is very profuse; the dose is gtt. 3 to 5 of the tincture. The treatment in the inter-menstrual period is essential to relieve the paroxysms. The tinctures of senecio aureus and caulo- phyllum thalictroides are invaluable in the radical cure of this very painful affliction of women. I usually alternate these two remedies, and give them in doses of gtt. 30 to 40 each, three times a day. If the patient be of a scrofulous habit, the compound tincture of iodine, in doses of gtt. 3 to 4 three times a day, may be ordered, in alternation with the senecio aureus. If there be any cutaneous disease connected with dysmenor- rhoea, sulphur will aid the other indicated remedies in the cure. If, however, the eruption of the skin be inclined to sup- 302 THE PRACTICE OF MEDICINE. purate freely, tincture of arsenic, in doses of gtt. 2 three times a day, acts admirably. When the dysmenorrhoea is associated with rheumatism, I have found the tinctures of cimicifuga and gum guaiacum to be very efficacious in doses suited to the strength of the patient. In all cases where the patient is anae- mic, iron should be used, alternated with helonias dioica. I prefer the phosphate or pyrophosphate of iron. The patient should avoid all very sudden changes, and keep the feet warm and dry, bathing them at night in warm water. Pruritus Vulv^. This is an intolerable itching of the vulvae; so severe as to prevent sleep, and to cause other nervous affections. Upon examination, the vagina will be found rather dry, and with an eruption on the mucous surface and labia. It is believed that this disease is caused by a stagnation of the blood in the vaginal veins, for the subjects of pruritus are often the sub- jects also of haemorrhoids, or piles. Treatment.—According to the above pathology, collin- sonia, in doses of gtt 10 to 15, three times a day, would be indicated, especially if constipation of the bowels existed with the pruritus. If the itching be more severe after the mens- trual period, an ointment of conium will usually lessen this symptom. If there be leucorrhoea with the pruritus, sepia, gtt. -| to 1, three times a day, will aid materially in the final cure. If haemorrhoids set in with the pruritus, I prescribe tincture of sulphur in doses of gtt. 5 to 10, or gr. 1 to 2, of pulverized sulphur, three times a day. I have tried sulphur- ous acid, with the very best effects, applying it locally, while I was giving the other indicated remedies internally. Plati- num is highly praised by some writers, as is lycopodium, used locally and internally. The tincture of grindelia robusta, 1 part to 10 of water, is a first-rate application, as is also a lotion of hamamelis, especially if the disease is connected with piles. diseases of the female generative organs. 303 Mastitis. This form of inflammation generally takes place at the commencement of lactation, especially in young mothers. Causes.—It originates from a stagnation of milk in the gland, or a tube of the milk gland. This, in turn, may be from the inability of the child to completely empty the breast, from imperfection of the nipples, or from undue pressure exer- cised upon the gland by tight dresses. There is first an inflammation of the milk-ducts of the mammae, which soon spreads and inflames the gland. The inflammation may, in some rare cases, begin in the subcutaneous cellular tissues (rather an erysipelatous form), and that spreading inward, produces a caking of a portion of the breast. This form may originate from injury of the breast by external bruises, from exposure to intense cold, or from severe pressure on the organ by tight clothing. This painful affection, if not arrested in the early stage, will result in an abscess, and when it onco begins to suppurate, a succession of abscesses may continue for months. Treatment.—If the patient can be seen in the early stage of the disease, phytolacca, used both locally and internally, will arrest the disease. I poultice the breast with Indian meal wet in a strong tea of the root, and give gtt. 5 of the tincture of green root every two hours. This treatment has seldom failed with me. The next best remedy is belladonna, used locally and internally. If all these fail the abscess should be opened to let out the pus. Scirrhus, or Cancer of the Mamm^;. Scirrhus is the most frequent form of cancer of the breast, and may begin deep in the gland or near the surface. It can be felt as a round tumor within the breast, small at first, but later large and very hard. As it increases in size, it drawo the nipple inward until it presents a navel-like depression. 304 THE PRACTICE OF MEDICINE. The progress of this tumor may be slow, but finally suppura- tion forms a deeper ulcer, with callous, elevated edges, dis- charging an ichorous fluid, and often having a very offensive odor, especially in very warm weather. This should be disin- fected. Medullary Sarcomata.—These appear as one or sev- eral tumors, which rapidly destroy the mammary gland, and not unfrequently conglomerate into large masses of irregular shape. Scirrhous cancer is distinguished from other tumors of the breast by very intense pain, which is stinging, burning and lancinating in character. Cause.—The cause is obscure, and there is some peculiar constitutional contamination, the nature of which we do not know. Treatment.—The only successful treatment of the medul- lary form is by the surgeon's knife at an early period. All cases that I have ever seen have proved fatal. The scirrhous form may be treated in the same way at the commencement, but unless it is done early I believe that enucleation by proper caustics is better. The chloride of zinc, gold and bromium have all been successfully used. As cancer comes under the domain of surgery, we deem it useless to discuss it here, but refer the reader to works on surgery. I have seen men who pretended to cure cancer fail to cure it many times. Epithe- lioma may be cured in its early stage. CHAPTER XXIII. DISEASES OF THE SPINE. THE spinal column may be considered as a continuation of the head, and the spinal cord and its membranes as answering to the dura mater, arachnoid, and pia mater, they being a continuation of the same membranes, and sending forth branches of nerves to the various parts of the body, like the brain itself. The diseases of the spinal cord correspond with those of the brain. Akemia. This condition is due to a deficiency of blood in the cord, and is generally associated with other diseases of the body. Its symptoms are obscure, but there is always great weakness, dyspnoea, frequent palpitations of the heart, and general anae- mia of the whole body. Hyperemia/ Hyperaemia of the spinal cord is usually combined with congestion of the brain, It may be the result of local distur- bances of the circulation of the blood, from haemorrhoids, menstrual affections, pregnancy in women, and tumors. It exists sometimes in febrile affections, and in severe spasmodic diseases. Symptoms.—There will be difficulty in voluntary motion and paralysis of the lower extremities, and sometimes also of the upper limbs. This paralysis almost always affects both sides, more or less,' rarely but one side. Respiration is often difficult, and the muscles of j)he bladder and the rectum are affected. 20 305 306 THE PRACTICE OF MEDICINE. Treatment.—The treatment of hyperaemia, in the active form, should consist of aconite, in doses of gtt. 1 every two or three hours, according to the intensity of the disease. This drug may be alternated with gtt. 10 of gelseminum, every three hours. In a passive form, gtt. 10 to 20 of the fluid extract of ergot may be required every three hours, or 5 gtts. of bella- donna. Spina Bifida. Hydrorrhachis congenitalis is an analogous affection to hydrocephalus. It is due to an imperfect development of the foetus, which may have been prematurely expelled from the uterus. There are instances, however, in which children are born with spina bifida. Like hydrocephalus congenitus, spina bifida consists of a dropsical effusion of serum, either between the dura mater and the vertebrae, in the subarachnoidal space, or within the central canal of the cord. When this effu- sion takes place before the vertebra has closed perfectly, the pressure of the fluid within prevents a final cure, and thus, from deficiency of the vertebral arches, the spinal column is posteriorly cleft in two; thus giving rise to the name, spina bifida. Only one of the vetebrae may be unclosed, or it may affect the whole spinal column. Very often, however, it is con- fined to the lumbar, cervical, or sacral regions. The fluid passes off, and, according to the quantity, forms a large or small tumor. After birth, this tumor rapidly increases and fluctuates, and becomes denser and larger when the child cries or strains in any way. The tumor is painful upon firm exter- nal pressure, and may cause convulsions, or, if hydrocephalus is associated with spina bifida, there will be stupor and general paralytic symptoms. Sometimes, portions of the spinal mar- row protrude with the serum. In this case, the tumors fluc- tuate less than when they are filled with serum alone. In rare cases, they are ruptured at the birth of the child, or else they burst after birth, and convulsions take place, finally ending in DISEASES OF THE SPINE. 307 the death of the child. All cases are apt to prove fatal before puberty. Treatment.—One of the leading remedies indicated by the pathological condition is carbonate of lime, gr. 1 doses, three times a day, alternated with phosphite of lime, gr. 2, three times a day. Occasionally, it is advisable to tap the tumor, and inject tincture of iodine and glycerine, in equal parts, into the sac. Iodine, gr. -|, iodide of potassium, gr. 5, water 3 ^, may be used, too, as an injection. Spina bifida, is, generally speaking, a fatal disease; nevertheless, we should do all we can to prolong life and effect a cure, where it is possible, although such efforts have seldom been successful under my observation. One patient, I recollect, got well with some curvature of the spine. Spinal Meningitis. This is an inflammation of the spinal pia mater. Swelling or the dura mater and of the arachnoid is seldom met with as a primary disease. Pathology.—The pia mater is generally of a pale-reddish color, sometimes purple, swollen, and infiltrated, with a jelly- like or bloody exudation. When the redness fades away, the membrane is of a dirty yellowish and greyish color, covered with a dirty looking exudation. Sometimes the whole mem- brane is inflamed, reaching to the cavity of the cranium. After recovery there are adhesions, hyperaemia, thickening of the membrane, and perhaps hydrorrhachis and atrophy of the spinal marrow. There is an epidemic form, combined with cerebral meningitis, as in spotted fever, which we will discuss in another place. Symptoms.—If combined with cerebral affections, there will be such marked brain symptoms as to altogether disguise the spinal affection. If swelling is confined to the spinal pia mater, we find pain in the back, at the point of inflammation, which is aggravated by movement. There is also pain in the 308 THE PRACTICE OF MEDICINE. limbs, which is made worse by motion. Stiffness in the mus- cles exists, and in some cases opisthotonos, especially if the cervical portion is the seat of trouble. The least motion of the spine gives rise to tonic spasms, while reflex irritation of the peripheric extremities of the nerves does not produce them. The acute form may terminate in the chronic form, with exu- dation and paraplegia as a result. This discharge may termi- nate in tubercular degeneration, followed by oedema of the lungs, catarrh of the bladder, etc. Treatment.—Where the skin is dry and hot, and the pulse small, thick, and like a cord or thread, aconite is a valu- able remedy, and may be ordered in doses of gtt. 1, every hour, until the pulse becomes soft and slower, and then every two hours. If there is a throbbing pain in the spine, drowsiness, with inability to sleep, and spells of nervous starting, gtt. 3, of belladonna, should be given every two hours, until these symptoms give way. If the affection is connected with, or proceeds from disease of the bones of the spinal column, the phosphate of lime will be a very good remedy in gr. 2 doses, three times a day. In the chronic form, where there is inabil- ity to lift the limbs, I use cocculus indicus, in doses of gtt. 1 to 3, every four hours until relief is given. In chronic cases, when aggravated by cold, changes of weather, dulcamara, in doses of gtt. 5, three times a day, may be given. Myelitis. Myelitis is of less frequent occurrence than meningitis; and when it exists it generally produces meningitis. Pathology.—Its pathology resembles that of encephalitis. There is redness, swelling and softening, either throughout the entire length of the gray substance of the spinal marrow alone, or it is an inflammation extending diagonally through a por- tion of the different parts of the spinal cord. Myelitis is the result of external injuries, and exposure to cold, or it may be associated with inflammation of other adjacent organs. In DISEASES OF THE SPINE. 309 some rare instances it has been seen during the course of typhus or typhoid fever and pneumonia. Symptoms.—One of the first symptoms is a disorder of sen- sibility and motility. The patient may feel a sensation of coldness, numbness, prickling and pain in the toes and fingers, which gradually extends from the periphery towards the trunk, on one or both sides. There is more or less pain in the spine, which is aggravated by pressure upon the spinal processes, and the parts which are innervated by the diseased roots are more or less constricted, and either very sensitive or the reverse. If the degeneration of tissue should take place throughout the whole substance of the spinal marrow, there may be complete anaesthesia or insensibility of the parts. The deficiency of motion first shows itself in unwieldiness of the peripheric muscles, and this may terminate in complete paralysis of the lower extremeties (this is of very frequent occurrence); but if the dorsal region is affected, it causes paralysis of the sphinc- ters ani and vesicae in addition. If the trouble be still higher up, there will be great palpitation of the heart. Should the cer- vical region be affected, the upper extremities, respiratory motion, deglutition and speech will be more or less deficient, If the lesion is confined to the cervical region, only the upper extremities are paralyzed. Prognosis.—The lower the seat of inflammation the more slowly it advances to a fatal termination. Patients may live ten or fifteen years with paraplegia, but where the cervical portion of the spinal cord is inflamed, death may take place in a short time, from paralysis of the respiratory muscles. Where the lesion is limited to one or more of the lateral cords the paralytic symptoms may be confined to one side for a while, with more or less insensibility ; or there may be insensibility on one side, and paralysis on the other side, as in some trau- matic wounds. One frequent symptom of myelitis is the erec- tion of the penis which may remain so for days. Treatment.—As this disease is generally accompanied by 310 THE PRACTICE OF MEDICINE. meningitis, the same treatment will be required as for that disease. In the active stage aconite, in doses of gtt. 1 every hour, will serve to control arterial excitement. If there is great pain in the sacral regions, anaesthesia of all the limbs, paralysis of the lower limbs, convulsive twitching and shocks of the paralyzed limbs, painful contractions of the flexor mus- cles, and paralysis of the rectum and bladder, gtt. 25 of ergot may be administered. The ergot may alternate belladonna every three hours. If this affection occurs after sexual excess (as it often does) or in connection with an inflammatory con- dition of the vertebrae, hypophosphite of lime will be of mater- ial service, alternated with other indicated remedies. I usually give it in the form of a syrup, gr. 2 or 3, three times a day. In the chronic form counter-irritation may be used, by vesica- ting the spine with diluted acetic acid, or croton oil. In the latter form hypophosphite of lime, sodium and magnesium in small doses, will aid in the radical cure of this disease. If softening of the spinal marrow should result, apoplexy will set in, and cause death; or, it may terminate in sclerosis medullae spinalis (hardening of the spinal marrow) ; this may also terminate in apoplexy, and finally in death. In either case medicines exert but slight control over the morbid process. Belladonna, in 5 gtt. doses, will mitigate the symptoms for a time. Multiple Sclerosis: Chronic Myelitis. This form of chronic myelitis is often associated with chronic encephalitis, which is characterized by the development of numerous insulated sclerotic nodules, of various sizes, and of a chronic inflammatory nature. These nodules are scattered throughout the entire spinal cord, and very often over all the brain. Occasionally a less intense, but more diffuse sclerosis unites the different nodules together. Women are oftener the subjects of this disease than men, and it rarely occurs later in life than thirty years of age, or earlier than ten years. DISEASES OF THE SPINE. 311 Causes.—Severe mental or bodily exertion may give rise to this disease, and it may also be caused by catching cold, trau- matic influences, pregnancy, hysteria, and acute diseases. Symptoms.—Disturbance of sensibility is often one of the first marked symptoms. A want of co-ordination (ataxia) is also often observed, and a peculiar tremor accompanying voluntary motions, which progressively increases. This tre- mor, which appears at every attempt to move, distinguishes sclerosis from paralysis agitans. Alteration in speech is another symptom, as is also alteration of the voice. Speech is more or less indistinct and hesitating, and the voice becomes monotonous and weak. The movement of the tongue and lips is impaired, and mastication and deglutition become very diffi- cult. The sight is disturbed, there being diplopia, amblyopia, and often blindness. Vertigo, sleeplessness, violent headache, and, occasionally apoplectiform attacks may be present, which are apt to be followed by febrile excitement and hemiplegia. The symptoms in each individual vary according to the extent and location of the sclerotic nodules. Treatment.—In cases where the gait is tottering, the legs weak, speech much embarrassed, amaurosis is present, pupils are widely dilated, and there is deafness, phosporus, in some form, is indicated, and I prefer the phosphide of zinc, in doses of gr. 1-10 to 1-15 in water, every four hours. Where the palsy is preceded by twitching of the muscles, or trembling, I order physostigma, in doses of gtt. 1 to 3, every four hours. Where there is vertigo, staggering gait, trembling, general debility, cholera-like convulsions in the limbs, transient blindness and sleeplessness, nitrate of silver, in very small doses, is indicated. This may be alternated with gtt. 1 of nux vomica (saturated tincture) every four hours. These reme- dies are also indicated in tabes dorsalis, or gray degeneration of the posterior columns. Electricity, properly used, will do good in chronic myelitis. The nitrate of silver will aid its curative effects, in small doses. Cold applications do good also. CHAPTER XXIV. DISEASES OF THE MOTORY APPARATUS. Rheumatism. RHEUMATISM attacks the fibrous tissues, joints, aponeu- roses, sheaths of the tendons, neurilemma, periosteum, and the musles and tendons. It is a very painful affection, caused doubtless by inflammation of a peculiar character, and some nutritive disturbance, not well understood now by the best pathologists. The immediate cause of this form of in- flammation is exposure to cold or wet. Rheumatism may be acute or chronic. Acute Rheumatism. This form generally has its seat in the synovial membranes of one or several joints. By some peculiar nutritive disturb- ance, the joints become inflamed, and yield a scanty exudation, which contains but a small quantity of fibrin or pus-globules. An inflammatory oedema of the surrounding cellular tissue rapidly takes place. In some rare cases, the exudation may contain both fibrin and pus-globules, especially where the in- flammation runs high, and in young and vigorous subjecs. Postmortem examination reveals ecchymosed spots in the synovial capsule, which is filled with a purulent exudate; even the ends of the bones may be infiltrated by bloody extravasa- tions. The heart and large vessels contain much fibrin; and there are often structural changes in the heart itself, such as pericarditis, etc. Predisposition.—Old age and childhood are less liable to this disease than youth and middle-age; and those who have once been attacked by this disease are more prone to it than 312 DISEASES OF THE MOTORY APPARATUS. 313' those who have not had it. Robust persons seem more liable to be attacked by rheumatism than the feeble and debilited. It prevails in all latitudes, but more in the temperate than in the hot or polar zones, and oftener in winter and spring than in summer and autumn. Symptoms.—The disease may be preceded by a chill or chilly sensation, or may come on gradually. Very soon the fever rises, with severe pain and swelling in one or several joints, which become very red. The swelling may be confined to the part first attacked, or it may spread from joint to joint, enveloping the spine and symphysis pubis, and sometimes even the joints of the toes and fingers. The pain is so excru- ciating as to compel the patient to keep in motion, which often aggravates the pain. Fever.—The fever is often very high, the temperature ranging between 104° and 104.9°, although the temperature may not run higher than 100°, and the pulse may not be over ninety to one hundred beats in a minute. Occasionally, there may be free perspiration without any reduction of the inflam- mation. The urine is scanty, and loaded with urates and uric acid. About twenty per cent, of the cases of rheumatism of the purely acute type are complicated with endocarditis, and about fourteen per cent, are complicated with pericarditis. Compli- cation with myocarditis are not so frequent, but occasionally it occurs with pleuritis, pneumonia, meningitis, or even cerebro- spinal meningitis. Its course is not regular, passing off some- times in from ten to twelve days, or continuing several weeks, and finally terminating in the chronic form. Rheumatism sel- dom ends in death, unless it be complicated with disease of the heart, lungs, or meninges of the brain. It is liable to return, and produce disease of the valves of the heart, which finally proves fatal. Treatment.—This form of inflammation has yielded to aconite (one drop every hour or two), and salicylic acid (from 314 THE PRACTICE OF MEDICINE. the oil of wintergreen), or salicylate of sodium, gr. 3 to 5 every three hours dissolved in sweet spirits of nitre. I usually add gr. 40 of salicylic acid to 1 1 of sweet spirits of nitre, giv- ing a teaspoonful every three hours. I alternate this mixture with the tincture of aconite until the fever falls considerably, and then lessen the quantity of both remedies. If the pain still remains after the fever is subdued, and is increased by motion, I order gtt. -| to 1 of bryonia every three hours; but if moving the limbs gives ease, gtt. 1 of rhus tox. is the indi- cated remedy. The most speedy relief to acute rheumatism is from an alcoholic or camphorated vapor bath, made by evap- orated camphor (made in alcohol) on an iron or flat rock, just hot enough to evaporate the spirits of camphor. This bath should be taken by the patient while his body is bare, so that the camphor may come into contact with the skin while the pores are all freely open. The patient may sit in a chair, well enveloped in blankets, with a plank under him, so as to pre- vent the hot vapor of the camphor from burning. I have relieved some very extreme cases in this way, in three sittings. Manaca — the franciscea uniflora (Pohl), (lately introduced from Brazil by Parke, Davis & Co., of Detroit, Mich.) — has acted well in some cases, given in doses of gtt. 10 to 20 every three hours. Benzoate of ammonium is also a good remedy where the disease is associated with more or less indigestion. Lithium and its salts are invaluable where there is an acid state of the urine. I have cured rheumatism in the sub-acute form with phytolacca and tincture of colchicum, given in gtt. 5 doses, ter in die, after the urine is alkaline. Chronic Rheumatism. This form rarely occurs, unless it has been preceded by the acute or sub-acute form. Post-mortem examination reveals a thickened condition of the synovial capsules and ligaments, and sometimes the cartilages of the bones are spongy, and the synovial fluid turbid. Occasionally single joints become very DISEASES OF THE MOTORY APPARATUS. 315 painful from motion, and show paroxysms of aggravation, chiefly at night or in damp, cold weather. In sub-acute attacks there is more or less swelling, but not much, if any, general fever. Sometimes the sub-acute or chronic form of rheumatism may be complicated with muscular rheumatism, and with certain forms of paralytic and neuralgic affections also, which are usually called rheumatism, or neuralgic rheu- matism. Muscular rheumatism receives its name according to the locality. The principal form is cephalalgia rheumatica, which attacks the frontal, occipital or temporal muscle, perios- teum of the skull, or the aponeurosis. Torticollis, rheuma- tism, or myalgia cervicularis ("stiff neck," or "crick of the neck"), has its seat in the cervical muscles, rendering any movement of the head very difficult and painful, and fre- quently drawing the neck to one side. This position may become a permanent one if the muscles should contract. Pleurodynia rheumatica is myalgia of the breast and intercos- tal spaces, and principally attacks the pectoralis major and intercostal muscles. When it attacks the pectoralis major, it hinders the motions of the arms, and when it attacks the inter- costal muscles, it impedes respiration and simulates pleuritis, for which it is oft-times mistaken. Omodynia rheumatica, myalgia scopularis, is rheumatism of the muscles of the shoulders and back, and causes great pain in moving the back or the trunk in any direction. Lumbago rheumatica, myalgia lumbalis ("kink in the back"), attacks the lumbar muscles and the lumbo-dorsalis fascia. It frequently strikes the patient down as' he attempts to stoop or lift some heavy weight, and is characterized by a lancinating, keen, darting pain in the lumbar regions or hip joint, and sometimes in some of the other muscles about the pelvic region. Treatment.—For lumbago, berberis vulgaris (tinct.) every three hours has proved very satisfactory in some cases, as has also gtt. 1 to 2 of the tincture of rhus tox., especially where the patient is compelled to move about to get a little 316 THE PRACTICE OF MEDICINE. respite from the pain. Where the pain is tearing, and there is irritability of the bladder, I order benzoic acid in doses of gr. 3 or 4 three times a day, alternated with cimicifuga. Should there be anaemia, iron will be required, as well as other remedies. Benzoate of ammonium is also a good remedy. In cases recently treated, manaca gave quick relief in doses of gtt. 30 of the plain extract every three hours. If there is constipation, torpid liver, sweat without relief, great soreness of the flesh, lameness and stiffness of the limbs, with a draw- ing pain in hips, thighs, legs and feet, chelidonium, in doses of gtt. 30 of the fluid extract or saturated tincture, acts admir- ably. Cimicifuga is very valuable alternated with chelido- nium. Where the pain is tearing, worse in the evening and at night, attended with great soreness, numbness, and swelling of the parts, arnica in doses of gtt. 1 to 2 every three hours will be apt to give more or less relief. If the pains are in the bones, and there is great irritability of the bladder, with strong ammoniacal smelling urine, benzoic acid is the indi- cated remedy, administered in doses of gr. 3 or 4 four times daily. If the small joints, as the fingers and toes, are the parts affected, caulophyllum will do good service, gtt. 30 to 60 of the saturated tincture. If the disease affects the perios- teum and synovial membrane of the joints, especially the small joints and fibrous tissues, and is accompanied with acid sweat and urine, I find colchicum, in doses of gtt. 20 three times a day, very useful, alternated with salicylic acid. In some cases phytolacca has acted remarkably well for me. If the pains are erratic, and much increased in cold, damp weather, and if there be constipation of the bowels, tension or drawing of the tendons, great sensitiveness to wind or open air, and hot head and cold feet, small doses of sulphur will do effective service. Where there are rheumatic pains in the limbs, attended with numbness of the joints, and keen pains when touched, a drawing of the fibrous tissues, joints and sheaths of nerves, with a feeling of formication and lameness, DISEASES OF THE MOTORY APPARATUS. 317 which is worse in bed or at rest, and better when moving about, rhus toxicodendron is the remedy indicated, and must be given every four hours in doses of gtt. ^ to 1. Rhododen- dron is highly praised by some English writers, especially in chronic rheumatism, as is sticta pulmoneca, but the latter has not seemed to do any material good in cases in which I have tried it. Ranunculus is recommended in cases that affect the chest, diaphragm and scapula, and in spasmodic pains in the arms and thighs, especially in women. When produced by mercury, or from gonorrhoea checked suddenly, sarsaparilla will aid iodide of potassium in the cure. Where it affects the heart, cereus grandiflorous and spigelia are the best remedies, giving gtt 10 of each every hour, or alternating them with one another. If the digestion is very feeble, nux vomica, in doses of gtt. 3 to 5, is a valuable remedy, three times a day. Gout. This disease very rarely attacks persons under thirty years of age, very young children or infants. Old men are subject to it that live oh rich diet, or those that habitually indulge in the use of beer, wine or other acids, and take but little exer- cise. It seems to be hereditary in families, and this predis- position to the disease is easily aroused and put into activity by surcharging the blood with nitrogenized substances. After gout has existed for some time, or become chronic, a chalky deposit is left, consisting of the urate of sodium, or sometimes of uric acid with lime, magnesium and ammonium. This deposit either lines the internal surface of the synovial capsule as a soft substance, or incrustates at the cartilages of the bones as a hard mass, or even fills the joints and causes, in many cases, anchylosis. At the same time there may be deposits on the external surface of synovial capsules or in the cellular tissues, which gives rise to hard nodosities. In one case that I examined—that of an old inebriate—there was a large deposit under the skin just above the knee-joint that was as large as 318 THE PRACTICE OF MEDICINE. an egg. Attacks of gout come on very suddenly, and gener- ally at night. They commence with a burning, screwing pain in one or both of the big toes or the heel. The parts affected soon become swollen and red, and the patient has fever, thirst, dry skin, and highly concentrated urine. The disease may abate in violence in the morning, and the patient may pass the day comfortably, but it will return the next night with the same violence. Thus it will be apt to continue for a week or ten days, when the pain, redness and swelling gradually subside, the skin of the affected part peeling off. If the patient's constitutional proclivity to the disease is not arrested, it will return again and again, involving other joints. It may finally attack the finger-joints, the knee-joints and the shoul- der-joint The disease eventually becomes chronic, and is attended by derangement of the digestive organs. The swell- ing also remains longer and longer between the attacks, and in some cases changes into a hard tophus. These hardened, chalky deposits within the joints not unfrequently terminate in abscesses, which may break and discharge pus mixed with calcareous substances. The internal organs, as the stomach, brain or heart, are also liable to be attacked. If it attack the stomach, it produces severe cardialgia, vomiting and nausea; if the brain, apoplexy, headache, vertigo, delirium and sopor; or, if it attack the heart, it gives rise to dyspnoea, syncope, palpitation, etc. Treatment.—One of the first things to be done is to regu- late the patient's diet and make him take exercise. In acute attacks, the following remedies are indicated: aconite, in doses of gtt. 1, every two hours, until the fever is subdued, and then gtt. 10 to 20 of colchicum, every three hours, should follow. When it becomes a chronic form the phosphate of ammonium may alternate with colocynth in small doses. The phosphate of lime in gr. 2 doses, is also a valuable remedy, and should not be forgotten. In some cases the iodide of potassium has done great good, and in others the gum guaiacum, in ammon- DISEASES OF THE MOTORY APPARATUS. 319 iated tincture, has proven valuable. Where there are gouty concretions, benzoic acid, or the benzoate of ammonium, will do good service in gr. 3 doses, three or four times a day. The carbonate, or citrate of lithium, in doses of gr. 3 or 5, three times a day, will meet this last condition, as well as, or better than the benzoic acid. Lycopodium is indicated where there are hardened concretions about the joints, and may alternate the carb. of lithium. Benzoate of ammonium will be found to do well in many cases. It should be given wherever the blood is surcharged with urates or uric acid. The digestion should also be corrected, so as to cut off the source of the acid in the blood, for which purpose tonics are required. For the relief of a paroxysm, the tincture of colchicum, in doses of 2 to 3 gtts. of the saturated tincture, every two hours, seldom fails. If the pain flies about from one joint to another, pulsatilla, 3 gtts., every three hours, promises well. If attacks of gout are attended with fever, aconite should be given, aconite tinct. 30 gtts. to aqua pura 4 f. Dose, a teaspoonful every two hours until the fever is controlled. Sometimes where pain is severe it may be relieved by painting the parts with veratrum viride, three times a day. Drop doses of bry- onia alba, every two hours, often relieves the pain. The patient's diet must be very light. CHAPTER XXV. DISEASES OF THE OSSEOUS SYSTEM. Rachitis. THIS is due to imperfect ossification, and a preponderance of cartilaginous and fibrous growth in the bony structures of the body. In consequence of this, the bones remain soft, and are easily broken or bent; the epiphyses of the long bones are easily bent, and the diaphyses are easily broken. Children are often very much deformed by this disease, their legs being crooked, their spines curved, and the breast so deformed as to present the sharpness of that of a chicken. Rachitis is apt to occur between the first and second dentition. Causes.—The causes of this disease are quite obscure. Some pathologists believe it to originate from a want of proper food, that is, food deficient in hypophosphites. Americans live on the finest flour, containing the starch of the grain, while the better part, which is the darker and coarser, lies next to the bran, and is rejected and fed to cattle. This coarser flour contains the gluten, phosphites, and other rich elements of the grain. Rachitis may sometimes originate from a want of proper assimilation, and, again, may be caused by nutritive disturbances in the cartilages or the epiphyses, and in the periosteum. Signs.—One of the first symptoms is a very obstinate diar- rhoea, consisting of a foamy, fermented discharge, with great emaciation. Children affected with this disease lie with their limbs extended, and dread being moved. Very soon the epi- physes become tumefied. The process of teething is very slow, sometimes no teeth appearing for the first year or more. Rachitis is manifested in the lower limbs first, and then the bones of the pelvis and thorax become involved in the disease. 320 DISEASES OF THE OSSEOUS SYSTEM. 321 Treatment.—One of the first things to be done is to examine the milk the child receives, and see whether or not it is of a wholesome character. If the food is of a proper kind, and the disease still developes, the child should receive proper medical treatment. Small doses of cod-liver oil should be given in an emulsion, made with good Maltine. The carb. of calcium (calc carb.) should also be ordered in small doses. Sometimes this may be alternated with calc. phosphate in small quantities. Very large, open fontanels, diarrhoea, and emacia- tion, are all indicative of rachitis. I had a case this past sum- mer of a little child, with the characteristic diarrhoea, tardy teething, emaciation, curved spine and bowed limbs. I put it upon the calc. carbonate (the white, flour-like substance be- tween the inner and outer layers of the oyster shell), and very small doses of bryonia to tone up its liver and stomach. Un- der this treatment it improved rapidly, and is now healthy. It has cut some teeth, and its limbs are about natural in shape. (It is now a healthy child.) Osteitis ; Exostosis. Osteitis consists either in inflammation of the periosteum, of the bone itself, of its marrow, of its medullary membrane, or of all these together. It is often very tedious in its course. Causes.—It often follows bruises, fractures and other in- juries ; or it may result from chemical influences. In some cases it seems to have originated from a certain constitutional contamination, such as scrufula, arthritis, scurvy, syphilis, mercurial poisoning, or some suppressed chronic affection of the skin. Symptoms.—It generally begins with heavy, burning pain, which finally assumes a tearing character, especially where the periosteum is also affected, which is often the case. The pain is increased by night air, motion, pressure or any light jar. The bone feels hot to the patient, and, if it is superficial, the 21 322 THE PRACTICE OF MEDICINE. skin and flesh of the limb soon participate in the inflamma- tory process. The general fever may not be very high. Terminations.—This disease may result in caries or necro- sis, and a large sequestrum may be thrown off, to be replaced, in favorable cases, by a new formation. I recently assisted in the removal of a large sequestrum from the ulna. We had, lately, in our surgical clinic, a case in which there was a large sequestrum of the femur, which we succeeded in removing. Such cases often occur, and if these irregular pieces of bone are not removed, they become sources of great annoyance to the patient, and may prove fatal. Treatment.—Where there is periostitis and enlargement of the bones, especially the tibia, with violent aggravations at night, daphne mezereum, in small doses, gtt. 1 to 2, three times a day, will be useful. If the disease is from the abuse of mercury, or from a syphilitic taint, gtt. 2 to 3 of nitric acid, three or four times a day, will give good results. After sup- puration takes place, small doses of triturated silicia will be proper, say gr. 1 of the 1st dec. trituration, every three hours. Staphisagria is a valuable remedy in many cases where osteitis takes place in the phalanges of the fingers. This may alter- nate with a good acid phosphate, in small doses. The phos- phite of lime is a valuable remedy where caries or necrosis of the bone has taken place. Where the disease attacks the bones of the nose, face or head, the chloride of gold, in doses of gr. 1-80 three times a day, will do good service. Angostura, as a tonic, is often called for in this affection, especially in caries of the long bones. If this disease occurs in scrofulous consti- tutions, small doses of tincture of asafoetida may be given in alternation with menispermum or aselli jecor. ol. If there are glandular swellings in scrofulous individuals, gtt. 1 to 2 of tinct. of scrofularia will be required,* three times a day. Where there is profuse suppuration and emaciation, small doses of the tinct. of cinchona must be given. *Scrofularia is the figwort, a good remedy. diseases of the osseous system. 323 White Swelling. Tuberculosis is a constitutional disease, but may localize itself, as it has often done, in different structures or organs of the body. When it attacks the joints, it usually appears on the hip, knee, ankle, elbow or wrist-joint. It is a form of in- flammation presenting a peculiar glossy, shining appearance, which has given it the name of " White Swelling." In the early stage the synovial membrane is highly injected, somewhat opaque, softened, and thickened in patches by fibrous exuda- tion. There is generally an effusion of lymph, of a pale yellow color, and of a pulpy consistency. The articular cartilage presents a grayish, or dull whitish color, and is generally thickened, softened and partially separated from its connection with the bone. The cancellated structure of the bones is ab- normally vascular, porous, humid, light and generally easily broken. In many cases its cells are distended with a yellow- ish tubercular material, of a semi-solid, osseous character. The ligaments are usually red, tumefied and softened. The synovial fluid is increased in quantity, but not to any great ex- tent. As the disease advances the lymph gradually increases in quantity, and may be mingled with sero-purulent matter. The synovial membrane finally becomes destroyed to a great extent, and what remains, presents a muddy, opaque and ragged ap- pearance. The cartilage is ulcerated, discolored, perforated, and partially detached from the bone. Large quantities of pus accumulate, sometimes thick, caseous, ichorous or sero- sanguinous. In some rare cases it "may be thin and almost black, from the necrosed conditions of the bones. If recovery takes place, the joints are generally left anchylosed, or firmly attached by new material to the surrounding structures. In time, an artificial joint may be formed, and admit of consider- able motion; but it is rarely the case that the joints recover mobility. These are the characteristic symptoms of tuberculo- sis of the joints, its general pathological changes, etc. 324 THE PRACTICE OF MEDICINE. CoXALGIA. Coxalgia generally attacks children from the third to the seventh year, but I have known it to appear in later periods of their life. Where there is constitutional diathesis, it may be excited by excesses, injuries, exposure to cold, or by certain wasting diseases. It rarely attacks both hips at the same time, but may be complicated with psoas abscess, ophthalmia, or pulmonary phthisis. Symptoms.—In incipiency the patient is easily tired, and complains of a pain in the knee-joint, or its inner side, which is much aggravated by motion, causing the child to limp when walking. The pain is also worse at night, and may prevent sleep by spasmodic jerking in the affected limb. This pain gradually extends up the limb, and is frequently felt over the instep also, or it may shift from one place to another, and sometimes cease for a while altogether. After some weeks, or even months, the pain is felt in the hip joints, and is intense over the articulation, deep-seated, and of a rather dull gnawing character. During the second stage, when the pain has be- come very violent, the buttock becomes flattened, the gluteo- femoral crease disappears, the limb appears longer, the muscles waste away, the appetite becomes capricious, the bowels con- stipated, and there is more or less fever, and sometimes copious sweat. The patient now begins to show emaciation and de- bility. In the third stage suppuration takes place. This may be known by the increase of the pain on the slightest motion, by throbbing and a sense of tension; by an increased swelling of the gloteal region; by oedema of the subcutaneous cellular tissue, and a turgid condition of the subcutaneous veins, by violent rigors, high fevers and copious sweats. The pus may work its way to the surface, which is indicated by a circum- scribed blush over the pointing part, and by the distinct fluctuation of the part, which, when opened, gives vent to large quantities of pus. Or the pus may make its way internally, DISEASES OF THE OSSEOUS SYSTEM. 325 by perforating the acetabulum into the rectum, bladder or vagina, or it may collect in a sort of pouch, between the inner surface of the iliac bone and the soft parts of the pelvis bones. The limb is shortened from one to one and a quarter inches, and the foot points either outwards or inwards. The neck of the femur is wasted away; sometimes the bone may be so de- stroyed as to allow the superior extremity to move about and attach itself in an entirely new position. Treatment.—In the first, and even in the second stage, when pressure on the trochanter causes pain in the hip-joint, gtt. 1 to 2 of the first dec. dilution (not stronger) of rhus tox. should be given every two hours. As soon as the hectic fever takes place, tincture of phosphorus may be given (2 dec. dilu- tion), gtt. 1 to 2, three times a day. If there is congestion of head, starting in the sleep, burning, stinging pain in the hip, gtt. 2 to 3 of tincture of belladonna may be administered with marked relief to the patient. In the third stage, where sup- puration has commenced, the phosphite, or the hypophosphite of calcium should be given gr. 1 to 2, three times a day, to restrain the suppuration. Where there is suppuration and rapid caries of the bone going on, with glandular swellings, silicea, in doses of gr. 1 of the first dec. trituration, may be given three or four times a day. In cases in which there is a free discharge of acrid pus, the iodide of arsenic will be of material service in doses of 1-20 to 1-30 of a grain, I usually triturate gr. 1 with gr. 9 of sugar of milk, then put gr. 4 to 6 of this into i 4 of water, and give a teaspoonful four times a day, well diluted with water. I give, in the first stage, the tincture of menispermum, in doses of 3 1, three times a day, and anoint the joint with an ointment of polymnia uvedalia and oil of cedar. Genu Album. White swelling of the knee is from the same constitutional taint that gives rise to hip-joint disease, and runs nearly the 326 THE practice of medicine. same course. It is excited by an external injury in many cases, such as fall, twist, or blow upon the knee-joint. Symptoms.—This disease generally begins with a severe, dull, heavy pain at the inner condyle of the patella or at the inside of the head of the tibia. The pain may be rather inter- mittent, and extend up and down the limb. Very soon inter- stitial deposits take place, and the joint begins to swell. The swelling is first confined to the front and sides of the patella, effacing the natural depressions in that region, and producing soft fluctuating sacs or bags instead of the usual depressions, Sometimes there is a considerable prominence just above the joint, over the lower part of the femur, bounded by the infer- ior portion of the patella, and on each side by the lateral liga- ments, its anterior wall being formed by the tendon of the exterior muscle. The popliteal region rarely, if ever, swells. The skin over the swollen part is tense and glossy, and the subcutaneous veins become very much enlarged. The knee joint is stiff and the leg more or less flexed. The thigh soon becomes considerably atrophied. The ligaments weaken, and the deformity of the joint increases, owing principally to the displacement of the head of the tibia, which causes the mus- cles to draw the leg outwards. In some rare cases there is actual enlargement of the diseased bones. As the disease advances adventitious deposits take place upon the synovial membrane, and the synovial fluid is absorbed. The fluctuation which marked the earlier stage now disappears, and the joint, now swelling largely, becomes firmer and more resist- ing, but still possesses some elasticity. In most cases, the diseased structure finally begins to suppurate, and the pus may be absorbed, or it may escape at different places about the knee, forming numerous fistulous openings, and leading to caries of the bones, or to necrosis of the larger portion of the diseased tissue. This disease must be distinguished from bursitis (house-maid's knee), on account of its frequent occurrence among female servants, from working in a kneeling diseases of the osseous system. 327 position. It is distinguished from synovitis by its superficial nature and the regularity of the tumefaction. . It may sup- purate, or become chronic—a solid tumor. Treatment.—If this affection of the synovial membrane follow a fall or blow, I give arnica, in doses of gr. -I to 1, every three hours, while a diluted tincture is applied to the knee. If there is general fever, or in case the disease follow exposure to cold, the tincture of aconite, in doses of gtt. -|, every half hour should be given, until fever is moderated, then three or four times a day. If the disease follow a twist or sprain, rhus tox., in doses of gtt \ to 1 should be given every two hours. I have cured some grave cases with these remedies, properly used. In scrofulous constitutions, the pure oyster- shell lime, in small doses, will be found a good remedy. I use the 1st dec. trituration, in doses of gr. 1 to 2, three times a day. Where suppuration has taken place, and the dis- charge is thin and acrid, and the openings are surrounded with pale spongy edges which bleed easily, small doses of tincture of iodine will be of material service. After caries takes place, and when there are fistulous openings and a cachectic condi- tion of the system, silicea will be required. If there be a dis- charge of foetid pus, with oedema of the limb, emaciation and exhaustion, tincture of arsenic, in doses of gtt. \ to 3, three times a day will prove a good tonic. I have found an oint- ment made of fresh uvedalia and oil of cedar to control this morbid condition of the capsule as readily as anything I have tried. This affection comes under the province of the surgeon, and to works on surgery the reader is referred for a full account of its pathology and treatment. CHAPTER XXVI. DISEASES OF THE NERVOUS SYSTEM. Neuritis. NEURITIS may be of the acute or chronic form. Acute neuritis is usually produced by the external injury, or by some destructive process in the adjacent parts, such as sloughing, ulceration or cancer. It generally begins with chilliness, or an actual rigor, which is soon followed by fever, headache, pain and sleeplessness. In some cases a red line may be seen in the skin, indicating the course of the inflamed nerve, and the tissue through which it is distributed exhibits a very marked degree of hyperaesthesia, and a sensation of numb- ness and formication. The chronic form is characterized by paresthesia and more or less pain, with sensory and motor irritation, subsequent paralysis, and a painful swelling of the nerve itself. Treatment.—Aconite in doses of gtt. 1 every hour, should commence the treatment, and be continued until the force of the fever is stayed. At the same time the course of the inflamed nerve should be rubbed with an ointment of hyperi- cum perforatum. Hyperaesthesia, which is one of its most common attendants, will require special remedies. In many cases, belladonna alternated with aconite, will relieve this com- plication, or it may require rhus tox., sulphur, arsenic or euphrasia, or hydrochlorate of cocaine rubbed on it. Neuralgia. Neuralgia is a pain in the nerves. All pain, in one sense, is neuralgia—pain of a sensitive nerve, but this is not the sense in which the term '- neuralgia " is used. It is an irritation in 328 DISEASES OF THE NERVOUS SYSTEM. 329 the course of one or several sensory nerves, which may exist in any part of the nerve, from its origin down to its termination, or over the whole course of the nerve. Not only is it felt where the inflammation exists, but in different places along the same nerve, and sometimes even throughout its entire length. This nervous irritation or pain may result from a great many different things; hence neuralgia may be a symp- tom of numerous pathological conditions. Some structural changes of the nerves themselves are occasionally found, espec- ially in paralytic conditions of parts. Neuroma, or tumors of the nerves, may exist without neuralgia; and neuralgia may exist without a single trace of structural change. It is there- fore very difficult to define the pathology of this affection, as it is often a mere symptom of very different conditions, such as peripheral or central. Peripheral causes are organic changes in the nerves themselves, or such as may occur in neigh- boring parts of the nerves, as in inflammation, caries, exos- tosis of the bones, tumors and affections of the uterus, liver, ovaries, stomach and kidneys, all these may be causes of neu- ralgia. The general central causes are structural changes in the spinal cord and brain, and their membranes, such as soft- ening, tumors, sclerosis, and morbid deposits, metallic poison- ing, exposure to cold, miasmatic influences; all these may give rise to neuralgia. Symptoms.—One of the most marked symptoms is pain, of a boring, cutting, tearing, excruciating character. It most commonly comes on in paroxysms, and is often felt running along the course of the affected nerve, and this pain is increased by touching the surface. There may be also spas- modic motions in those parts in which the sensory branches are distributed. The vaso-motor nerves may also be affected, causing paleness of the skin, chilly sensations, flushes of heat, perspiration, or profuse urination. The special forms of neu- ralgia are, viz.: cephalalgia, hemicrania, nervous sick headache, and migraine. Cephalalgia, or headache, may originate from 33j the practice of medicine. many morbid conditions of the system at large, and some con- stitutions are predisposed to it, and will have it after slight disturbances of the general health. Headache may be pro- duced either by hyperaemia, anaemia, or hysteria. Rheuma- tism and many other pathological conditions may also be asso- ciated with it. The trouble may return periodically — that is, may come on in the morning and cease at evening. Some- times it attacks only one side of the head, and sometimes it passes from one side to the other; or, again, it may be confined to the top of the head, or to the occiput or forehead. Some- times the pain is excruciating, and is associated with extreme nausea and vomiting of bile and slimy acid. Frequently the pain ceases when vomiting occurs, and sleep usually relieves it. Hysterical, anaemic, and chlorotic women are very prons. to cephalalgia, as are literary men of weak constitutions. The use of tea, coffee and tobacco, and of all alcoholic drinks or fermented beverages, leads to this disease. Treatment.—When the spells come on regularly, the tinc- ture of arena diadema, in doses of gtt. 3 or 4, will often over- come them. Other cases yield to belladonna or aethusa cyn. in small doses, and such as are associated with vertigo, dim- ness of sight, and ringing in the ears, call for argenti nitras. If the paroxysms are intermittent, and do not come on at any regular hour, quinine in gr. 4 to 5 doses daily will generally break them. If there be a throbbing pain of the occiput, I give ignatia amara in doses of gtt. 1 to 2 three times a day. Gelseminum sometimes cures neuralgia of the face. Tic Douloureux. This form of neuralgia attacks one or another branch of the trigeminus or fifth nerve, enters the supra-orbitalis or the infra-orbitalis nerve; and hence the names, neuralgia supra- orbitalis, neuralgia infra-orbitalis, and neuralgia infra-max- illaris. This form of neuralgia is generally confined to one side, but may attack first the right and then the left side. DISEASES OF THE NERVOUS SYSTEM. 331 The pain is generally paroxysmal, and very severe, sometimes shooting to the back part of the head and neck, and down into the shoulder and breast. Again, the motor nerves are affected, causing convulsive action of the muscles of the face and eyes, or trembling of the whole body. The vaso-motor nerves also are frequently affected, in which case we have pulsation of the arteries, swelling of the veins, and redness, paleness, and heat of the face. If the ramus ophthalmicus becomes involved, we have injection and redness of the con- junctiva, and a free flow of tears. I have a patient that has this last complication every time neuralgia comes on. If the second branch is affected, there will be a watery and slimy discharge from the nose, and if the second and third branches are involved, there will be a free flow of saliva. Treatment.—Where the patient is hot and feverish, or where the cheeks are red and the pain very severe, gtt. 1 of aconite should be administered every half hour until the fever is relieved. If the pain is of a tearing, cutting character (shooting from the side of the face up into the temples and ears, and then down into the neck), and is aggravated by motion or touch, and if it is attended by a deep flush of the face and twitching of the muscles of the face, the tincture of belladonna acts admirably in doses of gtt. 3 to 5 every four hours. If the eyes are puffed out, and there is burning, sting- ing pain (worse at midnight), pale, distorted face, with the disease originating from miasma, gtt. 1 to 2 of the tincture of arsenic will be of material service, used three times a day until the pain is gone. If the pain affects the stomach, gr. 5 of the subnitrate of bismuth should be ordered, and repeated in three hours if it fail to give relief. If it occur in females about the menstrual flow, and this flow be excessive and the pain severe, I give chamomilla in doses of gtt. 1 to 2 every half hour. If the pain exist in the infra-orbital and maxillary nerves, gr. 2 of quinia will be required every two hours, alternated with tincture of colocynth. In orbital neuralgia, coming on in par- 332 THE PRACTICE OF MEDICINE. oxysms, gelseminum in doses of gtt. 5 to 10 every half hour has acted finely with me in many recent cases; one dose of 25 gtts. is better. Cervico-Occipital Neuralgia. This rather uncommon form of neuralgia has its seat in the first four spinal nerves, and generally on one side, extend- ing over the upper part of the nape of the neck and occiput, over the lateral region of the head, and towards the lower jaw in front. Cervico-tracheal neuralgia is one form which attacks the whole tracheal plexus, shoulder-blade and arm; intercostal neuralgia is yet another form, and has its seat in the dorsal nerves, sometimes affecting both sides of the chest, but most frequently located between the fifth and ninth intercostal spaces on the left side. It produces a sense of tension in the chest, which gives rise to shooting pain when the patient attempts to expand that organ. The spinal process, where the dorsal*nerves emerge from the spine, is tender, and pressure on it increases the neuralgia. Lumbo-abdomincd neuralgia has its seat in the lumbar nerves, causing there and in the abdomen pain that is increased by pressure over the lumbar vertebrae. This pain may extend to the inguinal region, to the symphysis pubis, and in females over the crest of the ilium to the vagina and labia majora. Mastodynia, or neuralgia of the mammae in females, has its seat in the mammary glands, which often become very painful, although there is no external change of appearance. The pain may shoot into the axillae, or into the back and down into the hips. It often occurs with some irregularity of menstruation, as menorrhagia, dysmenor- rhoea, etc. It generally exists between the ages of sixteen and thirty years, but may occur later. Neuralgia ischiatica affects the nerves supplying the nates and posterior part of the thigh. Sometimes it runs along the nerves of the bend of the knee, and along the fibula into the external part of the ankle and heel, and external part of the foot; occasionally the DISEASES OF THE NERVOUS SYSTEM. 333 pain is only felt in the sole of the foot — neuralgia plantaris. Crural neuralgia generally has its location in the crural nerve, in which case the pain is felt in the lower and inner region of the thigh, the inner portion of the knee-joint, and the ankle (on the inner side), possibly passing into the big and second toe. It may be caused by uterine tumors, cancers, inflammation of the hip-joints, crural hernia, or by anything that presses on the nerve. Treatment.—The remedies mentioned in the treatment of the other local forms of neuralgia, as belladonna, aconite, arsenic, chamomilla and quinia, will be applicable here, under the same pathological conditions. If the neuralgia be caused by over exertion, arnica, in doses of gtt. 1 of the tincture, will give great relief and may be repeated every two hours. For a throbbing pain in the hip, ignatia amara, in doses of gtt. 2 to 3 will be required; for neuralgia of the 5th pair gelseminum. Anesthesia. Anaesthesia may be due to two pathological conditions: (1) an inability of the sensory nerves to convey the external impression to the central organs; (2) an inability of the cen- tral organs to perceive the impression. The first is the case when the nerve has been severed; and the latter may have its prime source in some diseased condition of the spinal marrow or brain, and is generally associated with paralysis of corre- ponding parts. The degree of anaesthesia varies greatly in each case; amounting, in some instances, to mere numbness or torpor, or, again, to complete deadness of the part affected. It is manifested by torpor of the capillary circulation, decrease in the heat of the part, dryness of the skin, oedema, livid color of the skin, ecchymosis, and sometimes by blisters filled with bloody serum appear on the toes and fingers. Trigeminal Anesthesia. In this form of the disease the patient does not feel any irritation upon the affected parts; but when eating he does not 334 THE practice of medicine. taste anything in the affected side, and the saliva drips from his mouth without his knowledge. He does not feel a glass or a cup when he puts it to his lips on the affected side. There may be also loss of sight, smell and taste. The reflex movements of the face are lost, the eyelids do not shut when the conjunctiva is touched, nor does irritation of the mucous membrane of the nose cause sneezing. Causes.—The central causes are apoplexy, softening and tumors of the brain, peripheric inflammation, and softening, hardening and atrophy of the nerve and of the Gasserian ganglion. Severing of this nerve or one of its branches, by a wound or surgical operation, or by wounding the nerve by severe blows, etc.; pressure upon the nerve by tumors or foreign bodies, and a fracture of the petrous portion of the temporal bone, may all give rise to this form of anaesthesia. These causes show the incurability of this affection, unless its cause be removed. Morbid Affections of the Motory Nerves. We have seen that the sensory nerves may be morbidly affected, either by an increase or by a loss of sensibility. So, also, may the motory neves be affected by spasm, cramp, par- alysis, and excess or deficiency of the nervous tone of the parts in question. Spasms, Convulsions, Cramps. Spasms may manifest themselves either as short, slight jerks of certain muscles; as violent, frequently repeated com- pleted contractions of the same or different muscles; as hasty motions without purpose, repeated mechanically; as irregular, misdirected motions, or incoordinate spasms; as trembling, tremor or rigidity of muscles. Spasms differ in violence and extent, and not in proportion to the importance of the lesions causing them. Sometimes very grave lesions in the central organs may be attended with but slight spasms; and again, a DISEASES OF THE NERVOUS SYSTEM. 335 slight reflex irritation may give rise to the most violent con- vulsions of a very persistent character. Causes.—The causes of convulsions are various. Child- hood is predisposed to this morbid affection of the nervous centres; the younger the child the greater its proneness to this disease. Any febrile or inflammatory attack in young child- ren may be followed by spasms. Two special forms of spasms of this early age are eclampsia and trismus. As the child advances in years to the age of puberty, the tendency is to different forms of chorea, stammering, squinting, and likewise to the incipiency of epilepsy. From the age of puberty to middle age there is a tendency or liability to hysteria, eclamp- sia, and tetanus; and in old age, tremor and writer's spasm are most common. Generally speaking, females are more prone to spasms than males, ceteris paribus. Exciting Causes.—Mental emotion, fear, and sudden shock to the nervous system, will often provoke an attack of spasms. Diseases of the central organs and their membranes, as soften- ing of the brain, encephalitis, myelitis, tumors, tubercles, inflammation of the cerebral and spinal membranes, and morbid processes in the bones encasing the central organs, are all ex- citing causes. Spasms are also caused by peripheric irritation of the nervous system, by strong light, tickling, wounds, blows, bruises of some organs (as the testicles or the uterus), irrita- tion over large surfaces (as the mucous membrane of the bowels by worms or indigestible food), conditions of the blood (as stagnation, loss of blood), and by qualitative changes of the blood in fevers, pyaemia, uraemia and cholaemia. Certain poi- sons, as alcohol, narcotics, strychnia, secale, lead and mercury, may also give rise to this trouble where there is predisposition to it. Prognosis.—The prognosis depends very much upon the causes. If spasms are the result of grave lesions of the inter- nal organs, as they often are, they are of a grave character, but not so much so as when they arise from peripheric irritation. 33G THE PRACTICE OF MEDICINE. Spasms from blood-poisoning, as in uraemia, cholaemia, are always unfavorable in prognostication. When they appear in the beginning, or during the course of exanthematic fevers, it indicates that these fevers are of a violent and dangerous type. The prognosis, however, is not quite so unfavorable in children as it is in grown people. Chorea. Chorea consists in a spasmodic, involuntary agitation of single or several groups of muscles, interfering with the regu- lar voluntary muscular movements. These irregular move- ments usually abate during sleep, and any effort on the part of the patient to restrain them, only aggravates them. Symptoms.—These motions of the muscles sometimes extend to all the voluntary muscles, and again only affect certain groups of muscles, as those of the face, upper half of the body, or one side of the body. It may be that the arm of one side, and the leg of the opposite side are affected with the disease. This morbid agitation may first start in a few muscles, and gradually extend over the whole body. This gives rise to con- stant jerking, twisting, swinging, and some very ludicrous movements. Intercurrent diseases have occasionally cured chorea, but fever increases it. The reflex motions are not in- terfered with, for when the patient itches, he can scratch him- self without hindrance, and can cough, sneeze, and evacuate the bladder and bowels with usual facility. The involuntary movements of the body are free in their action, as the respira- tory movements, the action of the heart, deglutition, and the peristaltic action of the bowels. The sensibility is also natural. The mental faculties may remain intact for a time, but they finally suffer from the long duration of the disease. The pa- tient, at first, begins to show a loss of memory, then weakness in other mental faculties, and, in some cases, marked imbecility of mind takes place, the disposition becoming irritable and peevish. DISEASES OF THE NERVOUS SYSTEM. 337 Causes.—Its predisposing cause seems to develope in the age between the time of the second dentition and puberty. Mental emotions, fright, fear, and ecstacy, are exciting causes; and debility, from long continued disease, rapid growth, and the sudden suppression of cutaneous eruptions may also pro- duco it. In some cases, no specific cause can be discovered. Treatment.—Agaric is indicated in cases that are attended with jerking of the muscles and frequent nictation of the eye- lids. Belladonna should be used in cases that are attended with emprosthotonos and opisthotonos. Caulophyllum, in small doses, acts well in young girls with irregular menstrua- tion. If chorea occur with rheumatism, cimicifuga, in small doses, will do good service, alternated with sticta pul. If the muscular motions are all over the body, and are attended by a melancholy mood, loss of memory and speech, or a disposition to pray, I give stramonium, in doses of gtt. 5, of the tinct. every two hours. Zinc and copper have been used successfully in some cases. If the spasms are the result of exposure to cold, belladonna, in doses of gtt. 4 to 5, every three hours, will generally arrest them readily. If not, I usually let the patient inhale about five drops of nitrite of amyl, every half hour, until relieved of the spasm. The inhalation of chloroform has the same effect. If the spasms are caused by diseased bones, they are incurable. If they are excited by fright and terror, hyoscyamus, in doses of gtt. 5, every half hour, may be followed by relief. If not, ignatia amara may be given in doses of gtt. 1 to 2, every three hours, alternated with gtt 5 to 10 of tincture of gelseminum. Sometimes stramonium will give relief, especially where the spasms affect the eyes and their lids.* If from softening of the brain, the phosphide of zinc is the remedy, in dose of gr. y1^, three times a day, well diluted with water, to prevent irritation of the stomach. If the spasms are provoked by worms, I would give spigelia, alternated with santonin, 3 1 to \ of the first, and the last in *Croton chloral has special influence over the nerves here. 22 338 THE PRACTICE OF MEDICINE. doses of gr. J to ^, three times a day in sugar. For writer's or painter's cramp, belladonna will often be sufficient, but it may fail; nux vomica may then be tried, and if it fails too, ignatia amara may accomplish some good. This may be given in doses of gtt. 1 to 2, three times a day. In some cases sta- phisagria does remarkably well in doses of gtt. 3 to 4, three times a day. Gelseminum is the remedy wherewith to check the spasm, but its effects are temporary. Hysteria. This is a protean disease that seems to affect almost the whole nervous system, without any apparent anatomical lesion. It would seem to consist of excessive irritability, hallucinations, neuralgic pains in the sensory nerves, and often convulsions in the motor sphere; or the reverse—anaesthesia and paralysis. Hysteria most commonly attacks the female sex, and is fre- quently connected with diseases of the female genital organs. Nevertheless, it sometimes attacks the male sex. It generally appears in females between ten and thirty years of age. After the climateric period, its occurrences are very rare, although it may occur up to fifty. Etiology.—A peculiar physical constitution, that consists in an emotional nature and a want of will power, together with abnormal conditions, of the female genital organs, menstrual irregularities, excessive gratification of the sexual appetite, depressing mental emotions, disappointed love, jealousy, wound- ed pride, a guilty conscience, grief and anxiety, reading trashy fiction that excites the imagination, and disappointed ambition, may lead to it. Symptoms.—-The symptoms are multitudinous, various, variable and very difficult to describe, for hysteria simulates a great many other diseases. Patients will often complain of a great many pains and aches that are hard to diagnose. The patient may have photophobia, a dislike to bright colors, or a dislike to bright flashes of light, sparks, and complicated DISEASES OF THE NERVOUS SYSTEM. 339 figures. Subjects are liable to phantasms and visionary hallu- cinations, and some have a perverted sense of hearing, ring- ing in the ears, and roaring or hearing of voices, etc. There may be a perversion of smell and taste, sentient nerves may be so disordered that the patient complains of headache, tickling cough, pain in the larynx, soreness of the mouth and tongue, pain in the mammary gland or ovaries, in the chest or about the heart, in the stomach, in the external genital organs, in the bladder or urethra, in the coccygeal region, or in the back and occasionally the feet. There may be anaesthesia of the sense of touch, especially in certain parts of the body. Glo- bus hystericus is a very common symptom; also spasmodic breathing, singultus, yawning, crying, laughing or screaming, spasmodic retentfon of urine, stricture of the constrictor ani, and local spasms about the head; aphonia may exist with hemiplegia and paraplegia. These last symptoms may last for years in spite of all treatment, or may be relieved by some moral influ- ence or change of condition. In some cases there is palpita- tion of the heart, cold extremities, red face, hot head, etc. Again there may be haemorrhage from the nose, throat, stomach or lungs. Treatment.—As hysteria is a functional disease, one very potent agency is the psychical and moral influence of the phy- sician over his patient. If the latter has no confidence in the attending physician, he had best retire and let another take his place, in whom the patient confides. A great many remedies have been reccommended for this disease from time to time, but none of them, with a few exceptions, have proven very successful. Ignatia amara is valuable in cases attended with a feeling of suffocation, globus hystericus, and convulsive cry- ing, or flatulence of the stomach and bowels. Camphor gives relief from a paroxysm, when used as snuff. Musk is an old remedy, and may be used in small doses of the tincture. If the condition is connected with uterine disease, cimicifuga, in doses of gtt. 20 of the tincture will aid other proper reme- 340 THE PRACTICE OF MEDICINE. dies. If there are spasms of the throat, I prescribe tincture of asaf oetida, in doses of gtt. 30, every two hours until relief is obtained. Some cases are benefited by vervain, alternated with Scutellaria, in doses of gtt. 30 each, every two or three hours; but, in most cases, the valerianate of zinc is better. If constipation exist, nux vomica, in doses of gtt. 1 to 2 of the tincture may be taken at every meal. Gelseminum may be ordered while there are spasms of the face or any part of the body. It should be given in doses of gtt. 25 to 30, alternated with the bromides. Cannabis indica is also a good remedy when there are hallucinations. Chloral hydrate gives relief. Trismus ; Tetanus. Trismus and tetanus are characterized by tonic contractions of the voluntary muscles. It may be several days before the disease fully develops from the injury that gives rise to it. The patient may occasionally have chilly sensations and pains in the injured part; and these symptoms are finally followed by drawing pains of the neck, stiffness of the jaws, and diffi- cult deglutition. All these symptoms gradually intensify, until finally the head becomes immovable and drawn back- wards, the lower jaw becomes set, and deglutition still more difficult, or altogether impossible. This is called trismus or lock-jaw. The disease seldom ends at this stage, but very frequently this tonic spasm extends further over all the dorsal muscles, down the sacrum, and over the muscles of the chest and abdomen, rendering the whole body as rigid as a stick. The muscles of the extremities are quite so badly affected, nor are the muscles of the face, but the eye-balls are often rigidly drawn towards the inner canthus, the eyes stare, the lips are drawn asunder and show the teeth, and the tongue is thrust out between the teeth, and often severely bitten. There is very fre- quently risus sardonicus, that is, in tetanus. This tonic contrac- tion of muscles has intermissions, the rigidity yielding occasion- ally to a relaxed state. These spells of intermission, however, DISEASES of the nervous system. 341 soon give place to sudden and violent convulsive attacks of very great rigidity, and in this way the disease progresses with alternate rigidity, and partial relaxation. So great are the con- tractions in some cases, that bundles of muscular fibres are severed, blood-vessels broken, and the blood extravasated in the parts thus violently affected. The following forms of tonic spasms have been recognized, viz.: opisthotonos, bending the body backwards; emprosthotonos, bending the body for- ward; pleurothotonos, bending the body side-ways; orthotonos, straightening the body. The most frequent form is bending the body backwards, opisthotonos, caused by predominating effect upon the dorsal muscles. The other forms are excep- tional. The will has no control over these spasms, and any effort to control them only increases the rigidity of the mus- cles. Occasionally the slightest touch or movement of the patient's bed, or a draught of air, will cause most violent con- vulsive concussions. The respiratory action is greatly dis- turbed, the breathing is carried on mostly by the diaphragm, and this function frequently becomes more and more difficult, until it finally ceases. There is always pain in the convulsed parts, and also in the pit of the stomach. The circulation is but little affected, and the pulse may be normal or rather quicker than natural. The urine and faeces may be retained, and singultus and vomiting be present. The brain is rarely affected, hence the patient suffers all the tortures of this pain- ful disease, and this torture is all the worse from the fact that there is full consciousness of his situation. Sleep is generally impossible in tetanus. Trismus Neonatorum. Tetanus of new-born infants presents the same features as the form of tetanus above described. It commences with stiffness of the jaws, and such difficulty in deglutition that the child becomes incapable of taking the nipple in its mouth, the rigity gradually extending over the whole body. Trismus, 342 THE PRACTICE OF MEDICINE. like tetanus, may terminate fatally in twenty-four hours, or it may last several weeks. If recovery takes place it does so very gradually. The majority of cases prove fatal from suffo- cation, or from exhaustion and starvation. Causes,—Wounding of the peripheric nerves of the skin and extremities, or of the face, head and genitals; and abor- tion and parturition, may all produce tetanus in impression- able persons. Lesions of inner organs may also cause tetanus. Central irritations, from concussion of the spine and brain, hyperaemia of the cord or of its membranes, extravasation of blood within the spinal canal and the skull may give riso to this disease. Small punctured wounds made by nails, pen- knives, needles, splinters, or any small substance, are much more liable to produce tetanus than large cuts. Strychnia and brucia in large doses produce tetanus. Treatment.—If the circulation is much disturbed, gel- seminum and aconite are excellent remedies, the former in doses of gtt. 25 to 50, the latter in doses of gtt. 1 every hour, until the gelseminum affects the muscular system. Bella- donna is required in most cases in which there is restlessness, twitching of the muscles of the face and limbs, inability to swallow (in which case atropia may be used by the hypoder- mic method), convulsions, spasmodic respirations,.open star- ing eyes, and involuntary discharges of urine and .faeces. Cicuta is a valuable remedy when there is stiffness of the whole body, in doses of gtt. 1 to 2 every half hour until its effects are manifested, after that the intervals between the doses may be prolonged. Nux vomica in very small doses, is an important agent where the respiration is greatly disturbed, and may be given every hour in doses of gtt. -§. The tincture of calabar bean has been highly extolled by some late writers, and will doubtless prove a useful remedy. The tincture of physostigma may be used in doses of gtt. 5 or 6, and if it fail to relax the muscles I repeat in an hour. Eserine is also very good in very minute doses of gr. 1-60 or the extract in doses DISEASES OF THE NERVOUS SYSTEM. 343 of gr. ^. Dr. Fraser recommends the subcutaneous injection of this drug, repeating it until the muscular system is decid- edly under its influence, and then maintaining the effect by administering the remedy monthly until the patient is out of danger. No rules can be laid down for the dose. It will vary in each case from gr. ^ to \ of the extract of calabar bean. Catalepsy. Catelepsy is a sudden loss of voluntary motor power. The patient falls suddenly, and all the muscles remain in precisely the same position as they were in when attack came on, mak- ing the patient appear like a statue. At first the muscles are rigid, but they very gradually grow pliant, so that they remain in any position in which they are placed. The patient usually loses all sensibility and consciousness, and recollects and perceives nothing. Occasionally some sensibility still remains, and, in some cases, both sensibility and consciousness are undisturbed. The patient sees, hears, feels, and knows everything going on around him, but has no power to move a muscle in his body. This disease, in the simple form, may end as suddenly as it began. The patient first takes a full inspiration, then sighs, yawns, and comes to, as if awakening out of a deep sleep. He often resumes his usual work with- out knowing what has befallen him. These attacks may follow one another in quick succession, and last but a few minutes. Grave attacks, however, last for hours and days. I saw one man who had these fits whenever very highly excited by religious revivals, and they lasted for several hours. I saw another case, that of a colored girl, which had been caused by religious excitement, and which lasted several days. Skoda mentions one case that lasted several months. Catelepsy may be combined with hysteria. It is often connected with ecstacy, St. Vitus's dance, somnambulism and other nervous derange- ments. Causes.—It is frequently caused by mental agitation, 344 THE PRACTICE OF MEDICINE. anger, fright, sudden joy, grief, disappointment, vexation, ecstacy, and religious excitement when carried to excess. Treatment.—When it results from anger or vexation, chamomilla in doses of gtt. 1 to 2, alternated with gtt. 1 to 2 of bryonia, will frequently be sufficient to check the attack. If it is caused by fright, let belladonna be alternated with St. Ignatius' bean, and these followed by gelseminum, in doses of gtt. 20 every three or four hours in the day. If caused by joy or grief, I give phosphoric acid, alternated with St. Igna- tius' bean, in doses of gtt. 5 three or four times daily until there is complete relief. If catalepsy results from disap- pointed love, gtt. 4 or 5 of tincture of hyoscyamus is an excel- lent remedy, given every three hours. If sexual erethism be the cause, stramonium will be the proper remedy, gtt. 5 every hour. If caused by ecstacy or religious excitement, I use stramonium, alternated with the tincture of sulphur, gtt. 5 each, three or four times a day until it brings relief. If caused by obstruction to the catamenial flow, gtt. 5 or 6 of pulsatilla acts well, alternated with senecio 3 ^ every three hours. When the cause is unknown, the tincture of cannabis indica, in doses of gtt. 4 to 5 three times a day, may cure the disease, and so will artemisia vulgaris. Scutellaria is a good remedy, in doses 3 -§ of the tincture three times a day. Epilepsy. This disease consists of chronic fits, which occur repeat- edly, but in many cases without exact typical regularity. They are characterized by a want of sensibility and conscious- ness, and are attended by clonic spasms. At first these fits do not affect the mind in the intervals, but finally the brain is attacked. Symptoms.—The disease is often preceded by severe head- ache, vertigo, dizziness, sparks floating before the eyes, roar- ing in the ears, trembling, nausea, a desire to empty the bow- els and the bladder, sometimes chilliness, palpitation of the DISEASES OF THE NERVOUS SYSTEM. 345 heart, dyspnoea, and soreness over the stomach and abdomen. The aura — which is a sensation as if cool air was passing quickly up the limbs towards the head — comes over the patient just before the attack. The fit generally commences with a shrill, piercing shriek, and then the person falls vio- lently to the ground unconscious. In many cases, convul- sions, tonic or partially clonic in character, alternate with one another in quick succession. These spasms are occasionally very violent, so much so, indeed, as sometimes to cause luxa- tions of the joints or fractures. The tongue is often badly bitten, and sometimes the teeth are broken by the contrac- tions. In some cases, extravasation of the blood upon the brain and its membranes takes place. The respiratory mus- cles are disturbed, and respiration is imperfectly performed; hence asphyxia and cyanosis may result, and the face and eyes may become much swollen. The saliva flows from the mouth, causing foam in the lips, which is often mingled with blood. The urine and faeces may pass off involuntarily, and in some cases there are erections of the penis. The convulsions last two or three minutes or longer, and then relaxation gradually takes place. The patient arouses with perhaps a deep sigh, having no knowledge of his past condition. In a short time he falls into a deep sleep, which may last several hours, and after awaking from it he resumes his former occupation. Fre- quently, however, delirium, agitation, or wild excitement fol- low the fits. This condition lasts but a shorl time, and then consciousness returns. The following may be put down as the characteristic of epilepsy, viz.: falling to the ground sud- denly, shrieks, and tonic contraction of the muscles — spasms, lasting from one-fourth to one minute. The intensity of the paroxysms greatly varies. In some cases it is very light, con- sisting merely of an epileptic vertigo. If this be the case, the patient does not fall nor have clonic spasms, but is uncon- scious for a moment, staggers, and trembles. If it attack the patient by night, while he is asleep, it passes off unnoticed by 346 THE PRACTICE OF MEDICINE. him. These fits occur quite frequently with some, and with others only once in a great while. Sometimes attacks come on during the day, and sometimes by night. Just before an attack, the patient becomes low spirited and morose, or grows excited and angry. Occasionally patients are forgetful, stupid, lewd, and unmanageable. Causes.—In some cases it is doubtless inherited, and in other instances is the result of improper marriages, as is the case with neuroses. The emotional, ecstatic state of mind produced by peculiarly morbid impressibility, the result of reading fiction constantly, doubtless leads to this as well as to other nervous diseases. Morbid changes within the brain and its membranes may develop epilepsy, as may repeated irrita- tions of the peripheric extremities of the sensory nerves, mas- turbation, etc. Differential Diagnosis.—Impostors sometimes endeavor to deceive physicians by trying to simulate epilepsy, but by opening their eyes and examining their pupils the truth will be at once known. If they are dilated by the disease, strong light will not contract them; but if the patient is feigning epilepsy, the pupils will then quickly contract when the light falls upon them. Prognosis —When the attacks come on very frequently, and are very severe, with asphyxia, one sided convulsions, par- alytic symptoms, long continued coma, delirium, mania, or great stupidity after awaking from the paroxysms, the disease is very apt to terminate fatally. Short attacks that are light have very long intervals between one another, and do not injure the health, indicate a more favorable condition, and when the attacks become less frequent and milder, then the condition is more favorable still. When the disease is inher- ited, the outlook is unfavorable. Treatment.—To ward off an attack let the nitrite of amyl be inhaled, gtt. 5 at a time, from the palm of the hand. Nitro- glycerine is slower in its action, but more enduring than ni- DISEASES OF THE NERVOUS SYSTEM. 347 trite of amyl. It may be taken in doses of gtt. 10 of the 1st cent, dilution, or gtt. ^ of the 1st dec dilution, and repeated if it fail. Artemisia vulgaris is indicated when the fits fol- low one another in rapid succession. Verbena hastata (ver- vain) has made some cures in doses of gtt. 60 of the fluid extract. Cocculus indicus has also proved itself efficient in many cases. Belladonna is valuable for old or long-standing cases, and may be administered in doses of gtt. 3 or 5, three or four times in twenty-four hours. For recent epilepsy in children, ignatia is a good remedy, in doses of gtt. 1 to 2 according to the age. The oxide of copper is useful in small doses, of gr. 1-30, three times a day. If the spells come on in females about the menstrual period, I order caulophyllum, in doses of gtt. 30 of the tincture three times a day, in the interval between the attacks. If epilepsy is attended by pain- ful menstruation, cocculus indicus, in doses of gtt. 4 or 5, three times a day, will generally give relief. Viscum alb. is an old remedy that is worthy of more general use. The bromides, especially bromide of lithium and bromide of sodium, or of ammonium, have often given relief from these attacks, for months, and sometimes made permanent cures. I usually give the bromide of lithium in doses of gr. 10 three times a day, gradually increasing it to gf. 20. Or bromide of ammonium 15 grs. ter in die. Acute Eclampsia: Puerperal Convulsions. This disease is very rare during pregnancy, and occurs before the sixth or seventh month, in the proportion of only one case in five hundred pregnancies, or even less frequently.' It occurs more frequently during the act of parturition, but seldom during the lying-in period. Primaparae are the most subject to it, and it usually commences during the dilatation of the os uteri, just at the expulsion of the foetus, or immedi- ately after the expulsion. If it set in during the lying-in period, it is at the commencement of labor-pain. The convul- 348 THE PRACTICE OF MEDICINE. sions in this disease resemble very much those occurring in epilepsy. If they occur during the opregnant state they are apt to cause abortion, and when at the commencement of labor, they are apt to retard and prolong it. If, however, they occur towards the end of labor, they generally hasten it. In many cases, after the expulsion of the child, the contractions of the womb cease, and haemorrhage results. Retention of the pla- centa and inflammation of the womb may also result from it. The convulsions seldom continue long after the birth of the child, but may in some rare cases; I know a case in which they continued for life. Where the mother has puerperal convul- sions, about one half the children die; the later the convul- sions the greater the chance for the child. The prognosis is doubtful in any case, although many live. Treatment.—Inhalation of chloroform often suspends the spasms; and its influence must be kept up until the child is born. Where there are rapidly occurring spasms, with redness of the face, cerebral congestion, dilated pupils, and cold hands and feet, belladonna, in doses of gtt. 3 to 5, every three hours, will aid the chloroform. Aconite may alternate with bella- donna, in doses of gtt. 1. Large doses of veratrum viride have been recommended for nausea and vomiting. When from reflex excitability, chloral hydrate will often ward off convul- sions, if given in doses of gr. 15 or 20, just as the first indi- cations of the spasms appear. The inhalation of gtt. 5 of nitrite of amyl, every half hour, will also ward them off, and often suspend them. If the spasms occur in labor, with a rigid os uteri, gtt. 25 of gelseminum should be administered and repeated every three (or two hours, if the spasms are severe), until the muscles are all relaxed, and the spasms relieved. The convulsions of children—"Eclampsia Infantum"—which often occur during the period of dentition, and from worms, may be cured by the removal of the cause, and by giving belladonna, gtt. -§ to 1, every three hours, alternated with gtt. ^ to A, of chamomilla. Gtt. 10 to 30 of the tincture of cypripedium and DISEASES OF THE NERVOUS SYSTEM. 349 Scutellaria, or half the quantity of the fluid extract, will give relief in most cases. Gelseminum may be required in some instances. Chloral cures spasms finely. Paralysis Agitans. This is a tremor to a great extent, but differs from it in its increasing intensity, and in its tendency to terminate in par- alysis, and finally in death. The attack may commence with a feeling of weakness, with trembling motions of the limbs and head. These feelings may be mastered at first by the power of will, but finally increases in intensity, until the patient has no control over them, not even in sleep. The disease becomes so serious in some cases as to deprive the patient of the power of locomotion, and sometimes ends in complete paralysis, and finally in death from exhaustion. Causes.—The causes are rather obscure. It is supposed to have its origin in a morbid affection of the brain near the corpora quadrigemina and adjacent parts, or it may be caused by mental excitement. Treatment.—Rhus tox. is one of our most trustworthy remedies, in doses of gtt. ^ to 1, three times a day. If the attack is attended by any affection of the mind, hallucination, or religious frenzy, I order gtt. 5, of the tincture of stramon- ium three times a day. Small doses of the tincture of arsenic will often do good service. Phosphoric acid (diluted acid phosphate) may be administered with benefit in many cases. The phosphide of zinc, where there is softening of the brain, in doses of gr. 1-10 or 1-15, three times a day, will often prove invaluable. Paralysis. Paralysis is the loss of the faculty of exciting the natural function of the motor nervous system and muscles. Causes.—It may arise from destruction of, or functional incapacity of those parts of the cerebrum, or ganglia at the 350 THE PRACTICE OF MEDICINE. base of the brain, or of the cerebellum, in which volitional impulses are converted into motor excitations. It may also arise from loss or diminution of conductive power of the motor nerves, or it may originate from a want of excitability and contractibility of the muscles themselves. Wounds, occurring in the peripheral nerves, or in the brain and spine, may also give rise to paralysis. Disease in the neighborhood of the nerves, such as exostosis, caries, aneurisms, enlarged glands, herniae, and tumors, are liable to produce it, as are neuritis, myelitis, encephalitis, cerebral and spinal apoplexies, soften- ing, scleroses, and tumors of the brain and spine. Poisoning of the blood with vegetable alkaloids, such as nicotine, ergot - ine, woorari (curari), saponine, hydrocyanic acid, camphor, and also some metallic preparations,* such as lead, copper, and zinc, are productive of paralysis. Typhoid fever, erysipelas, cholera, dysentery, acute articular rheumatism, diphtheria, syphilis, and scrofulosis may be followed by it. Paralysis may affect a single muscle, or group of muscles. It may attack one-half the body (hemiplegia), from a lesion in the brain on the opposite side, or from a spinal lesion. It some- times affects both halves of the body symmetrically, usually commencing in the lower extremities, and spreading thence to the trunk and upper extremities (paraplegia). If the lesion exists in both hemispheres of the brain, there is generally par- alysis of both sides of the body; or, with the most severe lesions, it may be confined to the opposite side. Treatment.—If there is a degenerative change in the brain and spinal cord, the tincture of phosphorus, given in small doses, will do good service. If there is congestion of the brain and spine, gtt. 2 to 3 of belladonna should be admin- istered every four hours until this symptom disappears. If paralysis is the result of softening of the cord, I use the phos- phide of zinc in doses of gr. 1-10, alternated with gtt. 2 to 3 of tincture of nux vomica. If the attack is connected with * Mercury may produce the affection. DISEASES OF THE NERVOUS SYSTEM. 351 rheumatism, rhus tox. is a most valuable agent, in doses of gtt. 1 three or four times a day. This drug is also the remedy for paralysis of the eyelids. It is one of our most powerful anti-paralytics. Cocculus indicus is also an efficient remedy for most cases of hemiplegia, paraplegia, and general paraly- sis, but some cases are incurable by any treatment, but may be benefited by electricity properly used. Hydrophobia. Hydrophobia, when it occurs in the human family, is an acute infectious disease, produced by a specific virus, almost always inoculated by the bite of a rabid dog, wolf, fox, cat, skunk, or horse; most frequently by that of a rabid dog. The latter has been known to produce this disease during the stage of incubation. Not everyone, however, that is bitten by a rabid dog will have hydrophobia. When the teeth go through the clothes, these may intercept the virus, and thus prevent the otherwise ill effects of the bite. It is estimated that only eight or ten per cent, of those bitten by rabid dogs take hydrophobia and die of it It does not require a severe wound to inoculate the poison; a slight abrasion of the skin may readily absorb the virus. In fact, it is considered that very large wounds, that bleed freely, are the least apt to be followed by the disease. Wounds of the face are considered most fatal, and next those about the hands. The wounds gen- erally heal during the period of incubation, about two weeks, but may last from three to six months, and, in very rare cases, two years. Premonitory Symptoms.—The wound generally becomes inflamed, and assumes a reddish or bluish color. Severe, tear- ing pains are sometimes felt in the bitten part, or there may be a burning, prickling or boring sensation in the wound. Small blisters may appear under the tongue. The appetite fails, the head is apt to ache, the patient becomes very gloomy, and sometimes ill-natured, apprehensive, excitable, anxious, 352 THE PRACTICE OF MEDICINE. and deeply concerned about his situation. He grows more and more restless and sleepless, and dreads light and fluids. In the second stage the patient has spasms of a paroxysmal character, which are easily provoked by an attempt to drink water, or by any sudden agitation or fright. These convul- sions may be light or very severe, and of a clonic character. They are often associated with maniacal raging and strange hallucinations, causing the patient to snap at all that come near him. The spasms last from one-half to three-quarters of an hour. The patient can generally drink warm soups more easily than cold water, and better when he closes his eyes than when he has them open. There are intervals when the spasms cease for a time, and the patient is himself; but occasionally even these intervals are omitted, and he has, at best, a per- verted imagination. In the third stage, or stage of paralysis, the patient becomes very weak, the convulsions grow feeble, and finally entirely cease, the muscles twitch, the pupils are contracted, the eyes are fixed, and the saliva is not ejected, but runs from the patient's mouth; the voice becomes very harsh and weak, the breathing short and rattling, the pulse small, irregular and rapid, and the skin is covered with clammy per- spiration. Death may take place in from two to eighteen hours after the third stage sets in, and is the direct result of a convulsion or asphyxia. Pathology.—One marked change, after death, is hyper- aemia of the brain and its membranes, of the cord and its membranes, and of the lungs and kidneys. The sinuses and peripheral veins are generally much distended with dark, coag- ulated blood. Diagnosis.—It may be distinguished from traumatic tetanus by the intervals between the spasms. In tetanus the spasms are continued, there is an increased reflex excitability, and consciousness remains clear until death, and the organs of deglutition are unaffected; but in rabies, consciousness is DISEASES OF THE NERVOUS SYSTEM. 353 often suspended, and the organs concerned in deglutition are much affected. Prognosis is very grave in any case. Treatment.—One of the most successful measures is cau- terization of the wound at once, which stays the disease in 33 per cent, of those bitten by mad animals. The wound should first be well syringed out with salicylic acid, permanganate of potassium (saturated solution) or a saturated solution of boracic acid, and then dried with a sponge. It should be then cauterized with caustic potassium, and suppuration maintained for several weeks by dressing of resin cerate, and the occasional application of a solution of potassium to the wound. Anagallis arvensis and convallaria majalis have been highly recommended, as has Scutellaria. As soon as the brain becomes involved, belladonna is one of our best remedies, in doses of gtt. 5, every three or four hours. Dr. Gryzmala says that he has found the xanthium spinosum to be a positive remedy in rabies, in doses of gtt. 10 to 20. It eliminates the poison through the skin and kidneys. He says he has cured one hundred cases with this drug. It can be alternated with belladonna or the anagallis arvensis. It may be commenced in doses of gtt. 10 to 15, every three hours. It is worthy of a trial, as our remedies are few. I have recently treated two cases that were bitten by a rabid dog in this city, with echinacea angustifolia, and neither of them ever had any signs of hydrophobia; but the same dog bit another dog, which was not treated, and the bitten dog became rabid in due time, and was killed, as I learned. This is doubtless a very valuable remedy in this disease, and as a preventive. 23 CHAPTER XXVII. DISEASES OF THE SKIN. Acne. ACNE, or stone-pock, is an inflammation of the sebaceous glands, caused by the retention of sebum. It is char- acterized by the formation of papules, tubercles and pustules. It may appear upon any part of the body, except the palms of the hands and soles of the feet, but generally appears on the face or nose. Acne may be complicated with other follicular diseases of the face, nose, or body. The disease consists of elevations about the size of a pin-head, or a pea, situated around glandular orifices, attended by more or less inflammation. If this inflammation is superficial, the disease is apt to run a mild course, presenting only slightly reddened elevations, with or without a central yellow suppurating point; this form is called acne vulgaris. When, on the other hand, the inflam- mation involves the glandular structures themselves, consider- able disturbance may be occasioned, which may end in small abscesses and then cicatrices. This form is called acne indurata. A form of acne may prevail with anaemia or chlorosis. The acute form may run its course in a few days or weeks, but the chronic form may run on forv years. It is mostly found in persons of light complexions, and usually commences about puberty, being believed to be associated with functional dis- orders of the sexual system. The severe forms may be pro- duced by derangement of the digestive functions, and very frequently it results from masturbation. The excessive use of iodide of potassium will sometimes give rise to acne. The local use of tar may also produce this affection; and persons who handle tar are liable to an artificial acne on the hands. 354 DISEASES OF THE SKIN. 355 Treatment.—The diet should be restricted, all stimulating, and highly seasoned articles of food and drink being entirely prohibited. If there are comedones in the skin, they must be pressed out with a watch key or extractor. Where there is inflammation, soothing applications should be employed, such as the ointment of the iodide of sulphur, made by adding 40 parts of rose water to 1 part of the iodide of sulphur. Large and painful pustules may be lanced, and indolent tubercles may be touched with the nitrate of silver or the chloride of gold. Sometimes a solution of biniodide of mercury, 1 part, and emulsion of almonds, 50 parts, is valuable, applied two or three times a day. Rumex crispus, strong tincture, may also be applied. The sulphide of potassium, 1 part, to the emul- sion of almonds, 30 parts, is an efficient application. Lotions of the sulphide of potassium, and the biniodide of mercury, are adapted to the indurated forms, the parts being well cleansed and softened with soap-suds before applying these drugs. The juniper tar soap is well suited to this disease, and salt baths render good service in some cases. Where there is a tendency to pustulation, small doses of antimon. tart, may be administered or the bromide of potassium, in gr. 1 doses. When the affec- tion follows onanism, and there are red pimples on the face, gr. 1-100 of chloride of gold will act well, given three times daily In the indurated form, with red, burning, gnawing pimples, surrounded with red areolae, and leaving brown spots, berberis vulgaris is useful, in small doses. In young, full-blooded persons, belladonna will often do great good, given in small doses of gtt. 2 to 3. Sulphide of calcium is applicable in cases in which large, firm pimples appear on the neck. If pimples and pustules appear in groups of three or four on the face, I give chelidonium majiis, in doses of gtt. 3 to 5, three times a day. If it occur in old scrofulous subjects, iodine is the remedy. Juglans cinerea is also efficient in small doses, 10 to 15 gtts. 356 THE PRACTICE OF MEDICINE. Alopecia. Baldness is the absence of hair, either partial or general, and may exist as an accompaniment of a variety of affections. Alopecia areata is a parasitic disease, characterized by the sudden appearance of white bald patches, of various sizes, either upon the scalp or in the beard. At times it affects the entire body. Occasionally it is unilateral, and occurs mostly in young people. It may appear in patches not larger than a nickel, and then spread rapidly. Other spots soon appear elsewhere, and in a short time the whole side of the head may be devoid of hair, which comes out by the roots, leaving a smooth surface. Small downy hairs appear on the affected part in some cases, but they generally fall off. Alopecia is now demonstrated to be a parasitic disease, the spores, which are highly refractive bodies, being found among the epidermal scales. Treatment.—Acetic acid 1 part, and glycerine 2 parts, may be applied thrice a day, or rumex crispus steeped in acetic acid, and then applied with equal parts of tincture of cantharides, will relieve this disease. As internal remedies, I employ moderate doses of phosphorus and muriatic acid. Ichthyosis. This is a congenital, chronic disease of the skin. It is characterized by a dry, harsh, dirty looking skin, generally covered with a species of furfuraceous scales. When fully developed the papillae become enlarged, the discoloration of the skin becomes more distinct, and the epidermal scales are lozenge-shaped, and separated by numerous lines and fissures. In more grave cases the scales form hard, dry, brittle plates of a yellowish or grayish color, separated by white intervening lines, which mark the furrows of the skin. Occasionally these scales become heaped up into black papillary, horny projec- tions. The disease affects the whole surface of the body, DISEASES OF THE SKIN. 357 especially the front of the knees, the flexures of the elbows and knees, and the face generally escaping. The skin is very dry in ichthyosis, and in winter it is apt to chap the face and hands, forming fissures. Diagnosis.—As pityriasis is the only disease that resem- bles ichthyosis, they are easily distinguished, the skin being more or less hyperaemic in pityriasis, but not so in ichthyosis. Moreover, the scales in pityriasis are branny, and readily fall off, while those of ichthyosis resemble fish scales, and are firmly adherent to the skin. Treatment.—The treatment of ichthyosis should be of a tonic character, as cod-liver oil, or chaulmoogra oil, internally and locally. The application with sapo viridis is also of much value in the local treatment. Internally, I find the iodide of arsenic to be one of the principal remedies. I use the 1st dec. trituration as follows: arsenicum iodatum 1st dec. tritu- ration gr. 2, aqua pura 1 4, dose gtt. 30 three times a day. If there should be much itching, the above may be alternated with clematis erecta, in doses of gtt. 2 to 5 thrice daily. If the skin has a brown or dingy color, gtt. 3 to 5 of comp. tinc- ture of iodine should be given three times a day, instead of the arsenic iodide. If the skin is dry and rough, like a hog's skin, the iodide of potassium may be ordered in small doses, alternated with the hypophosphites of lime, sodium and mag- nesium, in doses of gr. 2 of each three times a day. If the skin looks dirty, gray and cadaverous, I order the tincture of thuja oc, in doses of gtt. 1 to 2 three times a day. Washing the skin in an infusion of the bark of the quillaya saponaria also does much good. A generous diet should be allowed the patient, and the digestive organs should be kept in good con- dition, the kidneys being kept active. The skin should be washed daily in a warm alkaline solution, such as the bicar- bonate of sodium or the borate of sodium (§ 2 to a quart of warm water). 358 THE PRACTICE OF MEDICINE. Dermatitis Contusiformis. This is an acute affection of the skin, characterized by oval or round purplish nodules, varying from the size of a hickory nut to that of the fist. The attack is usually ushered in by febrile disturbances, loss of appetite, malaise, and erratic pains like those of rheumatism. The nodules are developed sud- denly, and appear in crops. They feel firm and hard to the touch, are tender upon pressure, and are of a reddish or pur- plish color when first formed, becoming darker and softer in a few days. They generally appear upon the anterior surface of the leg, their long diameters running lengthwise with the limb. In some cases they appear upon the face and arms, and are marked upon a dark red periphery. These nodules never suppurate, but disappear by absorption, fading away in color like bruises of the flesh. It generally attacks young persons, especially females, and is often associated with rheumatism and chorea. The trouble seldom lasts longer than two or three weeks, and tends to spontaneous recovery, although it may relapse in a short time. Dermatitis contusiformis is sup- posed to be due to embolism in the cutaneous vessels, and is somewhat allied to purpura. It is often followed by desqua- mation, and in young children appears between the folds of the skin around the neck and thighs. Treatment.—A solution of the tincture of arnica (one- tenth per cent.) may be applied locally, upon compresses of lint, alternated with an infusion of hamamelis applied the same way. If the disease is attended with a burning, stinging pain, rhus toxicodendron, in doses of gtt. 1 to 2 every two hours, will relieve the severity of the inflammation. If there is oedematous swelling of the parts, and an inflamed erysipela- tous appearance of the nodules, attended by stinging, burning pain, gtt. 2 to 5 of the tincture of apis mel. may be given every three hours until the pain and swelling subside. If the nodules assume a purple color, ptelea trifoliata (the tincture) DISEASES OF THE SKIN. 359 may be used in doses of gtt. 20 to 30 every three hours. When it occurs on the thighs of infants it is called intertrigo, and is often attended by diarrhoea. It should in this case be treated with small doses of borax, and boracic acid should be applied (in the form of a saturated solution) to the parts affected. If the discharge from the bowels are of a greenish color, gtt. 1 to 2 of the tincture of chamomilla may be admin- istered every three hours. If it appear behind the ears of infants, graphite (black lead) may be given, in doses of gr. ^ three times a day. In strumous subjects, sulphur should first be tried for several days. If there is a tendency to acidity of the stomach, sulphuric acid, in gtt. 2 to 3 doses, will be found useful. Herpes. There are different forms of this disease, but they are all characterized by an exudation, usually of a watery substance, beneath the epidermis. This forms globular vesicles, arranged in clusters upon an inflamed patch of skin, and that terminate frequently in the formation of a thin incrustation, without leaving marks or scars. Herpes Facialis.—This form of herpes appears on the face; when on the cheeks and upon the eyelids, it is called herpes phlyctcenoides; when it occurs upon the lips it is called herpes labialis or hydra febrilis — fever blisters. This second form frequently attends croupous pneumonia and intermittent and other fever, but it rarely ever occurs in the course of typhus. Treatment.—The milder forms of herpes may be met by the local application to the parts of camphor cerate, calendula jelly, or cologne water. Where there is much fever, gtt 1 of the tincture of aconite may be administered every two hours until the fever subsides or is lessened. In chronic herpes, the syrup, tincture, or the fluid extract of alnus rubra, may be given in doses suitable to the age of the patient. If there is a 360 the practice of medicine. red herpetic coloring of the skin around the mouth, with a burning sensation, the tincture of arsenic may be administered in doses of gtt. 1 to 2 every four hours until there is decided improvement. For herpes zoster, the local application of the tincture of hypericum is sufficient. Urticaria. This affection is characterized by prominent, smooth patches upon the skin, the color of which is either redder or whiter than the natural color of the surrounding skin. They are elevated either in the form of round nodes or long welks. These wheals are attended by an intense itching, stinging, and burning sensation. They vary in size, but are usually about the size of the finger nail, and are generally surrounded by an areola. They may be many in number, and most commonly are round or oval in shape. They are sometimes sore, and sometimes hard to the touch, and when uncomplicated, disap- pear without leaving any scar or mark upon the skin. This disease is called "nettle rash," from the burning, stinging, itching and tingling sensation, which is likened to the sting of the nettle. These wheals come and go suddenly, and are often excited by simply rubbing the skin. They are very lia- ble to change of base. Urticaria may occur at any period in life, and may appear upon any part of the skin or the mucous membrane. It is mostly of an acute type, excited by some dietetic error, and generally lasts about five or seven days. Occasionally, however, urticaria appears in a chronic form. Sometimes an ©edematous swelling precedes and accompanies this eruption. Again, an effusion of blood may take place into the wheals. An acute attack is generally ushered in with more or less fever, and more or less gastric derangement. The eruption appears suddenly, accompanied by severe itching, and may spread over the entire body. After the exciting cause is removed, the symptoms subside and soon disappear. Causes.—It may be caused by uterine diseases in females, DISEASES OF THE SKIN. 361 and by intestinal irritation in children. Overloading the stomach, or the use of wine or highly seasoned food, will give rise to it in some constitutions. Oysters, lobsters, crabs, mushrooms, sausage, eggs, and strawberries may provoke this disease. Large doses of copaiba, cubebs, turpentine, or vale- rian will produce it in some habits. Urticaria is easily dis- tinguished from any other skin disease. It bears some resem- blance to dermatitis contusiformis, but lacks the livid color of that affection. The intense itching of urticaria will at once distinguish it from dermatitis contusiformis. Treatment.—If excited by an overloaded stomach, an emetic of ipecacuanha should be given at once. If from impro- per food, the diet must be properly selected to suit the patient's digestive powers. Warm vinegar-and-water lotions may be applied to allay the itching. A mixture of chloroform and cream (3 2 of chloroform to § 4 of cream), applied on fine cloths, will also ease the itching. Gtt. 1 to 3 of rhus tox. administered internally, often cures this disease in one or two days' time. Gr. 5 or 6 of benzoic acid to 3 3 or 5 of rose water are often of material service, and a solution of f 1 of the tincture, or fluid extract of grindelia to § 5 or 6 of water, will often readily assuage the itching and stinging sensations. Sometimes gr. 2 of carbolic acid in 1 \ of glycerine (this to be combined with 1 2^ of water, and applied to the diseased sur- face), will be of material benefit. The Turkish bath may be employed, if the above applications fail. Should the disease be confined to the thighs, the tincture of allium cepa, in doses of gtt. 5 to 6 every hour, will aid the cure. Anacardium ia recommended by some writers. If the eyelids look puffy, the tincture of apis met should be given in doses of gtt. 3 to 5 every two hours until it affords relief. If the wheals are on the face, and of a scarlet color, with burning and stinging pain I use the tincture of arsenic in doses of gtt. 1 every three hours until it gives relief to the pain. If there are dirty, yellow blotches scattered over the legs, and attended with 362 THE PRACTICE OF MEDICINE. burning sensations, very small doses of the chloride of gold and sodium may be given three times a day. If there is a bright scarlet redness of the wheals, gtt. 3 of belladonna, every four hours, will give relief in a few hours. Eczema. Eczema is a catarrhal inflammation of the skin, running through the stages of erythema, papulation, vesiculation, pus- tulation, incrustation, and desquamation, and is characterized by the presence of a discharge of a thick consistency. It may commence abruptly or may come on very gradually, and may run its course in a few weeks; or it may become chronic and last for years. Sometimes it consists in a diffuse, superficial dermatitis, which causes numerous little vesicles upon an inflamed, irregular surface, and in some cases there may be pustules intermingled with the vesicles (impetigo). Again, the exudation may not be abundant enough to raise the epider- mis into vesicles, but only sufficient to slightly loosen it, so that it dies off and forms a scaly surface. Perhaps the epider- mis is actually thrown off, leaving a raw, moist surface behind (intertrigo), which occasionally becomes covered with a thin scurf, with a thick crust. Causes.—Eczema may be caused by direct irritation of the skin, by heat, or wet bandages, or it may arise from stasis of the venous capillaries. As this disease occurs most frequently on the lower extremities, so consecutive eczema takes place in the form of salt-rheum. In many cases, however, we can not trace the disease to any particular cause. When it attacks the scalp, it is called tinea furfuracea; and if it peels off in the form of thin asbestos-like layers upon the inflamed surface, it is called dandruff. The disease may also form thick crusts, and thereby mat the hair together, in which it is called tinea capitis, or "scald head." In children it is apt to pass rapidly through the erythematous and vesicular stage to the pustular stage, in in which greenish-yellow crusts are formed, covering a red and DISEASES OF THE SKIN. 363 cracked surface beneath. When it appears on the face of child- ren it is called crusta lactea. If it attacks the ears, it is attended with considerable inflammation and swelling, and sometimes abscesses. If it appears in the axilla, enlargement of the axillary glands is apt to follow, and it may result in abscesses. If upon the nipple, it is liable to be accompanied by severe pruritus, and a copious discharge of yellowish serum. If it exist upon the genital organs, there is generally consider- able heat, redness and moisture. If upon the arms, legs, thighs or feet, it proves very obstinate, and is always attended with intolerable itching. If in the flexures of the joints and the folds of the nates, it is apt to be of a severe and protracted type. When upon the hands and feet, it frequently assumes the fissured form, with but slight exudation and crustation. Chronic Eczema. This disease may start in a chronic form, or may be prece- ded by acute or subacute symptoms. If the chronic form attack the head, it is apt to cause dropping of the hair. Scrof- ulous or lymphatic persons, or women at the menopause, are very apt to be troubled with chronic eczema. Sometimes it attacks the ears and eyebrows, and may then produce a thick- ening of the skin. If it appears on the chin, cheeks and upper lip, it is very intractable; the parts will probably become infiltra- ted, and are often covered with bran-like exfoliate scales all the time. This disease constitutes about thirty to forty per cent, of skin diseases in many localities, traveling from head to foot, as age advances. It is most likely to attack the head of infants, the trunk of youths, the genitals of adults, and the lower extremities of very old people. The excessive use of mercury croton oils, cantharides, mustard, rhus toxicodendron and ven- enata, aniline dyes, and strong soaps of potassium will also provoke this disease. It is due to want of tone in the nerves, by which cell proliferation and capillary congestion, with their consequences, are produced. Eczema is developed as follows; 364 THE PRACTICE OF MEDICINE. an exudation of serum takes place from the congested vessels, which floats the over-supply of new cells, and the two push on to the rete mucosum from the papillary layer, separate the cell elements of the stratum Malphighii and stratum lucidum, and uplift the cuticle so as to form first papules, and then the vesicles. Diagnosis.—In the erythematous stage eczema may be confounded with erythema, but the subsequent course of the disease soon dispels all doubt. In the papular stage, it some- what resembles litchen. This disease affects the outside of the limbs, and is decidedly a plastic inflammation, while eczema is of a serious character. In the vesicular stage, eczema resem- bles herpes zoster and scabies, but the vesicles in herpes are larger than those of eczema, and appear mostly upon the face and genitals. Eczema is never attended by the characteristic neuralgic pain of zoster, nor does the eruption follow the course of the nerves. Eczema is not attended by the mighty itching so common with scabies, nor is it accompanied by acari, which are readily destroyed by parasitical treatment. It may be mistaken for impetigo in the stage of incrustation, but the crusts of impetigo contagiosa are superficial, and appear as if stuck on, while those of eczema are greenish yellow, and adhere firmly. In the squamous stage it might be confounded with psoriasis, seborrhoea, exfoliative dermatitis, and the folia- ceous variety of pemphigus, were it not that psoriasis has no discharge, and its scales are silvery white. The scales of seborrhoea, also, look oily, and are larger than those of eczema, and dermatitis has large, thin, and easily detachable scales in flakes, which when loosened leave a dry, reddish glazed surface. Foliaceous pemphigus starts from bullae, and the scales appear thick and parchment-like. These peculiar appearances must be noticed in the diagnosis. Treatment.—The diet should be well regulated, pork, pastry, and all stimulating drinks being strictly forbidden. As local remedies, bran washes and poppy fomentations, or DISEASES OF THE SKIN. 365 emollient poultices of marshmallow, boiled starch or linseed meal, may be used at the outset to allay irritation and inflam- mation in the parts. In cases in which there is but slight inflammation, the parts may be dusted over with the oxide or carbonate of zinc and starch in equal parts. Glycerole of tan- nin sometimes answers well. If there be severe itching, I use carbolic acid gr. 5, glycerine 1 \, water § 4^, applied three times a day on lint. I find grindelia robusta (tincture) very useful with glycerine aa 3 4, and bran water § 16, mixed, and applied as often as required to keep the parts moist. Pyro- ligneous oil of juniper 3 2, olive oil 3 4, mixed and applied three or four times a day, is an excellent remedy. I some- times use borax gr. 20, lime water 3 4, mixed and applied as above, three or four times a day. All these are applicable in chronic cases, or after the inflammation subsides. If there is great dryness of the skin, the oleates are the best remedies we have, as the benzoated oxide of zinc ointment. It only protects the parts from irritation. Chrysophanic acid, in the form of a cerate, is a useful application in the squamous stage. An ointment of dulcamara is also valuable in some cases. The oil of cade, a crude oil of juniper, is a most useful drug in the chronic form of eczema. The pyroligneous oil of juniper, or oil of cade, may be mixed with equal parts of olive oil. If there is much infiltration, the oleate of tannin is very success- ful, made by triturating and boiling § 1 of tannin in 3 6 of oleic acid; to be applied twice a day after cleaning the parts well. One part of sapo viridis and two parts of alcohol are often of material benefit as an application. The oleate of litharge, applied on linen cloths, also gives excellent results. The internal remedies are the following, according to the re- spective indications: Aconite, in the simple forms of acute eczema, in which there is more or less fever, and small doses of aluminium, where there are hard crusts on the arms and scalp. If the disease is in the bends of the limbs, with excor- iations between the legs and about the anus and genitals, car- 366 THE PRACTICE OF MEDICINE. bonate of ammonium may be ordered in doses of gr. 2 to 3. The disease attacks the face, head, legs, and genitals, which itch very much at night, the tincture of arsenic acts well in doses of gtt. 1 to 2, three times a day. The carbonate of bar ium is also a valuable remedy in cases attended with moist crusts on the scalp, swelling and induration of the glands, and in fat or lymphatic children. In the inflammatory stage, if there is a deep scarlet redness of the face, small doses of bella- donna are invaluable. Sulphide of calcium is often a useful adjuvant. Clematis erecta is very useful in moist eczema, when it occurs about the neck and on the head. Dulcamara is very applicable where there are thick brown or reddish brown crusts on the forehead and chin. Where there is a tendency of the skin to crack open, and the cracks look ragged, graphites, in small doses (not more than gr. j to i) will aid in the cure, especially if the disease be located about the ears. Hydrastis canadensis, in doses of gtt. 10 to 20 of the tincture, is a valu- able remedy where the digestion is feeble. In some cases of eczema of the face, iris versicolor, in doses of gtt. 3 to 5 of the tincture does good service. If there is a dry, grayish white crust, or an offensive eruption on the head of children, syrup of arctium lappa (burdock) is a valuable remedy, and often cures this form of eczema. The iodide of arsenic, when there is a syphilitic taint, is often absolutely required. It may be given safely as follows: iodide of arsenic, gr. 2, sugar of milk, gr. 18; triturate and add f 4, of water. A teaspoonful of this mixture may be given three times a day. When there is burning and itching of the vesicles upon the cracked sur- faces, with a greenish discharge, stiffening the clothes, the tincture or fluid extract of juglans cin., in doses of gtt. 3 to 10, according to age, has proved a valuable remedy. Moist eczema of the genitals, or where the hands and feet are cracked and rough, calls for the local application of petroleum. Piper methysticum is a valuable remedy where the skin is dry, scaly, cracked and ulcerated, especially on the feet and hands. In DISEASES OF THE SKIN. 367 the acute stage, with small yellow vesicles, red areolae, and itching at night, rhus toxicodendron, in doses of gtt. 1 to 2 every three hours, has proven a valuable remedy in my hands. Sepia has seemed to be efficient in some cases. Staphisagria is a valuable remedy when there is an offensive discharge oozing from under the crusts. Small doses of sulphur prove most potent in some chronic cases, especially when the erup- tion is dry and scaly. The dose is gtt. 5. In some cases the viola tricolor is a good remedy. Impetigo Contagiosa. This is an acute inflammatory affection of a contagious character, occurring mostly in children. It is characterized by one, two, or more discrete vesicles or vesico-pustules, which are generally umbilicated, vary in size from that of a split pea to a hazel nut, and are followed by flat, large, straw-colored, fungoid crusts. It may be ushered in with more or less fever, and in that case the eruption quickly follows. It appears in crops of small vesicles, which gradually develop into vesico- pustules. These vesicles, which are small at first, grow rapidly until they attain the size of a hazel nut. They are generally umbilicated and contain a lymph-like fluid with granular, and subsequently, pus cells. They are usually surrounded to a greater or less extent by red areolae. The fluid contents of these vesicles begin to dry up in about four or five days, and finally form flat shaped, straw-colored scabs about the size of a split pea or hazel nut, which look as if they had been stuck on. The most common seat of the eruption is upon the fore- head and cheeks, but occasionally it extends to the arms and head, and may implicate the mucous membrane of the eyes, mouth and nasal fossae. This disease was first described by Tilbury Fox, in 1864. It occurs mostly in children of the poorer classes, but the better-to-do and the rich are also liable to it. It may be epidemic, but most commonly occurs sporadi- cally. It is also contagious. It tends to run a definite course 368 the practice of medicine. and usually lasts for one or two weeks. In some localities it constitutes about one per cent, of all skin diseases. Vaccina- tion will sometimes produce this disease. It is not considered a parasitic disease, in as much as no fungus similar to that observed in vaccine crusts has, as yet, been found in the fluid of this affection, or in the vesico-pustules of the disease. Diagnosis.—In the first place, we must bear in mind that this disease occurs mostly in children, and that it is preceded by more or less fever, and consists of isolated vesicles, that are usually umbilicated, and about the size of a split pea, or larger, They are mostly situated upon the face, and generally follow in the wake of vaccination, presenting scales that appear to be stuck on. We need not mistake it for any other disease. It is most likely to be confounded with eczema and varicella. It may be distinguished from eczema by the fact that the children attacked are usually healthy, while those with eczema are not healthy; moreover, the scabs look as if stuck on, and are of a light yellow color and lie flat on the skin. The scabs of eczema, on the contrary, are of a greenish-yellow color and adherent. Impetigo is confined to the face and upper extrem- ities, while eczema attacks any part of the body. It may be distinguished from varicella by the smaller vesicles and different crusts of varicella, and by its constitutional distur- bance. Treatment.—Crude antimony is one of the first remedies in this disease, gr. 1 of the first dec trituration (of the homoeopathic pharmacy), three times a day, Euphorbia is indicated where the skin is irritable, doses gtt. 1 to 2 of the tincture every three hours. Bichromate of potassium in doses of gr. g- to ^ three times a day, is next in value to crude anti- mony. When the disease is quite pustular, small doses of tartar emetic will be found to do good service. When eczema follows vaccination, thuja oc. in doses of gtt. 3 to 5, every three hours, will be of material service. The nitrate of potas- sium may be called for when there is much fever at the begin- DISEASES OF THE SKIN. 369 ning. In vigorous subjects, in which the fever is considerable at the outset, gtt. 1 of tincture of aconite may be given three or four times a day, until the fever subsides. If the skin is very irritable it may be anointed with 5 parts of olive oil and 1 part of oil of cade, after washing well with soap-suds. Ecthyma. This disease consists of large, isolated, painful pustules, situated upon hard and inflamed bases, and followed by brown crusts. These pustules are oval or roundish, flattened, of a yellow or yellowish color, and are surrounded by a red areola. The disease is generally preceded by a slight fever. After a few days these pustules dry up and form flat, dark brown crusts, which, when removed, leave extensive excoriations that finally develop into temporary pigmented scars. This disease may occur at any stage of life; and usually attacks those that are badly nourished. It most frequently appears on the neck, shoulders, and back. It is a superficial lesion, and rarely extends beyond the papillary layer. It may be confounded with eczema and impetigo contagiosa, but is more likely to be mistaken for the large, flat, p>ns^u^ar syphilide. Ecthyma, however, develops more rapidly, gives rise to more heat and pain, and presents slight ulceration and brownish crusts; while the syphilide shows an ulcer more or less deep, with abrupt edges, and blackish, instead of brown crust. The disease may become chronic, and may then be protracted for an indefinite time by successive crops of pustules. Treatment.—The treatment of ecthyma must be begun by local applications. The affected parts may be anointed with a white precipitate ointment, say gr. 3 to § 2 of simple cerate. After the pustules burst, if the ulcers show but little tendency to heal a weak solution of carbolic acid may be applied; gr. 2 to 3 3 or 4 of water will generally be sufficient to heal them. One of the best internal remedies is the triturated crude anti- mony (1st dec trituration, in doses of gr. ^, every three hours'), 2-1 370 the practice of medicine. especially when the scabs are of a dark brown color. If the pustules are red 'or white, with an intense burning sensation, with thick crusts, arsenic is indicated, and may be given in doses of gtt. 2 or 3, of the tincture, three or four times a day, until the patient is decidedly better, when it must be discon- tinued. If the pustules are all over the body, and resemble those of small pox, the bichromate of potassium is the remedy and may be given in doses of gr. ^ every two or three hours, dis- solved in a wineglassf ul of water. If the pustules are on a very red base, and itch and sting, gtt. 1 to 2 of rhus toxicodendron should be given every three hours. If the pustules are large tartar emetic, in doses of gr. 1-8, may be given every two hours. Pemphigus. This disease is characterized by large, isolated bullae or blisters upon a red, inflamed, but not infiltrated surface. The blisters are large and filled with clear serum, greatly resem- bling those caused by a scald or burn. These blisters vary in size from that of a pea to that of a hickory-nut, and even to that of a walnut. This disease is almost always in a chronic form. There are two varieties of it, viz.: pemphigus foliaceus and pemphigus vulgaris. Pemphigus vulgaris generally ap- pears on the limbs, especially on the ankles. Occasionally it attacks the mucous membrane and other parts of the body, but this is rare. The blisters or bullae are rounded or oval, and rise abruptly from the skin (sometimes to the height of a cen- timeter or more), and may be attended by slight itching. The contents of these swellings are at first colorless, but later they become cloudy or milky. They usually appear in sucessive crops, each bulla running its regular course in four or five days. Acute pemphigus is most commonly found among children, rarely in adults. It runs its course in from three to six weeks, but its subject is very prone to relapses. Pemphi- gus foliaceus generally attacks the body, and, though an un- DISEASES OF THE SKIN. 371 common disease, frequently proves fatal when it does occur. This form usually commences with the appearance of a single flaccid bulla on the sternum, which spreads over the whole surface of the body. The bullae differ from those of pemphi- gus vulgaris in that they do not become tense, but remain flaccid, and when they dry up, form yellow, parchment-like flakes, that vary in size from one to four centimeters. Treatment.—The patient should take exercise in the open air, and have a liberal animal diet, as beef, fowl, fish, eggs, etc. Such local remedies, bran, starch or gelatine baths, are of material aid in the cure. As an internal medicine, rhus toxicodendron is one of our best remedies for acute pemphi- gus, and in the chronic form of the disease arsenic is a most valuable remedy. I prefer the simple tincture, in doses of gtt 2 to 3, three times a day. In the foliaceous variety, thuja oc. is oftener indicated than any other drug, the saturated tincture being given in doses of gtt. 3 to 5, every three or four hours. If the blisters itch very much, the muriate of ammonium should be ordered, in doses of gr. 1 to 2, three times a day. When there are watery vesicles on the palms of the hands, and they are very painful, I find gtt. 3 or 4 of tincture of belladonna very useful, given every four hours. Phosphoric acid (diluted acid phosphate) may be administered in small doses, as a tonic, ter in die. Rupia. Rupia consists of bullae, containing a purulent reddish mat- ter, which gradually dry and form a thick, dark crust. Under- neath this thick crust matter continues to form, which again dries, and consequently raises the center of the crust, while on the periphery it becomes encircled by a vesicated border, which also dries up into a crust. This accumulated matter, when dried up, resembles an oyster-shell, and, on removing the crust, a deep, foul, excoriating ulcer will be seen. Rupia is a late and malignant manifestation of syphilis. 372 THE PRACTICE OF MEDICINE. Treatment.—The iodine of potassium is one of the most trustworthy remedies, united with the iodine of ammon. as follows: iodine of potass, gr. 2, iodide of ammon., gr. 2; mix well, and add to aqua | 1—dose, a teaspoonful thrice daily. This is an active preparation of iodine, and will not remain in the system, as other preparations of iodine are known to do, to the great injury of the patient's future health. This pre- paration does its work, and is then eliminated. As a vegetable alterative, the fluid extract of berberis aquifolium (prepared by a good pharmacist) is a valuable addition to the compound iodine given above, and may be given in doses of gtt. 30, every four hours. The. iodide of arsenic is also a valuable remedy, provided the above fail to improve the condition of the patient in ten or fifteen days. It may be used in doses of gr. 1-50, three times a day, to children. Furuncle. Furuncle or boil, is a circumscribed inflammation of the skin and connective tissue, which varies in size from that of a pea to that of a hickory nut. It always has an indurated and inflamed base, and commonly terminates in suppuration and the formation of a "core." A boil commences as a small, round, inflamed spot, painful to the touch, and surrounded by a bright red areola, which changes to a purple color as the disease advances. It gradually increases in size, and becomes more and more sensitive to the touch, the pain increasing in intensity and becoming throbbing. In about five or seven days the swelling suppurates, and throws out a central slough called a "core." In rare cases, however, no core forms, and it is then called a blind boil. As soon as the discharge of pus takes place, the pain is reduced, and the inflammation quickly subsides. Occasionally one boil follows another in quick suc- cession, until a number have come and gone. Furuncles may attack any part of the body, but generally appear on the face, back, neck, knees and gluteal region. They are doubtless due DISEASES OF THE SKIN. 373 to disordered states of the blood. I have seen the free use of the common blackberry produce boils in a large family. They are more apt to attack children and young persons than old persons, although the aged are not entirely exempt, for I have seen them appear on old people, and become a great source of suffering to them. Treatment.—The usual treatment is to lance the boil, but this is not a good plan if done too soon, for the early use of the lancet always increases the inflammation, and very much retards the healing process. The first thing that I do, is to try to abort the boil by painting it with Lugol's solution, or the tincture of iodine. I have thus often aborted them. If I fail, I apply the lotion of arnica, aconite and hamamelis in equal parts. If the gatherings are of a dark red color, and very painful, gtt. 3 or 4 of the tincture of belladonna should be ordered every three or four hours, and a poultice of honey and flour applied to promote suppuration. When there is pre- disposition to boils, the patient should take sulphide of calcium carb. of calcium, or sulphur. Phytolacca is also an efficient remedy, in small doses. Carbuncle. Carbuncle is a phlegmonous inflammation of the skin, char- acterized by necrosis of the cellular tissue, suppuration, and finally discharge of the necrosed masses (usually called cores), with pus, through sieve like openings upon the top of the car- buncle. Symptoms.—A carbuncle usually commences with a severe burning pain in the affected part, and more or less general fever. As the disease advances, if not aborted, the part swells, and assumes a purplish color. The gathering is sometimes as large as a saucer, and again not larger than a fifty cent piece. At first, small openings are seen, and then the whole mass gradually sloughs away, leaving an ulcer with inverted edges, which granulates very slowly, and, when healed, leaves a per- 374 the practice of medicine. manent cicatrix. It appears on the neck, shoulders, back, forehead or buttocks, and may be mild, very severe, or fatal. Treatment.—At the beginning the carbuncle should be painted with the tincture of iodine three times a day, and this may abort it. If it goes on however, to sloughing, the ulcer should be dressed with carbolic acid and glycerine, equal parts, or if too painful, 1 part of carb. acid to 2 parts of glycerine. Arsenic is useful internally, in doses of gtt. 2. If very pain- ful, belladonna may be given; dose gtt. 3, ter in die. Malignant Pustule. This affection is sometimes called carbunculus contagiosus. It is characterized by a severe pustule, associated with a gan- grenous destruction of the surrounding parts, which pustule owes its origin to a direct inoculation of the poison from an animal affected with the disease called anthrax, milzbrand or charbon. It may be caused by transmission of the poison by flies, by inoculation of the poison from man to man, or it may originate from eating the flesh of diseased animals. It is oftener found among persons who have the care of diseased animals, or among those that work in manufacturing establish- ments where the hides, wool or hair of animals are prepared for use. The infection usually takes place on the most exposed parts of the body. Eating the flesh of such diseased animals first causes general indisposition, and more or less intestinal troubles, and in eight or ten days anthrax carbuncles appear, generally about the arms and head. In a few hours, or even in a few days, itching will be felt where the poison first took hold, as if some insect had bitten the part, and a little red speck, with a black point in its centre, will be seen. This little speck soon changes into an itching papule, capped with a small red or blue vesicle, which gradually enlarges. It very soon bursts its dark red base, which becomes covered with a crust, and very often secondary vesicles spring up around it, con- taining a yellow, red, or black fluid. The surrounding parts DISEASES OF THE SKIN. 375 now swell and extend over a considerable space, the cellular tissue underneath becoming infiltrated, and in some cases dis- colored lines marking the course of the veins, or red stripes showing the course of the lymphatic vessels in the oedematous region. The corresponding lymphatic glands also swell up. The symptoms depend upon the severity of the local disease. There is generally fever, great weakness, delirium, excitement, confusion, sweating, diarrhoea, pain in the lips, and, in fatal cases, collapse. When the outlook is favorable, after the dead masses have sloughed off, the wound gradually heals by healthy granulation springing up. Treatment.—Arsenic is one of the best remedies in this affection, and may be given in doses of gtt. 2 to 3 of the tinct. or gtt. 3 to 4 of Fowler's solution, thrice daily. The iodide of arsenic is preferable, in many cases the arsenic itself, and may be administered in small doses, say gr. 1-40. Bartholow says gr. 1-20. but that would irritate the stomach. Moreover, I have found it to act well in very small doses. I usually give the 1st decimal trituration of the homoeopathic preparation, in doses of from gr. ^ to ^ three times a day, well diluted with water to prevent irritation of the stomach. Epithelioma. This form of cancer may first begin as a wart, or a flat in- filtration. The first sign is often a simple crack, or a small, hard, pale, dusky lump, which sooner or later fissures, and is either moist, or becomes covered with a brown or yellow crust. This growth increases, it may be slowly, until it finally breaks into superficial ulcers. The typical ulcer is round, and usually about the size of a split bean or larger, has hard, sharply defined edges, and secretes a scanty, yellow, viscid fluid. This form may continue for years as a mere local disease without undermining the patient's general health in any way. This disease often attacks the lower lips especially those of smokers. If it attacks the scrotum it is called chimney-sweep's cancer, 376 THE PRACTICE OF MEDICINE. and when it appears on the face, it constitutes what English writers call rodent ulcer. Occasionally it first shows itself in the form of papules, which at first are movable, but which later tend to coalesce, and form reddish or purplish colored aggre- gations about the size of a walnut or smaller. These finally break up and form ulcers, which are attended with sharp, lan- cinating pains, increasing in degree as the ulcers increases in size. The ulcers are usually round, have hard, everted, indur- ated edges, secrete an offensive, pale yellow, viscid fluid, and bleed easily, Tissue after tissue gives way under this des- tructive ulceration, until finally the lymphatic glands become enlarged and suppurate, the patient ultimately succumbing from exhaustion. This form of epithelioma usually attacks the mucous membrane and cheeks, but may appear upon any part of the body. It may progress slowly or rapidly, and when left to itself usually proves fatal in from one to five years although, in a few rare cases, it may extend over eight or ten years. The affection may develop as a wart-like growth, or cauliflower excrescence, and varies in size from that of a split pea to that of a hazel nut. This ultimately breaks up and forms irregularly shaped, granulating excavations, which bleed easily, and slowly run the course of other epitheliomatous ulcers. Epithelioma is believed to originate from the endothelium of the lymphatic vessels. Diagnosis.—It is likely to be mistaken for lupus vulgaris, or may be confounded with syphilitic affections. Syphilitic formations, however, are always more rapidly developed than epithelioma, and the ulcers of syphilis are generally multiple, have a profuse secretion, and are devoid of pain, while the ulcer of epithelioma is single, with scanty secretion, and attended by severe pain. Again, lupus vulgaris is most commonly a disease of childhood, while epithelioma is one of middle life; its discharge, too, is very offensive. Treatment.—This disease may be cured in many cases, if taken very early. It is possible to remove the cancer by the DISEASES OF THE SKIN. 377 knife, the galvano-caustic, or, by what is preferable, Marsden's arsenical mucilage, which is a mixture of arsenic, gr. 40, and mucilage of gum acacia, gr. 20, applied to the ulcers in a plaster ^ of an inch thick. The chloride of chromium, applied with just enough gum acacia to form a plaster, will slowly enucleate the diseased mass, and it may be then dressed with powdered hydrastis. I have used a paste of chromic acid and balsam of fir with good effect, and also one of chloride of zinc Some recommend the tincture of thuja oc. internally; but I have found, recently, that a good fluid ex. of berberis aquifolium, in doses of gtt. 30 to 20, three or four times a day, acts better. I usually alternate this drug with gtt. 2 to 3 of tincture of arnica. Occasionally, I have found the chloride of gold and sodium to act very well, applied locally and taken internally. For internal use, gr. 1-60 is the proper dose. In advanced cases, I have had marked success by simply washing the ulcer with gr. 5 to 10 of sulphate of zinc to the ounce of water, and then powdering it with the pulverized hydrastis. I now have two cases under this treatment, which are mending very rapidly. If there is debility associated with epithelioma, arsenic, or the iodide of arsenic, is the best remedy. Paronychia. This is an inflammation situated around and beneath the nail, and which terminates in suppuration. It generally attacks the thumbs and fingers, seldom the toes, and first ap- pears as a dusky red and extremely painful border, either completely or partly surrounding the nail. The pain is throb- bing in character, and suppuration soon takes place. There is a form of this affection that attacks the big toe, which is usu- ally caused by ingrowing of the nail. Paronychia differs from whitlow or felon, in that the latter involves all or nearly all the structures of the fingers, and appears most commonly on the palmer surface of the hand. Treatment.—As a local application, the pith of the com- 378 THE PRACTICE OF MEDICINE. mon bulrush has been successfully used. If suppuration is tardy, the sulphide of calcium is very useful in doses of gr. 1 to 2 three times a day. The sulphate of sodium, in doses of gr. 1 to 2, may be taken thrice daily with excellent effect. If the gathering proves very severe, and will not readily heal, graphites (a homoeopathic trituration of say 1st. dec), black lead, may be used, in doses of gr. 1-5 to 1-10, three times during the day. Sometimes there is a tendency to the for- mation of proud-flesh, and in such cases, a little chloride of bromium may be occasionally applied to the spongy granula- tions until they are removed, and then the part washed in bor- acic acid, and powdered with iodoform. Felon. This is an affection of the various structures of the fingers, and is frequently followed by the destruction of the first, and sometimes of the second phalanx. It is attended with very great pain, which often prevents sleep for several days and nights. The pain is throbbing and tensive, often extending as high as the elbow, and even to the shoulder, and is aggravated by a depending position of the hand. The pain never ceases until the pus is evacuated, or until the diseased parts die. The swelling is sometimes enormous, involving the fingers, wrist and arm, the skin of which is red, cedematous, and puffy, resembling the skin of erysipelas. Very frequently the limb is stiff. The inflammatory process often commences in the deep- seated tissues, pus forming near the bone, in the connecting cellular substance, within the sheaths of the tendons, or beneath the periosteum. If this pus is not soon discharged, the disease will spread in all directions, burrowing along the finger and hand, and causing extensive destruction. Gangrene even may set in, followed by considerable sloughing of the tendons, and exfoliation of the phalanges. This grave form is always attended with constitutional disturbances; there will be fever, loss of appetite and sleep, pain in the head etc. DISEASES OF THE SKIN. 379 Treatment. Cases that I have seen at an early period, before pus has formed, I have usually cured by wrapping the finger firmly and evenly, so as to compress the superficial cir- culation. If this done promptly and properly, it seldom fails to cure the disease, but if it be neglected until the pus forms, an incision down to the bone is the only step that will cure this affection. When thus completely split open (not merely lanced), and an incision made with a scalpel down to the bone, it heals as a wound. When persons, however, would not sub- mit to this treatment, and absolutely refused to have the felon opened thus with a knife, I have resorted to medical treatment. The carbonate of ammonium in small doses, will sometimes lessen the pain, and enable the patient to sleep, and the sul- phide of calcium accelerates the suppuration. I have shortened the course of these painful whitlows on the fingers, by apply- ing tape, as mentioned above, keeping it moistened with iodine (tinct.) 3 2, aconite 3 1; keeping the tape wet with the solu- tion all the time. This lotion lessens the pain a good deal, and doubtless aids the bandage in maturing the disease, and drawing the pus to the surface. I have no confidence in inter- nal treatment, for I have never seen it render any essential ser- vice towards a cure. Psoriasis. This is a non-contagious disease of the skin, but one that seems to be constitutional. Symptoms.—Psoriasis is characterized by reddish, thickened patches, covered with white or yellow-white scales, resembling mother-of-pearl in color. These patches are of various sizes, and usually appear as small, reddish spots, hardly at all raised above the skin, but always covered with white scales. They generally develop rapidly, and in a few days are as large as a nickel, and look like drops of mortar on the skin. As they increase in size, they have a tendency to run together and lose the circular outline that first characterized them. In some 380 THE PRACTICE of medicine. cases, the centres of the patches become clear, giving the disease the appearance of rings. Some writers speak of these different stages as distinct varieties of disease, as psoriasis punctata, psoriasis nummularis, psoriasis gyrata, etc. These are not distinct varieties of disease, but simply different stages of the same disease. The scales of psoriasis are of a character- istic silvery whiteness, and are situated upon a red and inflamed base. The most common seats of this affection are the elbows, ankles, or knees, but it may appear upon any part of the body. It is supposed to be due to a perversion of the cell life of the rete. It generally attacks families predisposed to gout, and these in winter. Causes.—Its etiology is quite obscure. By some writers it is claimed to be of malarial, and by others, of traumatic origin. Next to eczema and psoriasis, it is one of the most common diseases of this country and of Europe. Diagnosis.—Its characteristics are the silvery whiteness of its scales (which look as if they were heaped up); its situation on an inflamed base of the cutis (which is much inclined to bleed in pin-point drops on the removal of these scales); and its location (the elbows and knees being its usual situation). Treatment.—The diet should be rich and of a healthy character, such as beef, fish, and fowl. Maltine and cod-liver oil are also of much benefit. I order bran baths to remove the scales, and then anoint the parts with chaulmoogra oil, or chrysophanic cerate. I do not use the latter too strong; gr. 1 to 30 of lard is strong enough to begin with. The oil of cade, either in full strength or diluted with olive oil, may be used also in many cases with good effect. A mixture of tar and alcohol (1 part of tar to 5 parts of alcohol) often answers well. The biniodide of mercury ointment (gr. 1 of the biniodide to gr. 50 of lard) has proven itself to be of much value; and a wash of the solution of calcium sulphide (not too strong) is of material service in obstinate cases. A wash every day with green soap is very good in indolent cases, in which the scales DISEASES OF THE SKIN. 381 are thickened and infiltrated. The internal treatment should commence with the tincture of sulphur, or with gr. 1 or 2 of the sublimed sulphur, three times a day. This routine should be continued for three weeks, and then changed for some of the remedies named below. When the scales are continually exfoliating, the carbonate of ammonia, in doses of 2 to 3 grs., may be given three times a day. If the skin be dry and scaly, arsenic in the form of a saturated tincture may be given, with a good prospect of pro- ducing effect. The dose should not be large, not more than gtts. 1 to 2 three times a day, lest it produce its toxic effects. Iris versicolor is a valuable remedy. Phytolacca decandra is also an efficient remedy, after arsenic. Berberis aquifolium, in doses of 30 gtts. thrice daily, acts well in this disease. The use of white precipitate ointment (1 gr. to 20 grs.) will often be followed by good results. The parts should be washed regularly in green-soap-suds. If there are white-pea sized spots on the face, ammonia carb. may be given in doses of 3 to 5 grs. three times a day. If there is itching of the back, arsenicum iodide 1-20 gr. will give good results. If there are patches of this eruption on the knees, then iris ver- sicolor will do good service; dose, 1 to 5 gtts. If the disease attack the hands, muriatic acid in doses of 3 to 4 gtts. three times a day is called for. If the skin crack, petroleum applied locally will prevent this painful cracking. Lichen Planus and Lichen Simplex — Lichen Agrius and Lichen Tropicus. Lichen is a chronic disease of the skin, commencing with dull red, flat-topped, angular-based, glazed papules about the size of a pin-head, which are attended by more or less pru- ritus. It is not very common in the United States, and when it does occur it is generally associated with a debilitated state of health. The eruption resembles millet seed, and at first it has a shiny appearance, but after a while it becomes covered 382 THE PRACTICE OF MEDICINE. with thin, micaceous scales. These papules start abruptly from the skin, are irregularly shaped, rather flattened on the top, and frequently present an umbilicated depression in the centre, which is really the opening of the follicle. They are usually discrete, but may be in patches, and, as a general rule, develop slowly and occur symmetrically. Sometimes stains are left, and occasionally small pits remain after the disease disappears. This trouble may occur at any age, but attacks women more frequently than men. It selects as its seat the front of the forearms, the wrists, the thighs, the abdo- men, legs below the knees, etc. It is believed to originate from a disturbance of the trophic nerves of the hair papillae. Hyperaemia results from this disturbance of the trophic nerves of the hair papillae, and there is a formation of new tissue in parts affected by this disease. Prognosis.—The prognosis is usually favorable, except in the diffuse form of this disease. The lichen rubra of Hebra, which is generally associated with marasmus, may, unless suc- cessfully treated, terminate fatally. There is a constitutional predisposition to this disease, and it is apt to attack cooks, bakers, grocers, etc., in hot weather. Treatment.—The diet should be unstimulating, and of such articles as are easily digested. That form occurring in bakers, called "bakers' itch," is the worst form, and is attended with intense itching, with more or less fever, pains in the limbs, and gastric derangements. To relieve irritation and itching, local treatment may be resorted to. A wash of a solution of the tincture of grindelia robusta may be used, say 3 1 of the tincture to aqua pura f 3 — apply three times a day; or carbolic acid § \ to aqua § 7. The pyroligneous oil of juniper will be found effective in chronic cases. One of the most effective internal remedies is crude antimony, the 3d dec. trituration, in doses of gr. 1 three times a day. Arsenic, too, is invaluable in the chronic form of this affection, in DISEASES OF THE SKIN. 383 doses of gtts. 1 to 3 three times a day. Iodine produces good results in cases in which the papules are small and red, as does the iodide of sulphur, when the disease attacks the skin of the nose and chin. The bichromate of potassium in small doses, and the tincture of the bark of juglans cinera, in doses of gtts. 10 to 15 three times a day, also acts well. The patient should avoid heat. Prurigo : Pruritus—Itching. This disease of the skin is characterized by the develop- ment of small papules, which are about the color of the skin, but that are accompanied with very intense itching. It com- mences with the gradual formation of small, sub-epidermic elevations, that feel like shot, and are sometimes perforated by small hairs. The papules are the results of chronic inflam- matory changes in the papillary layer. Intense itching, with a sensation like the stinging of ants is one of the first symptoms, and usually continues with more or less intensity, throughout the whole course of disease. As the disease progresses, the skin becomes more or less thickened, rough, and harsh, and feels rather dry to the touch. Pruritus may appear upon the exterior surfaces of the lower extremities, but it is most fre- quently found upon the forearms, the trunk, and elsewhere about the body, It is very apt to commence before puberty, and to grow worse during the winter, and not unfrequently annoying the patient through life. This disease is not very common in the United States. Causes.—The predisposing causes are a constitutional taint or proclivity, senile decay, chronic diseases, etc. It is gener- ally connected with lowered vitality, or with decay of the skin. In this affection the skin loses its elasticity, firmness, and its fat, and its secretion is generally greatly disordered. The opinion has been advanced that the disease is caused by pedi- culi, but this has not been proved. Pediculi may be present in prurigo in uncleanly persons. The exciting causes are 384 THE PRACTICE OF MEDICINE. rich, indigestible food, stimulating drinks, extreme heat or cold, etc Diagnosis.— Pruritus is apt to be mistaken for phthi- riasis, but it is not accompanied with pediculi as phthiriasis always is. Pruritus vulvae of females must not be confounded pruritus. Pruritus scroti is the form generally met with in the male. It may involve this region alone, or it may extend along the perineum to the anus. It may also attack the orifice of the urethra. The disease is exceeding annoying. It is usually worse at night, and is aggravated by warmth. Pruritus ani occurs in both sexes, and in children also. The rectum is sometimes affected. Treatment.—Treatment of pruritus is both systemic and local. The patient must have a nutritious diet, and a sulphur bath once or twice a week. To allay the formication and itching, a carbolic acid lotion should be ordered, say carbolic acid 1 -| aqua § 4, and this may be alternated with a lotion of ext of dioscorea villosa, or mezereum, twice a day, after wash- ing with the suds of green soap. Internally, from 5 to 6 gtts. of tincture of sulphur should be given three times a day. If the affection has become chronic, then the tincture of arsenic, in doses of 3 to 5 gtt. should be given three times a day. Pruritus Simplex—simple itching, without an eruption, occurs frequently, and must not be confounded with true pruritus, which has papules. Simple itching is a merely perverted sensibility of the skin—hyperaesthesia, and is a very common accompaniment of a variety of skin affections. It is accom- panied with leucorrhoea in females, piles in either sex, and is often symptomatic of some nerve disturbance, as indicating some of the constituents of bile in the blood, or some other abnormal or foreign element in the blood, and it must be then treated in accordance with these foreign elements in the blood. Vapor baths will aid the successful treatment. As local reme- dies, the tincture of oil of peppermint, or menthol dissolved in alcohol, will give much relief from the itching. The cyanide DISEASES OF THE SKIN. 385 of potassium, grs. 15 to aqua pura, O 1, may give relief. Dilute ammonia water often relieves the itching. A lotion of chloral, grs. 10 to 30, to aqua 3 1, may be used, if the above named washes fail. Liquor picis alkali mis, an alkaline solu- tion of tar, may be used, if the above fail. It should be used first, about 2 to 4 3 to the pint of water. Zinc ointment may also be tried, if these fail. Scabies.—Itch. Scabies, or itch, is a contagious disease, caused by an an- imal parasite. It is a peculiar dermatitis or eczema, kept up by a peculiar animalcule — the itchmite, burrowing in the skin. The female itchmite begins the work of burrowing, forming just below the surface of the skin, a burrow in which her eggs are deposited, and the faeces are also there deposited, in which these mites live. The male is said to live on the outer surface of the skin. Very soon the young itchmites are hatched, all of which, at once, begin to take care of themselves. They, too, burrow in the skin, and thereby greatly increase the itching surface. The early symptoms of the disease are caused by the irritating presence of these little parasites at various points and characterized by the formation of minute,more or less inflammatory puncta, papules and vesicles. Late in the disease the burrows appear in the shape of more or less tortuous, beaded, yellowish or blackish lines, not larger than a very fine thread, and from one-eighth to one-quarter of an inch in length. And later still, scratch-marks and blood-crusts are seen, and the disease continues to spread until it covers most of the body. The first appearance of this disease is generally on the hands, and especially about the fingers. The wrists, the penis in men, and the mammae in females, are the parts that are next invaded. The other softer and more protected parts are then invaded. The axillae and buttocks are very apt to be attacked. The toes in children are sometimes af- fected. The itching is usually very severe, and it increases 25 386 THE PRACTICE OF MEDICINE. with the spread of the disease. It is much worse when the patient is warm in bed, or when by the fire. Diagnosis. — The diagnosis of scabies is not difficult. The presence of the burrows of the parasites is sufficient to decide the existence of this disease at once; and these should be looked for early in every suspected case of this disease. The mite itself can usually be extracted from the minute ves- icle at the end of a burrow by the aid of the point of a needle; but if it can not be found, it is not to be regarded as negative evidence in the final diagnosis, for it requires a good eye to see the mites in the burrow, or even when squeezed out. The burrows are easily seen on the sides of the fingers. We must take into consideration the regions of the body affected, as the favorite seat of the parasites, in making out our diagnosis, and we must remember that other skin diseases are sometimes found with scabies upon the body. Its attacking the skin between the fingers furnishes one very good differential symp- tom. Treatment. If we once recognize this affection, it is not difficult to cure. The body should be first well washed with sapo viridis and pulv. naphthol. R; Pulv. naphthol, - - - - 3 1| Saponis viridis, - - - - - 3 5 Aquae purae, - - - - - § 10 Or the following ointment: 5 Pulv. naphthol,.....3 1| Saponis viridis, - 3 5 Axungiae, -- - - - -3 10 This applied once or twice a day soon destroys the para- sites and relieves the itching. Sulphur is the old remedy and is often successful, but very unpleasant. If used, an ointment may be made with four drachms to the ounce of lard, and well rubbed in at night after washing with sapo viridis. This may be applied for three nights, then the skin thoroughly washed in warm soap suds, and the cloths and bed clothes changed. DISEASES OF THE SKIN. 387 If the patient be not relieved, the above course may be re- peated. Prairie Itch, or Army Itch.—This is a severer form of scabies, and more difficult to cure. It occurs in new districts, where it is often endemic for a considerable time. It is some- times accompanied by slight fever and general malaise, with the appearance of erythematous spots, which are covered with small, transparent vesicles of various sizes, from that of a pin's head to a mustard seed, situated on the neck, shoulders, back, and on the surface of the limbs. The eruption is accompanied by intense itching. When the patient ruptures the vesicles, there will exude an exceedingly acrid, irritating fluid, which prolongs the disease, unless this fluid be washed off with mild soap and water, then covered with wood ashes. Sometimes large black crusts are found covering the ulcers, and boils often complicate this variety of itch, especially if it be neglected. Treatment.—The syrup of rumex crispus internally, and a strong lotion of the root used externally, will generally cure this disease. I have often cured it with the following wash: 1> Cor. chlor. mere, - - - - 3 •§ Ammoniae chlor., - - - - - 3 2 Aquae purae, - - - - - 0 1 Wash the body or parts affected once or twice a day for about three days; then wash off in warm soap suds, and change the clothes and bedclothes, and if the patient is not clear of the disease the process may be repeated, as before, for three or four days. The long-continued use of sulphide of calcium as a wash, of suitable strength, has cured this variety, as well as ordinary scabies. Or, it may be taken in doses of 1-10 gr. three times a day, and an ointment used say 1 gr. to lard 1 I; use twice a day for three days, then wash off well. CHAPTER XXVIII. DISEASES OF THE SCALP. Anatomy. THERE are five layers of the skin covering the head, viz.: (1) the derm, or outer skin, which is thickly covered with hair, and contains countless sebaceous and sudoriparous glands (the sebaceous glands secrete an oily, fatty substance, and the sudoriparous glands are the organs of perspiration); (2) the epiderm; (3) the subcutaneous cellular tissue, con- taining the network of the larger blood vessels, in which also the nerves are imbedded, and which joins the epiderm to the aponeurosis. This is very tightly drawn over the head; (4) just beneath this last is found the second layer of cellu- lar tissue, consisting of loose meshes that connect the aponeu- rosis loosely with the pericranium; (5) the immediate cover- ing of the bones of the cranium, that transmits the vessels. All these tissues may be involved in disease, or a single one may be the seat of the disease. Rheumatism. The scalp is liable tp a peculiar form of rheumatism, in which the entire integument becomes extremely sore and painful. It occurs very frequently with those that are sub- ject to rheumatism, especially in cold, damp, or wet weather. Treatment.—If the blood contain an excess of acid, the benzoate of lithia or benzoate of ammonia should be given in doses of grs. 3 to 5 three times a day, and as soon as the urine is rendered neutral or alkaline then cimicifuga should be given, in doses of 20 to 30 drops every four hours, alter- nated with salicylic acid in doses of grs. 3 to 5 three times a 388 DISEASES OF THE SCALP. 389 day in sweet spirits of nitre — say salicylic acid grs. 40, sweet spirits of nitre f 4, dose gtts. 40 to 60 every four hours. The pain may be temporarily relieved by anointing the scalp in tinct. camph. or tinct. of menthol, 1 3 to 1 § alcohol. Dropsy of the Scalp. Dropsy of the scalp consists of a collection of serum in the cellular tissue of the scalp, or the serum may collect between the aponeurosis and the pericranium. If the collec- tion be in the cellular structure, it is very apt to spread down to the face, and is recognized, like dropsy elsewhere, by its pitting upon pressure with the finger. But if it forms under- neath the aponeurosis or the galea capitis, the swelling is tight, elastic, and fluctuating, and neither pits by pressure nor spreads over the face. These special forms of dropsy may occur with a general tendency to dropsy. Treatment.—In the commencement of this form of dropsy, a dose or two of the compound powder of cream of tartar, followed by a few doses of the acetate of potassium, may overcome this disease at once. But if there be anaemia, the nitrite of iron or Vallet's iron mass will be required after the serum is removed, and should be given until the dropsy is cured. If this treatment does not remove all traces of the dropsy, then the fluid extract of apocynum cannabinum should be given, in doses of gtts. 15 to 25 every three hours, alter- nated with fluid extract of. eupatorium, or the fl. ext. of poly- trichum juniperinum, do<*es of 3 \ to 3 1 every two hours. If these fail, then the acetate of potassium, in doses of 10 to 30 grs., may be given until it acts very freely upon the kidneys. I have had the petroselinum sativum (parsley) radix, in the form of a saturated tincture or infusion, to act well in dropsy, in doses \ 3 to 1 3 every two hours. And in some very obsti- nate cases, in which no one diuretic would act, I have used a compound fluid extract of eupatorium purpurium, chimaphila, and apocynum cannabinum, in doses of 3 ^ to 3 1 every hour 390 THE PRACTICE OF MEDICINE. until the kidneys act vigorously, then every two hours until the serum is removed. I give a good preparation of iron to ferruginize the blood at the last, to complete the cure. Erysipelas of the Scalp and Face. Erysipelas, in the acute form, attacking the scalp or face, is frequently a very dangerous form of inflammation. In severe cases the adjacent lymphatic glands are enlarged. I have seen cases that I am confident were contagious and inoc- ulable. But the disease often appears spontaneously under some peculiar conditions, not well known, and when so oc- curring, it is called idiopathic erysipelas. It is so contagious sometimes that it may be carried in clothing, or even on sur- gical instruments that have been used on patients suffering with this disease. When it originates thus from instruments it is called traumatic erysipelas. A very slight abrasion or cut may absorb the virus, and be followed by the disease, or it may be communicated by the nurse, or the attending physician. I once saw this disease conveyed from the scalp of an infant to the mother's arm, just over the surface that was directly in contact with the diseased scalp of the child. But it may, and often does, arise as mentioned above without any visible infection, seeming to be the result of some peculiar atmospheric condition, but occult. It is a constitutional dis- ease like scarlatina, measles and roseola. Prof. Da Costa, of Philadelphia, has conclusively shown that erysipelas is almost always attended by albuminuria, although in the traumatic variety this is either absent or appears in a very mild form. Erysipelas affects the skin to its entire depth, like phlegmon- ous inflammation; and it also invades the subcutaneous cellular tissue. The scalp and all the tissues, are cedematous, swollen, and penetrated by white blood corpuscles. The disease has a great tendency to spread gradually over the surface it first attacks. It seldom extends from the scalp to the neck and body. Sporadic cases of idiopathic erysipelas are met with in DISEASES OF THE SCALP. 391 general practice every year, and at times we have it in an epi- demic form, it prevailing over large districts of country. It pre- vailed in many parts of the United States from 1841 to 1846. Hirsch mentions this epidemic and says it was closely related to diptheria. But there was no exudation found on any part, either on the fauces or elsewhere, nor were there any symp- toms analogous to those of diptheria. Causes.—The specific cause of erysipelas is a subtle or- ganic poison or idiomiasm, derived from retrograde metamor- phosis of animal matter, which may take place either within or without the living body of individuals. In many cases the specific cause is evolved in the system by some derange- ment in the process of disintegration and elimination of waste from the tissues. Whatever retards or interferes with the natural tissue changes, by preventing the proper oxidation of the tissue materials, and their transformation into forms easily excreted and eliminated from the body, will favor the produc- tion of this disease, especially, when the specific atmospheric condition also favors the production of the disease. Poisons generated on the surface of wounds, ulcers, etc., are the fre- quent causes of traumatic erysipelas. The atmosphere is at certain times surcharged with organic albuminoid matter, which under some combination of atmospheric conditions, is so changed as to constitute the specific infection that produces epidemic erysipelas. All ages are liable to attacks of this disease. Symptoms.—Idiopathic or sporadic erysipelas usually be- gins with a sense of indisposition, similar to that which pre- cedes most febrile or inflammatory diseases. After two or three days of this premonitory indisposition, a chilliness is felt, or the patient may have a chill, which is followed by pains in the head, back and limbs, flushing of the face, heat and dry- ness of the skin, fullness and increased frequency of the pulse, some thirst, white fur on the tongue, scantiness of the urine, and an inactive state of the bowels. In severe cases, the pain 392 THE PRACTICE OF MEDICINE. in the head is severe, and there may be nausea and vomiting. In about twenty-four hours the temperature may reach 102° or 104° F., and the pulse may range from 90 to 110 per minute. There may be an increase up to the third or fourth day, at which time the fever reaches its greatest intensity, the temperature now being at 105° or 106° F., the pulse may reach 120 and the urine may contain more or less albu- men. The symptoms may not change during the fourth, fifth and sixth days, except a fluctuation in the temperature, more or less. Defervescence usually commences about the fifth or seventh day. Diagnosis.—Erysipelas is easily distinguished from other acute febrile diseases. The inflammation on some portion of the surface at the commencement of the fever, which presents a deep red color and abrupt margins, with burning pain, and a tendency to spread by continuity. Acute eczema rubrum, especially, may be mistaken for erysipelas. But acute eczema simply presents a red surface closely studded with minute pointed vesicles, accompanied by fiery heat and itching, the red surface having no abrupt margin, and the minute vesicles discharging a ser- ous fluid when they are broken; nor is eczema attended with so intense a fever as erysipelas is always accompanied. Ery- thema, too, is distinguished from erysipelas by its simple red surface, with little if any tumefaction, and the want of general fever. Prognosis.—Idiopathic erysipelas, occurring sporadically, or in the mild epidemic form, is a self-limited affection, tending to recovery, and hence is not fatal if properly treated. But there is a severe epidemic form that is frequently attended with great fatality. Pathology.—This disease seems to arise from a blood- poison which so acts upon the living tissues as to increase their elementary susceptibility and pervert the vital affinity, thereby inducing such molecular changes as distinguish this from all other forms of inflammation. diseases of the scalp. 393 Treatment.—If the disease appear in the phlegmonous form, aconite will be found useful at the outset, in doses of ^ to 1 gtt. every two hours, alternated with 2 to 3 gtts. of bella- donna, every four hours, as belladonna is not quickly elimi- nated from the system. Belladonna will be especially ser- viceable in those cases attended with intense dermatitis, high fever, redness of the skin, headache or delirium. If the inflammation invades the deeper tissues, the tincture of apis mellifica may be given in doses of from 3 to 5 gtts. every two or three hours. If there is burning of the skin, then the tinct. of rhus toxicodendron should be given in doses of 1 to 2 gtts. every two hours until the burning ceases. This remedy is also directly indicated when there is simply vesicular oedema, and a purplish color of the skin. When there is a smooth acute oedema of the eye-lids, and skin of the scalp and face, apis mel. is indicated. When the disease commences in a malignant form, or assumes that type at any time during the course of its attack, small doses of saturated tincture of arsenic should be given, say in doses of from 1 to 3 gtts. every three hours, well diluted with water. A tendency to gangrene, or a typhoid prostration, also calls for arsenic. The local applica- tion of the tinct. of veratrum viride, diluted with two parts of water, will allay the pungent heat and burning sensation, as will a solution of the sulphate of iron, 3 1 to aqua 01. I have seen the epidemic form of this disease yield to the chloride of iron, in doces to suit the age of the patient, say from 3 to 15 gtts., ter in die. Eczema of the Scalp. In eczema of the head, the inflammation extends to the hair follicles, and it passes rapidly into the pustular stage. It is a non-contagious affection of the skin, and is characterized by an eruption of minute vesicles, which are frequently con- fluent, and so dense in some cases that they appear like a large blister. These vesicles form thin scales as they dry up, or 394 THE PRACTICE OF MEDICINE. break and discharge a milky fluid of varied consistency, which soon forms crusts. This form of the disease, like eczema of the body and limbs, spoken of elsewhere, is acute or chronic. It has received various names, as ecthyma, porrigo, tinea cap- itis, and chronic psoriasis. Diagnosis.—To distinguish this disease we must look for the following characteristics, viz.: Vesicular eruption, which is often confluent, and discharges a limpid,' turbid, and milky fluid, which forms either thin or thick crusts. Pustu- lar eczema is often called impetigo and differs from the vesi- cular form simply in having pustules instead of vesicles. A vesicle is a very small blister, and a pustule is a pimple, and thus they are distinguished. Impetigo is pyo-genetic, or pus-forming, and forms ]pus instead of the milky, limpid fluid that is found in eczema. These affections may be found together upon the head, covering large patches on the scalp, and may be distinguished from each other by the thin scabs of eczema, and the thick and tense ones of impetigo, which are of a greenish-yellow or brown color, and always appear as crusts, because they have been formed from real pus. Causes.—This disease often depends upon a hereditary taint in the constitution, and is sometimes excited by cold, the sun's rays, etc. Treatment.—In simple eczema of the scalp, the tincture of rhus tox., in gtt. 1 to 2, repeated every three or four hours, will frequently make a decided impression upon the progress of the disease. But after the vesicles form crusts, and the disease becomes chronic, then the tincture of arsenic, in doses of gtt. 2 to 5, three times a day, is one of our most trust- worthy remedies. Viola tricolor, in doses of 5 to 10 gtts. may be given in alternation with the arsenic. The head should be well washed with suds made of sapo viridis, and wet in a solution of the sulphuret of potassium or the sul- phide of calcium. A wash of a saturated solution of boracic acid aids the removal of this affection. These remedies may DISEASES OF THE SCALP. SS5 be changed for clematis erecta, if they do not seem to be doing well; the dose is gtts. 5 to 6, three times a day. In some cases carb. of barium, in doses of grs. ^ to ^, given three times a day, is highly commended by some writers. As local treatment, I have found an application of the acetated tincture of the rumex crispus to the diseased surface have a curative effect. In the chronic form I have seen the rumex crispus do great good. Some time ago I treated a colored woman (who had a severe attack of eczema of the head) with the tincture of arsenic, in 5 gtts. doses, alternated with the tincture of dulcamara (bitter sweet), in doses of 5 to 10 gtts. three times a day. I applied also locally saturated solution of boracic acid to the scalp, three or four times a day, to prevent any sepsis. Occasionally I have found it necessary to apply the following lotion to the parts. Carbolic acid - grs. 5 Glycerine, - - - - --fl Aqua pura, - - - - - "% 3 Mix, and apply with a soft cloth or sponge three times daily. If the disease is in a chronic stage, then, in addition to some of the above indicated remedies, a wash of sulphureted potassium, applied three times a day, will aid in the final cure. An ointment of croton tiglium is also a good application, made as follows viz.: Croton tiglium, - - - 3 1 Aqua pura or rosae - - - - § 4 Dandruff is an eczema, in which the exudation is so scant} that it does not produce vesicles, but merely loosens the epi- dermis, which dries, and peels off in scales. It may be cured by using a wash of rumex crispus. Seborrhea Capilli and Vernix Caseosa. This disease principally affects the scalp, but may appear elsewhere upon the body. It attacks persons of any and all ages, but attacks females oftener than males. It often attacks 396 THE PRACTICE Otf MEDICINE. new-born infants; in their cases, it is more a physiological than a pathological condition, and is called vernix caseosa. It gen- erally appears in the form of an oily coating on the skin, or in the form of dirty-white scales, which are flat and more or less greasy. When it attacks the scalp, it may eventually cause baldness of the patient. When it appears thus on the scalp, it may be mistaken for eczema. But it must always be remembered that seborrhoea is a dry, oily disease, while eczema is not oily, but exudes a lymph-like fluid, and dries into scales, seated upon a reddened, infiltrated surface. The scales of seborrhoea are seated upon a pale, bluish colored skin, and are abundant, while the scales of eczema are rather scanty. If these differential points are noticed, the diagnosis is not diffi- cult. In bad cases, the entire scalp may be enveloped in a thick crust; especially is this the case in young infants. Treatment.—Before commencing the treatment, the oily scales should be saturated with olive oil, 2 parts, and gly- cerine part, and when thus softened, then after twelve hours they can be removed with a soft sponge dipped into soap suds. After the scales have been removed, the glycerole of tannic acid may be applied. If the disease should appear on the face, a powder composed of grs. 6 of tannic acid to grs. 40 of pow- dered rice, will have a salutary effect. Internally a most effective remedy is arsenic, in doses of 3 to 5 gtts. or the sat- urated tincture, three times a day, in water. Muriate of am- monia is also a valuable remedy, in doses of 1 to 2 grs., three times a day. Sulphur in doses of 1 gr.or 5 gtts. of the saturated tinct, three times a day, is often very effective. But when the skin is of a smutty brown color, or of a yellow, rather mottled color, arsenic is the remedy indicated. If there are large bran-like scales, and the hair is falling off, the muriate of ammonium, in doses of grs. 2, three times a day, will give positive results. In chronic cases, bryonia alba, in doses of gtts. 2 to 3 of a saturated tincture, may be given every three or four hours, with good effect. If the scales adhere very firmly to DISEASES OF THE SCALP. 397 the skin, the compound tincture of iodine (Lugol's solution) should be given in doses of gtts. 5 to 6 thrice daily. And if there be a copious formation of scales, which fall off in clouds, then the tincture of phosphorus, may be given, in doses of ^ to 1 gtt., three times a day, well diluted. If the disease be upon the face, the bromide of potassium is indicated, and should be given in doses of grs. 3 to 5, three times a day. If given in large doses, it will not produce its therapeutic effect; hence it must be given in small doses. Favus — Tinea Favosa. Favus is a vegetable parasitic disease, the fungus, how- ever, being of a different species from that which causes ring- worm. This disease first appears as a diffused, circumscribed, superficial inflammation, with slight scaling, followed by the appearance of one or several pinhead-sized, pale yellow crusts seated about the hair follicles, which develop into the charac- teristic lesions of the disease, raised, sulphur-yellow cups, that can be detached from the skin underneath, having a moist, excoriated surface. These cups are friable, and can be pulverized by pressing firmly between the fingers. They sometimes aggregate into masses. When the disease is over a large surface, ulceration may exist under the crusts. This disease is usually situated upon the scalp, but the nails and skin may be attacked in exceptional cases. If the nails are attacked, they become thickened, yellow, opaque, and brittle. Favus possesses a peculiar odor, like musty straw, or like the smell of mice. It is attended by slight, but not excessive itching of the parts affected. When this disease has been on the scalp, in a severe form and for a long time, a cicatrical condition, with permanent baldness, may ensue. It is a chronic disease. It is very hard to cure, and is very liable to return. Some English writers think it is incurable, but as we meet with it in the United States it is curable if properly treated. It is a rare disease. 398 THE PRACTICE OF MEDICINE. Diagnosis.—The diagnosis is not difficult. Its peculiar yellow, honeycomb-like cups, and its mice-like odor, are com- monly present, and even when the shape of the cups has been destroyed by suppuration or broken down by treatment, a small patch of the characteristic color can usually be seen here and there. The mouse-like odor is almost always per- ceptible, and most cases may be diagnosed by this odor. Treatment.—The first effort in the treatment is to kill or starve out the parasite. The parasite may be starved out by the administration of internal remedies that are capable of so altering their soil as to render it less suitable to the fructifica- tion of this fungus plant, and they may be killed by the use of local applications called parasiticides. But before any local applications are used, the crusts should be all carefully removed and the diseased hairs all extracted. The applica- tion of almond oil, olive oil and glycerine, or a poultice of marsh mallow, or a roast-turnip poultice, will remove the crusts. After the scabs and diseased hairs have been removed, a parasiticide of suitable strength should be applied, such as hyposulphite of soda grs. 5, glycerine and water aa 1 1. Mix, and apply with a bit of soft cotton three times a day. If the disease does not seem to mend under this appli- cation, the following may be tried, viz.: Sulphurous acid, 1 §; aqua pura, 1 1. Mix and apply, and cover the scalp with oiled silk. Corros. sublimate lotion acts well, but requires care to prevent its toxic effects by absorption. A lotion may be tried made with 1 3 to water 16 §; apply with a soft sponge. Chrysophanic cerate is also very active as a parasiti- cide. If there is much itching of the diseased parts, grinde- lia cerate may be applied. A lotion of carbolic acid or dias- corea is of much utility. The pyroligneous oil of juniper may alternate any of these applications. In using any of these parasiticides, care must be taken lest they be too strong and do more harm than good. Internally the arsenic iodide is a valuable remedy, 1 to 2 grs. of the 3d dec. trituration diseases of the scalp. 399 three times a day. Sulphur, in doses of 5 to 6 gtts. of the tincture, or the viola tricolor, will do well to alternate with the iodide of arsenic. Ringworm — Tinea Circinata. Tinea circinata, or ringworm, is a contagious, vegetable parasitic disease, due to the presence of minute spores and mycelia or threads growing in the epidermis, and giving rise to one or more circumscribed, circular, various sized, inflam- matory, squamous patches, occurring on the general surface of the body, and attended by itching. This disease usually begins as a small, reddish, scaly, rounded or irregularly- shaped spot, which soon assumes a circular form, healing in the centre as it spreads on the periphery, which is usually papular, but occasionally it is found composed of minute vesi- cles. This disease may attack the beard of the adult male, in which case it causes what is called "barber's itch." When it appears on the scalp, the hairs covering the diseased part gradually become brittle and break off, or become loosened and fall out. The integument where the hairs fall out or break off becomes wrinkled, and looks like the skin of a goose. Upon the body it spreads in a ring, until it attains the size of a dollar or half a dollar. As the skin becomes accustomed to the fungus, which assumes finally a cellular form in the old- est part of the patch, the redness in the centre fades away, while the disease continues to spread towards the periphery, where the sprouting mycelia are the most active. This dis- ease appears sometimes in a more active form, and is then called tinea kerion, from the Greek kerion, a honey-comb, and this aggravated form is owing to a more violent action of the parasite. In this form the hair follicles become very much inflamed, and exude a viscid mucus, sometimes resembling the juice of a ripe mistletoe berry. The fungus is mostly com- posed of spores and mycelia, and has but few granules in its composition. These spores resemble fish-roe, and are of uni- 400 THE practice of medicine. form size, but very small. They are more abundant on the head and in the beard than on those portions of the body where there is no hair, but the mycelia may be abundant on the neck and cheeks. Diagnosis.—This disease may be mistaken for seborrhoea, eczema, psoriasis, favus, sycosis, and acne. But it may be distinguished: (1) from seborrhoea by the acute nature of the disorder, and by the absence of enlarged follicles and a greasy surface; (2) and from the squamous stage of eczema by the abrupt marginal form of the eruption, loosening the hair, and the more rapid course; (3) from psoriasis, by exam- ination under the microscope; (4) from favus, by the absence of the characteristic crusts of favus; (5) from sycosis, b}r the loosened hairs, the peculiar characteristic tubercles, and the presence of the fungus; (6) from acne, by its appearing gen- erally on the hairy parts, while acne almost always appears on the face and cheeks. Ringworm does sometimes appear on the face, but oftener attacks the scalp and beard. If chloro- form be applied to the diseased part when the fungus is pres- ent, the part turns a whitish yellow color, as if sulphur had been sprinkled over the part This test should be made. Treatment.—The first step in the treatment is to kill the parasite. Sulphurous acid (but epilation is necessary before applying the sulphurous acid) may be applied of full strength, or diluted with water, if it is too painful. A solution of the mere corros. chlor. grs. 1 to 2, to 2 or 3 3 of water, will also kill the parasite. Iodine has been very successful in my hands; Lugol's solution painted over the diseased parts once a day, for a few days. Chrysophanic acid is also a very valu- able remedy in parasitic diseases; it may be applied, of suita- ble strength, in glycerine water.* Vascular N^ivus. Vascular naevus is a dilatation of portions of the net-work *Comp. citrine oint. cures this disease. diseases of the scalp. 401 of the capillary vessels of the derma and cellular tissue. It is sometimes pigmentary, as well as vascular. The pigmen- tary form is of a dark color, and generally elevated above the surrounding skin; It varies in size from that of a pin head and that of silver half dollar, and is sometimes covered with hair; sometimes is not elevated, but smooth—naevus simplex. This form is called " mother's mark." They appear on the body anywhere, and sometimes grow; then again they remain stationary. They appear on the face very frequently, and are unsightly. Treatment.—The pigmentary naevi may be gradually re- moved by applying the following: Collodion 3 1, mere. corros. chlor. grs. 5; mix and apply once or twice a day until the diseased parts separate from the sound parts. I have very frequently removed naevi from the face and neck by touching them with nitric acid, once a Aveek, for a few weeks. I removed some five or six black, unsightly naevi from the face of a young lady a few months ago, with nitric acid. If the naevi are of a vascular variety, the fluid extract of thuja oc applied twice a day often removes them in a short time. Chromic acid removes naevi, when applied. Alopecia Areata; Simple. Baldness. This is an absence of the hair, either partial or general. It is a symptom rather than a disease itself. It often appears in the form of various sized, white bald patches over the scalp. It may attack the beard also. It mostly attacks young people, and on one side of the head. It first appears in small spots, but spreads more or less rapidly, and other new spots occur until the hair may fall gradually from one side of the head. The hairs do not break off as in tinea tricophytina, but generally fall out by the roots, leaving a smooth, polished surface. Fine down may appear, but it soon disappears. This disease may run on thus for many years. It is believed to be of a parasatic origin, and caused by spores, formed in either 26 402 the practice of medicine. complete or incomplete rings. It may exist with many other diseases of the head. Treatment.—The treatment must be such as will destroy the parasite. Epilation, with the broad-lipped forceps, should commence the treatment. Locally, acetic acid, tincture of cantharides, or the tincture of iodine* may be applied once or twice a day. If these remedies do not seem to arrest the dis- ease in two or three weeks, then equal parts of glycerine and tincture of capsicum may be applied daily to the parts. The oleate of mercury is very highly extolled by some writers. Iodide of mere grs. 16; simple serate, 1 1; mix and apply lightly over the diseased surface once a day, or even twice a week is sufficient in most cases. The sulphide of calcium, (in trit. 1 dec.) may be given internally in doses of 1 grain of the 1st dec. trit three times a day. The tincture of phospho- rus (diluted) should be iried if the above remedies fail. The testa preparata (the white powder just beneath the inner layer of oyster shells), in doses of 2 grs. three times a day, is highly commended. Washing the scalp in a solution of borate of sodium helps to cure. *Iodine and glycerine, equal parts. CHAPTER XXIX. DISEASES OF THE BRAIN. Anemia. AN2EMIA of the brain, upon inspection, exhibits the grayish substance of the brain paler than natural, and sometimes nearly white, and the white substance of the brain of a milk white and glistening color. When the brain is cut open, fewer clots of blood are found than usually exist in the normal, healthy brain. The blood-vessels of the membranes are found empty, and sometimes an increased quantity of serum has been found between the subarachnoidal spaces within the skull. There is deficiency of arterial blood especially, more so than in the venous system. Causes.—This affection may be caused by haemorrhages, loss of other vital fluids, as in diarrhoea, summer complaint of children, long spells of fever, hepatization of the lungs, starv- ation, and anything that exhausts the vital fluids. Conges- tion of blood in other organs gives rise to it, by the with- drawal of blood from the brain, and compression of the carot- id or vertebral arteries, either by ligation, tumors, or emboli, prevents the flow of blood into the brain, and consequently produces anaemia of the brain as a legitimate result. Spas- modic contraction of these vessels, from emotions of mind or otherwise, may also cause this disease; and depression of the skull, extravasation of blood, exudations, tumors, etc., may all cause this abnormal condition. Heart and lung diseases may prevent the normal oxygenation of the blood in the lungs, and produce the same symptoms. Symptoms.—The symptoms differ somewhat with the cause. If anaemia be due to violent depletion, there will be 403 404 THE PRACTICE OF MEDICINE. sudden paleness of the face, cold perspiration of the forehead, gaping, slow respiration, dimness and flickering before the eyes, nausea and vomiting, faintness, and, in some cases, epi- leptiform convulsions. When anaemia is gradually developed, the symptoms then differ in each individual case, although all cases are attended by paleness of the face. There is apt to be either mental torpor, drowsiness, delirium, coma, sleepless- ness, restlessness, or great nervousness. Occasionally there is only vertigo and headache. There may be ringing in the ears, and specks floating before the eyes, accompanied with dimness of sight. Great weakness of the entire muscular sys- tem prevails in almost every case, and sometimes temporary paralysis, or convulsions of an epileptiform kind. Anaemia consequent upon summer complaint of children, was called " hydrocephaloid " by Marshall Hall, on account of its simi- larity to hydrocephalus. Anaemia of the brain may assume either the irritable or the torpid form. If it assume an irrita- ble form, the child will be very restless, start and cry out sud- denly in its sleep, and often grate its teeth while asleep. The face, too, becomes red, the pulse frequent, the skin hot, and spasms are apt to occur; hence the resemblance to acute hydrocephalus. In the second stage, collapse takes place and the child becomes apathetic, and does not look at surrounding objects. The eyelids are closed (the pupils failing to react against light), the respiration becomes very irregular, the pulse frequent and small, the body gradually grows cold, and in fatal cases the patient may die with comatic symptoms. Treatment.—A good diet is one of the main things in the treatment. The patient should have tender beef or mutton, fish, eggs, or tender fowl. As a medicine the nux vomica has special claims here, dose from 1 to 3 gtts., according to the age of the patient, every three hours. Phosphate of lime may be given, in doses of 1 to 2 grs. For vertigo, carb. of baryta may aid the above remedies. If there is delirium, ignatia amara may be given in doses of 1 to 2 gtts. three times a day. DISEASES OF THE BRAIN. 405 When convulsions occur, pulsatilla in doses of 1 to 2 gtts., according to the age of the patient, may be called for. When anaemia follows great loss of blood, arsenic is a valuable rem- edy, in doses of ^ to 1 gtt, according to the age of the patient. If there is general anaemia with that of the brain, the patient should have a rich, blood-making food, with phos- phate of iron, alternated with the tincture or fluid ext of cin- chona bark, or its extract. Insomnia — Wakefulness. Insomnia may result directly either from the peripheral sensory organs of the brain and nervous system, or from a disordered condition of the sensory nerves and nerve tracts, and sometimes from certain morbid states of the brain. Irri- tation of the sensory apparatus may be ranked in three classes: 1st, affections of the organs of special sense; 2d, dis- ease of the sympathetic nervous system; 3d, affections of the nerves of common sensation. Light upon the eyes may affect the organs of special sense. Darkness favors sleep, and light hinders it and renders it less profound and refreshing. Dur- ing sleep the sense of hearing is one of the most easily and quickly disturbed senses. It is also a very easily excited sense during a state of repose. The ear remains sensitive to sound long after the individual has fallen asleep. Even dreams may be the result of impressions of sound on the ear. An alarm clock awakens most persons at a stated hour Tem- perature is a factor in the production of sleep. A very high temperature will keep most persons awake, and humidity of the air very greatly increases the tendency to insomnia from the heat. The moisture retards exhalation, which tends to retain the heat, thereby preventing the passing off of effete materials, and causes a suspension of nutrition. This de- presses the functions of the body, irritates the nervous sys- tem, and leads to insomnia. Sleep can never be very pro- found and refreshing while the brain is in an over-excited 406 THE PRACTICE OF MEDICINE. state. Excessive cold will produce a condition of stupor that may end fatally if continued. Pain is one of the chief causes of sleeplessness. This is the result of excessive excitement of the peripheral nerves of sensation. Hence, flies, fleas, mos- quitoes, bed-bugs, or the parasites of itch, or many skin dis- eases, keep the subject awake until tired nature becomes exhausted for want of sleep. Wounds or injuries, as frac- tures, painful ulcers, and certain local inflammations cause insomnia. Injuries of the peripheral nerves often produce this tendency to insomnia. Neuromata, often developed in the stump of an amputated limb, become a source of persistent insomnia. Indigestion often prevents sleep, as well as many other diseases, rheumatism, gout, colic, and many other pain- ful inflammations. The direct action of certain agents upon the brain causes insomnia, such as tea, coffee, and tobacco. These articles increase the molecular movement of the brain, which results in sleeplessness. An occasional attack of insomnia, from certain disturbances of the mind or of the body, are not alarming, but the constant recurrence of this disordered condition is what is to be deprecated. Such a con- dition denotes a pathological departure from healthful physio- logical life, as it prevents requisite repair of the various organs and tissues of the organic structure of the body. Such a state of non-rest greatly interferes with nutrition, and hence the subject rapidly declines in health. Some grave disorders of the brain may cause insomnia, that is very diffi- cult to remove, or even mitigate. Wakefulness often precedes spasms, or meningitis, in children. It may precede tubercu- lar meningitis, and it also often ushers in the infective fevers, especially typhoid fever. It often indicates approaching insanity. Hence, the very great necessity of averting it. Many authors consider sleep to depend upon a comparatively bloodless state of the brain, and wakefulness upon the oppo- site condition of that organ. But doubtless insomnia is often caused by the one in great "excess, or by the other. The nor- DISEASES OF THE BRAIN. 407 mal activity has much to do with insomnia, and altogether the deficiency or excess of blood in the brain. The type of insomnia is liable to vary with the course of each individual disease, and the treatment must vary with these peculiarities. Treatment.—Valerian is useful in hysterical excitement, causing insomnia; it may be given in doses of 15 to 30 gtts., repeated three or four times in the twenty-four hours. Bella- donna relieves that plethora of the brain that often leads to insomnia, and thereby assists sleep; its dose is about 4 to 5 gtts. of tinct. Hyoscyamus is a powerful narcotic and ano- dyne when given in large doses, but if the dose be too large, it is liable to produce delirium, or in some subjects even maniacal fury. The ^ of a grain of hyoscyamin, for children, or one grain for an adult; but T^ of a grain of the hyoscyamin should first be tried until its effects are witnessed. Stramonium much resembles belladonna in its action. It is not directly hypnotic, except in spasmodic diseases. Phosphorus does good in cases of insomnia from cerebral anaemia, and in the in- somnia of the aged. But it is not a direct hypnotic The dose is Y^g- of a grain. All the anaesthetics are hypnotics; that is, they have the power to abolish consciousness, produc- ing a condition resembling sleep. This effect is the result of a reduction of molecular movement of the living protoplasm of the brain, it being too low for the excitement of consciousness. Most of the anaesthetics, such as alcohol, paraldehyde, ether, compound spirits of ether, chloroform, chloral (in large doses), butylic chloral, and amyl nitrite, are too unsafe to use in this 'way. Paraldehyde may be given in doses of 40 to 50 grs. in cases of insomnia from exhaustion, or in cases of debility, given in water. Chloral hydrate until recently was used a good deal as a hypnotic. It answers well in puerperal con- ditions, and in spasms of young women at confinement. The dose is from 15 to 20 grs. Ten grains is a medium dose, dis- solved in water, or sweetened water. It is indicated in hyper- vascular states of the brain. It is valuable when the in- 408 THE PRACTICE OF MEDICINE. somnia follows prolonged mental application or excitement, especially in mania. Insomnia with delirium tremens is amenable to chloral. I have given old topers 10 to 15 grs. of chloral, in the stage of " the horrors," and they would fall into a profound sleep for twelve or fourteen hours, and awake all right. In chronic cases it will not do so well, as it is too depressing and, continued too long, it produces motor debility. If the stomach reject chloral, it may be given in the form of an enema in milk, as follows: Chloral hydrate, - - - - 3 1 Albumen — white of an egg, - - § 1 Lac—(milk), ----- % 2 Mix and use as an enema. In cases in which chloral is too depressing, the butyl- chloral hydrate has been recommended in place of chloral hydrate, especially when there is cardiac weakness, as it is less depressing to the heart. It is also useful for facial neuralgia and hemi-crania. It is not much used as a hypnotic, but may be given in solution like that of chloral hydrate. The dose, as an anodyne, is 5 or 6 grs., repeated every hour, until it produces its effects. As a hypnotic for general purposes I have found the piscidia erythrina—Jamaica dogwood—to an- swer that purpose admirably, in doses of 10 to 15 gtts. to be repeated in two hours, if it fail to produce sleep. I have used it in insomnia from fractures with positive success. And when the patients awake, they have none of the languid feelings that follow opium, nor do they experience any headache, or nausea, or other bad feelings. In cases of insomnia from deficient cerebral circulation amyl nitrite is a valuable article. It can be given by inhalation, by dropping 5 gtts. on a handkerchief, and inhaling the vapor, and repeating it every fifteen or twenty minutes until it produces sleep. Opium will also pro- duce sleep, by its direct action upon the brain. Under its specific influence the blood accumulates in the veins. Small doses contract the capillaries, but larger doses dilate them. DISEASES OF THE BRAIN. 409 Opium is a very active soporific, but it is narcotic, and can not be taken with safety where there is congestion of the brain or spine. Where there is anaemia of the brain, with pain of any part, opium can be taken with good effect. I prefer the aqueous extract, made much like McMunn's elixir of opium, the dose of which is 25 to 30 drops. A combination of chloral hydrate, sodium bromide, and morphia forms an active and safe hypnotic. The soothing, anodyne effects of morphia are much increased by adding T^-g- of a grain of atropine to \ gr. of morphia; and the disagreeable effect of the morphia is much lessened. The bromide of lithium is a mild soporific, given in doses of 10 to 15 grs., at night, and next to the lithium salt is sodium bromide; potassium bromide is the least soporific of them all. Calcium bromide is recommended as a hypnotic. Hydrobromic acid is recommended as a hypnotic in some cases, such as cases of excitement or exhaustion of the brain, but in such cases the bromides of soda and am- monia will do as well or better. But the bromides do not an- swer in active congestion of the brain and the spinal cord. In cases of insomnia from hysteria, asthenic mania, and insomnia from sexual excess, the bromide of soda or ammo., or lithia, will act charmingly. In insomnia from determination of blood to the brain, gelsemium will be found to act like a charm; the dose is 20 to 25 gtts. of a good tincture. Conium is useful in cases of insomnia of mania, through a sedative influence on the nerves and spinal cord. It aids other hypnotic remedies in cases of nervous excitement. The dose of the fluid extract is 15 to 20 gtts. or 1-60 of a grain of conium. In cases of insomnia from intracranial inflammations, the tincture of aconite should be added to the bromides, so as to give 1 to 2 gtts. every two hours. If there is repletion or congestion of the brain, chloral hydrate in 10 to 15 grs. will produce sound refreshing sleep. This article has an influence over the capillaries of the brain similar to that of belladonna, but its soporific power is superior to any remedy in cases of re- 410 THE PRACTICE OF MEDICINE. pletion of the brain and spine. The saturated tincture or the fl. ext. of piscidia erythrina—Jamaica dogwood—in doses of 15 to 25 gtts. often produces sweet, refreshing sleep, especially in cases of nervousness or insomnia from pain or excitement of mind, but not where there is congestion. Hyperemia of the Brain. Hyperaemia is a disease consisting of an over-supply of blood to the brain. It may be the result of active congestion from rush of blood to the brain, or from stagnation of blood in the cerebral substance, owing to passive hyperaemia of the brain. In post-mortem examinations, a large quantity of blood is usually found in the vessels and sinuses, especially in the lower part of the cranium. The gray substance of the brain appears swollen and darker than usual, and the white substance generally presents a reddish color. The subarach- noid meshes contain no fluid. In chronic cases the blood ves- sels are dilated, the substance of the brain itself is often found atrophied, and the subarachnoid spaces are filled with fluid; consequently they may present a darker appearance. But in some cases the above conditions do not all prevail, the vessels being sometimes found empty of blood, although dur- ing life there were symptoms of hyperaemia. This fact is quite difficult to account for, and proves that the dead body does not always reveal clearly what was going on in the living organs. When the brain is atrophied, there is, in addition to the hyperaemia, an increase of cerebrospinal fluid in the cra- nial cavity and in the cavity of the spinal canal. The remedy is belladonna 5 gtts. twice a day, or the bromides. Congestion of the Brain. Congestion takes place in consequence of undue activity of the serous membranes that envelop the brain. Congestion may be active (arterial), or mechanical (venous). CAUSES.—The immediate cause of congestion is dimin- DISEASES OF THE BRAIN. 411 ished arterial resistance, and that may be the result of agen- cies that have a weakening or paralyzing influence upon the involuntary muscles of the walls of the vessels. Fatigue may result in such an effect Warmth may produce this result; injuries produce a reflex hyperaemia by their influence on sen- sory nerves before the real inflammatory dilatation sets in. The dilatation of inflammation is due to direct injury of the walls of the vessels, by which an abnormal quantity of blood passes through the vessels, resulting in congestion. Conges- tion may also arise from the sudden removal of pressure, as in case of removal of much ascitic fluid in abdominal dropsy, or on the removal of a large ovarian tumor; also by the bleeding that occurs when the pleura is emptied by aspiration, and by the removal of the vaso-motor action of the sympathetic, either directly or reflexly — that is, by inhibition. We have an example of this process in cases of aneurism, or the section of the vaso-motor nerves in any part of their course, from the centre in the medulla down the cord into the spinal nerves or sympathetic plexuses. Certain drugs are believed to paralyze, temporarily and directly, the vaso-tonic nerves, such as nitrite of amyl, alcohol, and tobacco. The results of active hyperae- mia are such as might be expected to follow an increase of arterial blood in a part, and the rapidity of its flow in any organ or tissue. The symptoms in a superficial part are: Increased heat and redness, pulsation, and a sensation of throbbing, some increase in bulk, marked elevation of temper- ature, etc. Venous or mechanical congestion is characterized by the slowing of the blood in the veins and capillaries, instead of accelerating it. This may be produced by some mechanical obstacle to the return of blood through the veins. The congestion of a finger from a tight band around it is an example of this form of congestion. Causes.—Anything that weakens the forces that propel the blood along in the venous system, or that opposes an unusual resistance to this circulation; anything that lowers the blood- 412 THE PRACTICE OF MEDICINE. pressure and slows the stream must tend to produce venous congestion. Such causes may exist in any part of the vascu- lar system, the heart, arteries, capillaries, or veins, some hav- ing a general and some a local influence. These causes may be ranged under two heads, viz.: (1) Those that diminish the vis a tergo, or the force by which the veins drive the blood through their caliber; and (2) those that directly impede the return of the blood by the veins and capillaries back to the heart. Diminished power of the heart is the chief in the first group of morbid causes of congestion; many chronic exhaust- ing diseases, as well as acute febrile disease, such as typhus and typhoid fever, and those degenerations of the structure that lead to dilatation of the cavities of the heart. By these means the vis a tergo is diminished, and this cardiac failure is the result of diminished fullness of the arteries and overful- ness of the veins, clinically observed in many cases. The fatty, atheromatous, or fibroid changes of the arterial walls, so common in old age, greatly weaken the circulation in the arte- ries so affected. It matters not whether a direct impediment to the return of blood by the veins, or a failure in the forces of circulation exists, the veins and capillaries dilate, and the blood accumulates in them, and moves with diminished veloc- ity. Important changes take place in vessels. The most important of these changes are, the transudation of serum, the diapedesis of the red blood-corpuscles, haemorrhages, fibroid induration, thrombosis, and necrosis. Symptoms of congestion are various — excitability, depres- sion, headache, sensitiveness to light, noise or touch, flicker- ing before the eyes, ringing in the ears, formication, great restlessness, and sometimes convulsions, dizziness, hallucina- tions, vivid or frightful dreams. Treatment.—If there be rush of blood, or delirium, aconite acts well in doses of gtt. 1 every hour, alternated with gtt. 2 or 3 of tincture of belladonna. If, however, the patient craves death, and complains of heat, noise in the head, and DISEASES of the brain. 413 sparks before the eyes, gr. 1-50 of chloride of gold should be taken every three hours. If it occur in children during denti- tion, gtt 3 to 5 of gelseminum may be given every three or four hours. If there be loss of sight or hearing, convulsive movements of the muscles of the head and face, wild, stupid expression, with delirium and sleeplessness, gtt. 4 to 5 of the tincture of stramonium should be administered every three hours until these symptoms subside. In some cases that I have had in females, in which there was hysteria, and when it occurred about the menstrual period, the inhalation of gtt. 5 or 6 of nitrite of amyl has given very ready relief to the hyperaemia. If this affection be caused by mental emotions, ignatia amara should be ordered in doses of gtt. 3 to 5 every four hours. If hyperaemia is easily provoked by exercise, tincture of phosphorus may be given in doses of gtt. 1 to 2, well diluted in water, every two or three hours. If it occurs in females from suppression of the menses, small doses of iron act admirably, alternated Avith gtt. 5 or 6 of pulsatilla (tinct.) every two hours. If it result from hypertrophy of the left side of the heart, I have found the tincture of cereus grandi- florus to give immediate relief in doses of gtt. 15. Collinso- nia, in doses of gtt. 20, should alternate this treatment. Vertigo. This may originate in its milder forms from indigestion, or from nervous exhaustion, but if it appears in a more ag- gravated type, it points to disease of the brain, kidneys, liver, or heart. It is often associated with structural lesions of the brain, and often exists with hyperaemia or anaemia of this organ. It may be of rather an epileptic or psychical character, and occurs under varied conditions ; while quiet, or during motion, on rising or upon stooping, on suddenly turn- ing the head, during sleep, while reclining, from bright and dazzling light, from swift motion, as in riding in the cars, from witnessing a surgical operation, or from seeing blood 414 THE PRACTICE OF MEDICINE. flowing. It may also arise from looking up or down great heights. It generally occurs in adults. Treatment.— If vertigo occurs from dilatation of the right ventricle, from emphysema, or during pregnancy, and is ac- companied with pale, puffed lips and face, gtt. 3 or 4 of the tincture of arsenic will aid in relieving it ; and if there is also headache, I order gtt. 5 of tincture of belladonna every four hours. If indigestion is the cause, gtt. 5. of nux vomica gives good results, used three times a day, and alternated with gtt. 2 of nitrate of iron. The patient should keep the bowels open with cascara or senna and cascara. Tubercular Meningitis. This disease generally occurs in scrofulous children, but persons of all ages are subject to it. The chief morbid indication consists in the deposition of tubercular material be- tween the membranes of the brain. It often occurs in families, a member or members of which have died with scrofula or consumption. Symptoms.— When meningitis appears in children there will be more or less fever, with quick and irregular pulse, vomiting, constipation of the bowels, clay colored stools, red tongue, and continuous heat of the whole body. There is al- ways great irritability, disturbed sleep, grinding of the teeth, pain in the head with intolerance of light and noise. Severe vertigo, when the patient stands erect, and great debil- ity soon set in. Delirium is very often attendant upon this disease, and if it is not present the patient is greatly dis- tressed, and very often cries out suddenly, and sometimes is so drowsy, that it is difficult to keep him or her awake long at a time. The disease generally has its seat in the pia mater, the miliary granulations being found in the immediate neighbor- hood of the vessels of the brain, either in the convexity or the base of that organ. In post-mortem examinations, yellow, cloudy patches have very frequently been seen along the ves- DISEASES OF THE BRAIN. 415 sels, the ventricles also being dilated and containing hydro- cephalic effusion. The quantity of fluid varies greatly in each case, and in some, indeed, there may be none at all. Occa- sionally white softening of a portion of the fornix and the corpus callosum has been seen, and again, in other cases, there there is no softening of any part. Miliary tubercles are often found in almost all parts of the body. This disease, doubtless, depends upon a scrofulous constitution, which has a tendency to bring on inflammatory exudations, that lead to cheesy de- generation. In adults there may be mere indisposition at first, short naps full of dreams, starting in the sleep, loss of appetite, con- stipation of the bowels, fever towards evening, and headache and vertigo. Then follows meningitis, with facial paralysis, vomiting and delirium. In some cases, however, the symp- toms come on more gradually, and instead of delirium, there will be headache, vertigo, great sensitiveness to noise and light, vomiting (especially when moved about), and either constipa- tion or diarrhoea. There may be either general or partial convulsions at this stage of the disease. Paralysis of the face, eyelids, or muscles of the ball may set in, and the pupil may be dilated. The patient cries out suddenly in some cases, and convulsive movements take place, which often distort the face and eyes. There may also be squinting or winking of the eyelids, and chewing or grinding of the teeth. One or another of the extremities may become paralyzed, and convulsions of the opposite one may appear. The muscles of the tongue and those of deglutition may become paralyzed, and very often the pulse falls down to about 60 per minute and the temperature to about 100° F. Diagnosis.—It is quite difficult to distinguish this affec- tion from simple meningitis. If the patient has any tendency to tuberculosis, we may then conclude that the disease is tubercular meningitis. The prognosis is always bad. Treatment.—Where there is fever, and a quick, small 416 THE PRACTICE OF MEDICINE. pulse, gtt. ^ to 1 or 2 of aconite (according to age), may be given every one or two hours, as the fever may be more or less severe. If the pupils are dilated, and there is headache, ver- tigo or delirium, belladonna should be taken, in doses of gtt. 1 to 5, according to the age of the patient, until these brain symptoms disappear. If there is merely drowsiness and stupor, hyoscyamus, in doses of gtt 3 to 5, may be prescribed every two or three hours, until relief is given. If there is evidence of effusion upon the brain, gtt. 3 or 4 of bryonia alba may be taken every three hours, alternated with small doses of tincture of helleborus niger, in doses of gtt. 10, four times a day. Should the above not act well on the kidneys, apocynum cannabinum should be tried, in doses of gtt 15 to 20, every three hours, with gtt. 10 to 12 of digitalis to each dose. I have always found these last to act well in hydrocephalus. After the effu- sion is removed, to complete the cure, if such be possible, I give arsenic, in doses of gtt. 2 to 3 of the saturated tincture, three times a day. Iron may alternate with the arsenic, if there be anaemia. Acute Meningitis. This disease is considered to be an inflammatory affection of the pia mater. Upon post-mortem examination, this mem- brane is generally found unchanged, although in some cases it has been found to be anaemic, and in others to contain the usual amount of blood. Usually, the cortex and white sub- stance of the brain are more or less compressed, and appear dry and firm, the ventricles perhaps being dilated on account of the effusion, but the surrounding brain tissue not being so extensively softened as in tubercular meningitis. The choroid plexus shows greater hyperaemia than the superficial portions of the pia mater, but there is seldom any exudation at the base of the brain. The hyperaemic, or inflammatory nature of this disease can not be accurately determined by the anatomical evi- dences as presented upon post-mortem examination. DISEASES OF THE BRAIN. 417 Causes.—The exciting causes are dentition, eruptive fevers, acute pulmonary affections, and concussion of the brain from wounds. It affects children from one to five or six years of age, but rarely later than that. Symptoms.—The symptoms are so nearly like those of tubercular meningitis that it is hard to distinguish one from the other. If, however, there is a hereditary tendency to scrof- ula, we may conclude that it is tubercular meningitis, and not simple acute hydrocephalus. In many cases there are certain prodromic symptoms, such as an inability to swallow, very dry skin while the head is moist, and frequently paralysis of the face and extremities, although this last symptom is not so common in this form as in tubercular meningitis. Besides this form of meningitis, there may be also simple meningitis of the base of the brain. In this form there is often a formation of quite dense, hard strips of connective tissue, and in the more active forms of inflammation there may be fibro-purulent infil- tration into the tissues of the pia mater at the base of the brain. Where hydrocephalus is associated with this form of the disease, it is apt to be very profuse and hard to remove. Hydrocephalus generally prevails between the ages of sixteen and thirty years, and may last from thirty to sixty days, or even seventy days. Symptoms.—This form of meningitis usually commences with a chill, which is followed by more or less fever, thirst, sweat, loss of appetite, and severe headache. The fever may be rather paroxysmal; that is, the temperature may runup as high as 104° F. in the evening, and fall, in the morning, to the normal state. In many cases, however, the fever contin- ues high all the time, while in others, the temperature, at times, falls very low. There is much irregularity, also, in the condition of the mental faculties. There may be periods of entire consciousness, and then again attacks of wild delirium. There may be paralysis, contractions and spasms, alternating one another. These motor disturbances, however, are entirely 27 418 THE PRACTICE OF MEDICINE. wanting in some cases, and death may take place during coma. These indications distinguish this form of meningitis from all others. Again, hydrocephalus occurs in constitutions in which there is no hereditary tendency to scrofula or tuberculosis; and it will also be remarked, that paralysis occurs much later than in tubercular meningitis. It may be distinguished from typhoid fever by the absence of enlargement of the spleen, which occurs in typhoid fever. It differs from cerebro-spinal meningitis, in not having the epidemic character of that dis- ease. The prognosis is generally not favorable. Treatment.—If the children are emaciated, and have large fontanelles and green or slimy stools, the phosphate or the hypo- phosphite of potassium may be ordered in doses of gr.^ to 1,three times a day. In the first stage of febrile excitement, aconite should be given in doses of gtt. 4 to ^ (according to age)every two or three hours until the fever subsides. The effusion should be removed by the diuretic effects of apis mel. and apocynum cannab., in doses to suit the age of the patient. If there is wild delirum, hyoscyamus, or stramonium may be taken, ter in die, in doses of gtt. 1 to 2. Sometimes, when other diuretics have failed to act well, I have had signal success with small doses of tincture digitalis (say gtt. 2 to 10, according to age), given in an infusion of pipsissewa. At other times, I have found digitalis to act well upon the kidneys, alternated with the tincture of apocynum cannabinum. I have had some cases that, after the inflammatory symptoms were subdued, needed small doses of iodine to prevent a return of the effusion. The tincture of sponge also acts well under similar circum- stances. Bryonia alternated with belladonna sometimes has a good effect, especially where the liver is torpid, and the bowels constipated. If there is coldness of the extremities, while the head is hot, twitching of the muscles of the limbs, a bluish appearance of the tongue and mucous membrane of the mouth, and convulsive movements of the tongue, I use the acetate of copper, in small doses. If, after the active symp- DISEASES OF THE BRAIN. 419 toms have subsided, there is still pain in the head, vomiting, etc., small doses of phosphide of zinc should be taken, saygr. 1-20, thrice daily. Cerebro-Spinal Meningitis. This consists of an acute inflammation of the pia mater of the brain and spinal cord, giving rise to an exudation of pur- ulent matter. It generally occurs about the base of the cere- brum, the pons, the optic nerves, the medulla oblongata, the spinal cord, and especially about the dorsal and lumbar verte- brae. Not only is it not uncommon to find the substance of the brain congested with punctiform haemorrhage and small spots of softening, but in some cases in which the disease has existed long, the substance of the brain is found juicy and oedematous, presenting a watery appearance on section. " In some rare cases," says von Ziemssen, " the substance of the brain is found to be tough in consistency." This disease has been described under different names, such as brain fever, pernicious fever, malignant typhus, exanthematic typhus, spotted fever, etc. It has prevailed in France, Italy, Spain, Ireland, Germany, and in various parts of the United States and North America. I have passed through two epidemics of it in Georgia. The young are more liable to it than the old, and males more so than females. The first invasion of it that I remember to have read of was that which prevailed in Gen- eva, in the year 1805. It is now believed to be an infectious disease, but writers that I have consulted seem to be ignorant of the nature of the germ. It most commonly appears either in winter or spring, and more frequently when there have been great rain-falls and sudden changes in the atmosphere. It is believed to attack most fiercely families that are poorly fed, and that are living in damp and badly ventilated houses, built upon the ground. It may prevail in the most healthy regions, however, as an epidemic. Symptoms.—Meningitis of this type almost always sets in 420 THE PRACTICE OF MEDICINE. suddenly, commencing with a severe and generally protracted chill, which is followed by a high fever, violent vomiting, headache and prostration. The pain may be in the front or back part of the head. The temperature is not always the same, varying from 100° F. to 104° F., and sometimes, indeed, there may be intervals of normal temperature. The pulse may be rapid and small, or it may not even correspond to the height of the temperature, varying thirty beats in a few hours. In severe cases there may be coma or delirium, but generally there is only somnolence. Sometimes there are convulsions, stiffness of the neck, and finally tonic contractions of the ex- tensor muscles of the spinal column. Orthotonos is quite common; opisthotonos not quite as usual, and pleurothotonos is rarer still. In some instances the neck is not affected, but there is itching, aching of. the limbs and spine, and such sensi- tiveness of the skin that motion and touch cause pain. Oc- casionally there may be erythema, roseola, urticaria, and pete- chia. In most cases there are apt to be ecchymosed spots on the limbs and breast, which occur about the second day. They differ in size from that of a pin's head to that of a silver dollar. About the third or fourth day the tongue becomes dry, and cracked in places, or still remains moist and heavily coated. The bowels are either constipated or too loose. In severe cases there may be such profound coma or delirium that the faeces and urine pass involuntarily. Convulsions frequently take place, deep coma and death closing the scene. If the case is about to terminate favorably, the headache and pains in the limbs and spine gradually lessen, and convalescence takes place about the second week. The disease does not last long in severe cases, sometimes terminating fatally in from twelve to twenty-four hours. Sequels.—Injury of sight and hearing, chronic hydroce- phalus, chronic meningitis, imbecility of mind and paralysis, may all, under certain condition, follow this disease. Diagnosis.—Meningitis is somewhat difficult to diagnose, DISEASES OF THE BRAIN. 421 especially when it ocurs with pneumonia. It differs from tuberculous meningitis in the suddenness of the attack, the irregularity of the pulse and the temperature. It is distin- guished from typhoid fever by the difference in the eruptions. Treatment.—The fever in this disease demands aconite, which should commence the treatment, in doses of gtt. 1 to 2, given every hour, until the circulation is regulated. After this is effected, it should be continued in drop doses, every two hours. The headache calls for belladonna, which may be taken in doses of gtt. 5, once in three or four hours, until the pain in the head is relieved. If the pain in the spine is also relieved by it, it may be discontinued for a time, until the symptoms return or delirium occurs. If there is severe pain in the back part of the head, with vertigo, paralysis of the lower extremities, convulsions, emprosthotonos, stupor and feeble and irregular pulse, gtt. 3 to 5 of cannabis indica may be given every two hours. If this drug fails to give relief to the paralysis, gtt. 5 of tincture or fluid ext of gel- seminum may be given every three or four hours, until it sub- dues these symptoms. At the same time, I have always found strong counter-irritation (produced by turpentine), all along the spine, a good auxiliary. In most cases, the disease calls for such remedies as have the direct power of contracting the morbidly distended vessels of the cerebro-spinal centres, thua forcing the abnormal quantity of blood out of these vessels. Belladonna, ergot, physostigma and chloral hydrate have this power. If there is sleeplessness, the chloral, in doses of 10 to 15 grs., every three hours, so as to deplete the brain, will do good service. Chloral has direct influence over an excited and congested brain. Small doses, say 10 grs. alternated with 5 gtts. of the tincture of physostigma, or 1-100 gr. of physos- tigmine, will quiet the brain admirably. 422 THE PRACTICE OF MEDICINE. Sunstroke. Prof. H. C. Wood, of Philadelphia, says this disease is the result of paralysis of the vaso-motor nerves, or of some controlling centre of the brain, which influences the produc- tion of heat in the body. Some writers believe that it is from an imperfect decarbonization of the blood, while others think it arises from hyperaemia of the pia mater and other portions of the brain. Arndt says it is a diffuse encepha- litis, but there are others who declare that it is caused by venous hyperaemia, due to a diminished activity of the heart's action. These are all conjectures, however. Causes.—All writers agree that this affection is caused by the influence of intense heat, and not from mere exposure to the sun's rays, as first alleged. Pathology.—Post-mortem investigations have not thrown much light upon the real pathology of sunstroke. Prof. H. C. Wood, in his paper on " Thermic Fever," written in 1872, states that '■' the right heart and pulmonary arteries, with their branches, are engorged with dark fluid blood. There is also venous congestion of the lungs and entire body. The heart, especially the left ventricle, is rigidly contracted in every case, a condition caused by coagulation of the myosin." It is un- certain, however, whether the above conditions are really post- mortem, or ante-mortem phenomena. Sunstroke seems to at- tack the unacclimated in preference to the old residents of a locality. The want of pure water also seems to give rise to the disease, as do the use of spirituous liquors, fatigue, debility, bad ventilation and depression. Symptoms.—One of the first premonitory indications of the approach of " sunstroke," is an inelasticity of the muscles, general indisposition, debility, thirst and loss of appetite. There may be dizziness or headache also, and the chest may feel oppressed, breathing be frequent and strong, the throat be dry and swallowing be painful. The voice, too, is apt to be DISEASES OF THE BRAIN. 423 more or less changed, becoming hoarse and weak. Much anx- iety and restlessness of mind exists, the extremities grow numb, the patient becomes drowsy and restless, and there is often vertigo or bleeding from the nose, paleness of the face with redness of the conjunctiva, and very often notable weak- ness of the knees. Sometimes there is nausea, vomiting, cold perspiration, and sudden diarrhoea. The mind also becomes clouded and confused. After these symptoms appear, if noth- ing is done to ward of the attack, the "stroke" will speedily follow. The patient falls down, as if from a blow upon the head, with entire loss of sensibility and consciousness. Sub- sultus tendinum, partial spasms, violent convulsions, or paraly- sis of the spinal cord now set in, so that the limbs lie motionless. The face may at first be pale, but it soon becomes flushed, suffused, and sometimes cyanosed, finally assuming a dull, leaden color. The respiration may be oppressed, slow, sigh- ing, rapid, deep, rather difficult, and very often stertorous. The pulse soon becomes feeble and very quick, finally becom- ing irregular, intermittent, small and thready. The premon- itory symptoms, and the intense heat of the season distinguish this disease from apoplexy. The latter may occur in hot weather, but it does not show the above well-marked prodrome. Sunstroke is not necessarily fatal, but often leaves very un- pleasant effects. Treatment.—If the patient can have attention when he feels the above depressed symptoms, the disease may gener- ally be averted, by the use of moderate doses of gelseminum. This drug should be administered in doses of gtt. 20 to 25 (of the saturated tincture of the green bark, or the root), every two hours, until the patient is relieved, which may be with the first or the second dose. Gtt. 10 may then be taken every two hours, to prevent a return of the morbid symptoms. If the patient has already fallen, and has lost consciousness, glo- noine* (nitro-glycerine) acts well, in doses of gtt. 1 to \ of the *See Author's New Materia Medica. 424 THE PRACTICE OF MEDICINE. first cent, dilution in water, repeated every two or three hours, if the first dose fails to relieve the symptoms. If there is still consciousness, but dizziness, redness of the face, and dilated pupils, gtt. 2 to 3 of belladonna may be taken every three hours, until the patient is decidedly better. If none of the above remedies seem to relieve the head, the patient should inhale gtt 5 of nitrite of amyl. every half hour, until he is well relaxed, and then belladonna will relieve. Apoplexy. This disease is characterized by a sudden loss of con- sciousness due to intra-cerebral haemorrhage and the pressure of clots of blood upon the brain. These clots of extravasated blood are sometimes as large as an apple, and sometimes not larger than a marble. They may be round or spread out in layers, and there may be one or several of them. Varieties.—An overloaded condition of the vessels of the brain gives rise to that variety of apoplexy that is appropri- ately called congestive apoplexy. Haemorrhagic or sanguin- eous apoplexy, however, is the most frequent occurrence. This form consists in the rupture of a vessel, from which the blood becomes extravasated upon the brain or in its substance, press- ing upon the nervous masses. It comes without warning in most cases. The patient is generally suddenly struck down, devoid of all consciousness or voluntary motion. This is called primary apoplexy. Sometimes there may be premoni- tions, such as headache, giddiness, fulness and throbbing of the arteries of the head, bleeding from the nose, dimness of sight, contraction or dilatation of the pupil, noises in the ear or deafness, flashes, mist, etc., before the eyes, vomiting, numb- ness or tingling of feet or hands, unsteady movements of the limbs, and partial paralysis of the muscles of the face, or of the limbs. The patient falls into a comatose state in some in- stances, and in others only becomes drowsy, and finally coma- tose. This is called ingravescent apoplexy, because the symp- diseases of the brain. 425 toms gradually grow worse. It is a far more serious type than the primary form, because we here have evidence that the cause of the symptoms are still in operation, and that the case is haemorrhagic in its origin. Moreover the brain has under- gone organic and permanent pathological changes. A primary case may be of the congestive variety, which may be finally relieved without leaving any injury. Symptoms.—Some of the first indications of approaching apoplexy are headache, giddiness, faintness, sickness at the stomach, oppressed pulse with reaction following, in the early stage of an ingravescent case before the patient becomes comatose, there is generally very great depression in the circu- lation from the shock to the nervous system. The surface is also cold, pale and clammy, and the pulse frequent, small and weak. As coma comes on, the pulse grows full, slow and labored, and the surface becomes warm (being sometimes warmer then normal), and rather moist; the countenance has a peculiar, brbated appearance, and is often rather congested; the pupils are insensible to light, and in many cases, largely dilated, (or one dilated and the other contracted) ; the respi- ration is labored and often stertorous from paralysis of the soft palate; the bladder becomes inactive; the urine is retained; and the bowels are sluggish, and apt to be constipated. Several of these symptoms may occur as the result of dyspepsia or indigestion. Vomiting and headache are more important in- dications, when they come on suddenly without any obvious cause, and not on first rising in the morning. The vomiting may be continued beyond emptying of the stomach; and if these symptoms are associated with degeneration of the arte- ries and albuminuria, we may reasonably infer that there is a clot of blood, large or small, in the brain. Predisposition.—Men or women that have very large heads, large, broad necks, very broad shoulders, a well developed muscular system (with which are associated very large cerebral arteries), great heart power, and, of course, a vigorous circula- 426 . THE PRACTICE OF MEDICINE. tion; (which drives the blood with force to every part of the system, but especially to the brain), are very liable to apo- plexy. Now, if the lungs become impaired or feeble in their functional activity, so that the blood is imperfectly oxygenated, congestion may result, and a tendency of the vessels of the brain to rupture. A little intemperance, either in eating or drink- ing, uncontrolled passions, excessive sexual indulgence, close mental labor, or anything that favors cerebral congestion, will develop apoplexy. Diseases of the heart or kidneys also favor the development of this disease. Apoplexy occurs most com- monly after the fortieth year; rarely in early life. Cerebral haemorrhage sometimes proves fatal, but it does not always kill instantly. I have seen some men live several years with this disease, and others die in the first attack. Causes.—The direct cause of apoplexy is disease of the coats of the blood vessels; hence the increasing tendency to the disease in advanced years. As old age comes on there is a gradual tendency to degeneration or osssification of the arte- ries and attenuation of the veins. This degeneration of the arteries, or their ossification, renders them inelastic, and as the blood is forced through them by a strong heart, they give way and apoplexy is the natural result. It is true, an aneu- rism, involving an artery of the brain, may rupture and pro- duce apoplexy in those who are not constitutionally predis- posed to the disease. Unsoundness of the body generally may be a predisposing cause of apoplexy. Granular disease of the kidneys and hypertrophy of the left ventricle of the heart may also predispose to this disease. Diagnosis.—Apoplexy is distinguished from epilepsy by the epileptic attack being ushered in with a scream, and being always attended with convulsions and frothing at the mouth, which symptoms do not occur in apoplexy. To distinguish it from poisoning by opium and alcohol, the history of the patient's previous habits must be known. The odor of the breath will determine whether or not he has been imbibing alcoholic DISEASES OF THE BRAIN. 427 liquors. The pupils should be examined to see if they are contracted as in opium poisoning. Treatment.—Where there is a full, strong and quick pulse, dry, hot skin, aconite is indicated and should be given in small doses, until a decided impression is made upon the cir- culation. I give of aconite, gtt. 20; aqua pura, | 4; dose, a teaspoonful every hour. This remedy is far better than vene- section and is not attended by danger. If the face is red and swollen, and there is strong throbbing of the carotids, convul- sive movements of the muscles of the face and limbs, dilatation of the pupil, loss of speech, suppression or involuntary dis- charge of urine, gtt. 3 to 5 of belladonna, every three hours, should be given until these symptons are relieved. If there is a tendency to a calcareous degeneration of the coats of the arteries, phosphorus is needed. It may be given in doses of gtt. 2 to 3, largely diluted with water, 3 1 may be added to | 4 of water; dose, 3 1, ter in die. Thrombosis: Embolism. Thrombosis may be produced by a formation of a clot of blood at the spot where occlusion exists, but embolism is caused by a clot or mass, which is formed in the heart and carried along by the stream of blood until the artery becomes so small that it can not proceed any further. Emboli may consist of clots of blood, masses of fibrin, connective tissue growths, or chalky formations, which originate from endocarditis, aneur- isms of the aorta, etc. Thrombosis owes its origin to some structural changes in the vascular walls themselves, such as inflammation, fatty degeneration and ossification or calcifica- tion of the arteries, by which the speed of the current may be so slackened that the blood is finally blocked up. The left caro- tid artery is much oftener obstructed than the right. Sometimes several arteries are blocked up at the same time. Whenever the embolus is lodged in a terminal artery of the basal brain system, or is carried beyond the circle of Willis, it first causes 428 THE PRACTICE OF MEDICINE. red softening of adjacent brain tissue. Finally the red color fades into yellow, *. e., yellow softening of the brain, and if the patient should live a few months, this affected tissue is con- verted into a semi-fluid milky mass, which is called white soft- ening, and which may be absorbed, leaving a cyst filled with a thin fluid. Predisposing Causes.—Rheumatism is one of the prime causes of embolism, but thrombosis has its predisposing cause in a morbid condition of the vascular system, and is mostly met with in the aged. Symptoms.—Embolism resembles an apoplectic attack without premonition. In some cases there is no coma or loss of consciousness, but there may be delirium, aphasia, paraly- sis and vomiting, all of which may soon pass off. Thrombosis may come on slowly, with dizziness, headache and a general confusion of mind, loss of memory, numbness, coldness and a creeping sensation in one side or all over the body. Some- times there are convulsive movements in some parts of the body. There may be symptoms resembling an apoplectic fit, Occasionally there is no loss of consciousness. This condition may terminate in death, or the patient may recover. Diagnosis.—It is quite difficult to diagnose between embol- ism and haemorrhage, unless we notice the predisposing causes, such as valvular disease of the heart and diseases of the lungs. It is impossible to distinguish between thrombosis and haemor- rhage of the brain, except that thrombosis is not so frequent. Treatment.—Whenever this condition shows inflammation, belladonna, in small doses, will always do good service. If it be due to an atheromatous condition of the arteries, phosphorus or phosphoric acid (Horsford's Acid Phosphate), may be given in small doses. If there is hemiplegia, nux vomica, in doses of gtt. 1 to 2, every three hours, will be useful; but large doses do more harm than good by increasing the force of the cerebral circulation. If there is vertigo, iodine may be used with good effect. If there be sleeplessness, moderate doses of tincture DISEASES OF THE BRAIN. 429 of hyoscyamus, say gtt. 10 to 15, every three or four hours, will produce refreshing sleep. Cocculus indicus, in small doses, say gtt. 3 to 5, may also be given with good effect. If there are convulsions, belladonna, in doses of gtt. 5, may be given every three hours, alternated with gtt. 15 to 20 of gelseminum. Aphasia. Under this head fall a variety of deficiencies of speech. When the patient understands what is said to him, and can express himself in writing, but is unable to make himself intel- ligible by means of words (the organs of speech being in per- fect order), his disease is called ataxic aphasia. This con- sists in an interruption between the idea and the organs of speech. Sometimes the aphasia does not amount to entire speechlessness, and the patient may be .able to utter some words of one syllable, or it may be that he can only utter a few senseless syllables and words. Ataxic aphasia is occasionally complicated with agraphia—an inability to join either a letter or a combination of letters into intelligible words, although the hands may be able to perform other mechanical move- ments. Amnesic aphasia is an incapacity for recollecting words, although the idea is present and the patient can articu- late. This form is due to an interruption between the idea and the word, the verbal expression being wanting. Treatment.—Loss of memory for words and of the power of articulation have been cured with gtt. 1 to 2 of the 1st cent. dilution of glonoine* (nitroglycerine) taken every two or three hours, until it gives relief. Bromide of potassium in very small doses is also valuable in some cases of congestion, and stramonium has often proven very successful in cases in which there is a want of coordination of the organs of speech. When there is difficulty in understanding what the patient is reading, small doses of conium will do good service. Where * See the Author's Materia Medica. 430 THE PRACTICE OF MEDICINE. there is simply a difficulty in talking, I give thuja in doses of gtt. 1 to 2 three or four times a day, and find it serviceable in most cases. When this affection consists merely in making constant mistakes in writing, ignatia amara may give relief in doses of gtt. 3 to 5 thrice daily. When the trouble is only absent-mindedness, cocculus indicus, in doses of gtt. 5 every three hours, is indicated, and may be alternated with Hors- ford's acid phosphate. If the patient is forgetful, and has headache, carbonate of ammonium is indicated. Thrombosis of the Cerebral Sinuses. The free passage of the blood through the vessels may be interrupted by various causes. Although the sinuses are of a rigid nature, and incapable of collapsing, coagulation of the blood may readily take place in them. The propelling power of the heart may be weakened also, or inflammation of the coats of the sinuses may cause coagulation of the blood. Marasmus may lead to it when it appears among children who have been much reduced by long attacks of diarrhoea and teething; also among adults who are feeble, and whose pro- pelling power of the heart is impaired by various causes, such as exhaustion by long continued suppuration, cancer, and senile marasmus. This form of thrombosis is usually found in the longitudinal and transverse sinuses. The phlebitic form of thrombosis generally originates from the disease of the bones of the cranium, but occasionally it accompanies otitis media from disease of the petrous portion of the tempo- ral bones. In this case it is located in the adjacent sinuses, that is, the transverse and petrous. This form of thrombosis may also arise from disease of other cranial bones. Symptoms.—When thrombosis is accompanied by maras- mus in children, the symptoms much resemble those of hydro- cephalus, as both conditions give rise to cerebral anaemia and collapse, followed in both by coma and somnolence. If diar- rhoea (in very young children) occur, and is followed by cere- DISEASES OF THE BRAIN. 431 bral disorders of an active, motor kind, such as rigidity of the muscles of the back and limbs, there is a strong probability that thrombosis exists in the superior longitudinal sinus. This affection has not such definite symptoms in the adult, sometimes showing nothing but apathy and general depres- sion, such as headache, delirium, loss of consciousness, and more or less disturbance of the motor functions, either in the form of spasms or paralysis. In some rare cases the veins outside of the cranium, which communicate with the diseased sinus within, swell up, and epistaxis, cyanosis of the face, and fullness of the vessels take place, when the affection is located in the longitudinal sinus*. (Edema of a limited space may take place behind the ears in thrombosis of the transverse sinus, or the internal jugular vein may have less blood in it on the side of the lesion than on the opposite side. If the sinus cavernosus is the seat of the thrombosis, there is apt to be hyperaemia of the fundus oculi, oedema of the eyelids and conjunctiva, and in some cases prominent eyeballs. There may also be neuralgia or paralysis of the motor nerves, from pressure, etc Prognosis.—This is very unfavorable. Treatment.—The carbonate of and aqua ammonia have both a tendency to liquify the blood, and thereby to dissolve the thrombosis. Especially is this the case after free haemor- rhage, when the circulation is languid from want of cardiac force. Bartholow even advises the intravenous injection of aqua ammonium, 3 1 to f 2 of water. I strongly advise this treatment in cases in which large venous trunks, as the pul- monary artery, are blocked up by thrombosis. Again, he advocates this drug in sudden paralysis of the heart from chloroform, or from the bite of serpents or spiders. Brunton and Fayrer have shown that intravenous injection is without value. Ammonium is the most trustworthy remedy we have, given by the mouth. 432 THE practice of medicine. Dementia Paralytica. This is a diffuse disease of the brain, in which the cord also is often implicated. It is characterized by a combination of physical changes with certain motor disturbances in the muscles of various parts of the body. These changes gener- ally run a chronic course, and end in death, if not relieved. Pathology.—In chronic cases, post-mortem examination shows atrophy of the brain. The dura mater lies in folds over the frontal lobes; the pia mater is generally more or less cedematous; the ventricles are often enlarged, the dura mater often adheres to the skull and' may be thickened, and there are also extravasations of blood upon its surface, which give it either a red, yellow or livid color. The brain tissue itself shows interstitial encephalitis, which in time leads to the destruction of the ganglionic cells, and to atrophy of the brain itself. The spinal cord generally presents gray degeneration of its posterior columns, or granular cell myelitis. Causes.—Dementia paralytica may be hereditary, or abuses of alcoholic liquors or excessive mental labor may produce it Excessive venery is one of the most fruitful sources of this disease, and syphilis and the morbid influences of acute febrile diseases also give rise to it. It rarely ever occurs under the age of twenty years, and is most common between the ages of thirty and forty. Symptoms.—There may be premonitory symptoms preced- ing the final attack of this disease, such as dizziness, headache and rheumatic pains in the legs, which come and go suddenly, and are worse at night. Irritability, poor memory of recent events,while past ones are distinct in the mind, are indications; and frequently the muscles of the face and mouth may trem- ble, etc. The speech, perhaps, becomes lisping, as if the patient was intoxicated, and the voice is changed. Occasion- ally the trouble begins with an apoplectic attack. As it pro- gresses the patient is inclined to have exaggerated ideas of diseases of the brain, 433 himself and of his possessions, and loses his natural affection for his family, squandering his money if not prevented. In some cases the patient shows great anger, and even violent rage, rendering him dangerous to his friends or family. There may be a melancholic mood, or he may be in a hypochondriacal frame of mind, which again may change to excitement. Klep- tomania is also of frequent occurrence, and the patient some- times pockets whatever he or she may fancy, believing that they are only taking what belongs to them, and it is impossible to convince them of the contrary. The motor disturbances, when there is gray degeneration of the posterior column, con- sists of want of co-ordination, such as staggering upon shut- ting the eyes, a jerky, unsteady gait, difficulty in turning round, and trembling upon attempting to write. If granular-cell myelitis is present, there will be an awkward, shuffling, help- less gait and unsteadiness in attempting to turn about quickly. In many cases there is more or less unilateral facial paralysis, and apoplectic attacks may frequently occur, leaving behind hemiplegia, and although this may disappear, the mind still continues to degenerate. The attack may also be combined with unilateral or general epileptiform spasms, which occasion- ally end in the death of the patient. Senile Dementia. Senile dementia has symptoms corresponding to those of general paralysis, with the exception of a peculiar weakness of memory. Chronic alcoholism also resembles senile demen- tia. Senile dementia, as occurring in advanced age, may be known by a lack of motor co-ordination, or by the existence of marked hemiplegia and the absence of extravagant delirium. It is almost always of a childish character, and is free from epileptic attacks. The apoplectic attacks of the aged are asso- ciated with serious permanent paralysis, provided they do not end in death. The dementia of old age is more regular, and not subject to remissions or intermissions. 28 434 the practice of medicine. Treatment.—The carb. of ammonium is one of our most successful remedies, taken in medium doses three times a day. Phosphorus in moderate doses may alternate it, and hypophos- phite of lime, in doses of gtt. 1 to 3, three times a day, will doubtless prove valuable. Especially where the memory is injured will the carbonate of ammonium do good. If this disease is caused by sexual abuses, nux vomica, in doses of gtt. 5, three or four times a day, will have a good effect. Delirium Tremens. Delirium tremens is acute alcoholism, and occurs in con- sequence of excessive use of alcoholic drinks. It often follows the sudden withdrawal of stimulants from an habitual drunk- ard. It is a very strange disease, and is marked by varied symptoms, such as hallucinations or visions, the patient seeing demons, ghosts, rats, flies, birds, snakes and horrid sights, such as great beasts, persecuting officers, etc Those imagin- ations are always of a very frightful character. I have known some persons to imagine that a familiar friend or relative was pursuing them with the purpose of killing them. I saw two cases some time since in which the patients fancied that their brothers were thus pursuing them to murder them, and they both cut their own throats to prevent this from being done. When I was attending my first course in the University of Georgia, at Augusta, there was there an unfortunate old ine- briate suffering from this disease who would run and hide in some corner of the hospital, because he fancied that the students were an army pursuing him to put him to death. The victims have a wild expression, but seldom lose consciousness. They are rarely able to rest unless they force sleep with soporifics. They are generally harmless, but in some rare cases they become violent, maniacal and even destructive and dangerous to others, as well to themselves. Tremor is very common with this condition, and tetanic and eclamptiform convulsions take place quite frequently. Different tempera- diseases of the brain. 435 ments exhibit different signs of this morbid impress upon the brain. This disease is always worse after night, and the attacks last from a few days to two or three weeks. Post- mortem examinations of old topers show various lesions of the brain, such as anaemia and dryness of the organ. The stomach, too, shows many lesions, such as a thickened mucous mem- brane, and there is fatty degeneration of the liver, and often hyperaemia of the kidneys. There are, of course, many other nervous effects of this disease not mentioned in the above cata- logue of symptoms. Treatment. —Actaea racemosa is a valuable remedy when there are sleeplessness, convulsions or tremors, headache and melancholia. Where there are hallucinations (especially at night) soreness about the stomach or nausea, gtt. 1 to 2 of tincture of arsenic is required. In young subjects, when there is congestion of the head and great excitability of the senso- rium, want of memory, indistinct speech, cramps in the limbs and trembling of the hands, belladonna will do great good, in doses of gtt. 3 to 5, every three hours, but if ordered in larger doses it will do more harm than good. Where there are illu- sions of sight and hearing, cannabis indica, in doses of gtt. 5 to 6, every three hours often allays these. Gtt. 5 is the safest dose, although some few will require gtt. 10. If there is pal- pitation of the heart, vertigo, nausea, thirst and headache, I use gtt 5 to 6 of digitalis (tincture), every three hours, or gtt. 3 to 5 of convallaria majalis every two hours, until the heart is quieted. If there be persistent wakefulness, gel- seminum sometimes produces sleep where morphia has failed. Occasionally chloral hydrate has served me better than any- thing else, producing sound sleep, from which the patient awakes very much improved in mind. Where there are epilepi- form convulsions, ignatia amara, in doses of gtt. 3 to 5, will give relief in a short time, and may be repeated every three hours. 436 THE PRACTICE OF MEDICINE. Dipsomania — Chronic Alcoholism. The long-continued use of alcoholic liquors, although the victims may not ever become intoxicated, shatters their whole system to its foundation. They soon lose their manliness, and every emotion of enlightened humanity, their constant cravings for strong drink overpowering their very best inten- tions and strongest will-power. They have to struggle contin- uously with this mighty temptation, and too often are found yielding in their unequal conflict with a created appetite. Their better judgment dictates a cessation of the ruinous habit, but the strong cravings of an insatiable thirst call for more and more, and are never satisfied. If the subject of dipsomnia cease from indulgence for a time, he falls into a deep, melancholic mood, which shows a suicidal tendency, and to which only a resort to their accustomed stimulant brings ready relief. Hence the poor victim plunges again into the profound depths of his iniquitous debauchery, and continues in it until he either dies with a ruined constitution, or becomes a habitual drunkard, and in this state terminates a miserable life of sinful excess. If there is any class of sufferers that the physician should pity more than another, it is the misera- ble drunkards, descending from a life of promise and hope to an untimely grave, and worse still to the poor inebriate's hell. It is a noteworthy fact that many of our most talented men at the bar, in the field of science, in the halls of Congress, and leading physicians and mechanics fall victims to this most destructive vice. The higher the individual stands in the scale of intellectual or moral being, the lower he falls into the depths of human degradation. Physical Degeneration.—Alcoholic drink produces varied effects upon the mind and body of different individuals. In some it gives rise to varied forms of insanity, and in others, to exaltation and absurd delusions. Again,we sometimes find forms of melancholia with religious mania, delusions of mal- DISEASES OF THE BRAIN. 437 treatment by friends and relatives, and a kind of tranquil de- mentia, or imbecility. Apoplectic and epileptic attacks are very often the result of long continued use of alcoholic drinks. Among the many physical disorders produced by chronic alco- holism or dipsomania may be mentioned various degrees of amblyopia and amaurosis, with atrophy of the optic nerve. Chronic inflammation of the stomach may arise from it, ren- dering digestion very difficult, and interfering very much with nutrition. The liver, too, is almost always diseased, and the condition often ends in cirrhosis. The kidneys frequently suffer from Bright's disease, and some die with anaemia. At first, the sexual appetite is greatly stimulated, but this finally ends in impotency. Children begotten in drunkenness are not only very nervous, but often epileptics or imbeciles from birth. Post-mortem examination reveals meningitis haemorrhagica, atrophy of the cortical substance, fatty degeneration of the ganglionic cells, thickening of the coats of the veins, thicken- ing of the mucous membrane of the stomach, and occasionally flat erosions of the mucous coat of the stomach. Treatment.—Nothing but moral suasion can reclaim the habitual drinker of alcoholic or fermented liquors. Of medi- cines, nux vomica may be tried, in doses of gtt. 5, ter in die. Hyd. chloral quiets the patient, in doses of 15 grs., ter in die. Opium and Morphia Poisoning. So prevalent has the habitual use of opium and morphia become, that I have been for years very cautious about pre- scribing it for any length of time. I am utterly amazed at the reckless and indiscriminate prescribing of opium by phy- sicians, while they see the criminal effects of their careless- ness. It is now the custom of most practitioners to prescribe either by the mouth or by hypodermic injection, laudanum, Dover's powders, or morphia, for every little pain and ache that their patients may complain of. The destructive habit of opium eating has increased alarmingly in the last ten years. 438 THE PRACTICE OF MEDICINE. It is now entailing untold misery and degradation upon thou- sands and thousands of unfortunate victims. It is difficult to detail the symptoms; these may be found in works upon toxi- cology, to which the reader is referred. It is necessary, how- ever to mention here some of the chronic effects of this evil habit: General emaciation, pale, shrivelled, dry skin (looking like fish scales), flabby muscles, loss of appetite, feeble diges- tion, constipation, irritability of temper, giddiness, headache, sleeplessness, neuralgia, loss of memory, energy and will power, and sometimes paralysis and diseases of the bladder. These results are the effects of opiates upon the substance of the nerves. The brain is in a state of hyperaemia, and very frequently fluid is found in the subarachnoidal spaces in the ventricles. Sometimes there are sanguineous effusions into the brain. There may be other anatomical conditions in certain cases after death. Treatment.—"We may first, with propriety, give the reme- dies for acute poisoning by opium. To remove the opium from the stomach, the stomach pump is used, but as that apparatus is not at the command of every country practitioner, he may have to resort to emetics. It requires active emetics, as there is great insensibility of the gastric nerves, caused by the obtunding effects of the opium. The sulphate of zinc is used by some, ipecac, and lobelia by others. I have succeeded well with the tinctures of these last articles (made from fresh materials), or saturated tinctures, in doses of 3 5 each, given every ten minutes until thorough emesis takes place. Gr. 1-16 of apomorphia, given hypodermically by injectidh, will pro- duce speedy emesis, or gr. ^ given by the mouth will give the same result. After the stomach has been entirely emptied, it should be thoroughly washed out with green coffee-tea, or with green tea. This forms the tannate of morphia, which lessens the poisonous effect very much, and I think to a great extent neutralizes the opium. In addition to the tea of green coffee, freely taken, I always give tincture of belladonna in DISEASES OF THE BRAIN. 439 doses of gtt. 5 to 10 at once, and repeat it in two hours if the first dose does not counteract the effects of the opiate. The patient should be kept moving all the time, to prevent com- plete narcosis. By these means I have just saved the life of a lady here, and that of several patients before her. I also • saved in this way the life of a little girl of eight or ten years of age, who had eaten a large quantity of the blooms of stra- monium. As an antidote to the opium habit, gtt. 15 of the tincture or fresh root of ipecacuanha, given three times a day, has proved valuable when other remedies failed. The patient's resolution is the best remedy in the world. Belladonna and atropine are antidotes to the tonic effects of opium, the first in doses of 6 to 8 gtts. of the fl. ext, or 5 gtts. of the tinct., and atropine in doses of 1-100 to 1-75 gr., and repeated until the pupils dilate and the mouth becomes dry. Excessive doses should not be given, as there is danger of producing the toxic effects of the atropine, or the belladonna, which would be as fatal as the opium. I have never failed to counteract opium with a tea of green coffee, alternated with moderate doses of belladonna. Digitalis also counteracts opium; dose, 15 gtts. of a saturated tincture. Tumors of the Brain and its Membranes. The connective and epithelial tissues of the blood-vessels and their sheaths are liable to become altered by the modifica- tion of newly-formed elements, and by changes in their rela- tions to their connective tissue and vascular distribution over the brain. Causes.—Hereditary predisposition, the habitual use of alcoholic spirits, syphilis, blows or bruises of the skull, and tuberculosis may all give rise to tumors. These tumors, which retain the character of the diseased tissue, are called gliomata, and are formed by proliferation of the glue-like cement — neuroglia. They usually resemble normal brain tissue, but sometimes assume a mucous character, and are soft. 440 THE PRACTICE OF MEDICINE. They afterwards, however, possess a firmer character, and are closely allied to sarcoma. These tumors grow very slowly, and may finally degenerate into a fatty tumor. The pineal gland may take on hyperplasia, in which case it presents a grayish-red, slightly lobulated, or smooth, round tumor, which may grow to the size of a walnut, or in time even larger. The sand tumor, psammoma, is an inflammatory proliferation of the cellular tissue, in which calcareous materials are deposited. It usually grows from the dura mater, at the base of the cra- nium, is hard and hemispherical in shape, white and smooth, and attains to the size of a plum or cherry seed. The pig- ment cells of the pia mater may give rise to melanoma (a small-sized tumor), but this is of rare occurrence. The gray substance may take on hyperplasia, constituting neuroma, which attains the size of a millet seed or even of a bean. This tumor forms on the ventricular substance, on the white sub- stance, or on the exterior of the brain. Cysts may also form from apoplectic effusions, abscess, and ramollisement. The large vessels at the base of the brain are liable to form aneur- isms, which sometimes burst and produce fatal apoplexy. This frequently happens in old topers of an apoplectic tendency. Tubercles, of a grayish, yellowish, or yellowish-white color, may form into hard tumors, which attain the size of a hazel- nut; they are found mostly in the cerebellum. Besides the above, other tumors may form, as syphilitic tumors, sarcoma, and carcinoma or fungus haematodes, which appear upon the surface of the dura mater. Symptoms.—These tumors do not always give positive evi- dence of their existence. Autopsies have revealed in some cases large tumors, of which there were no positive symp- toms during the life of the patient. The brain, in these exceptional cases, becomes accustomed to the morbid growth. Depression of spirits, melancholy, aphasia, sleepiness, amblyo- pia, amaurosis, inequality of the size of the pupils, strabismus, violent headache, mono-lateral anaesthesia, neuralgia, occasion- DISEASES OF THE BRAIN. 441 ally paralysis, cramps of certain affected muscles, epileptoid attacks, etc., all accompany these tumors in individual cases, some in one and some in another. Treatment.—It is plain that it is quite difficult to devise a treatment for these tumors, unless we can make an accurate diagnosis, which, from the concealed nature of these tumors, is almost impossible. Phosphorus is indicated in some cases, and in others belladonna, followed by the phosphide of zinc in doses of gr. 1-10 three times a day. If there is evidence of growths of an osseous character, but little can be done except to change the patient's diet to one of a vegetable character, to cut off the supply of excess of osseous materials, and acid fruits may be allowed for the same purpose. CHAPTER XXX. DISEASES OF THE EYE. IT may be well to define the parts of the eye, as this work may fall into the hands of young practitioners that may not be very familiar with the anatomy of that organ. There are three main enveloping coats of the eye, viz: the sclerotic coat and cornea, the choroid, and the retina. The sclerotic coat or sclera is the outer and protective coat. It includes the cornea, and may be said to completely cover the eyeball. It is fibrous in structure, a firm, dense membrane, and in childhood of a bluish-white color, as seen through the conjunctiva. It be- comes a yellowish-white color in adult and old age. The pos- terior portion of the sclerotic membrane is partly blended with the sheath of the optic nerve at its entrance into the eye, but a fine tissue from it and from the choroid is interwoven with the neurilemma of the optic nerve, and passes across the nerve entrance, being perforated like a sieve to allow the pas- sage of fibres to the optic nerve. This opening in the sclera is about the twenty-fifth of an inch in diameter, and the sieve- like membrane covering it is the lamina cribrosa. The sclera is a little over a millimetre in thickness at its posterior portion, and gradually becomes thinner as it approaches the front of the eyeball, up til it receives the tendons of the four straight muscles near the edge of the cornea. Anteriorly, the fibres of the sclera are merged into the cornea, and near the peri- phery of the latter it encloses the canal of Schlemm, which gives passage to a plexus of veins. The blood vessels are sparsely distributed over the sclera, and are thought to have no supply of nerves. Near the entrance of the optic nerve, however, and near the cornea, it is pierced by so many vessels 442 DISEASES OF THE EYE. 443 for the supply of the other parts of the eye, that its firmness is considerably lessened in these places. The cornea forms the transparent portion of the globe of the eye, and is curved so as to form a segment of a smaller sphere than the sclerotic coat. It is a dense, firm membrane, about the thickness of the sclera, but thinner at the center than at the periphery. It is divided into five layers: (1) epithelial layer; (2) the elas- tic layer of Bowman; (3) the true cornea; (4) the layer of Descemet; (5) the internal epithelial layer. The cornea is nearly transparent, but in old age the mar- ginal portion becomes more or less opaque from the fatty de- generation of its tissue. The opaque circle formed by this opacity is called the arcus senilis. The cornea contains no blood-vessels, and when blood-vessels are seen in or upon it, disease is present. It is largely supplied with nerves. The choroid, or uveal tract, is the second coat of the globe of the eye, and is a vascular and pigmental tunic covering the eye posteriorly, extending forward, and thus forming a part of the ciliary body and the iris. These two tissues form what ocu- lists call the uveal tract. The choroid, like the sclera, is pierced posteriorly to admit the optic nerve and the retinal vessels. Anteriorly near the equator, it is merged into a circle of plaits or folds, which form the ciliary body. The choroid is not divided into layers; but the delicate connective tissue, with the large vessels, and a large supply of pigment, make up the outer, and the capillary vessels the inner portion of this membrane or tissue. The retina forms the third tissue of the globe of the eye, and may be regarded as the organized expansion of the optic nerve. It is divided into ten layers. The iris is a continua- tion of the choroid. It is an iridescent, finely colored mem- brane, the opening of which is called the pupil. It hangs as a vertical screen just in front of the lens. It is near the centre of the eye, but slightly towards the nasal side. The crystalline lens is suspended from the ciliary process, just 444 THE PRACTICE OF MEDICINE. behind the iris, and in contact with the pupillary margin. Posteriorly, it rests against the vitreous body which is hol- lowed out to receive it. It is transparent, and bi-convex in its shape, inclosed in a transparent capsule. The lens hardens and becomes less elastic as life advances, and in very old age is of a straw color, and then of a brownish-amber tint. The zonula of Zinn, or the suspensory ligament of the lens, is the medium through which the ciliary muscle acts upon the lens or its capsule in accommodation. The vitreous body, or the vitreous humor, occupies the entire posterior part of the globe, between the lens and fundus, and is of a jelly-like appearance, nearly colorless, and contains about ninety-eight per cent, of water. It has neither nerves nor blood-vessels. The aqueous humor occupies that part of the globe just in front of the lens, and is situated just posteriorly to the cornea. It is composed of nearly pure water, and when let out soon reforms. The optic nerve arises from two roots, chiefly from the corpora geniculata, but also from the thalamus opticus and the cor- pora quadrigemina. This nerve is spread out upon the retina, and is the nerve of sight. The conjunctiva is the covering of the eyeball, hence called the ocular conjunctiva. It extends back nearly the equator, and there is reflected on the inner surface of the eyelids. It is somewhat loosely attached to the sclera (except in the corneal margin), and is quite vascular. There is a fold towards the inner canthus called the plica semilu- naris, a rudiment—rather like a third eyelid. Still nearer the inner angle is the caruncle. Just on the margin of each lid, near its inner angle, is situated the punctum lachrymale, the opening into the canaliculus, which leads to the lachrymal sac The lachrymal gland lies in the lachrymal fossa, near the outer angle of the roof of the orbit itself. The gland secretes the tears, which reach the eye-ball through from six to twelve small ducts, that lie under the gland, and open into the con- junctiva at its reflected portion. DISEASES OF THE EYE. 445 Diplopia. Double images are produced by paralytic strabismus, and an operation for concomitant strabismus may also lead to this defect. Monocular diplopia may result from irregular refrac- tion, from abnormal curvature of cornea or lens, from malpo- position or dislocation of the lens, from inequalities of the corneal surface, from old cicatrices, or 'from bands of mem- brane stretching across the area of the pupil. The internal eye may be examined by means of reflected light. The ex- amination must be made in the following manner : If a piece of glass is held just in front, and very near the eye, while a lamp is placed by the side of the patient's head, on a level with the eye, this throws the rays of the lamp into the eye, and illuminates it, so enabling the examiner to see the retina through the slip of glass. The ophthalmoscope is much used for this purpose. The oculist may acquaint himself with its use by examining the sound eye ; thus becoming familiar not only with the use of the instrument, but also with the appear- ance of the eye in a normal state. It is necessary to know the ap- pearance of the healthy eye before we are prepared to diagnose the diseases peculiar to that organ. In order to make the ex- amination of the eye satisfactory it is best to dilate the pupil with a weak solution of atropia, gr. 1 to ten or twelve ounces of water. It is necessary in the examination first to exclude daylight, and then to place at the left side of the patient a good strong lamp, level with the eye. I then take a mirror in the right hand, putting it close to my own eye (holding the mirror some six or eight inches from the patient's eye,) and then turning it towards the lamp so as to reflect the rays into the patient's eye, it will so illuminate it that I can determine its condition. If the lens is opaque, however, we can not ob- tain an illumination. Having illuminated the eye with the mirror, we may hold the convex lens in the left hand at the 446 THE PRACTICE OF MEDICINE. proper distance to focus the glass upon the part we wish to examine. Hyperemia of the Conjunctiva. This is a very common disease, and may be produced by excessive use of the eyes, or by optical defects, such as occur in asthenopia. The eye presents the appearance of a mild case of conjunctivitis, except that there is no discharge from the conjunctiva, and not much lachrymation, itching or smart- ing. There is no heavy feeling in the lids, nor are there the same aggravations in the evening. Reading by too weak of too strong a light, or reading in the cars, by an artificial light, or directly in a glaring sunlight, often excites congestion or hyperaemia of the conjunctiva. This condition may be but a reflected irritation from more serious disease of the internal structures of the eyes. Continuous use of the eye for a length of time will increase the pain and asthenopic symptoms in the eye. Treatment.— If there are optical defects present, they must be obviated by the use of appropriate glasses. All over- work of the eyes must be avoided. The eye douche will pal- liate this affection, if used with the lids closed. This may be used with a solution of the tincture of fluid extract of hama- melis, tincture of opium, gr. 1 or 2 of sulphate of zinc, or gr. 2 to 4 of the acetate of lead, to half a cup of warm or cold water, thrown on the lids twice or thrice a day. In some cases, it will be better still to saturate a bit of cloth or lint with one of the above lotions, and let it be laid over the lids for an hour. Re- peat this three or four times a day. If there is very great pain, the vapor of bisulphide of carbon, spirits of rosemary with one-eighth of its quantity of ether in it, or the vapor of chloroform, may be thrown against the external lid, for a few minutes at a time. The application may be made by putting the above lotions in a wide-mouthed vial, and hold- ing the vial under the closed lids for a few minutes. This DISEASES OF THE EYE. 447 procedure is generally quite soothing. I have found a lotion of gr. 20 of belladonna to 3 3 or 4 of water, applied as a fomentation, useful in quieting the pain and contracting the vessels, if they are enlarged. Gtt. 2 to 4 of belladonna, in- ternally, three times a day, never fails to lessen the pain, or photophobia. Conjunctivitis. This disease is easily diagnosed, although it is posjiblefor the physician to mistake it for other inflammatory affections of the eye. In simple conjunctivitis, instead of the usually invisible vessels of the conjunctiva, we have a complete net- work of deep-red vessels plainly visible, which are superficial and movable at the touch of the finger upon the smooth sur- face of the sclerotica. In deep-seated, severe forms of con- junctivitis, like the scrofulous, lymphatic, and granular varie- ties, we see close parallel lines of immovable subconjunctival vessels running towards the edge of the cornea, and forming a red or pinkish zone around its circumference. In iritis the zone is very distinct, and is formed by the congestion of the deeper-seated vessels of the conjunctiva, and not by inflamma- tion of the sclerotic coat. The vessels are on the sclerotica, but they are not a part of it. In scleritis, or in epi-scleritis, still another redness is presented, of a rather violet or purple color. This commonly appears in circumscribed patches, and may be mistaken for conjunctivitis. The bright red color and papular appearance of conjunctivitis, and the peculiarity of the deep-seated spots of scleritis, render the differential diagnosis quite easy. Causes.—It may follow slight injuries of the eye, contact with some foreign substance (especially of an irritating nature), exposure of the eyes to dust, strong vapors, smoke or very cold winds, a strong glaring light, impure air, prolonged looking at near objects, and sometimes poisonous insects may 448 THE PRACTICE OF MEDICINE. get into the eye and lodge there* for some time. The latter cause is common in the southern parts of the United States. Symptoms.—These are itching and a sensation of heat in the lids, or a feeling as if there were sand in the eye. If there is any suspicion that any foreign body has really lodged in the eye, the lid may be everted and the eye thoroughly examined. If anything is discovered, it may be removed with a bit of sponge, lint, very soft silk gauze, or by water. Treatment.—If no foreign substance be found, I use gr. 1 of sulphate of zinc to an ounce of rose-water, using a few drops every four hours. If there is very great redness and enlargement of the capillary veins, I add gtt. 5 or 6 of the sat- urated tincture or fluid extract of belladonna, or I put it in another ounce of water and use a few drops three times a day. In some cases that I have had, I have used gr. 1^ of sulphate of zinc, gr. 3 of acetate of lead and f 1 of water, dropping in a little of this thrice daily. Sometimes I have treated with gr. 3 to 5 of boracic acid to | 1 of rose water; I use it in the way of other lotions given above, and have found that the disease always yields very quickly to it. If there is great irritability of the eye, and the vessels are greatly engorged with blood, I have found nothing that exerts such an immediate effect upon them as the tincture or fluid extract of belladonna. This remedy, given internally or applied locally, contracts the veins and thus forces the excess of blood out of them. Catarrhal Conjunctivitis. The symptoms of this form of inflammation of the con- junctiva are more marked than those of the simple form of the disease. The superficial vessels of the conjunctiva are highly engorged, and in old people chemosis is usually present. The edges of the lids are swollen, the palpebral conjunctiva is distended from serous infiltration (especially at its reflected portion), its papillae are also enlarged, and its surface presents a velvety appearance. A secretion of clouded mucus takes DISEASES OF THE EYE. 449 place from the lids, sometimes alternating with a secretion of muco-pus. This discharge is sometimes profuse (but seldom so much so as it is in purulent conjunctivitis), and is slightly contagious in character. It will inoculate the sound con- junctiva. Symptoms.—The patient can not see well at a distance, and there is a feeling of dryness and as if there was sand in the eyes. In some cases there is burning or smarting. The pain is rarely very acute. These are subjective symptoms, and fre- quently vanish as the disease becomes chronic, which it will do if not cured. Treatment.—In the acute stage the cold douche, or com- presses of cloths wet in cold water, aid in lessening the inflam- mation. The internal administration of aconite, in doses of gtt. 4- every hour or two alternated with belladonna., will be attended with good results. In cases where the pain is great I have used collyria of sulphate of zinc, gr. 1, 1 1 of water or rose water. I have alternated this with gr. 2 to 3 of boracic acid to the ounce of water. In some cases I have used gtt. 5 or 6 of the fluid extract of belladonna in an ounce of water applied to the eyes, thrice daily, with good effect. After the acute symptoms have passed off I have found gtt. 10 to 15 of euphrasia attended with good results, given every three hours. A little of the fluid extract of hydrastis, added to an ounce of water, often does good service, or gr. 1 of muriate or nitrate of hydrastin, added to I 1 of water. In cases where there is a profuse mnco-purulent discharge, small doses of the sulphide of calcium may be given internally, while the solution of the nitrate of silver (say gr. 1 or 1£ to 1 1 of water) may be applied locally a few times. The sulphate of zinc (gtt. 2 to § 1 of water) will complete the cure. I have found it bet- ter in some cases to gradually lessen the strength of the solu- tion of zinc as the disease gives way. Complications.—Blepharitis, or ulceration of the cornea, may take place in this disease. Then, again, inflammation of 29 450 THE PRACTICE of medicine. the nares, throat or bronchial tubes may supervene and call for other remedies. The exciting cause will always influence the selection of our leading remedies. This condition is pro- duced by exposure, contagion and abuse of the eyes, or it may follow some of the exanthematous fevers, and hence the treat- ment will have to vary to suit the cause of the disease. Simple collyria of boracic acid gr. 10, alum gr. 2, water 3" 2, may be used, or gr. 1 of sulphate of zinc, gr. 1 of nitrate of silver to aqua pura 3 2 will often be found very serviceable. If the discharge assumes a puriform character, a solution of nitrate of silver is invaluable, gr. 5 to 1 1 of water, applied to the lids while they are averted. The patient should close his eye, so as to bring the averted lids together, and the solution applied with a camel's hair brush. The solution may be washed off in a second or two with tepid water dropped from another brush, or from a bit of linen cloth. This course often cures the worst cases of this disease in a few days. It need not be repeated more than twice or thrice a week. If the congestion of the conjunctiva is high (as evinced by a bright red color and a swollen condition of the conjunctiva), and if the sub- conjunctival vessels are implicated, and there is pain and photo- phobia, irritating applications must be avoided, as they will always increase the disease. Gelseminum acts well in doses of gtt. 1 to 15 every three hours, alternated with gtt. 2 to 4 of tincture of belladonna. A solution of gr. \ of sulphate of zinc to 3 1 of water, or gr. 1 to 2 of boracic acid to 3 1 of water, will do much good applied to the eyes. Chronic Conjunctivitis. In the chronic form of this disease the strength of the col- lyria will have to be much modified from the strength of that given in the acute form. Some cases prove very tedious under any form of treatment. If the disease is purely local, and not associated with any other catarrhal affection, or trouble of the lachrymal duct, it may be relieved by a proper course of treat- DISEASES OF THE EYE. 451 ment I have had singularly good success in some cases of conjunctivitis of long standing, by touching the swollen papillae at the retrotarsal fold with a smooth crayon of modi- fied sulphate of copper. It should be as cautiously applied as a strong solution of nitrate of silver would be, and should be thoroughly washed off, and not applied again until the eye has fully recovered from the previous application. The internal administration of the tincture of arsenic, in doses of gtt. 2 to 4 three times a day, has proved efficient with me in many cases. The patient should avoid dust, smoke and strong winds, should use his eyes as little as possible, and avoid strong light. Purulent Conjunctivitis. Purulent conjunctivitis is a more severe and dangerous form of catarrhal conjunctivitis, and may be distinguished from ordinary conjunctivitis by having a greater amount of secretion and more intense swelling of the lids. This is in consequence of the serous infiltration being sub-conjunctival, of the very great injection of the sub-conjunctival vessels (as well as of the increased vascularity of the conjunctiva itself), of the chemosis that is so frequently present, and of the large size of the papillae of the mucous tissue, which are called granulations. Diagnosis.—If, upon inverting the upper lid, the conjunc- tiva is sufficiently transparent for us to see the lines of the Meibomian glands, which run towards the tarsus, it is catarrh of the conjunctiva. If the infiltration is so very great as to hide these glands, it is purulent, granular, diphtheritic, or some very grave form of ophthalmia. If it be purulent con- junctivitis, the cornea is apt to become involved, and hence the disease is much more contagious. Treatment.—It is not uncommon to find a high fever during the inflammatory stage of purulent conjunctivitis, and the treatment must be antiphlogistic. Compresses of very 452 the practice of medicine. cold water, or better still, of ice-water, should be applied, and frequently renewed. Aconite should be ordered in doses suf- ficient to control the pulse — that is to say, gtt. 1 to 2 every one or two hours, according to the demand in each case. If there be photophobia, gtt. 1 to 3 of belladonna may be taken every two or three hours; or if pain sets in and there is no photophobia, gtt. 15 to 20 of the tincture of the green root of gelseminum should be given every three hours in alternation with the aconite. This course has given me entire satisfac- tion in several epidemics of this disease. Leeches used to be applied, but I prefer cupping in the temple when it is neces- sary. After the inflammatory symptoms have been controlled, as evidenced by the subsidence of the swelling of the lids, by their pale red color, and by the relaxed appearance of the con- junctiva, then stimulating collyria may be used with good effect in most cases. I prefer the saturated solution of boracic acid, alternated with a solution of acetate of zinc, or sulphate of zinc, gr. ^ or 1 to ^ 1 of rose water. These may be dropped into the eyes twice or thrice a day, and their strength may be reduced as the disease gives way. This reduction of the strength of the collyria I have always found essential to rapid improvement. If the cornea is involved, it is best to apply the collyria to the everted lids by means of a pencil brush, and Wash it off immediately with tepid or gum water. Military Ophthalmia. This is a variety of purulent conjunctivitis often compli- cated with a follicular granulation. It appeared in the French and English armies stationed in Egypt, and from this received its name. It spread so fearfully that after the Napoleonic war England alone had over 5,000 blind, helpless soldiers to care for. It is very contagious in crowded armies, or among crowds anywhere. Bad ventilation and filth always increase its contagiousness very much, which seems to depend on atmospheric conditions. DISEASES OF THE EYE. 453 Treatment.—If the fever runs high in the acute stage, aconite should alternate other proper remedies, such as small doses of the sulphide of calcium. After the force of the inflammation is subsided, I use a local application of the sul- phate of zinc or boracic acid, in doses to suit each individual case, always reducing the strength as the disease yields. Sometimes the use of mild mucilaginous solutions does great good, as a mucilage of quince seed, the pith of sassafras twigs, or the leaves of the wild cherry tree, steeped in water and dropped into the eye. Again, the vapor from a 10 or 20 per cent, solution of prussic acid, held under the eyes (so that the vapor can be conveyed to those organs with a funnel, with its large end held over the eye), will relieve irritation and grad- ually lessen the inflammation. A solution of the fluid extract of belladonna gtt. 10 to § 1 of water, will relieve the pain and contract the enlarged capillaries, thereby gradually lessening the inflammation. I have used a weak solution of sulphate of zinc, with happy results, say gr. ^ to § to the ounce of water, into which gtt. 10 of tincture of belladonna has been dropped. Ophthalmia Neonatorum. This is a purulent conjunctivitis, which generally sets in a few days after birth. At first the discharge may be light, but sometimes it increases in a few days with very great rapidity. Causes.—Leucorrhoea in the mother is a frequent source of this disease. Gonorrhoea in women who happen to con- ceive, will also produce this condition in so grave a form as soon to destroy the sight of the child. Treatment.—In mild cases in which the discharge is whitish, sparse and of a mucus character, the free use of cold water) into which a few grains of boracic acid have been dis- solved) will frequently check the further progress of the dis- ease. Cold compresses may also be applied. The secretion should be frequently removed with a very soft sponge and tepid water. In severe cases the administration of aconite, in 454 THE PRACTICE OF MEDICINE. doses of 1-15 to 1-20; every hour, will aid in the reduction of the inflammation. Aconite may be alternated with gtt. ■£ of the tincture of pulsatilla, or with gr. ^ of sulphide of calcium, taken every two hours. This course will generally carry the case through to a favorable termination. Some cases, how- ever, require great care, as they may become aggravated, and thus prove very obstinate and dangerous. If the case assumes a severe form, collyria of alum, gr. 5 to the 3 1 of water. dropped into the eyes or thrown into them with a small syringe, will often be attended with good results. If the above fail, gr. 2 to 3 of the sulphate of zinc to the ounce of water. will be proper used in the same way. Some cases do better with the use of collyria and the nitrate of silver, g. 1 to the 3 1 of water, used three times a day with a syringe. This treat- ment is indicated in those cases in which the discharge is purulent and very copious. If, in a few days, the discharge still continues Tinchecked, and a slight haze appears upon the cornea, I use a strong solution of gr. 5 to § 1 of distilled water with a little salt in it. Sometimes this will give very speedy relief, improvement following the first application. It need not be repeated very often. After using this solution of nitrate of silver, cold compresses may be ordered to allay all irritation and excitement. Arsenic internally is required in old chronic cases. Gonorrhoeal Conjunctivitis. It is not uncommon for persons who are suffering with gonorrhoea to have gonorrhoeal conjunctivitis, due to some of the gonorrhoeal secretion getting into the eye. I saw a very bad chronic case of it once in a white child, nursed by a servant girl, who had contracted gonorrhoea, and in washing the child's face, or putting her hands about its eyes, she had transferred the virus of the disease to the child's eye, and it had, up to that time (a period of several years) proved incurable. The active form of this disease is one of the most destructive kinds DISEASES OF THE EYE. 455 of conjunctivitis, and is very rapid in its progress. In its mild form it resembles the mild form of purulent ophthalmia, and will usually yield to similar treatment. If it result from the introduction of the virus into the eye, the inflammation is very violent, and the disease will prove very obstinate, finally des- troying the sight, if not well treated. It has been my misfor- tune to treat some very grave cases of gonorhoeal conjunc- tivitis. There are quite a number of cases that prove to be comparatively mild, but with some subjects it is a grave disease. Treatment.—One of the worst cases I ever saw, was that of a young man in the city of Columbus, Ga., who applied to me in 1845 for treatment, stating that a professor of the Savan- nah college and other eminent physicians had failed to cure him. Knowing that these experienced physicians had prob- ably exhausted all the list of old remedies, I concluded just to try applying an ointment of calomel to the lids and in the corner of the eyes. I accordingly made an ointment of gr. 4 to 5 to § 1 of unsalted butter, and had him apply it well, working the lids so as to spread it over the entire surface. In a few days he began to improve and his health was entirely restored. Internally, gelseminum and aconite are the remedies in the active stages of the disease, gtt. 1 of aconite every hour, and gtt. 20 of gelseminum every three hours, until the in- flammation is much reduced. At the same time a saturated solution of boracic acid should be dropped into the eyes three times a day, after washing them out with a little tepid water. If ulceration of the cornea happens to takes place, which it often does, a strong solution of nitrate of silver should be applied to the ulcer with a pencil, washing it away immediately. Rheu- matic iritis often follows this form of conjunctivitis. In this variety the biniodide of mercury* answers very well, in small doses of say gr. 2 to 3 2 of iodide of potassium, \ 4 of water; dose gtt. 30, three times a day. A solution of belladonna is also effec- *This preparation will not salivate, so it is harmless. 456 THE PRACTICE OF MEDICINE. tive, say gtt. 5, to | 4 of water; dose gtt. 30, three times a day. This treatment, if properly carried out, seldom fails to cure the affection in a short time. Diphtheritic Conjunctivitis. This disease is very rare in America, but prevails epidem- ically in some portions of Europe, especially in Berlin. Symptoms.—It resembles gonorrhoeal conjunctivitis, but is much more severe and more dangerous to the sight. The dis- charge at the outset is of a yellowish color, and flocculent, and the lids are much swollen, rigid, painful and very hot. In a few days the discharge becomes of a purulent character, and a fibrinous exudation takes place from the conjunctiva, the cornea becoming rather hazy, and ulceration and sloughing ensue in most cases. Treatment.—The treatment may be commenced with ice or cold water compresses, and gtt. 1 of aconite every hour until a decided impression is made upon the disease. As soon as the discharge assumes the character of pus, the stimulating collyria should be used. This should be commenced with a solution of nitrate of silver, gr. 5, and distilled water § 1, applied to the closed lids with pencil. In doing this we must carefully avoid its coming in contact with the cornea, by wash- ing off the solution with water. Internally, the biniodide of mere gives good results with iodide of potassium; say mere biniodide gr. 2, iodide of potassium 3 2, water § 4; dose, a teaspoonful three times a day. If the cornea becomes ulcer- ated, gtt. 2 to 3 of tincture of arsenic should be ordered thrice daily. Jf the disease should not give way under this treat- ment in a few days, gtt 2 of Donovan's solution is necessary every three hours, instead of the above preparations. It is very probable that the internal use of the sulphide of calcium, as an antiseptic, would do as much good in this form of con- junctivitis as in the previously described forms of this disease, and that in severe cases the ointment of calomel would be of as DISEASES OF THE EYE. 457 great utility as it is in the gonorrhoeal form. It is certainly worthy of a trial. Acute Granular Conjunctivitis. One of the first symptoms of this form of conjunctivitis is severe pain in the eye, photophobia from ciliary irritation, and a sensation as if there was a foreign substance, like sand, beneath the lids. Upon everting the lids, the papillae will appear swollen and small, gray points will be found, which are true or follicular granulations. The conjunctiva gradually becomes more and more swollen, and a profuse purulent dis- charge is soon established. At this stage it is difficult to dis- tinguish it from the simple purulent form of conjunctivitis. This purulent stage generally continues for several weeks or less. Causes.—This form of conjunctivitis generally arises from contagion and deficient hygienic conditions. It spreads rapidly, like military ophthalmia. Neglect or improper treatment are apt to cause it to assume a chronic form, and this always proves tedious and often fatal to the eye; or, if it is not fatal, it is at least injurious to the sight, and produces such extreme photo- phobia that the patient can not bear light. Chronic Granular Conjunctivitis. In this condition the secretion is diminished, the inflam- matory excitement disappears, and the disease seems to be centered upon the upper lid, which keeps up the chronic inflam- mation of the eyes. The cornea is very apt to become affected with pannus. This is a vascular development in the epithelial layer of the cornea. The granulations sometimes extend from the upper lid to the ocular conjunctiva, and thence to the cornea, but pannus may follow friction and pressure upon the cornea by the roughened surface of the palpebral conjunctiva. When we see pannus, we may know that we have a case of granulation of the lid to deal with. These granulations may 458 THE PRACTICE OF MEDICINE. be both follicular and papillary, and are found on the inner surface of the upper lid. They appear mostly upon the reflected portion, and the pannus is generally seen upon the upper half of the cornea. It may finally extend downwards and encroach upon the pupil, impairing the vision very much. This may be the first thing that alarms the patient, and it may cause him to seek the advice of the physician or oculist. It is a dangerous condition. Treatment.—This affection is very subject to relapses, and the treatment, to be successful, must be continued for months and sometimes even for years before it is cured. Though obstinate, it is not a hopeless condition, for I have cured it after it had existed for years. Pannus (which is something growing over the eye), is usually an unfavorable omen to a successful issue, and the unskilful physician may mistake it for pterygium, although this is quite a different formation. One of the first things to be done for this affection is to improve the patient's general health. As local applications, I have used a crayon of crystal alum or of copper, and some- times one of copper and borax. Gr. 1 of nitrate of potassium acts admirably applied to the closed lids with a soft brush wet in water, or used in a saturated solution and immediately washed off to prevent injury to the cornea. I have found, however, in most cases of long standing, that the smooth crys- tal of sulphate of C9pper is one of the best applications, and soon removes the granulations. In some cases, in which there is great irritability and photophobia, I think that it is best to use mild collyria, as gr. -| of sulphate of zinc to 3 1 of rose water, or gr. 2 of boracic acid to § 1 of water. When the sul- phate of copper is used it should always be washed off before the lid is closed. It produces pain in many cases, which may be lessened by the application of tepid water for a time, fol- lowed by the vapor from prussic acid,* or water in which the prunus virginiana has been steeped. Cold compresses some- *Dilute. DISEASES OF THE EYE. 459 times lessen the pain considerably. The patient should avoid using the eye just after these applications, and the crayon should not be applied until all the irritation created by the application of the caustic to the lid has subsided. Sometimes this may be three or four days, and again only two days. If there is adhesion of the lids upon rising, a mild rose ointment may be applied to them occasionally. In subacute cases, gr. 1 to 2 of the nitrate of silver may be required for a few days, and in some cases gr. 1 to 2 to the § 1 of distilled water. It should be applied to the everted lids with a soft pencil brush, and then in fifteen or twenty seconds washed off with another brush dipped in weak salt water. Sometimes mild astringent ointments are required, such as gtt. 3 of tannin to | 1 of cocoa butter, applied on the everted lid and allowed to melt there. A dry compress, just tight enough to exert gentle pressure upon the swollen lid, will also do much good. Chlo- rine water properly diluted may be used in some cases with good effect, especially where there is pannus from granulated lids. One writer recommends 3 2 of olive oil to 3 \ or 1 of spirits of turpentine. This would have to be used with cau- tion, commencing with not more than 3 \ of the turpentine to 3 2 or 3 of the olive oil. Scarification of the swollen and gran- ulated lids is recommended by some oculists, and has fre- quently proved beneficial. It can be required, however, only in case of extreme tumefication of the lids. It has always been my rule to give the patient an alterative course of treat- ment, for I have usually found this form of conjunctivitis asso- ciated with a scrofulous or strumous constitution. I usually give the iodide of potassium, and alternate that with the tinc- ture of stillingia, menispermum, phytolacca, or corydalis. Whenever the crayon seems to increase the irritation and lachrymation, and to produce severe and prolonged pain, it is doing more harm than good, and should be at once abandoned, a mild application being used instead for some time. Occa- 460 THE PRACTICE OF MEDICINE. sionally the iodide of arsenic is required in doses of gr. 1-16, ter in die. Scrofulous Conjunctivitis. Scrofulous ophthalmia has its primary seat in the conjunc- tiva, the iris, sclerotica, and cornea, all becoming finally involved in the inflammatory process. Diagnosis.—One prominent symptom is great irritation of the ciliary body, with photophopia, which so affects the orbi- cularis that its spasmodic closure renders it nearly impossible to see the eye at all. When the ball is to be seen, if the patient will inhale a small quantity of chloroform or ether, the orbicularis will be so relaxed that the eye can be thoroughly examined. The palpebral conjunctiva will be found red, swollen, and looking like velvet on its surface. The ocular conjunctiva is injected, and the pinkish zone around the peri- phery of the cornea will be found to be well marked. The cornea will probably appear dull, opaque or ulcerated, and the iris, perhaps, will be found contracted. There may be also more or less neuralgic pain in the ciliary body, and such intense photophobia that the patient can not be induced to face a moderate light with open eyes. The disease, however, is not always of so severe a type, and the dread of light is much less in a great many cases. Upon examination in some cases, the cornea will be found nearly transparent, and the disease con- fined to the conjunctiva and edges of the lids. Again the cor- nea may be found unaffected, but the ocular as well as the pal- pebral conjunctiva is diseased, and the inflammation is so deep seated as to reach the vessels beneath the conjunctiva, as shown by a pinkish zone around the edge of the cornea. The plexus of ciliary nerves is greatly irritated, and the eye is exceedingly sensitive to all external influences. Lachrymation is very free, and irritation is soon followed by most intense reaction. In chronic cases these symptoms are not so severe., The ciliary irritation, and the consequent extreme sensitive- DISEASES OF THE EYE. 461 ness of the eye, are characteristic of this disease, and must not be forgotten or overlooked in the diagnosis. Treatment.—Internal treatment is the principal weapon in this disease, which is only one of the visible manifestations of a constitutional taint that must receive our special considera- tion. Local applications are at best only palliative. Warm fomentations soothe the eyes. Ciliary neuralgia may be met by applying gtt. 1 to 2 of diluted belladonna to each eye, and the mild zinc ointment applied to the edges of the lids will allay the irritation. The syrup of rumex crispus, tincture of stillingia, phytolacca, menispermum or corydalis may be taken in 3 -J to 1 doses three times a day, alternated with iodine or echenacea 20 gtts. If 30 to 60 gtts. of the tincture of the fresh root of echenacea be given three or four times a day, and a weak infusion dropped in the eye three times a day, it will aid the above treatment greatly. This plant is a pow- erful alterative or catalytic; it grows in many parts of the United States (see Botany). Phlyctenular Conjunctivitis. This is called herpetic or pustular conjunctivitis by some writers, while others consider it a phase of scrofulous ophthal- mia. It most commonly occurs in children, and generally in those with a tendency to a scrofulous constitution. Symptoms.—The simple form may be recognized by a red- dened point upon the inflamed base of the conjunctiva, very slightly raised, and usually situated at the limbus of the cor- nea, or upon the sclerotica near its junction with the cornea. This red point frequently terminates in a small vesicle, which may change into a small ulcer and finally disappear, leaving behind no trace of its existence. Treatment.—The iodide of potassium 3 2, and the binio- dide of mere gr. 2.- water % 4, seems to be the internal remedy indicated, and a little calomel dusted into the eye from a fine pencil brush will allay much of the local irritation. This may 462 THE PRACTICE of medicine. be repeated once or twice a day, as may be required. The calomel has a specific effect upon this disease, and can not be replaced by any other powdered substance. It will always do good unless there is too much irritation, and if that is the case a fomentation of stramonium leaves, or of hops, may be used first, and then the finely powdered calomel very cautiously applied. In this way the disease may be cured. Phlyctenular Corneitis. Excoriation and ulceration may attack the cornea, espec- ially in the herpetic or phlyctaenular variety of scrofulous oph- thalmia. Some of the most prominent objective symptoms are those of herpetic conjunctivitis, but more strongly marked, and attended with greater ciliary irritation, congestion, and photophobia. Scrofulous ophthalmia, with great photophobia, is almost always connected with disease of the cornea. There is apt to be a vesicle in the limbus of the cornea. Treatment.—The specific indication in this disease is tinct of arsenic, given every two or three hours in doses of gtt. 1 to 2, not more, for too much never fails to cause violent irri- tation of the stomach. For the photophobia, spigelia (tinct.) in doses of gtt. 10 to 20, three or four times a day, will be of material aid in relieving this affection of the eyes. The sul- phide of calcium, alternated with belladonna, is also invaluable in this condition. Occasionally, where the disease is attended with pain in the ball, or dull headache, the tincture of macro- tis is indicated, in doses of gtt. 5 every two hours, and will do good service. If there be neuralgic pain, gelseminum in doses of gtt. 10 to 15 of the tincture, will be of material ser- vice, especially if there is ciliary neuralgia. Belladonna may alternate it every three hours until they bring relief. Ulceration of the Cornea. Ulceration of the cornea is almost always the result of weak vitality or impaired health. DISEASES OF THE EYE. 463 Symptoms.—It is characterized by more or less congestion of the conjunctiva, pain, photophobia, and lachrymation. Strumous ulceration occurs in scrofulous ophthalmia, gener- ally beginning as an opaque speck, and in ophthalmia neona- torum there is ulceration very similar in appearance to that which occurs in the disease under consideration. At first a grayish opacity appears, with a transparent centre, whieh opacity soon assumes a yellow color, and as resolution sets in the yellow changes back to a gray tint. Small bloodvessels may be seen running from the sclerotic coat to the ulcer. In some cases there may be a transparent ulcer of the cornea, by which the patient's vision is not much clouded, he suffering only from irregular refraction of light, owing to the uneven- ness of the diseased surface of the cornea. In such a condi- tion of the cornea all objects appear distorted, on account of the superficial ulcerations upon the cornea. Crescentic ulcer- ation of the cornea, as is described in gonorrhoeal ophthalmia, is also very common in this affection. Sloughing ulcer (from suppurative corneitis in feeble constitutions), and the indolent ulcer of the aged, are frequently complicated with hypopyon and suppuration of the tissues of the cornea. The greatest danger in ulceration lies in the tendency to leave a scar or cicatrix more or less opaque upon the cornea, which may occur near the centre of the pupil. If this happens, it interferes with vision. Again, perforation of the cornea may set in, and if it does prolapse of the iris may result, causing adhesion between the cornea and iris, and either distorting or displacing the pupil. Iritis may originate from this, or the perforation may be small, and admit a deposition of matter on the' surface of the lens capsule, forming capsular cataract. Treatment.—A bandage over the eyes greatly promotes the healing of the ulcer upon the cornea, it being essential that the exposed surface of the cornea should be well protected from the air and light. A fresh layer of epithelium will then be quickly formed to cover the denuded nerve fibres, and thus 464 THE PRACTICE OF MEDICINE, the photophobia will be relieved. It is best to keep the pupil dilated by atropia whenever the ulcer is situated in the centre of the cornea, but if located at or near the margin of the cor- nea, eserine or pilocarpine may be used to contract the pupil and draw its edge away from the seat of disease. It is best for the patient to be well fed, and to remain in the light, as the bandage protects the eyes from dust, wind or smoke. No local applications are advisable. When ulceration occurs in the course of granular or purulent ophthalmia, such applica- tions as are required for the diseased conjunctiva may be used and applied as directed under that head. No irritating sub- stance, however, should in any case touch the diseased cornea. The internal treatment in ulceration of the cornea is deter- mined by the symptoms existing in each case. In most cases arsenic will be required for the constitutional dyscrasia asso- ciated with this form of eye disease. The sulphide of calcium, in doses of a few grains, may also do much good, especially in those cases in which there is profuse suppuration. Occasion- ally, when there is much frontal pain, belladonna, alternated with macrotis (tincture), will give good results. As the dis- ease is often associated with derangement of the digestion, some good tonic will be required, as nux vomica, alternated with arsenic. If it be associated with syphilitic dyscrasia, I give biniodide of mere in very small doses, say mere binio- dide gr. 2, iodide of potassium 3 2, aqua f 3, dose gtt. 60, ter in die. Corneitis. This frequently accompanies the scrofulous form of oph- thalmia, and diffuse corneitis is often found with purulent con- junctivitis, or a chronic form of granular conjunctivitis of the lids. Suppurative corneitis, which is often met with in puru- lent ophthalmia, or from mechanical injury of the eye, or from surgical operations on the corneal tissue, is a much more dan- gerous form of the disease. With this form there is often severe ciliary neuralgia. The rose-colored zone around the DISEASES OF THE EYE. 465 cornea, the contraction of the pupil, and the chemosis, are all generally present. There is seen a gray opacity, which finally changes to a yellow color as the tissues become broken down, and the anterior chamber may be perforated. Extensive cor- neal abscess may finally ensue, and interstitial infiltration result, forming onyx. Pus may fall to the bottom of the ante- rior chamber, and suppurative inflammation result, which may extend to the iris. Injuries of the cornea readily produce sup- purative corneitis, especially in aged and enfeebled persons, and it may follow diabetes, cholera, and typhus and typhoid fe,ver. In the indolent form of corneitis there may be but lit- tle pain, but the necrosis may extend to the whole globe. Treatment.—In the severe suppurative forms of corneitis, the eye should be always bandaged at once, and considerable pressure be made upon the eye-ball. Pressure, properly reg- ulated, has a direct controlling effect upon the suppurative process, thereby aiding in saving more or less of transparent corneal surface. If the inflammation runs high, a cold com- press may be used to control it. In some cases, in which the inflammatory symptoms are not marked, but there is consider- able pain, hot compresses may do great good; as soon, how- ever, as there is marked injections of the eye, they should be discontinued at once. If there is great pain, a few drops of solution of belladonna, say gtt. 5 or 10 to the § 1 of water, allowed to fall into the eye, will generally relieve the pain, and more or less diminish the capillary enlargement If the reac- tion is considerable, aconite, in doses of gtt 1 every hour, should not be forgotten. As soon as ulceration of the cornea takes place, sulphide of calcium, in doses of gr. 1 to 2, should be given every two hours. The tincture of cannabis indica, in doses of gtt. 2 to 3, may alternate the calcium. If there is intense ciliary neuralgia, gelseminum, in doses of gtt. 20 every three hours, may be alternated with some gtt. 15 of the tinc- ture of macrotis racemosa, or cereus grandiflorus. 30 466 THE PRACTICE OF MEDICINE. Anterior Staphyloma. If the cornea becomes perforated in disease of that tissue, staphyloma of the cornea and iris may result. In this case the iris may fall against the opening, lymph being then secreted, and a cicatricial tissue, something like the opaque cornea, formed. This being weak and inelastic, under inter- ocular pressure bulges forward, of course, and forms a partial or total staphyloma of the cornea and iris. This is to be relieved by a surgical operation, provided the staphyloma is partial, but if it is total the sight will be inevitably lost. Episcleritis. This affection usually commences in the form of a dusky- red spot, which is beneath the conjunctiva in the episcleral or superficial tissue of the sclerotic coat, near the edge of the cornea. As the disease advances, it generally changes to a purplish color. It causes considerable ciliary irritation, and also neuralgia, if it involves the edge of the cornea. It often occurs in the course of scrofulous ophthalmia, and is generally accompanied by conjunctivitis with more or less mucus dis- charge. It must be distinguished from phlyctaenular ophthal- mia. It results from debility or overwork. It is easily relieved by applying warm fomentations and atropia if there is ciliary irritation. The eyes must have rest. Hyperemia of the Iris. Hyperaemia of the iris would resemble simple iritis, were it not that there is no exudation. Causes.—Over-exertion of the eyes in looking at near objects,-small type, reading by a dim light, or anything that strains the vision, will cause hyperaemia of this organ. It is indicative of congestive of the deeper seated structures of the eye. It often occurs, as stated before, in scrofulous ophthal- DISEASES OF THE EYE. 467 mi a, and may result from the use of strong and irritating caustics. Treatment.—This depends upon the affections associated with it. The proper treatment for iritis will relieve hyperae- mia of the iris. Simple Iritis. In this disease, the conjunctiva and sub-conjunctival tissue are usually found injected, there being also a well defined rose- colored zone around the cornea. The pupil, also, is usually contracted and discolored, the iris is of a bluish color (which finally becomes greenish, the brown iris turning to a reddish brown hue), and there is generally a plastic exudation on the surface of the diseased iris. In grave cases the lids may be tumid, and chemosis may set in, the posterior surface of the cornea being mottled with specks of minute depositions of lymph. There is sometimes also more or less photophobia and dimness of sight, and again great pain in the entire globe around the orbit, and in the temple. This pain is more intense at night, and there may be very great photophobia and lachrymation. In the acute form, diffuse retinitis and hyalitis are associated with it. These complications are detected only by the ophthalmoscope. Suppurative Iritis. The symptoms of this form of iritis are somewhat similar to those of the above described form. The inflammation, how- ever, is deeper seated, and the tissues of the iris become swollen and thickened. Syphilitic iritis usually also assumes this form, but rheumatic iritis, when it occurs in rheumatic subjects, is the simple iritis described above. In suppurative iritis there is a copious exudation, the swollen tissues of the iris impede the circulation, the vessels are congested, and very frequently large veins are seen on the face of the diseased iris. This is best determined by a lateral illumination of the eyes. 468 THE PRACTICE OF MEDICINE. Sometimes small yellowish nodules appear upon the edge of the pupil. The aqueous humor becomes so increased in quan- tity that the eye stands out more prominently than natural, and the admixture of this fluid with the pus and lymph thrown out by the inflamed iris, is such that it looks turbid. I had a case not long since that had become chronic, and sight was lost In this instance there was such a profuse quantity of aqueous humor, that the eye-balls stuck out very prominently, and the pus and lymph caused the entire globe to assume a whitish color. This was the case of a young man in this city, who can now see very well. I cured him by constitutional treatment The iris is sometimes so completely covered with exudation as to be invisible, and the exudation may finally set- tle to the bottom of the anterior chamber of the ball, forming hypopyon. In syphilitic iritis, tuberculous nodules of a red- dish-yellow hue are often seen on certain parts of the iris. Sometimes they project so as to touch the posterior surface of the cornea, but this is rare. Serous Iritis. Children born of syphilitic parents are liable to this form of iritis. Pathology.—In this disease there is increased secretion of the aqueous humor, which is also turbid and deposits minute specks of lymph upon the posterior surface of the cor- nea, hence the appellation applied to it—" keratitis punctata: " it is often associated with choroiditis. Cause.—Changes of temperature, cold, rainy, windy weather and the excessive use of the eyes are very common causes of iritis. Rheumatic iritis is developed by whatever tends to produce rheumatism. In rheumatic ophthalmia, the pain often extends over the side of the face and head, and this form is very liable to relapse. It is sometimes of a traumatic origin, or it may be caused by syphilis. It is believed that the majority of cases occurring among children are of a syph- DISEASES OF THE EYE. 469 ilitic character, especially those of an idiopathic nature. An acute attack may terminate in chronic iritis, but this is not very often the case unless it be associated with choroiditis. This complication often exists. Prognosis.—In the early stages of the attack, when adhe- sions between the iris and the capsule of the lens have not formed, the prognosis may be considered favorable. If, how- ever, such adhesions have taken place, it is very unfavorable unless they can be overcome. Where the edge of the pupil becomes firmly adherent to the capsule, it causes such irrita- tion from the efforts of the pupil at dilation and contraction, that it constantly tends to produce subacute attacks of iritis, that finally end in blindness. Treatment.—One of our best remedies is atropia, which should be given in doses large enough to greatly dilate the pupil so as to prevent adhesions, if possible. I use gr. 4 to 3 1 of water, a few drops of which should be allowed to fall into the eye at intervals of five or ten minutes until it dilates the pupil; to be repeated whenever the pupil contracts again to any considerable extent. The pupil should be kept dilated to its maximum size in most, if not in all cases. Some mild cases may not require more than one or two applications of this solution to keep the pupil sufficiently dilated. This solu- tion not only prevents adhesion, but gives the inflamed mus- cles of the iris perfect rest by the complete paralysis (for the time being), of the constrictor papillae. But for this paraly- sis, the iris would be in constant motion in attempting to reg- ulate the size of the pupil in accordance with the light thrown upon it. If the eye does not tolerate atropia well, duboisia may be tried in its stead. If adhesions have already formed, an effort should be made to break them up by using, alternately, atropia and calabar bean, which will produce alternate dilata- tion and contraction of the pupil, and may thereby break up those adhesions already formed. As internal remedies, the main one is aconite at first, while the inflammation runs high. 470 THE PRACTICE OF MEDICINE. The aconite may be alternated with small doses of belladonna, say gtt. 2 to 3, every four hours, so as to control the venous capillaries and prevent stasis. In the rheumatic form bryonia may be given in doses of gtt. 4 to 5, every three hours, altern- ated with gtt. 10 to 15 of macrotis (tincture) every three hours. If there is very intense pain in the globe of the eye, warm medicated fomentations will do good service. In some cases small doses of tincture of spigelia, alternated with gelseminum, say gtt. 10 to 15 of each, every three hours, will relieve the pain and lessen the inflammatory excitement. In the syph- ilitic variety, the biniodide of mere* and iodide of potassium (biniodide gr. 2, iodide of potassium 3 2, distilled water § 4; dose, a teaspoonful three times a day) should begin the treat- ment, then other remedies as indicated. Atropia, twice a day, Avill generally keep the pupil sufficiently dilated to prevent adhesions and neuralgia. The patient should be confined to the house. The room need not be darkened if the atropia is con- stantly used to prevent photophobia. If he go out, he should protect the eyes with blue glass. Iris versicolor is a good remedy. Choroidal Hyperemia. This disease is of frequent occurrence, but as the vessels of this tissue (except in persons of light complexion) are almost entirely obscured by the pigment layer, it is quite impossible to diagnose, even with the ophthalmoscope. If, however, there is hyperaemia of the retina, hyperaemia of the choroid may be suspected. The iris and ciliary bodies are often congested with this tissue, and, if this be the case, it may be diagnosed with a good ophthalmoscope in experienced hands. Treatment.—Hamamelis may be given in doses of gtt. 3 to 5, every three hours, and a solution, say one part of it to 3 or 4 of water, may be dropped into the eye, and compresses of * Those who do not believe in this drug may try iris versicolor. DISEASES OF THE EYE. 471 lint wet in it and applied over the lids. These remedies will generally relieve the affection in a few days. Simple Choroiditis. Simple or disseminated choroiditis is quite difficult to diagnose without a good ophthalmoscope, as the symptoms attending it are common to other diseases of the eye. Slug- gishness and more or less dilation of the pupil are common in this as well as in some other affections of the eye. There is also some failure of sight, and imperfect vision, so that but part of an object is seen at once. The external appearance of the eye may be natural, and there is seldom any pain. Upon examination with the ophthalmoscope, the choroid coat and the vitreous humor appear clouded, and there are small yellowish- white patches of lymph, either at the periphery or about the macula lutea, or optic disc. Later, if atrophy of the choroid occurs, the white portion of this tunic is seen shining through in spots. If this affection originates from syphilis, white patches will be seen with a pale-red zone around them. After- wards there may be consecutive atrophy of the optic nerve and retina. There is a great tendency to complication and to atrophy of the retina or optic nerve in this disease. The exu- dations may be finally absorbed (leaving but slight evidence of their former existence), and sight may be restored. Treatment.—The cause of the disease will greatly modify the treatment. It often originates from syphilis, or some dis- order of the liver and stomach may give rise to it, all of which complications must influence the treatment. The eyes should be protected from light by blue glasses, and the patient must avoid reading or using the eyes in any way that strains them in the least. One of the best remedies is the iodide of arsenic in small doses of say gr. 1-30 to 1-40, taken three times a day, well diluted. If there is pain or congestion, gtt. 3 to 4 of belladonna, given three times a day, will remove this trouble in a few days. 472 THE PRACTICE OF MEDICINE. Suppurative Choroiditis. This is called ophthalmitis, and is a grave disease of the eyes, which runs its course rapidly. Symptoms.—The eye-lids are red, swollen and rather cedem- atous, and there is so much chemosis that the eye also looks swollen. The iris is discolored and rather bulged out, the eye- ball is sensitive to the touch, and the pupil presents, if clear, a yellow reflex from behind the lens, which is from the puru- lent infiltration of the vitreous humor. There is often great pain in and about the globe of the eye. The sight becomes very rapidly impaired, and in some cases is utterly lost. Causes.—Suppurative inflammation of the iris and cornea (in diseased subjects), typhus, typhoid, pyaemia, wounds of the eye, surgical operations or sympathetic ophthalmia may all cause suppurative choroiditis. It is also like most sup- purative diseases, often provoked by high living. Treatment.—The treatment should be commenced with cold compresses, which, if the inflammation runs high, may be dipped in ice water, and often renewed. The best internal remedy is aconite, in doses of gtt. 1 to 2, every hour until the pulse is controlled, then every two or three hours to keep down all arterial excitement. If, however, the cold applications do not relieve the pain, warm fomentations must be tried, and if the pain is still great, I advise the administration of a small quantity of gelsiminum, say gtt. 20, every three hours. It requires very active treatment to save the sight in some cases of this disease, or the patient may even have to be turned over for surgical treatment in removing the ball. Complications.—Tubercles of the choroid are seen some- times by the use of the ophthalmoscope, with small, circular, rose-colored or grayish-white spots generally in close proxim- ity to the optic disc. This condition often exists with miliary tubercles. Tumors, ossification, carcinoma and sarcoma are DISEASES OF THE EYE. 473 occasionally met with within the choroid, but fortunately they are rare. Hyalitis. Inflammation of the vitreous humor, notwithstanding the fact that it is usually associated with diseases of the other structures of the eye, occurs sometimes as an idiopathic affec- tion. In simple hyalitis, with the use of the ophthalmoscope, a cloudy appearance of the vitreous humor may be detected, and delicate shreds of various sizes and shapes may be seen floating about in the fundus. It is not uncommon for this form of hyalitis to be associated with retinitis, choroiditis or cyclitis. A suppurative form of hyalitis generally supervenes in suppurative iritis or irido-choroiditis, and may occur after an operation for cataract or other severe injuries of the eye. It may also terminate in a very grave ophthalmitis, and destroy sight. Treatment.—The treatment varies according to the pri- mary seat of the disease, which is usually the choroid or retina. It seldom occurs in an idiopathic form. Galezowski asserts that the hyaloid membrane only can become inflamed. Effu- sion of blood or lymph, degenerated, fatty or pigment cells, may cause opacities of the vitreous humor. Musce Volitantes. These are either opaque or transparent, and are best dis- covered by looking towards the white surface of the eye-ball. They are usually the result of over using the eyes. They consist of the debris of cells and shells of tissue, or fibre float- ing about in the vitreous humor, changing their position as the eye moves about in its orbit. They appear very much like small threads or globular bodies. Rest to the eyes, and improvement of the general health having been attended to, the use of blue glass will aid in the cure. A haemorrhage of blood into the vitreous humor may occur, either from a diseased 474 THE PRACTICE OF MEDICINE. condition of the coats of the vessels, or as a result of some traumatic injury to the choroid coat. Upon examination of the eye with the ophthalmoscope, there may be a darkened appear- ance of the fundus, or a red reflex of it. Treatment.—We must first remove the cause, let it be what it may. Most commonly it lies in irido-choroiditis, or some disease of the deeper seated structures of the fundus. The tincture of hamamelis, in doses of gtt. 5, will doubtless be of much utility. The tincture of arsenic will perhaps do good. Glaucoma. This is a most dangerous affection of the eye, and without immediate surgical aid will most likely terminate in blind- ness, and finally in degeneration of all the tissues of the eye. It is readily discovered by a careful examination with a re- liable ophthalmoscope. It may be either of acute, subacute or chronic form. The acute form is attended by increased tension of the eye-ball, which can be determined by touch. There is«also fulness and swelling, as in iritis, conjunctivitis, or sclerotitis, but the tension of the ball indicates an attack of acute glaucoma. With this characteristic tension, there will most likely be periodic dimness of vision lasting for a few minutes or hours, and also presbyopia. The pupil will be more or less dilated, and on looking at a lighted lamp or candle, the rainbow halo will appear around it. This halo is red on its outer border, and a bluish-green on its inner edge. There may be ciliary neuralgia over the eye, or in the temple, face, or forehead. This neuralgia is so severe after the dis- ease is fully formed, as often to cause vomiting, nausea and high fever. The disease may be mistaken for fever. The lids are generally puffed out and swollen, the conjunctiva is highly injected, and there is chemosis, and often cloudiness of the aqueous humor. The iris appears bulged out, and is dis- colored, and the pupil is dilated with decided tension of the DISEASES OF THE EYE. 475 eye-ball. The sight is much impaired, but is seldom totally lost in this stage. Sometimes there is photophobia and lachry- mation, which are primary symptoms of this affection. The acute attack may pass away, and the sight become much bet- ter or even as good as ever, but finally the condition again oc- curs, and it continues to do so until the sight from repeated injuries is finally totally lost. It is called glaucoma from the reflection of a bluish-green color in the eyes. At first the ophthalmoscope may reveal nothing but a cloudiness of the cornea, but as soon as the disease becomes confirmed, the op- tic disc becomes more or less excavated, and the veins of the retina grow dilated, turgescent and rather tortuous in their course. At a later stage of this disease there may be arterial pulsation, and haemorrhage and cloudiness of the vitreous humor. In some cases, however, there is such deep cloudiness that nothing whatever can be seen with the ophthalmoscope. The other symptoms, however, are so well marked that a diag- nosis may be made in almost any case. Subacute glaucoma only differs from the acute form in having less severe symp- toms and a less rapid course. The chronic form is an ad- vanced stage of the acute form, in which the inflammation is fixed and gradually progressive, and in which the vision gradu- ally grows dimmer and dimmer. Chronic, non-inflammatory glaucoma may attack and completely destroy the vision of one eye, from the fact of aid not being sought in time. In these cases the eye may look natural, with one exception, the pupil being slightly dilated and looking rather sluggish. There may be increased tension of the eye-ball, and the ophthalmo- scope will reveal excavation of the optic nerve. More or less inflammatory symptoms will finally be manifested, as in the inflammatory form described before. Absolute glaucoma, in which all perception of light has disappeared, may be known by a pale-greenish opacity of the lens. In this latter stage ciliary neuralgia is severe. Pathology and Cause.—The pathology of this disease is 476 THE practice of medicine. as yet rather obscure. There is generally, at first, an affection of the iris, ciliary body and choroid, and then an increase in the humors of the eye, and an increased tension and excavation of the optic nerve. The cornea, sclerotic coat and retina also become involved. The secretion of the fluids of the eye is attributable to some irritation of the nerves controlling these secretions, which irritation is reflex from the sympathetic ner- vous system. Thus the increased fluids are the essence of the disease, and the great tension of the globe of the eye is the cause of the inflammatory symptoms. The mechanical pres- sure irritates the interior tissues of the eye, and produces in- flammation, and finally degeneration, from lack of nutrition. Treatment.—In the early stage of this affection we must attend to any constitutional dyscrasia that may exist in the system of the patient. In the advanced stage, sometimes nothing but iridectomy will prevent the frequent recurrence of glaucoma. Eserine has recently proved efficient in this disease, lessening the tension of the eye-ball. Bright light must be avoided, and blue glass must be used to protect the eyes. Retinal Hyperemia. In the active stage of this affection there is more or less photophobia and lachrymation, but in the passive or venous form, these symptoms are wanting. Upon examination of the retina with the ophthalmoscope, a reddened disc will appear from the congestion of the capillary vessels upon its surface. If only one eye is diseased, we may compare them, and thus easily diagnose this affection of the retina. In the venous form, the veins of the retina are much dilated, dark and tortuous. Causes.—In many cases, we find this due to imperfection in the refraction or accommodation; and here the use of suit- able glasses is the first remedy to be tried. Sometimes it is caused by exposure to a bright light, or by using artificial DISEASES of the eye. 477 light too much. Occasionally disease of the stomach and liver will set in, and if this be the case the tincture of English celandine acts well, in doses of gtt. 15 to 20, three times a day, alternated with gtt. 4 or 5 of tincture of cereus grandi- florus. every three hours. If it exists in females with any uterine disease, I order tincture of macrotis, in doses of gtt 20, every three hours,- alternated with gtt. 4 or 5 of bella- donna. Retinitis. In this condition the ophthalmoscope reveals a veiled or hazy appearance of the retina, more decided at the optic disc, which is cedematous, and indistinct at its outer border. The retinal veins are dark and tortuous, and the pupil may be dilated and sluggish. There is generally no photophobia, pain, lachrymation, or other symptom which accompanies reti- nal hyperaesthesia. Causes.— The causes are similar to those described in retinal hyperaemia, and hence the treatment also will be sim- ilar at first, but will have to be longer continued. Prognosis.—Our prognosis should be made very cau- tiously, as the sight is very apt to be injured (as the veil or cloud grows thicker and thicker) , until sometimes the patient is almost blind. One great danger in this disease is atrophy of the retina, which permanently destroys the sight. Dark blue glasses will protect the eyes very much, but their use in looking at near objects is injurious. In the parenchymatous form of retinitis, the appearance of the eye in the ophthalmo- scope is much more striking. Here the optic disc is of a red- dish-gray color, and its outline is so indistinct and irregular that it is difficult to distinguish it from the retina. The veins are usually swollen and tortuous, but the arteries are generally diminished in size. Here and there the vessels may be hidden by a grayish exudation, and extravasated blood may be seen in various parts of the retina. There may also be hypertrophy, 478 THE PRACTICE OF MEDICINE. stasis, proliferation of cells, colloid or fatty degeneration, and sclerosis. Sometimes the blood stasis may be relieved, the exudations and extravasations may become absorbed, and thus the patient may regain, more or less, his power of vision. It often ends, however, in atrophy of the optic nerve and retina. Very frequently the power of vision may remain tolerably good until the region of the macula lutea is invaded by the inflam- mation. Causes and Treatment.—A neglected hyperaemic condi- tion of the retina will lead to this inflammation of the retina and optic nerve, as will diseases of the heart, abdominal vis- cera, pregnancy in females, Bright's disease, diabetes, syphilis, or affections of the cerebrum. Whenever the cause can be ascertained, treatment should be with a view to its removal. If the disease is of a syphilitic origin, the treatment is more apt to prove successful than when it is due to Bright's disease or cerebral affections. Arsenic is one of our best remedies in the nephritic variety. The eyes must be protected with blue glasses. Optic Neuritis. The optic nerve is the primary seat of inflammation, the affection being often connected with disease of the brain itself. Vision is much impaired, and in many cases atrophy of the optic nerve and the retina takes place, loss of sight beinc the legitimate result. A very reliable prognostic sign is obtained by testing the vision. If we find that the vision is materially diminished, we may prognose an atrophy of the nerve. If the condition originate from the brain, there will be headache (which may have preceded this affection of the nerve), and there will be giddiness, nausea, vomiting, loss of memory, taste, hearing, and smell, and either paralytic or convulsive attacks. The primary ophthalmoscopic symptoms are hyper- aemia and oedema of the disc, which is of a reddish color, indis- tinct in outline, and less transparent, the effusion of lymph in DISEASES OF THE EYE. 479 the optic nerve giving it a striated appearance. The inflam- mation extends to the retina, and renders it hazy. It looks dark and tortuous, and its arteries are shrunken and scarcely visible, the vessels being partly hidden in the infiltration. There may be bloody extravasations around the disc. In the cerebral form, the inflammation is limited more to the optic nerve. Treatment.—The treatment varies according to the cause, the general health of the patient, and the peculiarities of each individual case. Arsenic is a good remedy in ordinary cases, in doses of gtt. 2 to 3 of the saturated tincture. If the cere- brum is affected, phosphide of zinc, in doses of gr. 1-10 to 1-15 three times a day, will doubtless prove of much utility. The chloride of gold and sodium, in doses of gr. 1-50 three times a day, is also effective in this disease. In many cases the iodide of potassium will prove of much value. In the early stage of a hyperaemic condition of the optic nerve and retina, belladonna, in small doses of say gtt. 1 to 2 every two hours, will do good service. If there is great determination to the head and face, I find gelseminum very useful, in doses of gtt. 20 to 25 every three hours. If there is frontal headache, the tincture of macrotis is indicated, in doses of gtt. 20 every three hours. If there is dimness of sight early in the disease, I order tincture of spigelia, in doses of gtt. 10 to 15 every two hours. Some cases, of cerebral origin will be benefited by phosphorus in small doses. Atrophy of the Optic Nerve. The term amaurosis may be confined to degeneration or to primary disease of the optic nerve. A marked symptom is dilated and sluggish pupils, and when the eye is totally blind its complete immobility affords another sign. In spinal amaurosis, the pupil may be somewhat contracted. Upon examination with the ophthalmoscope, the disc is pale (from 480 THE practice of medicine. attenuation of the small nutrient vessels on its face), there is bluish or bluish-green discoloration (especially in spinal amaurosis), the retinal vessels are generally much diminished in size, sight is more or less impaired, and the field of vision is contracted. Our prognosis will rest upon the limitation of the field of vision. Blindness comes on very rapidly, but if the vision is equilaterally contracted total blindness is not apt to ensue, unless some new cerebral symptoms manifest them- selves. The patient is likely to be troubled with dark spots before his eyes, which sometimes interfere very much with the sight. Causes. — Meningitis of the base of the brain is a frequent cause of this disease, especially in the chronic form. Tumors, or pressure upon the optic nerve, and disease of the cord, also give rise to it. Prognosis. — If blindness comes on suddenly it is fco be considered unfavorable, especially in very young persons. If the disease remains stationary for some time it is to be re- garded as a favorable sign, but as an unfavorable one where it progresses slowly but surely. After the amaurosis has continued for some time and the field of vision is not con- tracted, there may be a favorable diagnosis. If the line of distinct demarcation between the good and poor field of vision be well defined, it is a favorable sign, but when the field of vision contracts irregularly in both eyes at once, or in quick succession, it may be regarded as unfavorable. Scotoma in the center of the field of vision is very unfortunate, especially, if the field be much contracted. Treatment. — This must of necessity differ to suit each case. It is to be treated similary to optic neutritis. The con- stant current of a good battery is invaluable in neuro-retinitis, amblyopia, and progressive atrophy. Small and repeated doses of nux vomica have proven valuable in some cases. DISEASES OF THE EYE. 481 Amblyopia. By this term is to be understood imperfect vision, in which the affected eye presents no very marked symptoms without the use of the ophthalmoscope, and in which the imperfect vision is not due to anomalous refraction. This word ambly- opia is used to express impaired vision from any cause except optical defect. In cases where glasses fail to improve the acuteness of sight, the patient is amblyopic. The imperfec- tion of vision is not attributable wholly to deficient refractive power, but to some disease of the fundus of the eye-ball, dis- coverable only by the ophthalmoscope in the hands of a skill- ful oculist. Diagnosis.— If the patient is requested to look through a pin hole in a blackened card, it will enable us to tell this affection from anomalous refractive power. For if this im- proves the sight, then refraction is faulty, and the case will be benefitted by properly fitted glasses. If the vision is not at all improved, the imperfection of sight must be sought in some disease of the inner structure of the eye, which can only be determined by the ophthalmoscope. Faulty refraction, can of course, be quickly determined by concave and convex glasses, provided they are at hand. Causes. — Congestion of the brain and nervous structures of the eye, and the suppression of exhalation from the skin, may cause this disease, as may the suspension of the catamenia in females. Very large doses of quinia often produce ambly- opia, and so will an anaemic condition of the brain, that is, a deficiency of blood in the brain. Anaemia of the brain and retina may result from exhausting attacks of disease, from haemorrhage, or in feeble women from long nursing. Treatment. — In hyperaemia of the retina the tincture of cereus grandiflorus, in doses of gtt. 10 to 15, every two hours, will produce favorable results. This may be alternated with gtt. 3 to 4 of the tincture of belladonna, or if there is much 31 482 THE PRACTICE OF MEDICINE. pain, cimicifuga will do good in doses of gtt 10 to 15 of the tincture. In some cases the tincture of pulsatilla has a good effect in doses of gtt. 5 every three hours, especially, if in fe- males with suppressed menstruation. Bryonia is signally successful. If the hyperaemia is due to anaemia, iron must be given, with helonias dioiaca. If there is severe throbbing headache, sanguinaria is indicated, in doses of 5 or 6 gtts. of the tincture, four times per diem. If the patient complains of a rush of blood to the head at times, then phosphorus is indi- cated, dose ^ to 1 gtt. three times a day, well diluted. If this disease is from blood poisoning, that should be corrected first, then the eyes treated as above directed. If from decayed teeth they should be extracted or filled. CHAPTER XXXI. DISEASES OF THE EAR. INFLAMMATIONS of the external auditory canal are not as common as those of the middle ear. In some cases only the integument is affected, and in others the periosteum and bone are involved in the diseased process. When the area of inflammation is circumscribed, there will be abscesses or boils in the meatus but when a much larger area is inflamed there will be what is called diffuse inflammation of the ear. The diffuse form of inflammation of the external auditory meatus differs from the circumscribed, in that it does not terminate in abscess, but as its name implies, is diffused over the integ- ument the auditory canal. Inasmuch as the pther cuticular » layer of the tympanic membrane or drum-head is continuous with that lining the meatus, there is always great risk lest this membrane become involved. Children are very liable to this disease, that, if neglected, is very likely to terminate in perforation of the tympanic membrane, and injure the hearing. It should, therefore, receive proper attention. Symptoms.— One of the first indications of this disease is an itching and uneasiness in the canal, followed by pain, and a sense of tension and fullness. Upon examination the parts will be found red, tender, and more or less swollen, with pain- ful mastication. If the inflammation is severe, the entire ear will be red and swollen, and stand out from the head. Should the periosteum become involved in the inflammatory process, there will be very intense pain in the lower part of the canal. As soon as a discharge commences, the pain ceases, and the swelling subsides. Otitis may run on a week or ten days, when not interrupted by treatment. If the suppuration is 4s3 484 THE PRACTICE OF MEDICINE. prolonged, it may be followed by granulations or polypi, that soon yield to applications of caustics. Causes.— Irritation of the ear by the use of ear-picks, and the application of strong liquids and oils, such as camphor, Harlem oil, or any of the essential oils, will produce diffuse inflammation of the ear. Sometimes, sitting in the cold air, in a window or door, will provoke this disease, especially in those who have once had it. Treatment. — Von Troltsch advises the application of leeches on the tragus, first filling up the meatus with cotton to prevent the blood from falling into the inner ear and clog- ging it by coagulation. Some writers recommend scarification of the cartilaginous wall, in the early stages of the disease, be- fore suppuration commences. Prof. Roosa, of New York, ad- vises the application of warm poultices by means of Clark's aural douche. I have known poultices of boiled cottonseed to ease the pain very much, the sweating they produce relaxing the tension, and lessening the inflammation considerably. The internal use of aconite gives good results, in doses of gtt. 1 to 2 every two hours, and a local application of gtt. 2 to 3 diluted with a teaspoonful of water, may be rubbed on the ex- ternal meatus. It relieves the heat and tension of the part. If there is a throbbing, boring pain, gtt. 3 to 4 of belladonna may alternate the aconite, diluted with water, and applied to the part twice a day. Boils in the Ear. Furuncles, or boils in the meatus auditorius, are very pain- ful. If they happen to be deep within the meatus they are more painful than when nearer the surface. Cause. — They doubtless depend upon some local morbid condition, for they generally occur in persons that do not have boils in other parts of the body. They seem to occur with otorrhoea, and lotions of alum are said to produce them in some constitutions. DISEASES OF THE EAR. 485 Diagnosis. — The circumscribed core will distinguish the boil from ordinary forms of inflammation. It generally be- gins in the hair cyst, and the core is found at this point. Treatment. — If the system is strumous, sulphur, in small doses, should be used, or sulphide of calcium three times a day, in doses of gr. 1 or 2, will soon arrest the constitutional tendency. After the furuncle commences, if the top is touched well, twice or thrice, with the comp. tinct. of iodine, it may abort it, as it frequently does boils and carbuncles ap- pearing elsewhere on the body. When much inflamed, the tincture of aconite is the remedy that should be applied to the boil once a day. Abscess of the Ear. The meatus is subject to abscesses, which often prove very troublesome, being attended with severe pain in the ear, which prevents the patient from sleeping. These abscesses are swell- ings of various sizes, flat or round, and of a very firm consist- ency, with broad bases, but without any well defined border, Their color may not differ from that of the surrounding in- tegument, but they are always extremely sensitive to the touch. Sometimes the adjacent tissues are so intensely swollen that the auditory canal is quite closed, and the hearing is almost entirely suspended for a time. In some severe cases the external ear is so swollen that it stands out very straight from the head, and is very tender to the touch, the motion of the jaw in chewing causing great pain. There may be more or less general fever for a few days. Treatment.—If the patient is seen at the beginning of the trouble, warm fomentations of hops or mullein leaves, may cut short the attack. If it is not thus aborted, the abscess should be opened as soon as possible. Eczema of the Ears. Eczema of the outer ear is a very common affection. After repeated attacks, the auricle and meatus become thickened, 486 THE practice of medicine. the calibre of the latter being more or less narrowed, and con- sequently deafness folloVs, to the extent of the narrowing of the auditory canal. This affection is characterized by a dis- tinct eruption, with some redness and small vesicles which generally run together. There is also a viscid discharge from these vesicles which stiffen the linen. The vesicles appear in successive crops, and so frequently prolong the disease for years. The eruption in most cases causes much itching and heat, and proves very obstinate. Treatment.—We must moderate the inflammatory action at the outset Lime-water and some bland oil, as olive or cas- tor oil, will sometimes do good service at. first. If there is a discharge an application of starch and oxide of zinc, in equal parts, serves to exclude the air. If the auricle is raw, a wash of boracic acid (saturated solution) is a good application, or gr. 2 of sulphate of zinc to § 1 of rose water, may be gently applied with a bit of cotton or on a small stick. After the dis- charge has moderated, or been checked, and the parts become dry, the oleate of mercury will aid in the cure, applied with a fine, soft pencil brush. At the same time, the patient should take the tincture of arsenic, in doses of gtt. 1 to 2, three times a day, alternated with gtt 30 of berberis aquefolium, or the tinct. of dulcamara. Occasionally, after using the above reme- dies two or three weeks, the patient should have the sulphide of calcium, in doses of gr. \ to 1, three times a day, for two or three weeks, and then the old remedies again, or the tincture of sulphur for two or three weeks. If the ear continues to discharge a viscid fluid, gtt. 2 to 3 of the tincture of rhus toxi- codendron taken for a week or two, will sometimes have a good effect. The red iodide of mercury ointment (say gr. 4 to 6 | 1 of simple ointment) may be carefully applied, or the oleate may be used, made by adding gr. 2 or 3 of the biniodide of mer- cury to 1 1 of oleic acid. DISEASES OF THE EAR. 487 Simple Otorrhea. Otorrhoea is a discharge from one or both ears, very often of a purulent character. It is a very common disease in chil- dren, and it sometimes attacks infants. It may first start from the lining of the meatus auditorious externus as a result of inflammation, but it afterwards becomes chronic, and then tedious and obstinate. Sometimes during dentition, the sup- pression of this discharge induces disease of the brain, and so it is best not to suppresss it by local applications during that period, but to treat the constitutional vice. These cases are generally dependent upon some strumous taint, which should always be removed. Treatment.—Where there is a profuse, ichorous discharge with debility, gtt. 1 to 2 of tincture of arsenic should be ordered three times a day. If there is caries of the mastoid process and ossicula, with a foetid discharge, I administer gr. 1-50 of the chloride of gold, three times a day, or the sul- phide of calcium in gr. 1 to 2 doses may be given three times daily. Locally, boracic acid (saturated solution), is an excel- lent remedy. Aspergillus. Aspergillus is an inflammation of the auditory canal believed to be a secondary disease, resulting from diffuse inflammation of these parts. It is mostly found associated with eczema of the ear. Microscopical examination has dem- onstrated the identity of this fungus in the diseased auditory canal. Prof. Roosa states that he has never seen a case of this growth of vegetable fungus in a sound eaf. He further says that this fungus is actually a mould such as is found upon damp walls and bread that is kept dry. Symptoms.—There is itching and a sensation of fulness m the ear Tinnitus aurium, vertigo, impairment of hearing and more or less pain, not very acute but dull, are all present. By 488 THE PRACTICE OF MEDICINE. examining the meatus, whitish or sometimes rather blackish flakes may be seen adhering to the walls of the canal, which are often mistaken for epidermis or hard wax. I have seen these flakes completely block the canal, thereby destroy- ing the hearing until they were removed. When this is done the mass may be soft. When the casts are removed the tissue beneath is found to be red and tender. This fungus soon returns after being removed, if not destroyed by proper reme- dies, both-local and constitutional. Diagnosis.—The diagnosis can not be certainly made with- out the microscope in the hands of one experienced. Several varieties of aspergillus have been seen, but as the treatment for one variety does not differ from that of another, it is use- less to separate them. Treatment.—The treatment of this fungus is somewhat like that of other parasitic diseases, tedious, although rather simple. One of the first things to be done is to destroy the parasite, and then to treat the inflammation, for after the removal of the fungus, the inflammation still remains in some cases. The ear should be thoroughly syringed out with warm water and then dried with lint and an astringent applied. Some cases have done very well by applying 50 or 60 per cent, of alcohol, or if the parts are very tender, one part of alcohol to three of water into which tannic acid may be dissolved ad sat- urandum. Eucalyptus (tincture), one part and glycerine one part is a good remedy. Hardened Wax. Accumulations of hardened wax do not constitute a primary affection, but are a mere symptom of some other disease ; hence their removal, though attended with temporary benefit, is not attended with final success. I have tabulated statistics of 165 cases (by Toynbee) in which the hardened cerumen was removed, 60 cases proved successful, 43 were much improved, 103 were considerably improved, and there were 62 DISEASES OF THE EAR. 489 that were very slightly or not at all benefitted. In 105 of these 165 cases, some other primary disease existed; hence the mere removal of the hardened cerumen did not prove a success. This wax in the external auditorius is indicative of obstruction of the eustachian tubes, or of a thickening of the tympanic mucous membrane, or of debility of the auditory nerve, or of anchylosis of the stapes. The ear should be well examined with a good instrument in every case after the hardened wax is removed. Causes.— The causes in cases not depending on other diseases are the narrow calibre of the meatus, the application of cold, the mixture of dust from a gin, flour, or threshing mill with the cerumen, and also the habit of using the end or point of a towel or an aurilave, whereby the cerumen is pushed towards the membrana tympani. Symptoms. — One of the first symptoms is sudden deaf- ness, which may follow a cold (by which the dermis is tumefied), getting water in the ear, bathing, etc. This deaf- ness may suddenly disappear for awhile, w ch a cracking sound in the ear, caused by the movement of the hardened mass of cerumen. A feeling of fulness is often complained of, and not unfrequently there is giddiness or pain, and singing in the af- fected ear, or in both if both are attacked. These collections may remain in the ears for many years, if not treated properly. If this mass is very hard, it is liable to cause more or less in- flammation of the meatus, and consequently should be removed. Diagnosis. — The speculum, with a good reflector, in a good light, is the only certain means of determining the true condition of the ear in deafness. Treatment.— The first thing to be done is to remove the hardened mass of cerumen, which can be done by putting a few drops of equal parts of water and glycerine into the ear. This soon softens the wax, and then it can generally be re- moved with a syringe and warm water. Where these hard- 490 the practice of medicine. ened masses of cerumen have been retained in the ear for a long time, it may be difficult to remove them. If the mass can not be removed after the use of the above means, Prof. Roosa advises that a solution of bicarbonate of sodium be used with the syringe ; a teaspoonful to half cup of warm water is sufficiently strong. If this fail, I have found the probe generally successful in breaking up the mass, and then the syringe and warm water will soon remove it. I have had cases in which I had to use fine forceps to dislodge the mass from the meatus. Where the hearing is still very defective, after the removal of these hardened masses of cerumen, Politzer's method of inflating the middle ear should be employed to replace the drum head, which, in such cases, is generally found sunken inward. Sometimes small flakes of cerumen still remain, and cause very unpleasant symptoms. If this happens, they may be seen by means of the reflector and the speculum, and then removed with the syringe and warm water, or soda water. Foreign Bodies in the Ear. I have known several bad cases of disease produced by unskillful attempts to remove foreign bodies from the ear or nose. Injudicious attempts to remove foreign bodies from the ear are calculated to do more harm than the foreign bodies themselves. After a thorough examination, if any foreign substance is seen in the ear, it should be carefully removed, so as not to press the substance against the membrana tympani or drum-head, for this would not only cause great pain to the patient, but might also injure the hearing permanently. There are various means at our command for the removal of foreign bodies from the ear, but the safest is the syringe and warm water. This seldom fails, if anything else would succeed. A loop of silver wire has also been used with success. DISEASES OF THE EAR. 491 Insects in the Ear. It is not uncommon for small insects to crawl or fly into the ear, and they soon produce very unpleasant, if not painful sensations. As soon as they come into contact with the mem- brana tympani, they produce extreme pain, in the ear. I once saw a colored woman, into whose ear a wheat-bug had crawled, and fastening upon the membrana tympani, produced the most excruciating pain, rendering the woman almost frantic A physician extracted it very easily with a long pair of forceps. I was called to see an old toper some years ago, into whose ear a green fly had crawled while the old man lay in a profound stupor from intoxication. This insect had deposited its eggs in the ear, and they had turned to larvae or maggots, annoying him greatly. I readily removed them with diluted spirits of camphor. Treatment.—Labarraque's chlorinated sodium will kill the larvae of most insects, and then the syringe will usu- ally remove them. If it does not, the forceps must be used. Catarrh of the Ear. This is most frequent of all affections of the ear, and one of the most common causes of deafness. Acute aural catarrh may at first consist in mere hyperaemic swelling of the mucous mem- brane, with more or less increase of mucus secretion, or the disease may extend into the most dangerous form of inflamma- tion. The mild form may pass off in a few days without impairment of function. It may be the result of a cold, of getting the feet wet, or of exposure of the ear to cold air. Symptoms.—This disease commences with running of the nostrils, dull pain over the eye-brows, sore throat, ringing noises in the ears, slight impairment of hearing (which is relieved by sneezing), and with coughing and blowing the nose. It involves the eustachian tube and tympanum, and there may be catarrhal inflammation of the nasal passages, fauces, 492 THE PRACTICE OF MEDICINE. bronchial tubes, and sometimes the lungs may be even involved. There may also be redness of the membrana tympani, and increased secretion. Hearing is somewhat impaired. When the inflammation runs higher, the symptoms are more general. There will be sore throat, painful and difficult deglutition, and coughing, sneezing or blowing the nose, which increases the pain by forcing the air through the constricted and inflamed eustachian tube. Sometimes there are cracking sounds in the ear, and a sensation as if the drum was bursting, or else this last can not be inflated at all, from the fact that the tube is com- pletely closed up. In this case the patient's own voice rever- berates. This form of inflammation is apt to affect the mem- brana tympani and the. mucous lining of the whole cavity, and if not checked, results in the chronic form, in which the hear- ing remains impaired. The pain in this disease is in propor- tion to the degree of inflammation, and to the layers of the membrana tympani involved in the trouble. Aural catarrh is more common in early life than in maturity, but the disease is, generally sp'eaking, more severe in adults than in children. Prognosis.—If acute catarrh of the ear does not run on to suppuration, and the membrana tympani does not become per- forated, the prognosis may be considered favorable in most cases. But if secondary changes should take place in the fenestrae or labyrinth, the prognosis is unfavorable. Treatment.—Some writers advise the local abstraction of blood by means of leeches, which has succeeded very well with me in connection with general treatment. The leeches should be employed early, and applied near the seat of the disease, six or eight in front of the tragus and some below the lobe of the auricle. Fomentations, or the vapor bath, applied to the inflamed ear have done well with me. I usually apply the steam from a pan of boiling herbs, such as mullein, balm, horse- mint, etc., which should be very frequently repeated. If the pain is very acute. I apply the wilted leaves of stramonium to the ear, and a liniment of belladonna, camphor and aconite in DISEASES OF THE EYE. 493 equal parts, rubbing on six or eight drops once or twice in the day. Again, I use aconite and belladonna with the spray apparatus, using gtt. 1 of aconite and gtt. 3 of belladonna each time. Chronic Otorrhoea. Suppuration of the ear, called "running of the ear," depends upon a peculiar diseased condition of the middle ear, and is a very loathsome affection. It is mostly a sequela of some previous disease, such as scarlet fever, of measles and the exanthemata, an old, neglected catarrh, or it may originate from some injury of the internal ear. Children have it very frequently, and sometimes without any apparent cause. It is a condition of very serious import, and should always receive the most prompt attention. If it is not effectually treated it may be followed by the loss of hearing. It is attended not only with bad health, and with all the disadvantages of loss of hearing, but it is also a source of great distress to the patient, as he is aware that he is a loathsome object to his friends. This chronic or sub-acute catarrhal inflammation of the middle ear, attended with suppurative inflammation of the tympanum, may result from small-pox, scarlet fever, measles, typhus fever, diphtheria, pneumonia, ordinary cold or a scrofulous or syph- ilitic dyscrasia. The final results are, exostosis, polypi, diseases of the mastoid cells, caries, necrosis, meningitis, cerebral and cerebellar abscesses, pyaemia, phlebitis, paralysis and some- times even insanity. Drs. Toynbee and Roosa cite a great many cases of fatal cerebral disease, as the result of tympanitic affections. These fatal terminations may take place after the patient has had otorrhoea for several years. The roof of the tympanum being in contact with the meninges of the brain, and the bone here being rather thin, porous, and sometimes entirely absent, the tympanum in some cases actually forms a portion of the cavity of the cranium. This fact should not be forgotten by aurists and physicians. The floor of the tympanum being sometimes 494 THE PRACTICE OF MEDICINE. membranous and bony, aud lying somewhat lower than the floor of the external auditory meatus and the orifices of the mastoid cells and eustachian tubes, is often the seat of puru- lent suppuration. Polypi and exostoses of the tympanum may result from this disease, and the chronic suppuration may prove fatal, either by caries and pressure, or by blocking up the discharge and thereby producing meningitis. Suppura- tion of the tympanum is very apt to affect the mastoid cells, and acute periostitis or caries may result therefrom, extend- ing to the meninges of the brain and proving fatal thereby. Caries may affect the temporal bone, and if so, renders the disease very dangerous, as it is apt to result in meningitis, abscess, phlebitis or haemorrhage. It is quite difficult to deter- mine when caries has taken place, but if suppuration persist- ently resists treatment, and is very offensive to the smell, caries may occur from the pus or from the products of its decomposition entering the circulation through the mastoid veins or lateral sinus. According to the latest aural authors, it appears that from one-third to one-half of the cases of abscesses of the cerebrum arise from abscess of the ear. This is readily conceived, if we remember the immediate connec- tion of the dura mater with the roof of the tympanum. The cerebellum may contain collections of pus, especially after chronic disease of the mastoid cells. There may be caries of some portion of the temporal bone and disease in the mastoid cells, without perforation of the drum head, but such cases are rare. Small perforations through the drum head are more unfavorable than large ones, or where the membrane is entirely destroyed. Symptoms.—One of the first symptoms of this disease is a discharge of pus from the ear, which varies greatly in quan- tity and consistency, and may only appear at intervals, or be continuous in its character. It may be scanty or very profuse in quantity. The patient is apt to suffer from pain in the ear when he or she takes cold, and this pain is apt to be much less DISEASES OF THE EAR. 495 or entirely absent after a free discharge is established. Upon examination of the ear after discharge has ceased, there will be seen at the bottom of the cavity of the drum a hard mass of dried pus and wax. With chronic suppuration of the middle ear hardened or impacted cerumen is often found, which may completely suppress the discharge. The drum head or mem- brana tympani in this affection is almost always found to be perforated or entirely destroyed, and very often with it comes the loss of the mallus and incus, and in some cases the stapes also. In spite of these losses, fair hearing may still remain in some cases, but usually this is very much impaired or entirely lost for life. If the fenestrae are seriously involved in the inflammation, the power of hearing is quite limited or entirely destroyed. The general health may or may not be very much impaired in these cases of old chronic suppuration of the middle ear. Some physicians, and most non-profes- sionals, have a prejudice against arresting the discharge, but there are no grounds whatever for such fear. Treatment.—If the discharge is very offensive, and there is caries of the mastoid process, or if the meatus externus is seen lined with pus, the drum seen to be perforated, the ossi- cula are destroyed, and there are fistulous openings through the mastoid process, or where there has been syphilis, or where the patient has taken mercurials to excess, the chloride of gold will be an appropriate remedy, and may be taken in doses of gr. 1-60, three times a day. If the patient is very feeble, and his health declining fast, and there is a profuse and ichorous discharge from the ear, I find the tincture of arsenic useful, in doses of gtt. 1 to 2 every three or four hours. If this disease occurs in persons, old or young, who have sores about the head, and especially behind the ears, and who have great tendency to ulceration on the body, black lead (graphites) is a valuable remedy, in small doses. If it occurs in cori'nection with tonsillitis and catarrh of the eustachian tube, iodine in small doses will aid in the cure, or a wash of boracic acid. CHAPTER XXXII. DISEASES OF THE NOSE. Catarrh : Coryza. THIS is an inflammation of the mucous membrane, lining the nasal cavity, which frequently, in a few days, involves other parts of the respiratory mucous tissue. It is character- ized by redness and swelling of the mucous membrane with a discharge from it, which is thin and watery at first, but finally becomes muco-purulent It is called catarrh, meaning " a flowing down." It is also called " cold" by the people, because they see it very often resulting from sudden changes of temperature, or from exposure to wet and cold air, while the body is perspiring freely. It is usually preceded by more or less indisposition, a sense of dullness, more or less weight about the head, and sometimes a dull pressure in the head, giving rise to the name gravedo or coryza. There is hyper- aemia of the mucous tissue which causes dryness, prickling and constant sneezing, which is soon followed by the characteris- tic discharge. In mild cases the morbid process may end in disease of the nares, but it usually soon extends further. It generally spreads very soon from the mucous membrane to the epidermis, inflaming the nose-wings and the upper lip. Sometimes it spreads upward into the frcntal sinuses, or through the lachrymal duct to the lachrymal sac, and some- times even to the conjunctiva, the Highmorian cavities, or back- ward into the retro-nasal cavity. In this case it often affects the eustachian tubes, causing constant ringing in the ears, and some deafness. It may finally extend to the larynx, trachea and bronchial tubes, giving rise to a tickling cough. Catarrh may also be attended by neuralgia of the fifth pair of nerves, 496 DISEASES OF THE NOSE. 497 causing extreme suffering. It often prevails as an epidemic. Some persons have a predisposition to this condition, and there is a form of it that prevails in the summer season called "hay fever," which, doubtless, is produced by some peculiar irritant upon the mucous membrane. It is believed that the pollen of certain plants causes this fever, which is like a severe cold. Causes.—The most frequent cause of common catarrh is a sudden change in the atmosphere or exposure of the body to a stream of cold air when the skin is perspiring freely. The vapors of burning sulphur, or those of iodine and and acrid gases may also produce catarrh. It is one of the initial symptoms of measles. The epidemic form is caused by some peculiar (unknown) poison in the air, which is perhaps a deficiency of ozone. Some writers believe catarrh to be con- tagious, like purulent ophthalmia. The average duration of simple catarrh is about two or three weeks, although some complicated cases last much longer. An acute attack, if neg- lected, or if dependent upon peculiar constitutional dyscrasia, often terminates in a chronic form, which is quite tedious. Nasal blennorrhcea, or purulent nasal catarrh, is characterized by a purulent secretion. This form is sometimes found in young babes as the consequence of infection from acrid leu- corrhoeal discharge at the time of confinement. Gonorrhoeal virus may also produce it in a grave form. The gonorrhoeal form is very obstinate. Treatment.—In the stage of incubation, in which there is a dry state of the mucous membrane, headache, sneezing, run- ning of the nose, roaring in the ears, thirst, dry cough and hot and dry skin, gtt. 1, of aconite every hour, or gtt. \, every half hour, will be the proper remedy to begin with. If the discharge becomes acrid and burning, the carb. of ammonium in doses of gr. 1 to 3 every hour will relieve this peculiarity. If there is loss of smell and great soreness of the nose, the muriate of ammonium is an efficient medicine in doses of gr. 2 to 3, every hour, In cases attended with frequent sneezing 32 • 498 THE PRACTICE OF MEDICINE. and symptoms of asthma, aralia racemosa acts very well, in doses of gtt. 20 to 30 of the tincture, every hour. If there is a throbbing headache, excoriating discharge from the nose, hoarseness, and a burning, raw sensation in the throat, with dry cough at night, gtt. 1 to 2 of tincture of arsenic should be given three times a day, until these symptoms are relieved. Summer colds, with violent sneezing, are relieved by gelsem- inum and aconite, gtt. 1 of aconite to gtt. 20 of gelseminum every three hours. In some cases that I have treated in which there was a free, watery discharge from the nose, a burning sensation, frequent sneezing, redness and swelling of the nose, intense redness of the face, severe pulsating headache, injec- tions of the conjunctiva, profuse lachrymation, dryness of the throat and swollen tonsils, all of which are worse in the even- ing, belladonna will give relief, in doses of gtt. 1 to 2, every three hours. Where the catarrh is attended with alternate chills and fever, and fluent discharges from the nares, I order camphor, in doses of gtt. 2 to 3 of the saturated tincture, every two hours, and follow it up with such other remedies as are indicated. If there is soreness of the chest, cough with tough sputa, pain over the root of the nose and soreness of the eyes, gtt. 3 to 5 of tincture of sanguinaria may be taken every two hours until the symptoms are relieved. If the disease occurs in children, and they have what is called the " snuffles," small doses of the carbonate of ammonium is the best remedy. If they are feverish I give gtt. ^ of aconite every two hours. Chronic Catarrh: Ozena. This form of catarrh results from an acute attack in conse- quence of bad treatment or neglect, especially when the acute form was attended with a purulent discharge. It may and often does occur from a scrofulous or syphilitic dyscrasia in the person attacked. Symptoms.—At the beginning of the disease the mucous membrane becomes thickened and livid, and finally shrinks, DISEASES of the nose. 499 becoming thin and pale. The epithelial cells are partially destroyed, or become turbid, the mucous membrane appearing uneven and opaque. There is generally a profuse purulent discharge of an offensive odor. The discharge frequently forms crusts, which firmly adhere to the membrane beneath, and which are of a greenish color, sometimes being mixed with blood. Chronic catarrh usually attacks persons of a scrofulous or syphilitic taint. A patient may have chronic catarrh in a mild form, attended by a very profuse but thin discharge, or sometimes by a thick discharge, which is not offensive. It may entirely destroy the bones of the nose. It may also pro- duce polypoid excrescences. It may then spread to the frontal and Highmorian cavities, or to the skin surrounding the nos- trils, excoriating the upper lip, and infiltrating the cervical glands. This form of catarrh is always attended with the loss of smell. It is of a very intractable character as well as a very annoying one to the patients and their friends or associates. Treatment.—If the nasal bones are sore to the touch and ulcerated, or if there is a foetid discharge from the nose, ulcer- ation of the nostrils, of a syphilitic origin, the chloride of gold and sodium is the proper remedy, in doses of gr. 1-50, three times a day. If scabs form in the posterior nares and behind the uvula, the carb. of barium is a valuable agent in doses of gr. 1-10, three times a day. When it attacks the antrum Highmorianum, I use berberis vulgaris, in doses of gtt. 30, of the tincture or berberis aquifolium in the same quantity. If ' caries, pain in the bones and neuralgia attend ozaena, I order the tincture of arsenic, in doses of gtt. 1 to 2, alternated with gr. 1-50 of chloride of gold and sodium, given every three hours. If there is a discharge of crusts, tinged with blood, or ulcers on the septum or mucous membrane of the nose, and if there is a foetid discharge from the nose and loss of smell, I administer the bichromate of potassium in doses of gr. 1-10, every three hours. If the disease occurs in old syphilitic patients, or after the abuse of mercurials, the iodide of potas- 500 THE PRACTICE OF MEDICINE. sium is the proper remedy, alternated with the tincture of stil- lingia. Where there is a thick yellow or green and foetid dis- charge from the nares, and where the nose is swollen, and the alae are ulcerated, pulsatilla is invaluable in doses of gtt. 3 to 5 of the tincture, every three hours, especially in females, whose menstrual discharge is irregular or scanty. Influenza. This is a type of catarrh that, in many respects, resembles the preceding forms, but differs from them in several particu- lars. It attacks not only the respiratory apparatus, but also the digestive organs, and is attended by considerable fever and pain in the head and limbs. Causes.—The exciting causes are unknown. It often spreads very rapidly over certain localities. Diagnosis.—The distinction between influenza and com- mon epidemic catarrh lies in its rapid march over a country, and its entire independence of weather and season. Treatment.—If the fever is high, and there is a dry cough, I find gtt. 1 of aconite very useful, given every two hours, and if there is headache and profuse discharge from the nose, gtt. 20 of gelseminum may be added to each dose of aconite. If there is an acrid discharge from the nose, I have found small doses of iodide of arsenic one of our best remedies, or if there is profuse lachrymation, I use sabatilla. Rose Cold: Hay Fever. This is a febrile form of catarrh, affecting the conjunctiva and the mucous membrane of the nose and upper air passages, and is sometimes attended by symptoms resembling those of asthma. It attacks those that are peculiarly predisposed to it, and is very apt to occur every year about the time certain plants bloom, or when hay is being cut and stored away. In some persons it may occur at any time from May to Septem- ber in certain localities. DISEASES of the nose. 501 Causes. — From experiments, carefully conducted, the pollen of flowers of certain plants has been found to readily excite the mucous membrane of the respiratory passages, and develop hay fever. The pollen of freshly dried grass quickly produces the disease, which is always more mild in the house than in the air. Inhabitants of certain localities are much less subject to attacks than others. It is a very rare disease in some portions of the Northwest, and there are some places on the Northern lakes where it is entirely unknown. This was tested by a friend of mine in this city. Treatment.—To entirely prevent this disease, the patient should be advised to take up his sojourn at the seaside, or on an island or narrow peninsula where the air is least impreg- nated with the pollen of plants and grasses. There are also many high mountains entirely exempt from this disease. There have been a great many remedies proposed for hay fever, some of which are valuable. If the discharge from the nose is profuse, and if there is soreness of the throat, arum triphillum is the remedy indicated, in doses of gtt. 1 or 2 of the tincture every two hours. Gtt. 2 or 3 of tincture of cam- phor, every two hours, is proper while the chilly stage lasts. After the fever sets in I find nothing better than aconite and gelseminum, given every three hours in moderate doses. If it affects the trachea or bronchial tubes, I order euphrasia hourly, in doses of gtt. 2 to 5 of the tincture. It may be alternated with grindelia, in doses of gtt 5 to 20. Epistaxis. Bleeding of the nose is often in consequence of an anaemic or chlorotic condition of the patient. It may occur with dis- ease of the heart, lungs and spleen, and in that case is an unfa- vorable omen. In advanced life it indicates threatened apo- plexy. Causes.__Mechanical injuries, such as a fall or blow on the nose, are the exciting causes of this trouble, or hard cough- 502 THE PRACTICE OF MEDICINE. ing may produce it. It often occurs from suppressed menstru- ation or haemorrhoids, and from picking the nose. Treatment.—If from mechanical injuries, the internal remedies are aconite or arnica, but if from arterial congestion, attended with palpitation of the heart, aconite is called for. If from congestion of the head, attended with vertigo, I give bel- ladonna, in doses of gtt. 3, every three hours, until the blood ceases to flow. I have usually aided the above remedies by applying to the bleeding surface small bits of lint, wet in a strong solution of Monsel's salt of iron. This seldom fails to arrest the bleeding quickly if pressed firmly against the bleed- ing vessel. In anaemia I find that the chlorate of iron, in doses of gtt. 20 or 30, three times, often arrests passive haemorrhages from the nose or other parts. If there is attenuation of the coats of the veins, with rupture, then hamamelis, in doses of gtt. 5 to 10, four times a day, will quickly arrest the haemor- rhage. The patient should keep very quiet, and his diet be light and heating. He should compress his upper lip. CHAPTER XXXIY. DISEASES OF THE FACE. BY closely observing the expressions of a patient's face, much may be learned of the degree and severity of dis- ease, by an experienced physician. A delicate expression of the face, together with long eyelashes and expressive, brilliant eyes, may be regarded as signs of constitutional tendency to tuberculosis. Thick upper lip and thickened alae of the nose indicate a scrofulous diathesis. Waxy and pasty skin marks chlorosis, while a peculiar pallor shows anaemia. A puffy condition about the eyelids, in anaemia, indicates albuminuria, or a sunken face marks diarrhoea or other exhausting diseases, such as haemorrhages, want of nourishment, etc. A wrinkled face in children or young persons is a sign of poor nutrition, and in boys or half grown lads points to onanism or other bad habits. Spasmodic distortion of the sardonicus muscle, is a sign of severe irritation and inflammation of the brain, which prevails in pericarditis, diaphragmitis, ileitis and disordered menses. It is also indicative of colic and neuralgia. A stupid, rigid, staring and sometimes smiling countenance is found in diseases of the brain and in typhus and typhoid fever. A very sad, anxious and restless expression indicates disease of the heart, pleura and lungs. A very apathetic, morose or long-faced expression points to disease of the bowels. Red- ness, if constant, indicates a tendency to gout and haemorrhoids or is a sign of indulgence in strong drink. A changing red- ness in children, reveals dentition, or in women, approaching menstruation. A very vivid, bright redness of the face reveals disease of the nervous system, as hysteria, etc., or it often indicates a haemorrhagic tendency. A dark, purplish redness 503 504 THE PRACTICE OF MEDICINE. marks a tendency to apoplexy, suffocation or congestion. A deep red spot on one side of the cheek occurs occasionally in encephalitis, and also in pneumonia, and occasionally in dis- eases of the heart and abdomen. A hectic flush occurs in phthisis. Sudden paleness around the mouth denotes in children colicy spasms. A pale, white and wrinkled face in children points to chronic hydrocephalus, while with them a very sud- den paleness, with severe limping, shows hip disease. Pale- ness in women indicates suppressed or profuse menstruation and chlorosis, or, in the pregnant state, threatened abortion or severe haemorrhage. Sudden paleness about the nose in scar- let fever indicates metastasis to the brain, and during desqua- mation, it points to the approach of dropsy. Very sudden paleness after a fall is a sign of concussion of the brain. Blue- ness of the face generally indicates diseases of the heart, as dilation of the ventricals and disease of the valves, but in chil- dren it denotes cyanosis, which is apt to prove fatal. A gray- ish livid or lead-color of the face signifies scirrhus or gan- grene. A yellowish color of the face points to disease of the liver. It is deep yellow in jaundice; not so deep in bilious fever. Brown spots on the face of women indicate either pregnancy or irregular menstruation. If irregular brownish spots, a little raised above the adjoining skin appear on chil- dren, they denote congenital syphilis. Small varices on the left side of the nose, lips, glans penis (in men), or labia (in women), indicate venous obstruction in the heart. Ring worms about the body or face points to disease of the kidneys. Erysipelas. This disease has been described under the head of skin diseases, nevertheless, it may be well to refer to it here. Ery- sipelas of the face—like that of other parts of the body, con- sists in an hyperaemic state of the cutis, with profuse infiltra- tion of the lymphatic, the cutis and the subcutaneous areolar DISEASES OF THE FACE. 505 tissue. It may assume a phlegmonous form of inflammation, as it does in erysipelas of the scalp. Treatment.—The reader is referred to erysipelas of the scalp for general treatment. I usually control the fever with aconite, and alternate that with the chloride of iron, in doses of gtt. 5 to 10, every three hours, sometimes making a wash of the sulphate of iron (say gr. 10 of it to 1 1 of water), and applying lint, or a cloth, wet in this solution to the part. Occasionally I use a solution of veratrum viride (tinct.) 3 1 to 1 1 of water, applied three or four times a day. If the fever runs very high (the skin being of a bright red color), and if the patient is inclined to be stupid or delirious, and complains of headache—belladonna is demanded, in doses of gtt. 2 to 3, every three hours; I alternate it with gtt. 1 to 2 of rhus toxi- codendron, which is apt to cut short the disease. If erysipe- las assumes a malignant form, and the swelling becomes very great, with severe burning, and a tendency to gangrene, the tincture of arsenic is indicated in doses of gtt. 2 to 3 every three hours. The disease may be prevented from spreading by aPplymg a saturated solution of nitrate of silver around the diseased patches so as to make a distinct ring of the silver around the diseased part. It must be carefully done or it will not succeed. Milk Crust. This affection is confined to nursing infants. It com- mences witn a patch of pimples, slightly elevated above the level of the surrounding integument. These patches increase in size, becoming more and more inflamed from rubbing, and the cuticle is raised in circles, which are soon broken by friction. The surface finally becomes raw and swollen, and pours out an ichorous, foetid exudate, which dries and forms a crust on the scalp that is sometimes hard to detach. The irritation of milk crust gradually increases, and the patches of the disease 506 THE PRACTICE OF MEDICINE. spread until it covers the entire scalp, or perhaps even attacks the ears, causing filthy ulcers upon or behind the ears. Some- times the secretion changes, first to a milky, then to a yellow, and finally to a purulent fluid. In this stage small pustules are developed upon an inflamed surface, hence it has been called " impetigo," which it resembles very much in this stage of the disease. At this time the crust becomes thicker and resembles dried honey in its appearance. Friction may cause blood to ooze out, which, mingling with the discharge, tinges it of various colors from brown to black. The discharge is often offensive. This disease is not always confined to the head and face, but sometimes spreads to the body, proving a source of great annoyance and suffering to the child. But it usually readily yields to a proper course of treatment. Treatment. —Where the discharge is acrid, and the dis- ease characterized by pimples and pustules, tincture of arsenic, in doses of gtt. -| to 1, three times a day, should commence the treatment. If the child is restless and is teething, and does not sleep well, belladonna will be found useful, in doses of gtt. \ to 2, of the tincture, twice a day, until the child becomes quiet and composed. If the teeth are slow in coming through the gums, the carb. of lime should be given in doses of grs. 1 to 2, thrice daily. This is a valuable preparation in tardy dentition. If there is great itching, sulphur will be the proper remedy for this symptom, in doses of grs. -| to 1 before each meal, triturated. And this may be alternated with rhus toxicodendron, in doses of gtt. -| to 1, three times a day. The head may be washed with carbolic soap and then anointed with sulphurous acid, and that alternated with an ointment of carbolic soap. Acne Punctata: Acne Rosacea. Acne punctata is simply a distention of the sebaceous fol- licles, the contents of which project above the surrounding skin and become black from the accumulation of dirt on the DISEASES OF THE FACE. 507 comedones. These comedones, when pressed out, resemble little warts. Acne punctata is simply an irritation set up around the hair follicles, which causes retention of the secre- tion and an inflammatory process. Acne rosacea is a chronic inflammation around the glands, erythema and a new growth of connective tissue, which is independent of the glands. Some persons are naturally predisposed to this disease, especially about puberty, and sometimes afterwards. Acne indurata, called " stone pock," is an indolent or chronic form. In this form the pimples are hard, with a dusky red base; they are often painful and feel tight on the face, and the skin is con- gested and thickened. In acne rosacea there is much conges- tion, with bright redness of the face or nose that is affected, the veins are varicose, the face is much disfigured, the skin is very red and dotted over with pustules, and skin becomes thickened, and under stimulating food or drinks there is a burning sensation in the parts affected, with flushing of the face. In men that drink alcoholic liquors, there is such flush- ing of the nose as to give rise to the name of "grog-nose." Acne strophulosa is the " white gum rash." Treatment.—Belladonna, at the commencement of the disease, will do much good; it should be given in doses of from gtt. 1 to 3, according to age, twice or thrice a day. This may be alternated with gtt. 5 of pulsatilla, every four hours. These remedies may cure acne punctata, but acne rosacea is very difficult to cure. In this form, if there is a varicose con- dition of the capillaries, hamamelis is a good remedy, in doses of gtt. 5 of the fluid extract, every three or four hours, while it is also applied, with glycerine, equal parts, to parts affected, twice or thrice a day. A wash of the acetated tinct- ure of rumex is a good local application, alternated with a wash of borax water. 508 THE PRACTICE OF MEDICINE. Lupus. Lupus is a spreading tuberculous inflammation of the skin, usually upon the nose or face, tending to destructive ulcera- tion; it is apt to affect women, and may also affect men of strumous constitutions. This is lupus non-exedens; there is also a variety called lupus exedens, characterized by its very rapid and deep ulceration, and by its occurring on other parts besides the face and nose. Symptoms.—Lupus begins either as a shining, soft, circum- scribed swelling of the skin, usually on one side of the nose, cheek or eye lid, which soon ulcerates; or as a mere crack or small excoriation, covered with a thin scab, under which it slowly spreads in extent, And when the scab is removed the discharge, which is viscid and scanty, soon dries and forms another somewhat larger one in its place. Hence the ulcer- ated surface is constantly enlarging in one direction, while in another it is healing; and thus it may continue for years wan- dering over the whole face, sometimes completely destroying the alae of the nose or the eye lids, though in other parts it may not penetrate the entire thickness of the skin. The cica- trix left by this disease is very irregular and shining, of a dense whiteness, causing perhaps eversion of the eye lids and great distortion of the features. In some parts it feels soft and pulpy. The cause is not known, nor is its pathology understood. Treatment.—The treatment of lupus non-exedens may be successful, lupus exedens but is not so amenable to treatment External treatment is usually the most available. In the milder forms of this disease it is to be remembered that patches often disappear without leaving a scar. No strong caustics should be used in this affection. The following mild stimulant is useful especially when the patches are more erythema-like in appearance, recent, spreading and superficial, with little infil- tration, and with no involvement of the sebaceous glands: DISEASES OF THE FACE. 509 ]J. Zinci sulphat. Potassii sulphuret. aa - grs. 30. Aquae rosae - - - - 3 3^. Alcohol - - - - - f. 3 3 If the above be too strong it may be diluted, but if is not too painful, it should be used full strength. A stronger prep- aration should be used if the ulcer does not improve under the above, as: B;. Echenacea pulv. - - - 3 1 Pulv. Calaminis - - - - 3 ■§ ^theris - - - - - 3 1 Collodii flexilis - - - - 3 5 Mix, and apply after the scab is removed gently. The sapo viridis is a good stimulating application, often curing this disease, especially mild cases. It is best applied by spreading it on cloth in the form of a plaster, and renewing it as often as necessary. Sulphur ointment will suit some cases. I have used powdered hydrastis canadensis very suc- cessfully in some cases, while I gave the fluid extract inter- nally. If there is anaemia, the ferri iod. is required. Caustic potash may be required in some cases, but should never be tried until the milder remedies have failed. If strong caus- tics are required, I would prefer fuming nitric acid, carefully applied. Lupus exedens is the name given to a rapidly-erod- ing, ulcerative disease of the face, usually infiltrating epithe- lioma, rodent ulcer, or supposed to be syphilitic, but is not true lupus. Lupus vulgaris is a cellular new growth, charac- terized by various sized and shaped reddish or brownish patches, consisting of papules, tubercles, or flat infiltrations, usually terminating in ulceration and cicatrices. This disease varies according to its locality and the stage of its develop- ment It usually begins with small yellowish red or brown points under the skin, which increase in size, coalesce, and 510 THE PRACTICE OF MEDICINE. thus form irregular-shaped, roundish or irregular, ill-defined patches of various sizes. The points enlarge, and finally form papules, and then tubercles. At this stage the lesions are from the size of a pinhead to that of a split pea, and may be covered with a thin layer of imperfectly formed epidermis, which is painless. The disease may now terminate in absorp- tion at this stage, by leaving thin cicatricial tissue, or it may go on to ulceration and complete destruction of the infiltrated-. skin. Late in the disease there is pain in many cases. The affection is mostly found upon the face, nose, cheeks and ears, but it may attack the extremities, as the fingers, or it may attack the trunk. It is a very destructive form of disease. It is not considered hereditary. It is not so common in the United States as it is in Europe. It oftener attacks the ill-fed and the debilitated. The history of the case will determine the diagnosis between lupus and syphilis, and the ulcers of lupus are more superficial than those of syphilis. It is dis- tinguished from epithelioma by the less pain in lupus; then the ulceration of epithelioma generally starts from one point and spreads peripherally, while the ulceration of lupus usually begins at many points within the patch. Epithelioma seldom occurs in the young; lupus begins in childhood. Lupus vul- garis is a very obstinate form of skin disease. Hygienic treat- ment is of much importance. Cod-liver oil internally is an effective remedy. It should be alternated with the iodide of potash. Locally, a mixture of equal parts of iodine tinct. and glycerine promises good results. Tar ointment is a valuable antiseptic remedy. The ointment of iodide of mercury suits some cases, but requires care. Applications of the 10 per cent, solution of the chloride of gold and sodium, and from 1-100 to 1-150 grain may be given internally at the same time. I usually put gr. 1 of the chloride of gold and sodium to (§ 1) one ounce of distilled water; dose from 3 to 5 gtts. three times a day. Cistus canadensis, in alternation with the chloride of DISEASES OF THE FACE. 511 gold and sodium, in doses of gtts. 30 three times a day, aids the cure. Lupus vulgaris may attack the face, nose, or fibrous tissue, cartilages, and even the mucous membranes. If the papules or tubercles are firm, they may be removed with a paste of arsenic, as described elsewhere. An ointment of pyrogallic acid is very good. CHAPTER XXXV. DISEASES OF THE MOUTH AND THROAT. The Tongue in Diagnosis. MUCH stress is placed upon the tongue. A moist tongue is regarded as favorable in disease. A dry tongue in- dicates diminished secretions, and in fevers, points to the use of acids. A preternaturally red tongue is common in the course of eruptive fevers, gastric and bilious fevers (so-called), and in many bad cases of chronic dyspepsia. The redness is often confined to the tip and edges of the tongue. A livid or purple tongue is an indication of defective oxygenation of the blood. A furred tongue is common, and with red edges and tip, and pointed, indicates inflammation and irritation of mu- cous membranes. A furred tongue occurs with diseases of the brain, in all varieties of fevers, and in most acute and danger- ous diseases. Some persons have a coated tongue when they first arise from sleep, especially users of tobacco. A white- coated tongue is not very unfavorable; a yellow-coated tongue indicates a disordered action of the liver; a brown or black coat indicates a low state of vitality and some contamination of the blood. A gradual cleaning of the tongue from tip and edges, indicates returning health. If the tongue gets browner dirtier and dryer each day, the muscular and nervous systems get weaker. When the fur separates in patches, leaving a red, glossy surface, it is unfavorable, especially in fevers. A deep red, strawberry tongue, with raised papillae occurs in scarlet fever. A red, dry tongue indicates inflammation of the brain and its membranes, and is also found in inflammation of the thoracic viscera and of the mucous tissue of the stomach and bowels. Red tip and edges with a dry streak in the middle is 512 DISEASES OF THE MOUTH AND THROAT. 513 seen in typhoid fever, and inflammation of the bowels. If red, clean and glossy, it shows a grave form of fever, and an ap- proaching brain complication and delirum. A deep red or dark, cracked tongue indicates ulceration of the bowels. A red, moist tongue, smooth, indicates chronic gastritis. An un- usual pale tongue may be found in chills and fever, in spasms, after great loss of blood, in chlorosis, anaemia, dropsy and in general exhaustion of vitality. If the tongue becomes pale in the course of an attack of gastic, bilious, or exanthematic fever, it portends a fatal termination. A lead-colored tongue is seen in cholera, gangrene of the lungs, or of the stomach, and also in scirrhus of the tongue. If the lead-colored tongue occurs in thrush or stomatitis, it indicates a fatal termination of either disease. A bluish-colored tongue shows an impeded circulation, and occurs often in asthma, whooping cough, croup, bronchitis, pneumonia, valvular disease of the heart, dropsy, particularly of the chest, cyanosis, scurvy and salivation. A dry tongue is seen in a great many affections, especially in such febrile affections as tend to affect the stomach, bowels and brain. A dry, dark-coated tongue, if cracked, is an unfavor- able sign in typhus and typhoid fever. The tongue coated at the tip is seen is phthisis pulmonalis, and in extreme cases of bronchitis. A tongue coated only on one side indicates dis- ease of the liver and spleen. This one-sided coating of the tongue may occur also in affections of one lobe of the lungs. In tonsillitis, and often in gastric irritation, there is a thick, white coating of the tongue. Dirty, or light yellow, or a dirty white coating on the tongue indicates a septic condition of the system. A deep yellow color of the coating indicates disor- dered functional action of the liver. In acute hepatitis or in the chronic form, there is often a buff-colored coating of the tongue, and this may occur in enteritis. A dark brown coat- ing during the course of fevers indicates a very grave form of fever. A dark or black coating of the tongue, in an attack of dysentery indicates exhaustion, mortification, and approaching 33 514 THE PRACTICE OF MEDICINE. fatality. In jaundice a dark, heavy coating upon the tongue denotes organic disease of the liver or spleen, such as abscess, tubercles, induration, etc. Children with hydrocephalus, and " cretins," have a long, large tongue. A very small tongue, if not inherited, or associated with paralysis, indicates phthisis. A very broad tongue occurs in scrofula, rachitis, and some- times in intermittent fever. A narrow and pointed tongue shows a tendency to tuberculosis or inflammation. A large, heavy tongue in old people, indicates a great tendency to apo- plexy, especially in old drunkards. A heavy, large tongue in fevers, if dry and associated with stammering, indicates con- gestion of the brain. A hard tongue with brownish or red tumors, with blue blood vessels interspersed through them, indi- cates approaching cancer of the tongue. Fleshy excrescences and lumps upon the tongue, are indicative of elephantiasis. A dry, hard tongue may occur with congestion and inflamma- tion, or in fevers, tonic spasms, scirrhus of the tongue, or in other degenerations of the substance of the organ. Glossitis — Inflammation of the Tongue. Glossitis may affect only a portion of the tongue, or it may pervade the entire parenchyma of the organ. A superficial inflammation of the mucous membrane of the tongue may exist with inflammation of the mucous membrane of the mouth, but this is not so grave a form of the disease as acute glossitis itself. This, like all other inflammations, is of all grades. Symptoms.—One of the first symptoms is rapid swelling of the tongue. I have seen cases of salivation in which death took place from suffocation, from the very great swelling of the tongue, filling up the entire space in the palatine arch, and so pressing on the epiglottis as to prevent respiration. I saw once a beautiful young lady, who for an attack of pneumonia was so severely ptyalized that she was seized with the most violent form of glossitis, by which she soon suffocated, and died in a few hours. Her tongue filled her mouth, and pro- DISEASES OF THE MOUTH AND THROAT. 515 truded considerably outside of the lips and teeth. This affec- tion occurs thus from other causes in some localities in the West This disease rarely occurs except in connection with salivation. Corrosive poisons taken in the mouth may produce this affection. There is pain, usually of a dull character, gen- erally referred to the larynx and root of the tongue. After twenty-four hours there may be a flow of saliva, the pulse is usually accelerated and increased in force, with elevation of temperature. In most cases there will be more or less head- ache, especially in the frontal region. The disease may result in suppuration, forming circumscribed abscesses. But in some favorable cases the inflammation may reach its climax in from three to five days, then decline and disappear by resolu- tion. Young and vigorous persons are more subject to this disease. In severe cases of this disease the adjacent lymphatic glands become implicated, and sometimes also the salivary glands. The pain is now severe, and extends to the ears and throat. Gangrenous destruction of large portions of the tongue has occurred in some cases of mercurial glossitis, which are often followed by lasting indurations, having a great tendency to renewed attacks from time to time. This is one of my objections to the use of mercury, a remedy of very doubtful utility at best, but one of very great danger, and a remedy that sober investigation is very fast laying aside (with some other useless and dangerous remedies) for more safe and efficient remedial agents. There is sometimes partial glossitis, commencing with a small, hard tumor about the size of a pea, on the back part of the tongue, which may increase in size and finally suppurate, breaking and discharging the pus into the mouth. The most serious form of this disease seems to be that form caused by anthrax virus in the blood. Treatment.—When glossitis is attended with severe sting- ing and burning pain, or with blisters on the tongue, then aconite, gtt. 1 every hour, alternated with apis mellifica in 1 gtt. doses every hour until better, should be given. If there 516 THE PRACTICE OF MEDICINE. is a tendency to gangrene, then 10 to 15 gtts. of baptisia should be given every two hours, and 5 gtts. of tincture of arsenic every four hours. If this disease be the result of sali- vation, then the sulphide of calcium (1st dec.) should be given three or four times a day, in doses of 1 to 2 grs., well triturated, 1 to 9; or 3 to 5 gtts. of the saturated tincture of sulphur every two hours. The tincture of sulphur is quickly absorbed, and thus entering the blood, is much better than the crude sulphur. Some cases following the use of mercury are benefited by nitric acid, in doses of 1 to 2 gtts. every three hours. Cancer of Tongue. Cancer of the tongue is usually of the epithelial variety, and usually begins at the tip and at one edge of the tongue. It first appears as a small, hard lump, which finally forms a round ulcer, with distinctly raised edges and an uneven bottom. It may be distinguished from any ordinary form of ulcer by its very great tendency to rapid encroachment upon the surround- ing parts, by its indurated and lardaceous bottom, by the milky, viscid substance that, upon pressure, exudes upon its edges, and by the burning, boring, lancinating pains attend- ing it, which shoot along the nerves like a flash of light. After the cancer has progressed considerably, the adjacent tissues begin to swell and the ulcer rapidly spreads, either upon the superior or inferior surface of the organ. As the disease advances deglutition becomes more and more difficult, and any motion of the tongue is very painful. The salivary glands are much excited, and saliva is secreted in great abund- ance. The disease is apt to affect the lymphatic and other glands about the neck, and especially those about the throat and tongue. In some cases the tongue becomes firmly attached to the floor of the mouth, so that its mobility is much impeded and sometimes almost destroyed. The organ shortens, grows hard and lumpy, and finally becomes ulcerated and emits a DISEASES OF THE MOUTH AND THROAT. 517 very offensive odor. It is not unusual for the glands of the neck to become so much enlarged that the patient can not open his mouth, and he gradually sinks from starvation and intense mental and physical suffering, or he may live for three or four years in this very painful condition of suffering. Treatment.—As an internal remedy, arsenic is one of the best, alternated with the hydrastis canadensis, gtt.. 1 to 2 of the tincture of arsenic three times a day, with gtt. 5 to 10 of hydrastis. The ulcer may be dressed with the powdered hydrastis. Inflammation of the Gums. In this affection there is tumefaction of the gums, which is either mere congestion or inflammation. It is often the result of affected or decayed teeth. The swelling may be oedematous and spongy in character, as it is in scurvy, ptya- lism, or sometimes it is found in connection with stomatitis. In such conditions the gums bleed easily if touched. Ulcer- ation of the gums occurs often from a diseased state of the teeth, and from scurvy, syphilis, mercurial poisoning, noma and stomatitis. Gum-boils generally originate from diseased teeth. Inflammatory swelling may reach such a height as to distend the cheeks and side of the face, ending finally, per- haps, in an abscess, which, if not opened, will break and dis- charge pus. Treatment.—If bleeding of the gums be from scurvy, acids, such as citric or malic acid, with sour pickles, sauer kraut and acid fruits as a part of the diet, or if this haemor- rhage be from inflammation, astringent washes, such as the infusion of hamamelis, may be used, or the diluted fluid extract, locally used, and at the same time the hamamelis should be given internally, in doses of gtt. 5 to 8, every hour, until the haemorrhage is checked. Tinct. of myrrh held in the mouth is good. In cases of inflammation the face may be bathed m the following liniment: 518 THE PRACTICE OF MEDICINE. Tinct of arnica - - - f 1. Tinct. of aconite - - gtt. 10. Chloroform - - - - 11. Tinct. of camphor - - - § 1. Oleum olivae - - - 1 2. Aqua am. - - - - 3 1- Mix, and bathe the face with this three or four times a day and keep the swollen parts covered with the leaves of plantago major, well bruised. If suppuration ensues, give gr. 1 of the 1st dec. trit. of sulphide of calcium, three times a day. If there is any excitement of the circulation, gtt. 10 to 30 of tincture of lycopus virginiana, every two hours, with gtt. 1 of aconite to alternate, will control the circulation in a few hours. Dentition. The order of dentition is about the following: The two lower incisors come out between the fourth and seventh month. Then the four upper incisors come out in three or four weeks after the lower ones. And then, between the eighth and tenth month of the child's age, the two molars of the upper jaw come out. The lower incisors appear, then very soon the lower molars appear. Between the eighteenth and twenty-fourth month, the canine teeth make their appearance, and in two months thereafter, they are followed by the four second molars. There are exceptions to this rule. The period of dentition is attended with great danger to some children. There may be increased secretion of saliva, or the lips may ulcerate, the gums may inflame, as may the tonsils and soft palate. Diar- rhoea and catarrhal inflammation may attack the mucous tis- sue of the entire alimentary canal. Bronchitis may super- vene. Some children are troubled with cutaneous diseases, such as urticaria, thrush, lichen, prurigo, eczema, crusta lac- tea and impetigo; or the irritation may be reflexed upon the brain and nervous system, and the child may be attacked with spasms and eclampsia. Or the circulatory system may be the DISEASES OF THE MOUTH AND THROAT. 519 seat of irritation, and the child may have fever. Hence chil- dren must be watched. Treatment.—To aid the process of dentition, the child should have the hypophosphite of lime, in doses of grs. 1 to 2, three times a day, or the carbonate of lime (found just beneath the inner layer of the shell of the oyster), answers very well, tritu- rated. To prevent spasms, the child should have a milk diet, and should take small doses of belladonna, gtt. ^ to 1, three times a day, alternated with the tinct. of melilotus, gtt. 1 to 3, according to age. Or, if that is not at hand, the tinct. of Scutellaria and cypripedium, in the form of normal tincture, or fluid extract, may be given in doses to suit the age of the child. • Diarrhoea should be met with proper remedies. Decay of the Teeth. Decay of the teeth is caused by the use of mercury, acids and hot fluids; and it is often the result of using the fine, white, starchy flour, so attractive now to the ladies on account of its whiteness. The coarser part, containing the gluten and the phosphates (the essential elements to form the teeth and bones), are rejected and thrown to the bran; hence, it is diffi- cult to find a child that cuts its teeth in time, or without great suffering. And it is equally as difficult to find adults with a sound set of teeth. And what will become of the next gener- ation ? Dental decay may be also the result of microscopic parasites, and to a want of silicea in the system; or it may be due to injury of the teeth by chewing hard substances. The habit of cracking hard nuts with the teeth is also a great source of decay in the teeth. Treatment.__The use of the 1st dec. trituration of silicea, alternated with the carbonate of lime (from the inside of the oyster's shell), is generally successful, if the patient will dress the teeth with prepared chalk, and borate of soda, after meals. 520 THE PRACTICE OF MEDICINE. Odontalgia. If the teeth decay the patient is subject to attacks of odon- talgia, or tooth ache. Sometimes temporary relief can be afforded by applying to the cavity, creasote, oil of cloves, extract of plantago major, oil of mint, or menthol. But the best thing is to have the teeth filled by a good dentist. Acon- ite and oil of cajuput will sometimes give relief. Belladonna will relieve it if it is from congestion of the head. Gelsemi- num, internally, in doses of gtt. 25, every three or four hours, will often relieve it. If the pulp of a tooth is exposed, and sensitive, the application of a drop of carbolic acid on a bit of cotton, kept applied for several hours, will give relief. Or creasote may be applied in the same way. Sometimes arnica applied in the same way, is followed by relief. Sometimes where the gums are inflamed, cold water gives relief. Some- times a cathartic of salts relieves. Mumps.—Parotitis Contagiosa. This is usually a mild febrile affection, accompanied by a peculiar form of inflammation of the parotid glands, running a definite, self-limited course. It is a contagious disease. We know nothing of the nature of this contagion. The disease prevails often in an epidemic form, attacking a large number of those in a vicinity that are subject to it. Males are more subject to it than females, and persons from fifteen to thirty are more subject to it than the very young or extremely aged. The disease rarely attacks a person the second time, if he has had the disease in both sides. It is an inflammation of the parenchyma of the gland itself, often spreading to other glands. The disease is easily known by the swelling of the parotid gland, which stands out very prominently behind the angle of the jaw, lifting out the lobe of the ear, obstructing the opening of the mouth, and rendering deglutition painful and very dif- ficult. Acids cause great pain when held in the mouth. The DISEASES OF THE MOUTH AND THROAT. 521 submaxillary glands are often involved, giving that region an cedematous appearance. By the end of the fourth day general febrile symptoms have usually disappeared, the local swelling declines and the patient is usually convalescent in seven or eight days, except in cases in which only one side was attacked at first, then the other side may be attacked. In some cases a similar inflammation attacks one or both testicles in the male, or the mammary glands of the female; and the ovaries in the female may be attacked. It is supposed that the inflammation attacking the testes of the male, and ovaries and mammary glands of the female, result from sudden recession or transfer- ence from the parotid gland to the above named parts. But the orchitis often supervenes while the inflammation and swell- ing are still in progress. When the testes are attacked they become very painful and much swollen, and the fever is much increased, sometimes the fever causes delirium. In some cases the metastasis is to the brain, converting it into a very serious disease. Diagnosis.—Mumps may be distinguished from ordinary adenitis or inflammation of the glands of the neck, first by the fever preceding the swelling of the glands, and second by the shape and location of the swelling itself. The swelling in mumps consist of enlargement of the entire parenchyma of the parotid gland which bulges out directly behind the ramus of the jaw, and soon somewhat overlaps the ramus a little, and always lifts out the lobe of the ear. Acute inflammation is rare in this gland from any other cause than mumps, and con- sequently, not hard to diagnose or differentiate. Treatment.—For the fever, aconite in doses of from ^ to 1 gtt. according to the age of the patient, may be given every two hours. If the glands are very much swollen and painful, an ointment of iodol or iodoform may be applied twice or thrice a day. If the brain is affected, belladonna, in doses of 3 to 4 gtt. may be given to adults, and from ^ to 1 gtt. for children, twice a day. If it attack the testes of the male, or 522 THE PRACTICE OF MEDICINE. the ovaries or mammary gland of the female, then from 3 to 5 gtt. of tincture of pulsatilla should be given every three hours, and at the same time the parts poulticed with wilted mullein leaves. Symptomatic Parotitis. We occasionally have this form of inflammation of the parotid glands associated with typhus and typhoid fever. It also occurs with scarlet fever, measles, smallpox, pyaemia and puerperal fever, and may occur in some other systemic dis- eases. The glands are much harder in this form of inflamma- tion, and much more prone to suppuration. I have had some very grave cases with typhoid and typhus fever, and also with measles. It is a grave disease. In some cases that I have met with in typhoid fever, after free discharge of pus from the gland, other adjacent parts would suppurate, and large fistulous openings would thus be formed, and often the abscess would be transformed into an ichorous cavity, and finally end in gangrene and death. If this disease occurs in the early part of an attack of typhoid fever, it is very apt to prove fatal, but, if it appear after convalescence is fully established, the patient, if properly treated, stands a chance to recover. Treatment. — When there is induration of the glands, the muriate of barium will have a curative effect ; it may be given in doses of 1 to 2 gr. of the 1st dec. trituration, three rimes a day. Or the iodide of barium may be given in 1 to 2 gr. doses of the 1st dee trituration, three times a day, and its ointment rubbed on the gland, ter in die. If suppuration takes place, the sulphide of calcium should alternate the barium in the form of the first decimal trituration, in doses of 1 to 2 gr. If the case does not improve in four or five days, then the 1st dec. trit. of silicea should be given in alternation with the sul- phide of calcium, three times a day, dose 1 to 2 gr., according to age, etc. If there are signs of gangrene, the tincture of arsenic will have a salutary effect, in doses of 5 gtt, every DISEASES OF THE MOUTH AND THROAT. 523 three or four hours, until the gangrene is arrested. After the opening of the abscess, the cavity may be dressed with gly- cerine and creasote, equal parts, or with listerine. In some cases the oil of eucalyptus is good. Tonsillitis. This inflammation occurs in cold seasons of the year, es- pecially in wet, changeable weather, and children and young persons are more subject to it than old people. Many persons have a very great proclivity for this disease ; so much so, that they have an attack whenever they get wet or take cold. It was in a chronic form in many instances, that I have noticed. I have also noticed that whole families are subject to it, while growing up to maturity. Symptoms. — This disease is often preceded by a cold, then the patient may have a chill, and feel as if he had some foreign substance in the throat, as a bit of bone, etc. This disease may come on gradually, and appear in a simple form of catarrhal inflammation of the mucous membrane of the tonsils, which is connected with simple pharyngeal catarrh. There is also a follicular form of catarrh of the tonsils which is deeper seated, and is soon followed by a thin, yellow, or white curdy substance that adheres to the parts. This substance consists of pus and epithelium. Diagnosis. — Tonsillitis may be mistaken for diphtheria, herpetic angina, or for superficial abscesses of the tonsils. In superficial abscesses of the tonsils, there is more or less in- flammation in the palatine arch. This superficial abscess terminates in spontaneous discharge of purulent contents, or the contents gradually desiccate, and sometimes the contents become foul or calcareous. And sometimes patients hawk up small cheesy-like substances of this kind. This form may give rise to extension, or to a parenchymatous amygdalitis, is known as congestive hyperaemia and serous infiltration, from which the tonsil or tonsils become greatly enlarged. Some- 524 THE PRACTICE OF MEDICINE. times only one tonsil is affected at first, and then the other be- comes involved. In either form, there may be much pain and swelling. If one tonsil only is enlarged, it interferes with respiration and deglutition, but when both are implicated in the inflammatory process, respiration is more difficult, and sometimes deglutition is impossible for a time. This disease may be associated with cedemia of the pharynx, or the inflam- mation may extend into the eustachian tubes, causing ear- ache. Or it may extend to the larynx, causing dyspnoea, or even alarming paroxysms of suffocation. All cases are attended with high fever, especially those that are allowed to run on to suppuration. The temperature may reach 104° Fahr., and there will be headache or delirium ; or convulsions even may occur in children. I have met with whole families with the chronic form, with great hypertrophy of the tonsils, and ' a tendency to frequent attacks of the acute form. Such fam- ilies have a taint in the blood, and like scrofula it is trans- mitted from generation to generation, unless it is removed by treatment. By examination, the enlarged tonsils are easily discovered as projections on each side of the arch of the fauces, between the folds of the palate, presenting a very red appear- ance, dry at first, but soon accompanied with excess of viscid saliva. But there is never a diphtheritic exudation. Treatment.—At the commencement of an attack of acute tonsillitis, the muriate of ammonium, in doses of 3 to 5 grs. three times a day, and aconite, in doses of gtt. ^ to 1, accord- ing to age, every two hours, will very promptly arrest this form of inflammation, if commenced in due time. But if not, and the tonsils become very red and oedamatous, and if attended by a burning pain, then the tincture of apis mel., in doses of gtt. 1 to 3, will do great good towards relieving these symptoms. In cases in which the patients have an attack every time they take cold, the carb. of barium, in doses gr. 1 to 2, of the 1st dec. trituration, three times a day, aids the final cure. If there is chronic enlargement of the tonsils, the iodide of barium, in DISEASES OF THE MOUTH AND THROAT. 525 doses of 1 gr. of the 1st dec. trituration, three times a day, has made some brilliant cures. When there is induration with hypertrophy, then Lugol's solution of iodine has served me very well, in doses of gtt. 5, three times a day. I have also often cured this disease, in its chronic form, with the iodide of potash. In some cases the iodide or the muriate of barium may be given in alternation with the iodide of potash. The old plan, of applying leeches to the throat is useless, and the Dover's powders ordered therewith, is worse than no treat- ment, as it dries up the secretions and does harm. Uvulitis — Inflammation of the Uvula. This disease is called "falling of the palate." It consists of more or less enlargement of the uvula. It is a source of great annoyance to the patient, as it keeps him constantly try- ing to swallow, and produces a hacking cough. The affection is often connected with phthisis pulmonalis. Treatment.—Aconite has a special affinity for the uvula as well as for the tonsils, and consequently, where there is much pain or soreness in the uvula, gtt. ^ to 1 of aconite may be given every two hours until relief is obtained. If there is livid redness of the parts, gtt. 3 of belladonna may be given three times a day, for the first two or three days. If the elongation is very great, and the inflammation runs high, then the following local application may be made, viz: r>. Monsel's salt - - - 3 1 Aqua pura - - - - I 3 Mix, and apply on a swab of cotton, wet in th-s, or by a small cloth mop, every three or four hours, being careful to wet the uvula well, and the muscles that maintain it in posi- tion. This solution is much more astringent than alum, that is commonly advised. In some very extreme cases of chronic elongation of the uvula, when associated with phthisis pul- monalis, it is necessary to snip off a portion of the uvula. 526 the practice of medicine. This is easily done with scissors, properly curved for the pur- pose. Laryngitis: Laryngo-Tracheitis. Laryngitis or laryngo-tracheitis is met with in all degrees of severity, from simple hyperaemia, with increased irritability of the texture to the most intense plastic or pseudo-membraneous inflammation. It may be acute, and run its course in a few days, or it may be chronic, and continue for months, or years. The inflammation may be limited to the epithelial or free sur- face of the membrane, causing hyperaemia, with increased mucus exudation, or it may extend to the sub-mucous tissue, exciting inflammatory exudation beneath the lining membrane as well as upon its surface. In this case there will be found great tumefaction. Or, the disease may be of a grade that causes the exudation upon the surface to be highly plastic, so that it may organize Into a false membrane, adhering to the surface. But mucous or superficial laryngitis, the sub-mucous form, the pseudo-membranous, and the ©edematous varieties are those generally met with. Either variety may be acute, sub-acute, or chronic in progress. Causes.—The superficial variety is of most frequent occurrence, and attacks persons of any age. It may be caused by exposure to cold, damp air, by excessive use of the voice, especially in the open air. It often precedes or accompanies tuberculosis. It may follow eruptive fevers. Pathological Changes.—It is not uncommon to find in cases of long standing, the basement membrane denuded of its epithelium in patches, giving the appearance of abrasions or slight ulcerations. In the pseudo-membranous variety we find, in addition to these changes, the addition of a large amount of fibrin and lymphoid cells in the exudation materials. And these plastic elements cause the exudative materials upon the surface of the membrane to solidify or organize into a firm layer of " false membrane," which is usually thickest on the DISEASES OF THE MOUTH AND THROAT. 527 vocal cords and the rima glottidis, but sometimes extending up- wards to the lower part of the pharynx, and downward through the entire larynx and trachea to the larger bronchi. The membrane does not permeate the mucous tissue like the mem- branous exudate of diphtheria, which serves to differentiate the two affections. Some pus cells, and red blood-corpuscles may be seen in the basis of this false membrane. In ©edema- tous laryngitis, a large part of the exudation is beneath the membrane, and mostly serum; hence there is an oedema of the parts. This form is called laryngitis. Bacteria may be found in the membranes of the pseudo-membranous form. Symptoms.—The great swelling of the mucous membrane produces such narrowing of the entrance from above into the larynx, that the patient has great dyspnoea, this inflammatory action also excites severe spasmodic action in the muscles, and imparts to the cough a peculiar spasmodic character. In the milder cases, in adults, there is a sense of fullness, soreness, and heat in the larynx, and roughness and hoarseness of the voice. There is generally, also, a dry, ringing cough with more or less dyspnoea. The fever may not run very high. There is increase of temperature in cases of children under five years of age, say, about 2°. Treatment.—If there is any appreciable fever, with a stinging, drawing pain, aconite is the remedy to begin with. It should be given in doses to suit the age of the patient, viz: t}. Aconite tinct. - - - 3l Sanguinaria tinct. If Aqua pura - 3' Dose for adults, 60 gtt.; children over ten years, 20 to 25 gtt. every two hours. While the aconite controls the fever the sanguinaria increases expectoration, thus loosens the membra- nous exudation, aids the natural efforts to detach it, and then, if continued, prevents its reformation. If there is oedema of the parts, apis mel. is indicated; dose 1 to 5 gtt. 528 THE PRACTICE OF MEDICINE. Angina Faucium: Sore Throat. Catarrhal sore throat generally involves the mucous cover- ing of the soft palate, tonsils, and fauces. The throat presents a red, dry, and somewhat swollen appearance, and after the advancement of the disease, there is a tough phlegm upon the tonsils, giving the appearance of diphtheritis. Ordinary catarrhal sore throat is often mistaken for diphtheria, and, yielding to a mild course of treatment, the physician publishes the cure for one of diphtheria. In the acute form of catarrhal sore throat there is considerable fever, deglutition is painful, the tongue is heavily coated, the salivary secretion is greatly increased, and the patient has a bad taste in the mouth. Sometimes when the pharyngeal muscles are involved degluti- tion may be prevented. The voice assumes a nasal tone. The inflammation may extend up into the naso-pharyngeal cavity, affecting the hearing and causing pain in the ears. Some per- sons are very subject to this form of sore throat. Causes.—It is caused usually by atmospheric changes, in those having a proclivity to this disease. It sometimes pre- vails as an epidemic It occurs after the eruptive fevers, un- less the patient is careful to avoid exposure to cold, etc. Treatment.—If the throat is dry, with a burning pain, aconite is the remedy: R;. Aconite, tinct. - - gtt. 32. Aqua pura - - - § 4. Give a teaspoonful every hour, if the fever is high, or every two hours if moderate. If there are stitch-like pains in the ears, and the tonsils are involved, belladonna may be given: $. Belladonna - gtt. 40. Aqua pura - - § 2. Dose, a teaspoonful every six hours until the pain is relieved. If there is oedema of the tonsils, then gtt. 2 to 3 doses of the tincture of apis mel. are indicated, given every two hours, until the oedema is relieved. If the phlegm is very tough, gtt 5 of sanguinaria should be given every two hours. DISEASES OF THE MOUTH AND THROAT. 529 Chronic Sore Throat. In this form of angina there are small elevations that may stand singly or be scattered over the surface of the pharyngeal wall of the fauces. The mucous membrane may be dry and smooth, or it may be covered with a tough mucus of various colors. In some cases there will be a kind of bloody crusts, which are hard to detach from the surface of the throat. If the disease extends into the naso-pharyngeal cavity, and is connected with chronic nasal catarrh, or should it spread down, into the larynx, there will be great laryngeal irritation and a harassing cough, much like that of bronchitis. This cough is often mistaken for that of phthisis pulmonalis. In this disease the fauces presents a red appearance, and the veins are large and radiate in every direction. There may slight pain only, but there is generally a raw, sore feeling in the throat, and a scraping sensation when the patient attempts to swallow. He is much annoyed all the time with a sense of dryness of the throat, and by the presence of a very tough phlegm, which accumulates constantly and causes frequent hawking. This phlegm eauses constant efforts to get rid of it, and in some cases small blood-vessels are ruptured, causing more or less haemorrhage, which is alarming to most patients. It is a dis- ease that very slowly yields to treatment. Clergyman's Sore Throat. This form of chronic sore throat often attacks public speakers, especially clergymen, and hence is called "minis- ter's sore throat" There is a form that consists of hoarseness from loud and forced speaking, or from speaking in the cold air. Any strain upon the vocal cords and muscles of the soft palate will thus cause hoarseness, and sometimes even com- plete aphonia. Excitable speakers very often produce this affection, especially in cold weather. 34 530 the practice of medicine. Treatment.—Arum triphillum is one of the best remedies, and is indicated by a profuse secretion of phlegm, and by hoarseness, which is aggravated by speaking: R;. Arum tinct. - gtt. 10. Aqua pura . - - - : 4. Dose, a teaspoonful four times a day. If no improvement in 8 or 10 days, then use the following: R;. Collinsonia - - - - 3 1. Stillingia, tine - - - | 1. Aqua pura - - - - 11. Dose, a teaspoonful three or four times a day in water. A gargle of alum does some good in allaying the irritation. Bichromate of potassium, in doses of gr. -§, three times a day, may alternate the above with benefit. Thrush—Parasitic Sore Mouth of Infants. This disease of the mouth of infants and children is caused by oidium albicans, which combines with the ephithelium into thick, white membranes, and covers a large portion of the mucous membrane of the mouth, which, if neglected, may extend downwards into the stomach and bowels. Symptoms.—This disease commences with numerous small vesicles or white specks upon the mucous lining of the mouth, and sometimes also on the tongue, gums, palate, and in grave cases extending into the gullet and along the fauces. There is pain and some fever. The neighboring glands are very often involved and become tender and swollen. If the disease, from neglect, extends into the stomach and bowels, there will be a dark eruption upon the anus and nates, with violent and very offensive diarrhoea. This affection may also invade the whole buccalcavity, and sometimes spread into the oesophagus and pharynx. The white membrane is soon transformed into a dirty-white or yellow color, or occasionally it assumes a brownish color, especially if so roughly handled as to produce slight haemorrhage. At the beginning of this disease this fake DISEASES OF THE MOUTH AND THROAT. 531 membrane adheres firmly to the mucous membrane, but about the third or fourth day it becomes loose and can be easily detached and removed. This parasitic affection is very fre- quently transferred from the child's mouth to its mother's nipples. It has been seen upon the rectum, female genitals and abraded skin of parts of the body touched by matter from the diseased surface. The mother's attention is called to this disease very frequently by the child's failure to nurse, or by the difficulty it has in nursing. If this disease occurs in chil- dren artificially fed, it is often complicated with intestinal catarrh, which adds very much to its fatality. Remote Causes. — An acid state of the stomach in chil- dren, which especially prevails in the artificially fed, greatly tends to the production of this form of fungus Over-nurs- ing also is likely to cause the same condition. The saliva, in health, is of an alkaline reaction, more so after the meals, but less so when the stomach is empty. The buccal mucus has an acid reaction, increased by contact with the atmosphere, which causes acid fermentation in the mouth. In young infants the secretion of mucus is in excess of saliva ; hence arises the great tendency to acid fermentation, and conse- quently the development of this fungus growth that causes thrush. The disease is very common in the artificially fed, as they are usually fed upon articles of food that very readily undergo acid fermentation. It is more frequent among arti- ficially fed children than among those that nurse at the breast. It is also noteworthy, that nursing children have a free flow of saliva, while children fed artificially usually eat so very fast that there is but little saliva mingled with their food ; conse- quently, acid fermentation must naturally ensue, and, finally, result in thrush or stomatitis, one or the other, and sometimes both. Treatment.__If there are heat and dryness of the mouth, then boracic acid is indicated. The diseased surface may be washed with a saturated solution, three times a day. Or, if 532 THE PRACTICE OF MEDICINE. this is not at hand, a saturated solution of borax may be used in the same way. Or it may be triturated, 1 gr. to 9 gr. of sugar of milk, and a little of this spread over the diseased sur- face, three times a day. But I prefer the former, when this disease is severe. Internally, the child should have baptisia tinctoria, in doses of 3 to 5 gtt., according to age, in a tea- spoonful of water, three times a day. Sulphur, or sulphurous acid, either, is a good remedy, or the sulphide of calcium, in small doses. Cancrum Oris. Ulcerative Stomatitis.— Aphthae, or canker of the mouth, may be the result of catarrhal inflammation. This form is characterized by erosions or small ulcers, or there may be only follicular inflammation, with deeper ulceration. Again, it may occur in connection with labial herpes or hydroa. Aphthae occurs mostly in children, but follicular stomatitis is found in women while menstruating, during pregnancy, and often in lactation, when it is called nursing sore mouth, and is quite troublesome to the mother. Aphthous ulcers are rapid in their formation, sometimes forming in "large numbers in a few hours. They generally appear on the mucous membrane of the inside of the lips, and cheeks, but sometimes also on the gums and soft palate, and occasionally upon the tongue. The bottom of the ulcers presents a white appearance, or in some cases is of a yellow color. Their edges are red, some- what raised, round, and from the size of a half duck-shot to that of a split pea. The follicular ulcers are small, round, and deeply excavated. All of these forms of stomatitis cause great tenderness of the surface of the mouth. The secretion of mucus and saliva is very much increased, and, in the putrid form, there is an offensive odor of the breath. This form of stomatitis, which is a very destructive ulceration of the border of the gums, produces a swelling of the mouth and a charac- teristic cadaveric odor. It mainly attacks children after their diseases of the mouth and throat. 533 first dentition has been completed, and is often found among those of filthy habits, and among inmates of hospitals, but sel- dom among those that are cleanly. It seldom occurs among adults, except as an epidemic in camps among soldiers that are not cleanly. Its production, like that of many kindred diseases, is very much favored by filth. It frequently appears in adults in a sporadic form, as the result of the abuse of mer- cury; or it may possibly arise from an enfeebled condition of the patient, or from poor food and uncleanliness. It makes its appearance at the margin of the gums of the lower jaw, and extends backwards to the lips, cheeks, and tongue. There is generally great fcetor of the breath, and a profuse, acrid, secre- tion constantly flowing from the mouth. It is not uncommon for the gums to bleed, especially when pressed, and the tongue is usually coated and swollen. The lymphatic glands of the neck and throat are also often enlarged. It is not generally attended with any great degree of fever. If stomatitis be neg- lected, especially in the follicular form, it produces very destructive ulceration of'the lips, gum, and tongue, sometimes destroying the gums, large portions of the tongue, and occa- sionally the cheeks. If not arrested, it proves fatal, Treatment.—In the treatment of the simpler form of aphthae, in which there is only superficial ulceration, the local use of borate of sodium or chlorate of potassium, and the inter- nal use of arum triphillum is sufficient. In graver forms, in which there are deep-seated ulcerations, baptisia, internally, and the application of sulphate of copper, will be required; say sulph. of copper gr. 10, gum arabic 3 2, cinchona bark, pulv. 3 1, water 1 1, applied three times a day. An occasional wash of hydrastis is also beneficial. Diphtheria. This is a contagious disease, doubtless of miasmatic origin. Klebs, a German investigator, and others also, ascribe this disease to the action of parasitic fungi or bacteria—the micro- 534 THE PRACTICE OF MEDICINE. coccus diphtheriticus. Though most frequently seen to attack the throat, it is not confined to it, but may appear on different parts of the body. It has been observed upon contused and incised wounds, but mostly attacks the throat, at times spread- ing to the upper pharyngeal and nasal cavities, and finally into the eustachian tubes, larynx and lachrymal ducts. This condition is attended by a characteristic fibrinous exudation, in the form of round, white or dull-yellow patches, of various sizes, at first sticking closely to the mucous membrane, from which it can only be forcibly detached. These patches spread until they cover the tonsils, uvula, palatine arch and pharyn- geal cavity with a sheet of false membrane, which in the course of a few days becomes gray-brown and less adherent. It consists of a fibrinous exudate, the interspaces of which contain serum, or in the latter stages, blood or pus cor- puscles. It frequently happens that globular bodies are seen (which consist of finely punctured masses of fungus) in layers upon the surface of this croup-like membrane. In the advanced stages it appears in spots between the uppermost layer of epithelium, and the croupous reticulum. The micrococci pen- etrate to the sub-epithelial tissue. This false membrane finally becomes loosened by means of infiltration with serum or pus corpuscles, and continued growth of new epithelium. The mucous membrane is in a state of hyperaemia, or some- times is dotted with numerous haemorrhages, and may also be infiltrated with serum, or sero-pus. In grave forms of the dis- ease there is a highly septic condition of the parts, and the mucous membrane undergoes a rapid necrosis, or putrefactive decomposition, large quantities of different varieties of bacteria appearing with the micrococci, mingled with the exudate. In some cases, an extension of this disease to the nose takes place, characterized by a thin, purulent, greenish dis- charge , which is so acrid that it excoriates the parts which it DISEASES OF THE MOUTH AND THROAT. 535 touches. The great danger in this disease lies in its liability to suffocate the patient, by spreading upon the mucous mem- brane of the larynx, trachea, and bronchi. When it thus attacks these parts, it much resembles croup, and is often mis- taken for it. I was called, not long since, to a lady who had this form of the disease. Two old physicians had entirely mistaken her condition, until she was totally beyond the reach of the ordinary remedies. The pharyngeal complication may commence early in the disease, or it may not take place under three or four days. It occurs oftener in children than in adults, and usually in grave cases. It may be recognized by prolonged respirations, a frequent dry cough, hoarse voice, great restlessness, and pain in the larynx and pharynx. Associated with diphtheria, there may be severe inflamma- tion of the parenchyma of the kidneys, with haemorrhage. It may also produce albuminuria, which, however, only occurs in severe cases. Long continued and severe cases of this disease are followed by heart affections (especially paralysis of the heart) and death. Upon post-mortem examination, the mus- cles of the heart are found pale, soft, and with fatty degenera- tion of their substance. In some cases I have known danger- ous inflammation of the stomach to follow swallowing of the diphtheritic exudation, or extension of the affection through the oesophagus. One case of this kind I cured by the use of powdered hydrastis canadensis, in doses of a few grains, three times a day. There was in this case, as there generally is in such cases, ulceration of the mucous coat of the stomach, which was healed by the powdered hydrastis canadensis. Autopsies have also revealed more or less hyperaemia of the vascular linings and the substance of the brain and spinal cord. There is sometimes more or less softening in certain portions of the spine, and not infrequently capillary haemor- rhages are seen here and there. The nerves themselves may be softened and dotted with extravasated blood. The stage of incubation extends over some five or six days, or it may not 536 THE PRACTICE OF MEDICINE. be so long. We meet mild forms of the disease, and severe, septic forms of it, in the same epidemic, and sometimes in the same family. The mild form, which may be called catarrhal diphtheria, is very easily cured, and this has led some pre- sumptuous young men to write in the various medical journals essays upon diphtheria, with the rash assertion that it can always be cured by chloride of iron, quinia, and the chlorate of potassium, which are almost inert in the graver forms of this disease. The trouble commences with fever and sore throat. The temperature may rise as high as 105° F., but declines the fourth, or sixth day. At first, the tonsils and fauces look red and inflamed, but very soon they exhibit patches of the characteristic exudation which may be first upon one and then upon the other tonsil; seldom upon both at once. This exudation very soon extends to the uvula, and to the palatine arch. The lymphatic glands of the jaw also swell. This fact may serve as a diagnostic point between diphtheria and inflammation of the throat. There is great languor, lassi- tude, headach, pain in the back and limbs and sometimes nausea. The disease may terminate, under proper treatment, not routine nonsense, in about ten or twelve days, or it may be cut short in five or six days. In many cases, especially in those treated routinely, a sudden rise of fever, with a rapid spread of the diphtheritic exudation takes place, exhibiting the fact that it is a severe case. This form is called croupous diphtheria. In many epidemics, this occurs at the very out- set of the attack. In such cases the exudation rapidly thick- ens and extends in area, spreading upwards through the pharynx into the nasal cavities, attacking the eustachian tubes or the lachrymal ducts, and sometimes even the conjunctivae. Or it extends downwards into the larynx, trachea and bronchi, and occasionally into the stomach. This exudation gradually changes its color to a dark brown or even to a black hue, emit- ting a very offensive odor. The submaxillary glands swell, DISEASES OF THE MOUTH AND THROAT. 537 the lymphatics enlarge still more and the urine is scanty, and albuminuria exists generally in proportion to the intensity of the disease. Digestion is often very much disturbed, the appetite fails, nausea and even vomiting take place, which last is often very troublesome in the latter stage, often continuing for weeks, or months after all other symptoms of the disease have disappeared. It may rise from reflected action from the brain, or be the result of the diphtheritic condition of the stomach. In such cases the patient may die from paralysis of the brain. The septic form of the disease, which often termi- nates in gangrene, may always be known by the rapid and ex- tensive breaking down of the tissues, by capillary haemor- rhages from the mucous membranes, and by the general blood- poisoning. In some epidemics, the disease shows a septic tendency at the very outset. In the grave form, the false membranes appear upon a red, cedematous mucous membrane, with an ichorous discharge, which disorganizes the parts it touches. Such discharges, be they either from the mouth or nose, emit a very offensive odor, and rapidly corrode the parts with which they come in con- tact. The lymphatic and submaxillary glands become very much enlarged, while the surrounding tissue also grows rather cedematous. The patient's face looks bloated, pale and wax- like, his pulse is feeble, quick, small and finally grows exceed- ingly weak, irregular and slow, and his temperature may be as high as 107" F., or it may be lower than usual. In this con- dition convulsions may take place, and be followed by death. This disease may be complicated with scarlet fever. It may complicate typhoid fever, pyaemia, puerperal fever, erysipelas, whooping-cough, measles and some other chronic diseases, especially when they occur in the dissipated. Sequele.—These are paralysis of the soft palate, and sometimes of the extremities, eyes, larynx, ears, nose or tongue. Diagnosis.—The mild forms of diphtheria might possibly 538 THE PRACTICE OF MEDICINE. be mistaken for catarrhal sore throat, in the first stage, but it can be easily distinguished as soon as the exudation takes place. It differs from aphthae in that it commences as minute vesicles and gradually forms ulcers without exu- date on them. All the,forms may be distinguished from simple croup by the exudation, and by the swelling of the glands. Prognosis.—Prognosis is generally favorable under pro- per pathological treatment, but under the old routine treat- ment, it is unfavorable in a large majority of grave cases and in many mild ones. One of the greatest dangers, if not met according to pathological indications, is the inva- sion of the larynx, and another is the risk of septic poisoning. Treatment.—There is no specific for this or any other dis- ease, as some young scribblers would have us believe. If we were to credit the vain babblers that are constantly wasting space in medical journals, we would be made to think that specifics had at last been found for this dreadful scourge— quinia, muriate of iron, and the chlorate of potassium—none of which have any power over the graver forms of this disease. It is possible they may have some influence over the mild vari- ety, but he that depends upon them in the grave, septic forms of the disease, will meet with sad disappointment. I have found muriatic acid, properly diluted, say 3 1 of it, to 1 1 of water, very efficient when applied with a camel's hair pencil, in dissolving the diphtheritic membrane. It is probable that lactic acid, pure, or diluted with one part water, would also be a good application, applied locally, or with the spray appara- tus. Where there are ulcers in the throat, and excessive sali- vation, gtt. 5, of nitric acid, given internally, and the 1st dec. dilution, applied to the ulcers, will prove beneficial. It may be given internally, well diluted with simple cold water, say gtt. 10 in 1 1, of water. If the exudate is soft, and there is great inflammation, salicylic acid will do good service, in doses of gr. 3 to 5, ter in die. In mild cases of catarrhal character, DISEASES OF THE MOUTH AND THROAT. 539 belladonna, alternated with phytolacca, in doses of gtt. 3 to 5 each, alternated every three or four hours, will generally be sufficient internally. Powdered sulphur blown over the ton- sils and palate, through a quill, three times a day, or the old wash of chlorate of potassium, or Listerine will probably be better. A wash of the diluted tincture of eucalyptus (50 per cent.) is a good application, and I alternate it with the per- manganate of potassium. This has proved very successful in ordinary cases. In the malignant form, I use mere iod. (say mere iod., gr. 1, aqua pura, 1 4. dose, a teaspoonful every three hours) until the most unfavorable symptoms give way. Bin- iodide of mere is safest. Merc, biniod. is also a remedy of intense action in the graver forms of the disease, the dose being about gr. 1-50, three times a day, well diluted with water. I use the biniodide of mere, as follows: biniod. mere gr. 2, iodide of potassium 3 2, aqua § 4, dose, a teaspoonful four times a day. This will not remain in the system as the other mercurials. In cases in which the breath is very offen- sive, and there are croupy symptoms, hoarse cough, extensive exudation of a dirty white or brown color, with ulceration under the deposit, great prostration, and feeble pulse, the iodide of arsenic, in doses of gr. 1-30 to 1-40, three or four times a day, will prove efficient in counteracting.these symp- toms, and aiding the above local applications in relieving the disease. A saucer of bromine water should be placed in the room of the patient, in all severe cases. Bromide, in doses of gtt. \ to 1, every four hours, is also a very active remedy in the worst forms of this disease. Ailanthus, in small doses of the tincture, say J to J gtt every half hour, has proved valua- ble in many cases. In some cases, the local application of a diluted tinct. of sanguinaria has proved a valuable aid, diluted and applied with the spray apparatus. Carbolic acid, diluted, and used the same way, is also invaluable. The chloride of calcium is also an efficient remedy, given locally as follows: aqua chlorin* \ I aqua distil. 1 3, syrup simplex 1 J, used as 540 THE PRACTICE OF MEDICINE. a gargle or with the spray apparatus. A gargle of thymol, just strong enough to be tolerated by the patient without pain, is a good local remedy, and may be alternated with a saturated solution of boracic acid. Quinia in 1 gr. doses sustains the patient in great prostration. A spray of the carbolate of am- monia or soda removes fcetor, and tends to destroy disease germs. In the malignant form the iodide of arsenic, 1 dec. trituration, in doses 4 to ^ gr. three times a day in a wine-glass of water, has acted well for me. Salicylic acid, locally and internally, is also valuable. The fumes of tar and turpentine are aids to prevent sepsis. The local application of turpentine and glycerine has cured several cases for me. Noma. This malignant ulceration of the cheek commences in the form of a small blister, generally upon the middle of the cheek, or near the corner of the mouth, on the inside of the cheek. It is filled with a red or brown, turbid fluid, which very soon bursts, the blister then appearing as a small superficial ulcer, with a foul basis, which soon assumes a gangrenous character. Under this little blister, before it breaks, a small hard lump may be felt, which consists of infiltrated cellular tissue and adipose tissue, intensified. The downward metamorphosis goes quickly on. The gangrenous decomposition is rapid, and on the outside there appears an cedematous enlargement of the cheek, which may be pale or livid. Very often this ulcer is covered with a thick, dark crust, under which gangren- ous destruction is progressing very rapidly. Very soon the greater part of the diseased side will be destroyed. The glands of the neck become enlarged and the face looks cachec- tic and pale. The strength of the patient soon gives way, diarrhoea sets in, and death takes place from exhaustion. Or perhaps the gangrenous destruction will extend over the entire cheek, and haemorrhage terminate the patient's miserable exist- ence. The disease is mostly found in sickly children, or fol- DISEASES OF THE MOUTH AND THROAT. 541 lowing scarlet fever, measles, typhus, and sometimes small- pox. When it does appear in adults, it is mostly as puerperal fever in females, or in males or females after the abuse of mercury, or after typhus fever. Treatment.—Arsenic is one of our most trustworthy rem- edies in combating this deadly disease. All of its symptoms show the profound sepsis of the blood and indicate a most pow- erful antiseptic remedy to meet it. The dose required is about gtt. 2 to 3 of the tinct, three or four times a day. The per- manganate of potassium may be applied locally, say gr. 10 to 18 to 1 1 of water. The arseniate of gold would be a good remedy in small doses of say gr. T^ to T|-g- ter in die. The chloride of gold and sodium may be applied locally in solution, 1 gr. to i 3 distilled water. From the very great success I have had with the tincture of echenacea, in cases of indolent ulcers of long standing, I think it would prove one of our best remedies in this disease.* *See the Author's Materia Medica. CHAPTER XXXV. DISEASES OF THE LARYNX AND (ESOPHAGUS. Bronchocele: Goitre. THIS is a disease of the thyroid gland, which causes great hypertrophy. Simple hypertrophy may appear in young children, but goitre is a degeneration of this gland. It seems that this enlargement contains cysts, composed of a thick, gummy or jelly-like material, of a brown or yellow color, called colloids. These colloids are either interspersed between the substance of the gland, or form separate oval appendages upon the gland, without involving the gland itself in the diseased process. In new-born infants, goitre consists in simple hyper- trophy of either the entire gland or of one of its tubes, and may press upon the trachea and impede respiration. Some cases are on record in which it was so great that it produced suffocation and death in a few days. Treatment.—Egg shells, without the inner coating, dried thoroughly and pulverized finely, have proven effectual. Iodine and the iodides are the most successful remedies in my hands. Iodide of barium is very good, in doses of gr. ^ to \ of the 2d dec. trituration, three times a day. OESOPHAGITIS. This inflammation is most commonly the result of mechan- ical irritation or injury, such as the irritation of foreign sub- stances, or arises from the action of some corrosive substance swallowed by the patient. Inflammation of the pharynx and stomach may spread to the oesophagus, and so may cause vio- lent inflammation of the lymphatic glands. It has been known to appear in the course of typhus fever, cholera, pyaemia, small- 542 DISEASES OF THE LARYNX AND QHSOPHAGUS. 543 pox and scarlet fever. These diseases may produce more or less inflammation and finally ulceration of the oesophagus. Sometimes it goes into a chronic form, and produces dilatation of its calibre. Occasionally when inflammation of this organ is the result of corrosive or scalding substances, stricture may be produced from the contraction of the ulcers. This condi- tion is very unpleasant. Symptoms.—One of the most constant and usual symptoms is painful deglutition, or in some cases, entire inability to swallow anything, the patient regurgitating his or her food all the time. This must of course prove fatal, if not soon relieved by proper treatment. Treatment.—Aconite is the remedy for the acute form of the disease, and should be given in small doses, very frequent- ly repeated, say aconite gtt. 10, aqua \ 4; dose, a teaspoonful every half hour, until the force of the circulation and the heat are subdued. If, after giving aconite for several hours, there still remains a burning pain and cramp, and the food is ejected as soon as it reaches the larynx, gtt. 2 to 3 of the tincture of arsenic may be ordered every three or four hours, until this condition is changed for the better. Where the patient com- plains of a pressing pain, and a feeling as though a foreign body had lodged in the oesophagus, gtt. 1 to 3 of belladonna may be taken every three hours, until the symptoms are relieved. Where there is a burning sensation in the entire oesophagus, gr. 1 or 2 of the 1st dec. trit. of the bichromate of potassium may be tried every two hours, until it relieves. If the patient complains of an empty or weak sensation over the abdomen, small doses of tincture of phosphorus may be given three times a day. Stenosis (Esophagi. This is a rare disease, and may be congenital or the conse- quence of morbid changes of adjacent organs, such as the glands of the neck. It may be the result of foreign substances 544 THE PRACTICE OF MEDICINE. of various kinds which have lodged in the act of swallowing and stuck fast, such as fungoid, carcinomatous and polypoid growth. Again, it may result from a contraction produced by a cicatrix, causing stricture of the oesophagus. In some rare cases it results from contraction of the muscu- lar layer of the oesophagus. This is called by writers septic stenosis. Symptoms.—The most noted symptom of all these forms of stenosis oesophagi is difficult deglutition. If the stenosis comes gradually, the patient may feel only slight obstruction to the free passage of food of a solid character, which is ob- viated by drinking a little water, but as the stricture advan- ces the obstruction increases, and the food lodges and may be ejected. Treatment.—This disease comes under the domain of surg- ery. Gelseminum may do good, given in doses of gtt. 20 to 25, twice a day. Acute Laryngitis. This is an inflammation that may be limited, or may extend to the arytenoid cartilages, upon the epiglottis and into the trachea, causing redness and swelling of these parts. In some severe cases there is oedema of the larynx, or there may be haemorrhagic infiltration of the mucous membrane and the submucous connective tissue. The symptoms of course corre- spond to these various complications. There is huskiness of voice and sometimes very great hoarseness. In severe cases, aphonia may supervene from the swelling of the vocal cords, and from more or less paralysis of the muscles of the larynx. In children, there is such interruption of the respiration that it resembles croup, and has led to the name of pseudo-croup. The swelling of the mucous membrane naturally narrows the glottis, hence the harsh, croupy cough and great difficulty in the respiratory effort. There may be a spasmodic cough, resembling whooping-cough, which is followed by a drawn DISEASES OF THE LARYNX AND OESOPHAGUS. 545 inspiration and coughing of various varieties. This disease is often mistaken for croup. These various sounds are the results of greater or less swelling of the vocal cords and the parts around them. The mucous membrane at first may be some- what dry, but it soon becomes moist, by an increased secre- tion in the inflamed parts, which at first may be clear, but later is slightly streaked with blood. It may finally change to a yellow color, from being mingled with pus-cells. There is usually some pain in the larynx, and a very disagreeable feeling of dryness or irritation, as if some foreign substance had lodged in the parts. There may also be considerable pain in the act of deglutition from inflammation of the arytenoid cartilages. This disease may terminate in eight or ten days, or it may continue for weeks and become chronic and trouble- some. Causes.—A predisposition to this affection exists in many persons, especially in those who are cachectic and feeble, and who keep themselves too heavily clad and too closely housed. The exciting causes are, cold air, dust, acrid vapors, straining the voice, wet feet, sudden exposure of the neck to a cold stream of air, catarrh, influenza and attacks of pharyngitis after using alcoholic drinks. It may also be the result of some constitutional diseases, as measles, typhus fever, syphilis and tuberculosis. Treatment.—Aconite should always begin tne treatment of the acute form. If the fever is high and the skin dry and hot, and if there is great restlessness, croupy cough, hoarse breathing and pain in the larynx, aconite should be given in small doses, say aconite gtt. 20, aqua 1 4, dose a teaspoonful every half hour. I usually alternate it with gtt. 3 to 5 of san- guinaria. Where there is but slight fever, barking cough, headache and drowsiness, or sudden aphonia, gtt. 5 of the tincture of belladonna should be ordered every three hours, until the symptoms are relieved. If the cough is very husky, the voice hoarse, the cough croupy and respiration difficult, I 35 546 THE PRACTICE OF MEDICINE. use bromine, in doses of m. \ to 1, every three hours, or per- haps it is best to make the 1st dec. dilution, and give gtt. 3 or 4 of that, every three hours. If the above remedies do not give relief, gtt. 2 or 3 of bryonia, may be given every two hours, alternated with gtt. 10 of drosera. Chronic Catarrhal Laryngitis. The chronic form of this affection often results from neglect, or from badly treated cases of the acute form. It may arise from over-taxing the voice in speaking and singing, or it may follow chronic pharyngitis, especially in those who use spirits and tobacco. I know of a great many cases from the excessive use of tobacco. Symptoms.—There is usually injection of the mucous mem- brane, with a kind of velvety sponginess of the lining tissue. In most cases, the vocal cords are thickened up, and some- times their surface is granulated, and covered with dilated veins. Occasionally, I have noticed that there was follicular inflammation and oedema, ulceration of the mucous membrane, and in a few cases, extensive destruction of the parts. A kind of secondary chronic laryngitis is often found in old cases of syphilis, and here we observe ulceration, neoplasms and per- ichondritis. This condition renders the voice hoarse or husky, and produces a collection of phlegm in the throat that keeps the patient continually clearing it. The phlegm may be clear, viscid, profuse or ropy, with pus cells in it. There is generally also a hoarse cough, may be more or less rawness, scraping, soreness and burning sensation in the larynx, which is much increased by speaking or singing. Treatment.—Iodine and iodide of potassium are valuable, both locally applied and taken internally. A solution of nitrate of silver may be used, in the form of a spray, say gr. 2 or 3 to 1 1 of water. The iodide of arsenic is a valuable rem- edy, where there is destructive ulceration; the dose is quite small. I use the 1st dec. trit, in doses of gr. \ or \, as it is DISEASES OF THE LARYNX AND ESOPHAGUS. 547 very acrid in substance, and must be used with care. If the phlegm is tough and stringy, the bichromate of potassium is indicated, in doses of gr. 1 to 2, three or four times a day, well dissolved in water. If ulceration is rapid, a solution of permanganate of potassium, gr. 5 to 1 1 of water, may be used with benefit with a spray apparatus, three times a day. If the cough is persistent, the tinct. of sticta pulmonaca, in doses of gtt. 5 to 10, is a valuable remedy. If this disease be from syphilis, stillingia, in doses of gtt. 10, is one of our best reme- dies, alternated with gold. Croupous Laryngitis. Croupous laryngitis causes an exudation of a fibrinous character which often lines the mucous membrane of the larynx like a real organized membrane except that it is rather more loosely attached. This membrane allies the disease to diphtheritis, and in children causes the one to be mistaken for the other by young or ignorant physicians. Differential Diagnosis.—It may be distinguished from diphtheria by inspection of the membrane, which in croup is a thin, tough, fibrinous-like substance, sticking to the fauces and larynx, while in diphtheria it is a thicker exudation, and is easily detached, leaving an ulcer beneath it, ivhich croup never does. Croup, also, generally attacks the child suddenly, with a hoarse, dry cough, which may abate at morning and return at night again, and so may continue, if not relieved, for several days. After the cough continues for a time, the breathing becomes hoarse and saw-like, caused by the stuffed- up air passages. This difficulty in the respiratory effort in- creases from hour to hour. The child evinces great distress, and is very restless, struggling terribly for air, and frequently rising up in bed and crying fiercely, until from exhaustion and the carbonized state of the blood, it falls to sleep. The face is at first suffused, but finally becomes pale, and eventu- ally if not relieved, cyanotic and covered with a cold sweat. 548 THE PRACTICE OF MEDICINE. The pulse which is at first strong and quick, now becomes very frequently small and irregular, until finally the sufferer is relieved by death. Treatment.—Acetic acid is a good remedy, and may be diluted so as to be used with the spray apparatus and given in small doses, while at the same time it is used locally. The tincture of iodine inhaled from hot water is also a good local remedy, and should not be forgotten. The acetic syrup of sanguinaria has proved the most valuable remedy with me, in doses of a teaspoonful every half or one quarter hour, until the patient vomits. I usually unite lobelia with it, so as to produce vomiting quickly. Bichromate of potassium is also an effective remedy, in doses of gr. \ to ^, four times a day. The inhalation of bromine is also valuable. Aconite should be given where there is fever. I have succeeded well with alum in large doses of gr. 10. GEdema of the Larynx. This disease seems to consist of a serous or sero-purulent infiltration of the submucous tissue. It generally follows some inflammatory attack, and is always a secondary disease, either the result of catarrhal laryngitis spreading the inflam- matory process down into the submucous connective tissue, or it is connected with laryngeal diphtheria. It may also origi- nate from chemical or mechanical irritants, from inflammation of any of the adjoining parts (as from wounds of the larynx) or from retro-pharyngitis, tonsillitis, pharyngeal diphtheria and also from parotitis. The most frequent causes are inflamma- tion of the perichondrium of the laryngeal cartilages, tuber- culosis, syphilitic poison, typhus fever, and carcinomatous ulcerations. It may occur from pyaemia, septicaemia, ulcera- tive endocarditis, variola, scarlatina, erysipelas and measles. It may extend over a considerable space, or be limited and more upon one side than the other. The inflammatory form consists of serous infiltration of the submucous connective DISEASES OF THE LARYNX AND (ESOPHAGUS. 549 tissue, or dropsy. It is either the result of general dropsy, in consequence of nephritis, malarial cachexia and amyloid degeneration of the kidneys, or it may be from a dropsical tendency to disease of the heart and emphysema and cirrhosis of the pulmonary tissue. Again it may be the result of com- pression of the superior and inferior thyroid or of the facial, internal jugular and innominate veins, by enlargement of the thyroid gland. The lymphatic and salivary glands may give rise to it, and so may aneurism of the aorta. The oeclematous parts are either pale or pale-red, flabby and translucent. Symptoms.—The most notable symptom in either form of this disease is laryngeal dyspnoea, which at first affects only the inspiration of air in the lungs, but as soon as the infiltra- tion spreads to the aryteno-epiglottidean folds, to the epiglottis itself, and to the superior cords, this difference disappears. There is a hoarse, barking cough, and more or less hoarseness of the voice. It will prove fatal unless speedy relief is afforded. Treatment.—In the inflammatory form, the internal administration of aconite, in gtt. -| doses, every half hour, will make a decided impression on the disease at the outset, and should not be forgotten. The tincture of apis mel. is a valua- ble remedy where the oedema is well marked, and may be given in doses of gtt. 5 to 8, every two hours. If this disease occurs in connection with general dropsy, arsenic is the remedy, in doses of gtt. 2 to 3, of the tincture (not Fowler's solution, but the saturated tincture in 96 per cent, alcohol). If it occur with scarlatina or diphtheria, gtt. 2 to 5, of arum triphilum should be ordered every one or two hours. If the swelling is of a deep purple color, and the pain deep in the throat and if the patient has a wild expression, belladonna is the remedy, in doses of gtt. 2, every hour. If the respiration is saw-like or rasping in sound, the cough dry and harsh, and expectoration tough and glairy, gtt. 5, of the tincture of san- guinaria should be given every hour, and acetic syrup well 550 THE PRACTICE OF MEDICINE. diluted, should be thrown on the parts with the spray appara- tus, three or four times a day. Tubercular Ulceration. This form of ulceration of the larnyx is almost always associated with pulmonary tuberculosis, but it may precede it in some exceptional cases. It commences with slight hoarse- ness, especially on taking cold, but this trouble is often at first overlooked. The laryngoscope shows partial injection and swelling of the vocal organs. Sometimes there is anaemia of the mucous tissue, and perhaps paresis of the muscles themselves. Ulcers follow renewed catarrhal attacks, and may be limited or may rapidly spread to the glottis, epiglottis, ven- tricular bands and vocal cords, forming extensive ulcerations around the glottis. I have seen some cases that had destroyed the vocal cords, the epiglottis, and a large portion of the mucous covering; of the larynx. In such conditions the voice is lost, or nearly so. Not only is there aphonia, but the cough is also without tone, and there is considerable difficulty in swallowing and much pain in the larynx. Diagnosis.—Ulceration presents no very distinct charac- teristics by which we can easily determine, this form from syphilitic ulceration. We must depend for this upon the pre- vious history of the "case. We must know whether or not syphilis has existed previously, and whether or not there are, or have been, any premonitory signs of phthisis pulmonalis. Prognosis. — Prognosis may generally be regarded as unfavorable. The progress of the disease may sometimes be slow, and if ulceration is not too extensive, if there is not too much increase in the circulation, and if there are no tubercles in the lungs, we may frequently prolong the life of the patient. Treatment.—In cases of great accumulations of phlegm and ulcers, with excessive granulation, I order nitrate of silver locally, gr. 1 to 1 2 of water, used in the spray apparatus, with small doses taken internally. If the ulcers are indolent and DISEASES of THE LARYNX AND 03S0PHAGUS. 551 sero-purulent, gtt. 1 to 2 of the tincture of arsenic should be administered three times a day. If phthisis exists, the hypo- phosphites should be given—as directed under phthisis pul- monalis. Spasm of the Glottis. This is called by some writers infantile asthma, laryngis- mus stridulus or laryngitis stridulosa, and this is its proper name. Symptoms.—It usually commences with slight attacks of dyspnoea, accompanied by a peculiar wheezing noise during the inspiratory effort, together with an anxious expression of the child's face. These attacks may not last long, and fre- quently occur at night. If not treated well the spells increase in intensity and length. The child is often attacked with fright, crying, laughing or a desire for drink, just as it is awaking from sleep. The inspirations are attended with a peculiar whistling, crowing and hoarse sound. The child makes great effort to draw the air into the lungs through the spasmodically contracted glottis. Sometimes expiration is very difficult, and at times is suspended for awhile, causing great agony in the expression of the child's face and great alarm to the parents. Sometimes there is a cold perspiration upon the child, the veins of the neck are much swollen, and the eyes look frightful indeed. The pulse may be small and inter- mitting, and all the symptoms are very alarming to the friends and parents of the child, and, indeed, may prove fatal. These alarming symptoms may only continue two or three minutes, and then, with a loud, hoarse, crowing cry, the child again catches its breath. There seems to be no very great evidences of catarrh or of febrile manifestations. The child may have a great many of these attacks a day, and if not arrested, the disease may terminate in convulsions and death. Children between two and fourteen months of age are most liable to croup. 552 THE practice of medicine. Treatment.—The most reliable remedies are gelseminum and lobelia. The dose should be small of both, say gtt. 10 of lobelia (tinct.) and gtt. 3 to 4 of tinct. of gelseminum, repeated every hour, until the child becomes weak and is inclined to drowsiness. If there is any congestion to the head, belladonna, in doses of gtt. J to \, every three hours, will bring relief. The bromide of sodium or ammonium, will do good service in some cases. INDEX. Acne, 354 treatment 355 diet, ointment of iodide of sul- pher, caustics, biniodide of mercury, rumex crispus, sul- phide of potass., juniper tar soap, salt baths, antimon. tar- trate, bromide potassium, ber- beris, belladonna, sulphide cal- cium, chelidonium, iodine, juglans cinerea, 355. Alcoholism, acute, 434 treatment, 435 actaea racemosa tinct. arsenic, belladonna, cannabis indica, digitalis, convallaria majalis, chloral, ignatia amara, 435 chronic, 436 physical degeneration in, 436 treatment, 437 nux vomica, chloral 437 Alopecia, 356 treatment, 356 acetic acid and glycerine, rumex crispus and acetic acid, tinct. cantharides, phosphorus, muri- atic acid, 356 Amenorrhcea, 299 treatment, 299 aconite, cimicifuga, pulsatilla, helonias, iron, chloride of gold and sodium, nux vomica bella- donna, 299 sepia, apis mel , senecio aureus, bryonia, sitz-bath, apiol, aletris, helonia, 300 Anaemia, 64 causes of, 64 treatment, 65 . Fowler's solution, iron, helonias, 65 Anaesthesia, 333 trigeminal, 333 Angina pectoris, 164 treatment, 165 , inhalation of nitrite of amyl, cereus grandiflorus, Fowlers solution, diet, 165 Aphasia, 429 treatment, 429 nitroglycerine, bromide of potash, stramonium, conium, 429 thuja, ignatia, cocculus, acid phosphate, carb., ammonium, 430 Antiseptics, 20 Aphthae (see Stomatitis, ulcerative) Apoplexy, 424 varieties, 424 symptoms, 425 predisposition, 425 causes, 426 diagnosis, 426 treatment, 427 aconite, belladonna, phosphorus, 427 Alopecia areata, 401 treatment, 402 epilation, acetic acid, cantharides, tinct. iodine, glycerine and tinct. capsicum, oleate of mer- cury, iodide of mercury, sulp- hide, of calcium, tinct. phos- phorus, testa preparata, borate of sodium, 402 Ascaris lumbricoides, 208 symptoms, 209 treatment, 209 spigelia, santonin, 209 Ascites, 205 symptoms, 205 treatment 206 apis mel., digitalis, apocynum cannabinum, tinct. croton tig., polytrichum junip., chimaphil- la, actinomeris, jalap, cream tartar, podophyllin, 206 diuretics, iron and tonics, syrup carburet iron, helonias dioica, nitrate of potassium, acetate of potash, 207 Asthma, 125 treatment, 126 ipecac, lobelia, gelsemium, ni- trite of amyl, nitrite potas., arsenic bromide of lithium, 553 554 INDEX. grindelia robusta, ptelea, erio- dyction, sylphium gummif, 126 aconite, iodide of antimony, can- nabis indica, sumbul, quebra- cho, cereus grandiflorus, digi- talis, iberis, 127 Bacteria, classification of, 23 Baldness (see Alopecia) Bile coloring matter, in urine, 61 Bites, of rabid animals, treatment, (see Poisons, 69 and 70) Bladder, diseases of, 245 inflammation of (see Cystitis) gonorrhoea of, 254 stone in (see Calculus, vesical) Blood, diseases of, 63 in urine, 61 Bones, diseases of, 320 inflammation of (see Osteitis) tuberculosis of, 323, 325 white swelling of, 323, 325 Brain, anaemia of, 403 causes, 403 symptoms, 403 treatment, 403 nux vomica, phosphate of lime, carb. baryta, ignatia amara, 404 Pulsatilla, arsenic, phosphate of iron, cinchona, 405 congestion of, 410 causes, 410, 411 symptoms, 412 treatment, 412 aconite, belladonna, 412 gelseminum, stramonium, ni- trite of amyl, ignatia amara, phosphorus, iron, pulsatilla, cereus, collinsonia, 413 diseases of, 403 embolism of, 427 causes, 428 symptoms, 428 diagnosis, 428 treatment, 428 belladonna, phosphoric acid, nux vomica, iodine, 428 hyoscyamus, cocculus indicus, gelseminum, 429 hyperaemia of, 410 belladonna, the bromides, 410 tumors of, 439 causes, 439 symptoms, 440 treatment, 441 phosphorus, belladonna, phos- phide of zinc, vegetable diet, 441 Breast, cancer of (see Mammae, can- cer of) inflammation of (see Mastitis) Bright's disease, acute, 239 causes, 239 symptoms, 239 treatment, 239 apis mel., arsenic, asclepias, apocynum cannabinum, euo- nymus, chloride of gold and sodium, nitrate of uranium, pilocarpin, 239 jaborandi, helonias, phosphoric acid, hypophosphites, benzo- ate of ammonium, turpentine, 240 chronic, 240 causes, 240 symptoms, 240 treatment, 240 dulcamara, nux vomica, arsenic, Pulsatilla, chloride of gold, phosphate of lime, helonias, Phytolacca, euonymus, rhus aromatita, apocynum can- nab., chimaphilla, eupatorium purpureum, 241 Bronchitis, 120 causes and symptoms, 120 physical signs, 122 treatment, 122 aconite and belladonna, 112 bryonia, ipecac, tincture of sponge, digitalis, chelidonium, sanguin- aria, tartar emetic, hypophos- phites, 123 Bronchocele (see Goitre) Bubo, 254 iodoform, compound tinct. iodine in, 254 Calculus, vesical, 247 symptoms, 247 treatment, 248 lithia carb., carb. potassium, eu- patorium, hydrangea, mullein, actinomeris, sarsaparilla, chima- philla, erigeron, cryngium, eu- patorium aromaticum, cory- dalis 248 lithia. benzoate of ammonium, liatris spicata, 249 Cancer of breast (see Mammae, cancer of) of womb (see Uterus, cancer of) INDEX. 555 Cancer of stomach, 177 Cancrum oris (see Stomatitis, ulcera- tive) Canker of the mouth (see Stomatitis, ulcerative) Carbuncle, 373 symptoms, 373 treatment, 374 tinct. iodine, carbolic acid and glycerine, arsenic, belladonna, 374 Catalepsy, H43 causes, 343 treatment, 344 chamomilla, belladonna, ignatia. gelsemium, phosphoric acid, hyoscyamus, stramonium, sul- phur, pulsatilla, senecio, can- nabis indica, artemisia, Scutel- laria, 344 Catarrh (see Coryza) Chlorosis, 66 symptoms, 66 treatment, 67 iron, helionias, arsenic, hypo- phosphite of lime, nux vomica, Pulsatilla, senecio aur., 67 Cholecystitis, 220 symptoms, 221 • diagnosis, 222 treatment, 222 berberis, chloroform, calcium carb., chelidonium, tinct. cin- chona bark, podophyllin, gel- semium, 222 nitro- muriatic acid, euonymin, aconite, 223 Cholera, 191 causes, 192 treatment, 193 tine, camphor, tinct. arsenic, sul- phate copper, veratrum album, acetate of copper, euphorbia corollata, belladonna, 193 iris versicolor, ozonized water, 194 Cholera infantum, 195 treatment, 195 ipecac., euphorbia.frhubarb,cham- omilla, sulphite of soda, 195 Cholera morbus, 194 causes, 194 treatment, 194 ipecac, iris versicolor, 194 euphorbia cor., creasote cam- phor aconite, chamomilla, dios- corea. 195 m Chorea, 336 symptoms, 66b causes, 337 treatment, 337 agaric,belladonna, caulophyllum, cimicifuga, stricta pulm., stra- monium, zinc and copper, ni- trite of amyl, chloroform, hyoscyamus, ignatia amara, gelseminum, zinc phosphide, spigelia, santonin, 337, nux vomica, staphisagria, gelse- minum, 338 Conjunctiva, hyperaemia of, 446 treatment, 446 glasses, eye-douche, hamamelis, opium, sulphate of zinc, vapor of bisulphide of carbon, rose- mary, chloroform, 446 belladonna lotion, belladonna,447 Conjunctivitis, 447 causes, 447 symptoms, 448 treatment, 448 sulphate of zinc, belladonna, zinc and lead water, boracic acid, 448 catarrhal, 448 symptoms, 449 treatment, 449 cold douche, aconite, bella- donna, sulph. zinc, boracic acid, euphrasia, hydrastis, sulphide of calcium, 449 complications, 449 treatment, 450 chronic, 450 sulphate of copper, nitrate of sil- ver solution, arsenic, 451 diphteritic, 456 symptoms, 456 treatment, 456 cold compresses, aconite, ni- trate of silver, biniodide of mercury, arsenic, sulphide of calcium, calomel oint- ment, 4">6 gonorrhoeal, 454 treatment, 455 calomel ointment, gelseminum, aconite, boracic acid wash, nitrate of silver, biniodide of mercury, 455 purulent, 451 diagnosis, 451 treatment, 451 compresses of cold water, aco- nite, belladonna, gelseminum, leeches, cupping, stimulating collyria, boracic acid, acetate 556 INDEX. of zinc, zinc sulphate, 452 Constipation, chronic, 195 treatment, 196 nux vomica, cascara sagrada, bryonia, aesculus hippo., alum, podophyllum, rhamnus, aloes, asafoetida, chelidonium, collin, sonia, hydrastis. euonymus, 196 robina, sulphuric acid, 197 Contagion, 75 Contagio-miasmatic diseases, 24 Contagious diseases, 24 Convulsions, due to worms, ignatia in, 211 (see eclampsia) Coxalgia, 324 symptoms, 324 treatment, 325 rhus toxicodendron, tincture of phosphorus, belladonna, calc. phosphite, or hypophosite, silicea, iodide of arsenic, tinct. menispermum, ointment of polymnia uved. and oil cedar, 325 Cyanosis, 63 causes of, 63 symptoms of, 64 treatment of, 64 cactus in, 64 collin sonia in, 64 Cystitus, 245 causes, 245 symptoms, 245 treatment, 246 aconite, belladonna, arsenic, can- tharides, arnica, actinomeris, citrate or carb. lithium, buchu, uva ursi, chimaphilla, pareira brava, turpentine emulsion, camphor, erigeron, santonin, hydrastis, 246 silphium perforatum, equisetum hyemale, 247 Delirium tremens, 434 Dementia paralytica, 432 pathology, 432 causes, 432 symptoms, 432. senile, 433 treatment, 434 carbonate of ammonium, phos- phorus, calc hypophosphite, nux, 434 Dermatitis contusiformis, 358 treatment, 358 arnica, hamamelis, rhus tox., apis mel., ptelea trifol., 358 borax, boracic acid, chamomilla, graphites, sulphur, sulphuric acid, 359 Diabetes mellitus, 236 symptoms, 236 treatment, 236 rhus aromatica, helonias, lycopus, trillium, uranium, nux vom,, 236 Diaphragmitis, 165 symptoms, 165 treatment, 166 aconite, bryonia, rhus tox., asclepias, hot compresses, 166 Digestive organs, diseases of, 167 Diathesis, 11 of climate, 12 bronchocele, 12 gouty. 13 nervous, 14 bilious, 15 lymphatic, 16 Dietetics, 43 Diplopia, 445 Diphtheria, 533 diagnosis, 537 prognosis, 538 sequelae, 537 treatment by muriatic acid, lactic acid, nitric acid, salicylic acid, belladonna, Phytolacca, sul- phur, chlorate of potash, lis- terine, eucalyptus, mercuric iodide, mere, biniodide, iodide of potash, iodide of arsenic, bromine water, bromide, ailan- thus, sanguinaria, carbolic acid, chloride of lime, chlorine water. thymol, boracic acid, quinia, carbolate of ammonia or soda, tar arid turpentine fumes, tur- pentine, 539, 540 Dipsomania (see Alcoholism, chronic) Disease, definition, 1 Dose of medicines, 47 Dropsy of scalp, 389 treatment, 389 cream tartar, nitrite of iron, Val- let's mass, apocynum cannab., eupatorium, polytrichum, ace- tate of potash, petroselinum sativum, chimaphilla, 389 ovarian, 281 symptoms, 281 diagnosis, 282 treatment, 282 apis mel., iodide of arsenic, can- INDEX. 557 tharides, tinct. arsenic, 283 Dysentery, 188 symptoms, 189 ^ prognosis, 190 treatment, 190 aconite, gelsemium, baptisia, hamamelis, ipecac, podophyl- lum, 190 mild aperients, sulphate of soda, tinct. aloes, colocynth, 191 Dysmenorrhoea, 300 treatment, 301 aconite, pulsatilla, acetate of ammonium, collinsonia, sepia, xanthoxylum, gelsemium vi- burnum, cimicifuga, guiacum, cannabis indica, senecio, au- reus, caulophyllum, comp. tinct. iodine, sulphur, 301 tr. arsenic, iron, helonias, cimici- fuga, guiacum, 302 Dyspepsia, 167 symptoms, 167 treatment, 168 careful diet, 168 bryonia, bismuth, arsenic, nux vomica, berberis, aletris fari- nosa, 169 chelidonium, euonymus, cornus circ, ignatia, hydrastis, he- lonias, iris versic, muriatic acid, phosphoric acid, robina, 170 podophyllum, lappor major, Pul- satilla, hypophosphites, lacto- peptine, 171 Eclampsia infantum, 348 treatment, 348 belladonna, chamomilla, cypri- pedium, Scutellaria, gel- semium, chloral,. 349 puerperal, 347 treatment, 348 chloroform, belladonna.acomte, veratrum, chloral hydrate, ni- trite of amyl. gelsemium Electicism, what it is, 31 Ecthyma, 369 treatment, 369 white precipitate ointment, car- bolic acid, triturated antimony, arsenic, bichromate potash, rhus tox., tartar emetic, d7U Eczema, 362 causes, 362 chronic, 363 diagnosis, 364 treatment, 364 diet bran washes, poppy fomen- tations, marshmallow poul- tices, starch and linseed poultices, oxide or carbonate of zinc, glycerole of tannin, carbolic acid, grindelia, pyro- ligneous oil of juniper, borax and lime water, benzoated ox- ide of zinc ointment, chryso- phanic acid, dulcamara, oil of cade or juniper, oleate of tan- nin, sapo viridis, oleate of litharge, aconite, 366. carbonate of ammonium carbon- ate of barium, arsenic, bella- donna, sulphide of calcium, clematis, dulcamara, graph- ites, hydrastis, iris versicol., arctium lappa, iodide of arsenic, juglans cinerea, pe- troleum, piper methyst, 366 rhus tox., sepia, staphisagria, sulphur, viola tricolor, 367 of the scalp, 393 diagnosis, 394 causes, 394 treatment, 394 rhus tox., arsenic, viola tricolor, green soap wash, wash of sul- phuret of potash or sulphide of calcium, 394 clematis, carbonate of barium, rumex crispus, dulcamara, boracic acid, carbolic acid, croton ointment, 395. Embolism of brain (see Brain) Emphysema, 137 diagnosis, 138 treatment, 138 tinct. arsenic, belladonna, arseniate of quinine, digitalis, ipecac and sanguinaria, senega, 138, 139 Endocarditis. 159 symptoms, 160 treatment, 161 chloride of gold, spigelia, cereus grandiflorus, convallaria, carb. of ammonium, aconite, 161 Enteralgia, 203 symptoms, 204 treatment, 204 chloric ether, dioscorea, nux vomica, colocynth iris versi- color, 204. santonine chamomilla, 205 + 558 INDEX. Epilepsy, 344 symptoms, 344 causes, 346 diagnosis, 346 prognosis, 346 treatment, 346 nitrite of amyl, nitroglycerine, 346 artemisia, verbena hastata, coccu- lus indicus, belladonna, ignatia, oxide copper, caulophyllum, viscum album, bromides of lith- ium, sodium, ammonium, 347 Epithelioma, 375 diagnosis, 376 treatment, 376 excision,caustic, chromium,thuja, chloride zinc, berberis, arnica, chloride gold and sodium, sul- phate zinc wash, hydrastis, 377 Erysipelas of scalp and face, 390 causes, 391 symptoms, 391 diagnosis, 392 prognosis, 392 pathology. 392 treatment, 393 aconite, belladonna, apis mel., rhus tox., arsenic, veratrum viride, chloride of iron, 393 Eye, diseases of, 442 Favus, 397 diagnosis, 398 * treatment, 398 almond or olive oil, glycerine, poultices, hyposulphite of soda, sulphurous acid, corros. subli- mate lotion, chrysophanic ce- rate, grindelia cerate, carbolic or dioscorea lotion, oil juniper, iodide of arsenic, 398 Felon, 378 treatment, 379 compression, incision, carbonate of ammonium, calcium sul- phide, iodine and aconite appli- cations, 379 Fever, 72 poisons of, 73 Fevers, exanthematic, 78 miasmatic, 24 Function, alteration of, 7 Furuncle, 372 treatment, 373 Lugol's solution, tinct. iodine, arnica, aconite, hamamelis, belladonna, honey and flour poultice, sulphide calcium, carb. calcium, sulphur, Phyto- lacca. 373 Gall-stones (see cholecystitis) Gastralgia, 174 symptoms, 174 treatment, 175 assaf cetida, dioscorea, peppermint, lobelia, ipecac, non-acid diet, nux vomica, celandine, pod- ophyllum, ignatia, amara, col- ocynth, 175 Gastritis acute, 171 causes, 171 symptoms, 172 treatment, 172 aconite, tinct. arnica, bryonia, charcoal, chamomilla, ipecac, nux vomica, 172 Gastritis, chronic, 173 symptoms, 173 treatment, 173 bismuth, arsenic, nux vomica, robina, capsicum, 173 Pulsatilla, ipecac, chamomilla, hydrastis, sanguinaria, podo- phyllum, dieting, 174 Gastromalacia, 180 symptoms, 180 treatment, 181 creasote, hamamelis, Monsel's salt, lycopus, 181 Generation, male organs of, diseases of, 250 Generative organs, female, diseases of, 279 Glottis, spasm of, 551 symptoms, 551 treatment, by gelsemium and lobelia, bella- donna, bromide of sodium or ammonium, 552 Goitre, 542 treatment by egg-shell powder, io- dine, iodides, iodide of barium,542 Gonorrhoea, 250 symptoms, 250 treatment, 252 aconite, gelsemium, sulphate of zinc yerbareuma, boracic acid solution, cannabis sativa, hy- drastis, cantharides, Pulsa- tilla, 252 mullein poultice, copaiba, oil santal, eucalyptus, piper me- thys , silphium gummif., per- INDEX. 559 manganate potass., alum, echenacea, 253 sequelae, 253 treatment, 253 of bladder, 254 Gout, 317 treatment, 318 diet, exercise, aconite, colchicum, phosphate of ammonium, phos- phate of lime, iodide of potash, gum guiacum, 318 benzoic acid, benzoate of am- monium, carbonate or citrate of lithium, lycopedium, aconite, veratrum, bryonia, 319 Haematemesis, 178 Haemorrhage, intestinal (see Intestinal haemorrhage, 197) Haemorrhoids, 198 causes, 198 symptoms, 199 treatment, 199 nux vomica, sulphur, Monsel's salt, aesculus. 199 aconite, hamamelis, collinsonia, ergot, carbolic acid, aloes, podophyllin, capsicum, muri- atic acid, ung. gallae, stramo- nium,hyoscymus.diet.injections cold water, 200 Haematuria 237 causes, 237 treatment, 238 arnica, rhus aromatica, canthari- des, uva ursi, terebonthina, tinct. iron, lycopus, capsella bursa, chimaphilla, equisetum hyemale, trillium, erigeron, 238 Haemoptysis, 142 treatment, 143 lycopus, aconite, ergot, charcoal, collinsonia, iron, hamamelis, 143 Health, definition of, 1 Heart, diseases of, 149 examination of, 149 Heart, hypertrophy and dilatation ot, 161 treatment, 162 nux vomica, collinsonia, tinct. arsenic cereus, lycopus, kal- m£ digitalis, iodide of arsenic, Shicum carb., and benzoate taJSSr.SU. /met pho, phorus, acetate of lead, pyro- phosphate of iron, lycopus, 163. Heart, nervous palpitation of, 163 treatment, 164 aconite, assafoetida, tinct. cam- phor, tinct., bark, cocculus indicus, pyrophosphate of iron, Pulsatilla, 164 Heart, valvular disease of, 156 treatment of, 158 diet, removal of stimulants, arsenic, lycopus, cereus, bella- donna, convallaria, phyrophos- phate of iron, tinct. phosphorus, 159 Hepatitis, 215 symptoms, 216 treatment, 216 belladonna, aconite, bryonia, 216 euonymin, chelidonium, leptand- rin, nux vomica, sulphide of calciura, pulsatilla, arsenic, lycopus, 217 Herpes, 359 treatment, 359 camphor cerate, calendula jelly, cologne water, aconite, alnus rub., 359 tincture arsenic, tincture hyperi- cum, 360 Hip-joint disease (see Coxalgia) Hydrocele, 262 treatment, 263 arnica, pulsatilla, chloride of gold and sodium, iodine, 263 Hydropericardium, 154 symptoms, 155 treatment, 155 digitalis, apocynum cannab., ac- etate of potash, pipsissewa, polytrichum, nitrate of potash, senecio aureus, 155 helonias, iron, cinchona, Hux- ham's tincture, 156 Hydrophobia, 351 symptoms, 352 pathology, 352 diagnosis, 352 treatment, 353 cauterization, syringing with sal icylic acid, permang. potash boracic acid, caustic potash resin cerate, anagallis, conval laria, Scutellaria, belladonna xanthium spinosa, echenacea 353 Hydrothorax, 145 symptoms, 146 treatment, 146 560 INDEX. apocynum cannab., nitrate of potash, digitalis, 146 asparagus, polytrichum junip., pipsissewa, tinct. arsenic, iron, helonias, byronia, asclepias, acetate of potash, squill, pars- ley root, eupatorium, 147 Hyperplasia, 6 Hygiene, 43 Hysteria, 338 etiology, 338 symptoms, 338 treatment, 339 ignatia amara, camphor, musk, cimicifuga, 339 assafcetida, vervain, Scutellaria, valerianate of zinc, nux vomi- ca, gelsemium, cannabis indica, chloral hydrate, 340 Ichthosis, 356 diagnosis, 357 treatment, 357 tonics, cod-liver oil, chaulmoogra oil, sapo virid., iodide of ar- senic, clematis erecta, comp. tinct. iodide potass., hypophos- phites of lime, sodium and magnesium, thuja.quillaya sap- onaria, diet, alkaline baths, 357 Infection, 75 Impetigo contagiosa, 367 diagnosis, 368 treatment, 368 antimony, euphorbia, bichromate of potash, tartar emetic, thuja, nitrate of potassium, 368 aconite, olive oil, oil cade, 369 Impotence, 265 treatment, 265 nux vomica, hypophosphites, he- lonias, stillingia, 265 damiana, electricity, diet, exer- cise, baths, 266 Intermittent fever, 100 causes, 100-102 stages, 101 treatment, 103 cinchona,cinchonidia, gelsemium, aconite, ipecac, alstoni acon- stricta, euonymin, podophyl- lin, iron, helonin, Fowler's so- lution, 104 ptelea, sabbatia stellaris, comp. tinct. iodine, resorcin, benzoate of soda, pilocarpine, apiol, eu- calyptus, ammonium carbazo- tate and picrate, 105 Intestine, catarrh of, 182 causes, 182 symptoms, 182 treatment, 182 aconite, gelsemium, 182 bryonia, arsenic, chamomilla, cor- nus circ, ipecac, iris versicolor, podophyllum, rhubarb, diosco- rea, colocynth, 183 Intestine, chronic catarrh of, 184 causes, 184 symptoms, 184 treatment, 184 arsenic, baptisia, 184 tinct. camphor, dioscorea, ipecac, tinct. podophyllum, 185 Intestinal haemorrhage, 197 treatment, 197 vegetable charcoal, hamamelis, Monsel's salt, ipecac, 197 Itch, 385 (see Scabies) Itch, prairie, 387 rumex crispus, corrosive subli- mate and ammonia lotion, sul- phide of calcium, 387 Itching (see Pruritus) Jaundice, 223 treatment, 224 chionanthus, chelidonium, hydras- tis, nitro muriatic ,acid, nitric acid, eunoymus, nux vomica, berberis, leptandrin, bryonia, centaurea, iodine, podophyllin, aconite, myrica cerif era, digita- lis, 225 chloride of gold, arsenic, sodium phosphate, sulphate of manga- nese, rhubarb, aloes, iodide and chloride of ammonium, iris versicolor, pottassium sulphate, chloroform, olive oil, chloral, diet, 226 Kidneys, diseases of, 233 Knee, white swelling of, 325 symptoms, 326 treatment, 327 arnica, aconite, Thus tox., carb. lime, tinct. iodine, silicea, tinct. arsenic, ointment uvedalia and oil cedar, 327 Laryngitis, acute, 544 causes, 545 INDEX. 561 treatment by aconite, sanguinaria, belladonna bromine, bryonia, drosera, 545, 546 Laryngitis, chronic catarrhal, 546 symptoms, 546 treatment by iodine and iodide of potass., nitrate of silver, iodide of arsenic, bichromate of pot- ash, permang. potash, sticta pulmonacea, stillingia, gold, 546, 547 Laryngitis, croupous, 547 diagnosis, 547 treatment by acetic acid, tinct. iodine, sanguinaria, lobelia, bichromate potash, bromine in- halations,, aconite, alum, 548 Larynx, diseases of, 542 Larynx, oedema of, 548 symptoms, 549 treatment by aconite, apis mel. arsenic, arum, belladonna, san- guinaria, acetic syrup, 549 tubercular ulceration of, 550 diagnosis, 550 treatment by nitrate of silver, ar- senic, hysophosphites, 550, 551 Leucorrhcea, 283 pathology, 283 symptoms, 284 treatment, 284 aletris farinosa, aesculus hippo, muriate of ammonium, 284 tinct. arsenic, baptisia, perman- ganate potash, collinsonia, Pul- satilla, hydrastis, hydrastin, cimicifuga, yellow marigold, balsam Peru, carbolic acid, boracic acid, alum solution, sepia, 285 Leukaemia, 65 symptoms, 65 treatment, 66 Thuja, sulphate of soda, nux, Fowler's solution, menispermin, nitrate of sodium, acetate of sodium, nitrate of potassium, carbonate of lime, phosphate of magnesium, 66 Lichen, 381 prognosis, 382 treatment, 382 grindelia wash, carbolic acid oil juniper, antimony, arsenic, 3&J iodine, iodide of sulphur bi- chromate potash, tinct. juglans, 383 • * A Life, qualities ot, 4 Liver, acute yellow atrophy of, 219 symptoms, 219 treatment, 220 aconite, bryonia, belladonna, ipecac, leptandrin, chionan- thus, berberis vulgaris, 220 cirrhosis of, 217 causes, 218 symptoms, 218 diagnosis, 218 treatment, 218 nux vomica, pulsatilla, tinct. arsenic, bryonia, chionan- thus, 219 diseases of, 212 hyperaemia of, 212 symptoms, 212 treatment, 212 bryonia, nux vomica, 212 chionanthus, euonymin, podo- phyllin, sulphate of mag- nesia, hydrastis, iris versi- color, centaurea, 213 torpidity of, 213 Lumbago, 315 Malarial haematuria, 76 cinchona, cinchonidia, hama- melis, tinct. iron, sulphite of soda, turpentine, oil of erig- eron, euphorbia, ipecac, butter- milk, chelidonium, 76 Malignant pustule, 374 treatment arsenic, iodido arsenic, 375 Mammae, cancer of, 303 cause, 304 treatment, 304 operation, chloride of zinc, gold, and bromium, 304 Mastitis, 303 causes, 303 treatment, 303 Phytolacca, Indian meal poultice, belladonna, incision, 303. Mastodynia, 332 Masturbation, 269 Measles, 88 mode of propagation, 88 symptoms, 88 treatment, 89 aconite, veratrum, gelsemium, belladonna, ipecac, bryonia, drosera rotund , 89, 90 treatment of sequelae, 90 Medicines, dose of. 47 Meningitis, acute, 416 562 INDEX. causes, 417 symptoms, 417 treatment, 418 potass, phosphate or hypophos- phite, aconite, apis mel., apocynum cannab., hyoscya- mus, stramonium, digitalis, iodine, tinct. sponge, bry- onia, acetate of copper, phos- phide of zinc, 418, 419 cerebro-spinal, 419 symptoms, 419 diagnosis, 420 treatment, 421 aconite, belladonna, cannabis indica, gelseminum, counter- irritation, ergot, physostigma, chloral, 421 spinal, 307 pathology, 307 symptoms, 307 treatment, 308 aconite, belladonna, phosphate of lime, cocculus indicus, dul- camara, 403 tubercular, 414 symptoms, 414 diagnosis, 415 treatment, 415 aconite, belladonna, hyoscya- mus, bryonia, hellebore, apo- cynum cannabinum, digitalis, arsenic, 416 Menorrhagia, 297 causes, 297 treatment, 298 ipecac, sabina, ergot, erigeron, cannabis indica. rue, crocus sativa, cereus, charcoal, chamo- milla, belladonna, bromides, hamamelis, trillium pendulum, ustilago, 298 tonics, senecio aureus, helonias, aletiis, 299 Metritis, acute parenchymatous, 286 causes, 286 symptoms, 286 prognosis, 286 treatment, 287 aconite, belladonna, ipecac, veratrum viride, turpentine stupe, 287 baptisia, 288 chronic parenchymatous, 288 causes, 288 symptoms, 289 treatment, 289 depletion, phytolacca, sepia, Lugol's solution, polymnia uved., 289 Metrorrhagia, 296 treatment, 297 ipecac, cannabis indica, _ secale cornutum, sabina, _ erigeron, apocynum cannabium, tril- lium pendulum, berberine, 297 Miasm, 75 Miasmatic fevers, 24 Micrococci, 25 Micro-organisms, pathogenic, 22 non-pathogenic, 22 Milk crust, 505 treatment by arsenic, belladonna, carbonate of lime, sulphur, rhus, carbolic soap washes, sul- phurous acid, carbolic soap ointment, 506 Motory apparatus, diseases of, 312 Mouth, diseases of, 512 sore, of infants (see Thrush) Mumps, 520 diagnosis, 521 treatment by aconite, iodol, iodo- form ointment, belladonna, Pulsatilla, mullein poultice, 521, 522 Muscae volitantes, 473 treatment by hamamelis, tincture of arsenic, 474 Myelitis, 308 pathology, 308 symptoms, 309 treatment, 309 aconite, ergot, belladonna, hypophosphite of lime, vesi- cation, sodium and mag- nesium, 310 chronic, 310 causes, 311 symptoms, 311 treatment, 311 phosphorus, phosphide of zinc, physostigma. nitrate of sil- ver, nux vomica, electricity, cold applications, 311 Nsevus vascular, 400 treatment, 401 collodion and corrosive sublimate paste, nitric acid, thuja, chromic acid Nephritis, interstitial, 242 causes, 242 symptoms, 242 treatment, 243 index. 568 aconite, cantharides, pulsatilla, hyoscyamus, sulphide of cal- cium, 243 Neuralgia, 328 symptoms, 329 treatment, 330 arena, diadema, belladonna, aethusa, nitrate of silver, qui- nine, ignatia amara, gelsem- inum, 330 cervico-occipital, 332 cervico-tracheal, 332 lumbo-abdominal, 332 sciatic, 332 Neuritis, 328 treatment, 328 aconite, ointment of hyperi- cum, belladonna, rhus tox., sulphur, arsenic, euphrasia, cocaine, 328 optic, 478 treatment by arsenic, phosphide of zinc, chloride of gold and sodium, iodide of potash, bella- donna, gelseminum, macrotis, spigelia, phosphorus, 479 Nerves, motor, morbid affections of, 334 Nervous system, diseases of, 328 Nose, diseases of, 496 Noma, 540 treatment by arsenic, potass, per- manganate, arseniate of gold, chloride of gold and sodium, echenacea, 541 Oesophagitis, 542 symptoms, 543 treatment by aconite, arsenic, belladonna, bichromate of pot- ash, phosphorus, 543 Oesophagus, diseases of, 542 stenosis of, 543 symptoms, 544 treatment by gelseminum, surgery, 544 Oligocythaemia, 65 treatment, 65 . baptisia, Fowler's solution, 05 Organisms, in living tissues, 23 Onanism, 269 Ophthalmia, military, 45*J treatment, 453 sulphide of calcium, sulphate of zinc, boracic acid, mucil- aginous solutions, prussic acid solution, belladonna, 453 neonatorum, 453 causes, 453 treatment, 453 boracic acid, cold compresses, aconite, 453 Pulsatilla, sulphide of calcium, alum water sulphate of zinc, aconite, nitrate, of silver, salt water, arsenic, 454. Opium and morphia poisoning, 437 treatment, 438 emetics, coffee-tea, belladonna, digitalis, 439 Optic nerve, atrophy of, 479 causes, 480 prognosis, 480 treatment by eledtricity, nux vomica, 480 Optic neuritis (see Neuritis, optic) Orchitis, 253, 263 treatment, 253, 264 clematis, dulcamara, mullein poultices, pulsatilla, tussilago, rhus tox., thuja occid., equise- tum hyemale, 253 aconite, cannabis indica, bella- donna, iodine, 264 Osteitis, 321 causes, 321 symptoms, 321 terminations, 322 treatment, 322 daphne mezereum, nitric acid, silicia, staphisagria, acid phos- phate, phosphite of lime, chlor- ide of gold, angostura, assafoe- tida, menispermum, cod-liver oil, scrofularia, tinct. cinchona, 322 Otorrhoea, simple, 487 treatment by arsenic, chloride of gold, sulphide of calcium, bor- acic acid solution, 487 chronic, 493 symptoms, 494 treatment by chloride of gold, arsenic, graphites, iodine,bor- acic acid, 495 Ovarian dropsy (see Dropsy, ovarian) Ovaritis, 279 causes, 279 symptoms, 279 treatment, 280 aconite, arsenic, conium, cimici- fuga, iodine, bryonia, rhus tox., staphisagria, thuja occidentalis, 280 ustilago, 281 564 INDEX. Oxyuris vermicularis, 207 -treatment, 208 injections of proto-sulphate of iron, root bark of apocynum cannabinum, apple tree bark infusion, cold injections, 208 Ozaena, 498 symptoms, 498 treatment by chloride of gold, carb. barium, berberis, arsenic, chloride of gold and sodium, bichromate of potash, iodide of potash, pulsatilla, 499, 500 Pancreas, diseases of, 231 Pancreatitis,' 231 treatment, 232 aconite, belladonna, pulsatilla, iris versicolor.carb. lime,euony- mus, chionanthus, berberis, 232 Paralysis, 349 causes, 349 treatment, 350 phosphorus, belladonna, phos- phide of zinc, nux vomica, 350 rhus tox., cocculus indicus, elec- tricity, 351 agitans, 349 causes, 349 treatment, 349 rhus tox., stramonium, tinct. ar- senic, phosphoric acid, phos- phide of zinc, 349 Paralytic dementia (see Dementia paralytica) Parasites, vegetable, 18 Paronychia, 377 treatment, 377 bulrush pith, calcium sulphide, sodium sulphate, graphites, bromium chloride, boracic acid, iodoform, 378 Parotitis contagiosa (see Mumps) symptomatic, 522 treatment by muriate of barium, iodide of barium, sulphide of calcium, silicea, arsenic, in cision, glycerine and creasote dressing, listerine, ucalyptol, 522, 523 Pemphigus, 370 treatment, 371 careful diet, -bran, starch and gel- atine baths, rhus tox., arsenic, thuja, muriate of ammonium, belladonna, phosphoric acid, 371 Pericarditis, 151 symptoms, 152 physical signs, 152 treatment, 153 aconite, bryonia, cereus grandi- florus, digitalis, spigelia, 153, 154 Peritonitis, 201 causes, 201 symptoms, 202 treatment, 202 aconite, bryonia, 202 colocynth, tinct. arsenic, carb- onate of lime, vegetable char- coal, belladonna, tinct. oil of erigeron, apis mel., hot fomen- tations, 203 Peri-typhlitis (see Typhlitis) Phosphates, earthy, in urine, 60 Phthisis, 132 treatment, 133 Lugol's solution, creasote, phos- phates, ptelea, euonymus, comp. syrup of phosphites, Fowler's solution, Peruvian balsam, io- dide of arsenic,cod-liver oil, sal- licin, quinine, salicylic acid, iodide of iron, of manganese, carbolic acid, phosphoric acid, maltine,petroleum, aconite, 134 hygienic treatment, 136 diet, exercise, bathing, climate, 136, 137 Pleurisy, 139 symptoms, 140 physical signs, 141 treatment, 141 aconite, bryonia, sanguinaria, wine of antimony, aslepias, diaphoretics, warm compresses, 142 Pneumonia, 127 causes and symptoms, 127 physical signs, 128 treatment, 130 aconite, bryonia, ipecac, sangui- naria, belladonna, chelidonium, iodide potassium, bromide so- dium, phosphorus, asclepias, hot compresses, 130, 131 Pneumothorax, 143 physical signs, 144 diagnosis, 145 treatment, 145 tinct. arsenic, aconite, arnica, delphinium, aspiration, 145 Poisoning, opium and morphia, 437 INDEX. 565 Poisons, wound and bites, 68 treatment, 68 bandage, sucking, alcohol, 68 brandy, whiskey, ammonia, echinacea, carbolic acid, per manganate of potash, arsenic, excision, chloride of lime, ipecac poultice, 69 bites of rabid animals, echinacea, cauterization, belladonna, glo noin, stramonium, chloroform, 69 and 70 Production, spontaneous, 23 Prostate, diseases of, 267 Prostatitis, 267 symptoms, 267 treatment, 267 Pulsatilla, digitalis, ignatia amara, barosma, chimaphilla, iodide of barium, senecio aureus, tur- nera aphodisiaca, thurja, ergot, 268 Prurigo (see Pruritus) Pruritus, 883 causes, 383 diagnosis, 384 treatment, 384 diet, sulphur baths, carbolic lo- tions, dioscorea and meze- reum lotions, sulphur, arsenic, vapor baths, oil peppermint, menthol, 384 cyanide of potass., ammonia water, chloral lotion, alkaline solution of tar, zinc ointment, 385 vulvae, 302 treatment, 302 collinsonia, conium, sepia, sul- phur, sulphurous acid, plati- num, lycopodium, grindeha, hamamelis, 302 Psoriasis, 379 symptoms, 379 causes, 380 diagnosis, 380 treatment, 380 rich diet, maltine and cod liver oil bran baths, chaulmoogra oil' chrysophanic cerate, _ oil cade, tar and alcohol, biniod. mercury ointment, calcium Zlhidl wash, green soap wash, 380 , tincture sulphur, .ammon carb. arsenic, iris versic, Phytolacca, berberis, white precipitate oint- ment, green soap suds, muriatic acid, petroleum, 381 Puerperal convulsions, 347 fever, 289 treatment, 290 antiseptics, veratrum, aconite, permanganate potash, bap- tisia, tincture arnica, bella- donna, 290 rhus tox., bryonia, turpentine, 291 Proctitis, 187 symptoms, 187 treatment, 18d aconite, gelsemium, ipecac, podo- phyllum, mild cathartics, 188 Pulse, as a symptom, 55 Purpura haemorrhagica, 70 treatment, 70 phosphorus, hamamelis. arsenic, 70 Pus, in urine, 61 Rachitis, 320 causes, 320 signs, 320 treatment, 320 diet, codliver oil, maltine, carb, calcium, calc,. phosphate, bryonia, 321 Remedies, specific applications of, 3D Remittent fever, 105 treatment, 105 belladonna, arseniate of quinine, tincture of camphor, xanthoxy lum, cinchonidia, irritation of skin, antiseptic treatment, sul phite of sodium, sulphurous acid, baptisia, muriatic acid, 107 aconite, gelsemium, quinine, cinchonidia, 108 Renal colic, 243 symptoms, 243 treatment, 244 belladonna, gelsemium, cannabis indica, bromides, coccus, cacti, berberis, chloroform, carb. calcium, citrate of lithium, ozonic ether, benzoate of am- monium, citrate of potassium, diet, arnica, piper methysticum, eupatorium, carbon, lithium, borax, 244 Respiration, as a symptom, 57 Retina, hyperaemia of, 476 cause, 476 celandine, cereus, macrotis, bella- 566 INDEX. donna in, 477 Retinitis, 477 causes, 477 prognosis, 477 treatment, by removal of cause, arsenic, protection of eyes, 478 Rheumatism, acute, 312 predisposposition, 312 symptoms, 313 fever, 313 treatment, 313 aconite, salicylic acid, 313 salicylate of soda, sweet spirits of nitre, bryonia, rhus tox., alcoholic or camphorated va- por bath, manaca, benzoate of ammonium, lithium salts, Phytolacca, colchicum, 314 chronic, 314 treatment, 315 berberis, rhus tox,, 315 • benzonic acid, benzoate of am- monium, manaca, chelidon- ium, cimicifuga, • arnica, caulophyllum, colchicum, salicylic acid, Phytolacca, sulphur, 316 rhus tox., rhododendron, ran- unculus, sticta pulmon., sarsaparilla, cereus, spigelia, nux vomica, 317 muscular, 315 of the scalp, 388 benzoate of lithia or ammonia, cimicifuga, salicylic acid, 388 tinct. camphor, tinct. menthol, 389 Rickets (see Rachitis) Ringworm, 399 diagnosis, 400 treatment, 400 sulphurous acid, corros, subli- mate, Lugol's solution, chryso- phanic acid, 400 Rose cold (see Hay Fever) Rupia, 371 treatment, 372 iodide potash, iodide ammon., berberis, iodide arsenic, 372 Scabies, 385 diagnosis, 385 treatment, 385 green soap and napthol washes, sulphur, 386 Scalp, diseases of, 388 rheumatism of, 388 treatment of, 388 dropsy of (see Dropsy) Scarlatina, 91 symptoms, 92 causes and mode of propagation, 93 treatment, 93 belladonna, aconite, ailanthus, baptisia, apis mel., 93 gelsemium, carb. ammonium, sulphite soda, Fowler's solu- tion, camphor, rhus tox., po- tass, permangan., 94 Schizomycetes, 25 Scrofula, 71 treatment, 72 alnus rubra, iodide of barium, hypophosphites, cistus cana- densis, menispermin, black walnut syrup, chloride of gold, iodide of potassium, iodide of arsenic, scrophularia and iodides, echinacea, 72 Scurvy, 67 causes, 68 treatment, 68 agave Americana, lemon juice, vegetables, 68 Seborrhoea capilli, 395 treatment, 396 olive oil and glycerine, glycerole of tannin, arsenic, muriate of ammonia, sulphur, bryonia, 396 Lugol's solution, tinct. phos- phorus, bromide of potass., 397 Secretions, classes of, 2 Septic diseases, 25 Skin, as a symptom, 58 diseases of, 354 Small pox, 94 course and symptoms, 85 treatment, 97 aconite, veratrum, digitalis, sul- phate of zinc, belladonna, apis mel., camphor, hydrastis, sarra- cenia, muriate of ammonium, Fowler's solution, baptisia, rhus tox., gelsemium, glycerole of carbolic acid, cimicifuga, bella- donna,carbonate of ammonium, collodion, carbonate of zinc, ' 97, 98, 99 Solids, of the body, 3. Sore mouth of infants (see Thrush) Sore throat, 528 causes, 528 treatment by aconite, belladonna, apis mel., sanguinaria, 528 chronic, 529 INDEX. 567 clergyman's, 529 treatment by arum triphillum, col- linsonia alum gargle, bichrom. potash, 530 Spasms, 344 causes, 335 prognosis, 335 Specific diseases, acute, 24 Spermatorrhoea, 276 treatment, 277 gelseminum, nuphar, phosphoric acid, staphisagria, bromide of camphor, cannabis indica, turnera aphrodisiaca, arsenic, collinsonia, electricity, baths, 278 Spina bifida, 306 treatment, 307 carbonate of lime, phosphite of lime, iodine and glycerine in- jection, injection of iodine, iodide potas., and water, 307 Spinal cord, anaemia of, 305 hyperaemia of, 305 symptoms, 305 treatment, 306 aconite, gelsemium, ergot, bella- donna, 306 diseases of, 305 multiple sclerosis of (see Myelitis, chronic) Spinal meningitis (see Meningitis, spinal) Spleen, diseases of, 228 Splenitis, 228 symptoms, 229 treatment, 229 cinchona, cinchonidia, ceanothus, biniodide of mercury, iodide of potassium, aconite, 229 bryonia, iodine, uvedalia, phos- phate of iron, sanguinaria, sil- phium perfolatum, iron and helonias, euonymus, 230 Staphyloma, anterior. 465 Stings, of insects, etc., (see poisons) 69>70 Stomach, cancer of, 177 forms of, 177 symptoms, 178 treatment, 178 bismuth, arsenic, hydrastis, 17« Stomach, haemorrhage of, 178 symptoms, 179 treatment, 180 Monsel's salt, tincture of oil ot erigeron, hamamelis, ipecac, vegetable charcoal, ergot, lyco- pus, 180 Stomach, perforating ulcer of, 175 symptoms, 176 diagnosis, 176 treatment, 177 arsenic, conium, atropine, bichro- mate of potash, diet, 177 Stomatitis, ulcerative, 532 treatment by borate of soda, chlor- ate of potash, arum, baptisia, sulphate of copper, cinchona, hydrastis, 533 Stricture of urethra (see Uretha, stric- ture of) Structure, alteration of, 7 Sunstroke, 422 causes, 422 pathology, 422 symptoms, 422 treatment, 423 gelseminum, nitro glycerine,bella- donna, nitrite of amyl, 423, 424 Susceptibility, 5 Symptoms, of disease, 55 Syphilis, 255 constitutional, 256 treatment, 258 compound iodine, echinacea, iodide of potassium, mer- curials, nitric acid, bichro- mate of potash, stillingia, corydalis, Donovan's solution, permqngante of potash, iodo- form ointment, 259 calomel dressings, chloride of gold, thuja, chloride of zinc, rhus venenata, berberis aqui- folium, caroba, cascara am- arga, aceitillo, 260 echinacea, 261 Taenia soleum, 209 symptoms, 210 treatment, 210 pomegranate root bark, koosso, male fern, kamala, cucurbita, pepo, turpeutine, oxide of zinc, pelletierine, chloroform, 211 Teeth, decay of, 519 treatment by silicea, carbonate of lime, borate of soda, 519 Temperature, as a symptom, 56 Therapeutics, laws of, 28 Testes, diseases of, 262 « Tetanus (see Trismus) Throat, diseases of the, 512 Thrombosis (see Embolism) 568 INDEX. Thrombosis of cerebral sinuses, 430 symptoms, 430 treatment, 431 carbonate and aqua ammonia, 431 Thrush, 530 symptoms, 530 causes, 531 treatment by boracic acid or borax solution, borax and sugar of milk, baptisia, sulphur, sul- phurous acid, sulphide of cal- cium, 532 Tic Douloureux, 330 treatment, 331 aconite, belladonna, tinct. arsenic, bismuth, chamomilla, quinine, colocynth, 331 gelseminum, 332 Tinea circinata (see Ringworm) favosa (see Favus) Tongue, as a symptom, 57 Tongue, cancer of, 516 treatment by arsenic, hydrastis, powdered hydrastis, 517 diagnosis, 512 inflammation of, 514 symptoms, 5l4 treatment by aconite, apis mel., baptisia, arsenic, sulphide of calcium, sulphur, nitric acid, 515, 516 Tonsillitis, 523 symptoms, 523 diagnosis, 523 treatment by muriate of am monium, aconite, apis mel., carbonate of barium, iodide of barium,(Lugol's solution, iodide of potash, barium iodide or muriate, 524, 625 Toothache: creasote, oil of cloves, plantago major, oil of mint, menthol, aconite, oil of cajiput, belladonna, gelseminum, carbolic acid, arnica, cold water, ca- thartics, 520 treatment, guide to, 36 Trismus, 340 neonatorum, 341 causes, 342 treatment, 342 gelseminum, aconite, bella- donna, cicuta, nux vomica, calabar bean, eserine, 342 Tuberculosis, of bone, 323, 325 Tumors of brain (see Brain, tumors of) Typhlitis, 185 symptoms, 186 diagnosis, 186 treatment, 187 belladonna, aconite, rhus tox., 187 Typhoid fever, 78 causes and symptoms, 79, 80, 81 complications, 81 treatment, 82 Baptisia, antiseptics, belladonna, ipecac, phosphoric acid, scutel- larin, sulphuric acid, 82 Turpentine, emulsion, aconite, vegetable charcoal, diet, nitric acid, muriatic acid, carbolateof iodine, chloral, antipyrin, 83 Typhus fever, 84 symptoms, 84, 85, 86 causes, 86 treatment, 86 aconite, Baptisia, hyoscyamus, belladonna, opium, muriatic acid, rhus tox., Fowler's solu- tion, 87 antipyrine, antifebrin, chloral, cascara, diet. 88 Ulcer of stomach, perforating, 175 Urea, 60 test for 61 Uric acid, in urine, 61 Urine, pus in, 61 blood in, 61 bile coloring matter in, 61 as a symptom, 59 examination of, 60 Urethra, stricture of, 254 treatment, by clematis, digitalis, dulcamara, pulsatilla, rhus tox., 255 Urine, the, 233 Urticaria, 360 causes, 360 treatment, 361 ipecac, diet, vinegar, and water lotions, chloroform and cream, rhus tox., benzoic acid, grin- delia, carbolic acid, Turkish bath, allium cepa, anacardium, apis mel., arsenic, 361 chloride of gold and. sodium, bel- ladonna, 362 Uterus, anteversion of, 291 retroversion of, 291 prolapse of, 292 displacements of, treatment of, 292 pessaries, sepia, 292 helonias, cimicifuga, lilum tig- INDEX. 569 rum, aesculum hippo., ustil- ago, aletris, nux vomica, chloride of gold and sodium, Monsel's salt, 293 cancer of, 295 symptoms, 295 treatment, 295 chloride of gold and sodium, ar- senic, iodide of arsenic, 295 conium, graphite, glycerine, creasote, thuja, 296 Uterus, polypus of, 294 treatment, 294 phosphate lime, sanguinaria, powered tannin, rhus tox., io- dine, 294 operation, nitric acid, 295 Uvulitis, 525 treatment by aconite, Monsel's salt, amputation. 525 Vaccinia, 99 Vegetable organisms, 18 Varicocele, 264 treatment, 264 hamamelis, 264 fluroic acid, collinsonia, 2t>5 Vernix caseosa (see Seborrhoea) Vertigo, 413 treatment, 414 arsenic, belladonna, nux vomica, nitrate of iron, cathartics, 414 Vital affinity, 5 Wax, hardened, in the ear, 488 causes, 489 symptoms, 489 treatment, 489 removal, syringing, bicarbonate of soda solution, 490 White swelling, 323, 325 Whooping cough, 124 treatment, 124 belladonna, aconite, drosera, rotund., nux vomica, lobelia, castanea, bromide of am- monium, nicrate of ammo- nium, stricta pulmon., erio dyction, trifolium, mullin, alum, 124,125 Worms, intestinal, 207 symptoms, 207 Yellow fever, 108 history of, 108 visitations of, 109 stages, 117 treatment, 118 antiseptics, baptisia, aconite, Fowler's solution, belladonna, tinct. camphor, alcohol, acon- ite and belladonna, nitrate of silver, turpentine, bryonia, 118, 119 NATIONAL LIBRARY OF MEDICINI NLM DD13fl5bb M $b MM NLM001385664