SYLLABUS OF NOTES LECTURES Theory^Pragtige of Medicine DELIVERED BEFORE THE STUDENTS OF THE UNIVERSITY OF PENNSYLVANIA, y by WILLIAM PEPPER, M. D., LL. D. Provost and Professor of the Theory and Practice of Medicine, Professor of Clinical Medicine, etc., etc . PREPARED (BY SPECIAL PERMISSION') FOR THE USE OF STUDENTS IN THE UNIVERSITY BY CUTHBERT BOWEN, B.A. Late Exhibitioner, Coleridge Prizeman and Honour Classman, University of Durham. Matriculate of London University. Member of the H. C. Wood Medical Society. One of the Assistants to the Demonstrator of Anatomy, Medical Department University of Pa. '86 - '87. £ acnW PHILADELPHIA: Press of Burk & McFetridge, 306 and 30S Chestnut Street. 1886. ^*2v Copyright, 1886, by Cuthbert Bowen, B. A. \D PREFACE. This little work being simply a reproduction of a student's private note book, which through the kind courtesy of Dr. Pepper he has received permission to submit to his fellow students in a printed form, it must be understood that for all inaccuracies and misrepresentations of the lecturer's actual statements which may be found therein, the compiler alone is directly responsible. CUTHBERT BOWEN. CONTENTS. PART I. I. DISEASES OF THE NERVOUS SYSTEM. I. General Considerations, (i.) Symptoms; (2.) Causes; (3.) Diagnosis. II. Diseases of the Membranes. Meningitis. (1.) Tubercular Lepto-Menin- gitis; (2.) Idiopathic Meningitis; (3.) Chronic Cerebral Meningitis; (4.) Cerebro-Spinal Meningitis ; (5.) Spinal Meningitis. Hydrocephalus. III. Affections of the Cerebrum. Anaemia. Congestion. Thrombosis. Embolism. Softening. Hemorrhage. Apoplexy. (1.) Simple; (2.) Marked; (3.) Fatal IV. Affections of the Spinal Chord. Congestion. Thrombosis. Embolism. Hemorrhage. Softening. Sclerosis. — (1.) Lateral; (2.) Posterior; (3.) Disseminated. Myelitis. — Anterior or Polio-Myelitis V. Affections of the Peripheral Nerves. Neuralgia .... VI. Epilepsy VII. Chorea or St. Vitus' Dance II. DISEASES OF THE KIDNEY. I. The Urine, (i.) Quantity; (2.) Quality; (3) Color. Anuria. Diuresis. Diabetes. (4.) Specific Gravity; (5.) Reaction; (6.) Detection of Abnormalities. Phosphatic Diathesis. Uric Acid Diathesis. Lithaemia Oxaluria ............ II. Renal Calculi, (i.) In Substance; (2.) In Pelvis; (3.) Occlusion of Ureter. Pyelitis .......... III. Congestion, (i.) Acute; (2.) Chronic. Bright's Disease. Acute and Chronic, Chronic Catarrhal Nephritis. Chronic Interstitial Nephritis. Amyloid Degeneration. Fatty Degeneration ...... IV. Uraemia V. Albuminuria. Hematuria. Haemoglobinuria. Chyluria VI. Morbid Growths. Hydronephrosis. Cancer. Perinephritis. III. DISEASES OF THE HEART AND BLOOD VESSELS. I. The Pericardium. Pericarditis. Acute and Chronic II. The Heart. Hypertrophy. Simple. Eccentric. Cojtcentric. Dilata- tion. Fatty Degeneration. Angina Pectoris. Palpitation III. The Endocardium. Endocarditis. {I.) Acute. (1.) Ordinary ; (2.) Ulcer- ative. Embolism. (II.) Chronic. (1.) Mitral Regurgitation and Stenosis; (2.) Aortic Regurgitation and Stenosis; (3.) Tricuspid Re- gurgitation; (4.) Pulmonary Stenosis ....... IV. The Circulation. Aneurism. Exophthalmic Goitre. Anaemias. (1.) Simple (2.) Toxic. Malarial and Metallic. Leuccemia. Pseudo-Leuccemia. Chlorosis ............ VI IV. DISEASES OF THE SPLEEN. Splenic Enlargement. Rupture. Inflammation. -Cancer. Hydatids of the Spleen V. DISEASES OF THE RESPIRATORY TRACT. I. The Nose. Nasal Catarrh. (I.) Acute; (2.) Chronic . II. The Larynx. Laryngitis. (l.) Catarrhal ; (2-) (Edematous ; (2.) Ulcer- ative ; (4.) Tuberculous; (5.) Syphilitic. Croup. (1.) Spasmodic or False ; (2.) Membranous or True. Tumors of the Larynx. Cancer . III. The Bronchi and Trachea. Bronchitis. Mechanical. Secondary. Fibrinous. Capillary. Rheumatic. Chronic Bronchitis. Winter Cough, Emphysema. Dilatation of the Bronchial Tubes. Asthma . IV. The Lungs. Atelactasis. Hypostatic Congestion. Pneumonia. Catarrhal, Croupous. Bilious. Cerebral. Malarial. Typhoid. Secondary. Pulmonary Phthisis. Catarrhal. Fibroid. Galloping Consumption . V. The Pleura. Pleurisy. Simple Acute. Plastic. Diaphragmatic. Purulent. Hydro-Thorax. Pneumo-Thorax. ....... VI. DISEASES OF THE DIGESTIVE TRACT. I. The Mouth. Stomatitis. (1.) Aphthous; (2.) Ulcerative . II. The Throat. Tonsilitis. (1.) Simple; (2.) Herpetic ; {^Phlegmonous* Quinsy. Hypertrophy of Tonsil. Retro-Pharyngeal Abscess. Phar- yngitis. (1.) Catarrhal ; (2.) Follicular; (3.) Ulcerative ; (4.) Phleg- monous ; (5.) Tziberculotis. Chronic Sore Throat .... III. The (Esophagus, (i.) Spasm; (2.) Obstruction; (3.) Paralysis . PART II. IV. The Stomach. Gastralgia. Dyspepsia. (I.) Chronic; (2.) Catarrhal; (3.) Nervous. Ulceration. Cancer. Obstruction of the Pylorus. Dilatation. V. The Peritoneum. Peritonitis. (1.) Local; (2.) General ; (3.) Chronic. VI. The Intestines. Typhlitis. Perityphlitis. Obstruction of the Bowels. Intestinal Neuralgia. Intestinal Dyspepsia, (i.) Atonic ; (2.) Catarrhal ; (3.) Nervous. Diarrhoea, Catarrhal. (i.) Acute ; (2.) Chronic; Craptilous. Lienteric. Bilious. Colliquative. Ulcerative. Dysentery : Bilious, Malarial, Typhoid, Malignant. Choleraic Affections. Asiatic Cholera. Cholera Morbus. Cholera Infantum ..... VII. The Gall Bladder. (i.) Inflammation; (2.) Dropsical Distention; (3.) Formation of Gall Stones ; (4.) Growth of Neoplasms. Jaundice. VIII. The Liver. Hepatalgia. Congestion. Hepatitis. Abscess. Cirrhosis. Ascites. Cancer. Syphilis of Liver. Amyloid Degeneration. Fatty Liver. Hydatid Tumors. Acute Yellow Atrophy. .... VII. THE FEVERS. Ephemeral. Simple Continued. Typhus. Typhoid. Small Pox. Scarlet Fever. Measles. Rotheln. Chicken Pox. Whooping Cough. Influenza. Malarial Diseases. Intermittent and Remittent Fever. Mumps. Diph- theria. Erysipelas .......... VIII. CONSTITUTIONAL DISEASES. Rheumatism, (i.) Acute. (2.) Chronic. Gout. Arthritis Deformans. Rickets PART I. I. DISEASES OF THE NERVOUS SYSTEM. Nervous Diseases may be divided into two main classes, i. Functional, in which we have a disturbance of the part, but are unable to observe any- anatomical changes in the structure of the nerve substance. 2. Organic, which are associated with definite anatomical change. It may be doubted, however, whether there is not always present some minute change in the structure of the nerve, even though we are not able to detect it microscopi- cally. Of nervous diseases those which we are accustomed to regard as Functional are by far the more numerous. We may further divide the dis- eases of the Nervous System into Acute and Chronic, using the terms in their ordinary signification. The diagnosis of Nervous Diseases is extremely difficult. Hysterical patients simulate the symptoms of the most complex nervous disorders, and this condition must be eliminated first in making a diagnosis. Again, we must ask ourselves whether the symptoms present can be explained as purely hysterical or is hysteria associated with some other nervous disorder, as is often the case. Neurasthenia may exist either with or without hyste- ria. This renders the diagnosis extremely difficult and perplexing. Toxic Agencies may simulate nervous diseases, e. g., Malaria, Arsenic, Lead and Copper, and the blood-poison of Septic Fever. All these must be excluded before determining the organic symptoms. ORGANIC AFFECTIONS. By the term Nervous System we understand the Brain, Spinal Chord and Nerve-Trunks, with their respective Membranes. They are cellular, vas- cular structures, with a more or less fibrous basis. Each portion of the ner- vous system is subject to distinct diseases. The Sheaths of the nerve-trunks are liable to Permeuritis ; the Membranes of the brain and chord to Meningitis. The Nerve-Cells are liable to Degeneration and Atrophy ; and, as they exert an influence over nutrition, we find serious diseases following lesions of the cells themselves. The Nerve-Fibres are also liable to lesions produced by inflammation, which may be either Acute or Chronic. This often ends in destructive changes, e.g., Abscess or Softening. Sometimes it causes Contraction, with Atrophy of the fibres, and an Increase of the Interstitial Connective Tissue, which we term Sclerosis. This is a very common change. Sclerosis, how- ever, is not always the result of inflammation. It may result from a slow wasting of the fibres or a slow overgrowth of the tissue, without inflammation. Thrombosis-, Embolism and Hemorrhage are frequent accompani- ments of nervous diseases. By Thrombosis we understand the formation of a clot in a venous trunk. Embolism is the plugging of an arterial trunk by a clot orbit of fibrin driven into it. Hemorrhage is more common in con- nection with the brain than with the Spinal Chord. This is also the case with the other two. These three lesions are intimately connected with Softening, which may result from either one of them. Tumors frequently appear in connection with diseases of the nervous system. The chief lesions, to enumerate them, may be said to be: — i. Anaemia, 2. Congestion, 3. Inflammation (Acute or Chronic), 4. Embolism, 5. Thrombosis, 6. Hemorrhage, 7. Softening, and 8. Sclerosis. While we observe that the number of lesions is not very great, we find that the Symptoms which they give rise to are extremely numerous. We have: — 1. Pain which is very common, and may be either Centric, i. e., referred to the line of the nervous system, or Eccentric, i. e., referred to other parts. Centric pain, in the case of cerebral disease, is located by the patient in the brain itself. Pains vary extremely in character. We speak of — 1. Girdle pain; the patient feels hooped in, as by a circle, at the point of the disease. These are examples of what are termed eccentric. 2. Radiating, i. e., along the nerve-trunks. 3. Darting or irregular. These fulgurant or lightning- like pains are very characteristic of Locomotor Ataxia. II. Many Disorders of General Sensibility. 1. Vertigo, or Dizzi- ness, is very common. There is a feeling of unsteadiness. The patient cannot balance himself, he feels that surrounding objects are moving while he himself is standing still. 2. Numbness in different parts of the body. 3. A feeling often described as "pins and needles." 4. Fonnication, i. e., a sensa- tion as though ants were crawling on the person. III. More or less Impairment of Sensation. 1. Anesthesia, which may be slight or marked. By it is meant the total or partial destruction of sensibility. Contact with a pin may not be perceived — hot and cold are not distinguishable. 2. Hyperozsthesia, i. e., exaggeration of sensibility. Of this there are several grades. IV. Disorders of the Special Senses. Among these the — 1. Eyes furnish most symptoms. We find — 1. Strabismus , or squint. 2. Photopho- bia, which is due to an exaggerated sensibility of the Retina. 3. Hemiopia; and 4. Double Sight. 5 . Impairme?ii of Vision in some form or the other is very common, and must be looked for. Again, the vision is sometimes very well preserved, even when, 6. Changes in the Optic Nerve or Retina are revealed by the opthalmoscope, 7. Inflammation and Afrophy of the Optic Nerve; and 8. VVasiing of the Retina are often indicative of brain trouble. 2. Subjective sounds are referred to the Ears. Patients complain of Tinnitus. 3. We also have impairment of Taste and Smell. These, however, are not of very much moment. V. Disorders of Motion. Paralysis, i. e., loss of motor nerve power. This is independent of the muscles. A joint may be anchylosed, or a mus- cle be wasted, and yet no paralysis exist. This may be slight, marked or 5 absolute. We may have Local Palsy, as of the extensors of the forearm (e. g., from lead-poisoning) or of the External Rectus muscle of the eye. Paralysis of an entire member, or Monoplegia. This term is an objectionable one. Hemiplegia, or paralysis of half the body, either with or without the face. Paraplegia, or paralysis of the lower half of the body. Some persons cannot walk, yet, if placed on their back, they have full power in their legs. This comes from a want of co-ordination, which we term Ataxia. This may be found in any voluntary muscle whatever, and we must not regard it as a special disease, but only as a symptom. Sclerosis of the posterior columns of the chord is frequently referred to as Locomotor Ataxia. VI. Various Uncontrollable Movements, i. Fibrillar Contraction. This is the earliest symptom of Progressive Muscular Atrophy. 2. Tremor \% an important symptom in connection with disease of the chord. There are certain forms of Functional Tremor, as in Copper-Poisoning. This is entirely different from (3) the Spasmodic Jerking of the involuntary muscles which is seen in Chorea. Tremor is sometimes present when the muscle is not in use, but generally it only manifests itself on exertion. VII. Changes in Reflex Action. Reflex action is a response to stim- ulation at a distant point. It may be diminished, increased or entirely lost. We generally employ it, under the form of Ankle Clonus and Patella Reflex or knee jerk, in order to determine the existence or absence of certain ner- vous diseases. Patella Reflex is absent in Locomotor Ataxia. • It is increased in irritation of the Motor Columns of the Chord. VIII. Changes in the Electrical Condition of Muscles. This may be impaired, increased or lost. When muscles have undergone degeneration they lose the power of responding to electrical irritation. In health, mus- cles will not respond to the Galvanic Current as to the Faradic. This may be reversed in case of disease of the nerves. The electrical state of the mus- cles is a valuable guide in Prognosis. IX. Disorders of Circulation and Nutrition. The extremities may be hot with congestion and redness, or may be deathly cold. In one form of Xerve trouble we have a Pseudo-Hypertrophy of the muscle, though asso- ciated with muscular atrophy. In atrophy of the muscles, the Transverse Markings become dim. The fibres become granular. In some cases we find peculiar Cutaneous Eruptions, or Herpes. A close relation exists be- tween Eruptions and disease of the nerve-trunks. Clustered Herpes around the trunk with a tendency to spread is associated with injury to the inter- costal nerves. Racemose Herpes is associated with the Trifacial Nerve. X. Memory very often fails. XI. Disorders of Speech. These are frequent, and are of great import- ance. When articulate speech is lost we know we have a lesion in the left side of the brain in a limited area, near the Fissure of Sylvius. This condition is termed Aphasia. XII. Convulsions. These are sudden attacks, with or without uncon- sciousness, attended with uncontrollable spasmodic movements of various parts. They may themselves last many minutes, and be followed by hours of unconsciousness. They may be confined to a few or extend to many muscles. They are very characteristic of Epilepsy, and occur in many blood- poisons as Scarlet Fever, etc., and accompany many tumors of the brain, depressed fractures of the skull, etc. XIII. Disorders of Respiration. Cough may arise from Centric Irrita- tion. In some cases we have Hiwried Respiration, and, when there is pressure on the brain, Slowed Respiration. CJieyne-Stokes, or Tidal, or Ascending and Descending breathing, is met with in Tubercular Meningitis. It is sometimes noticed where there is actual trouble in the Pneumo-Gastric roots, e. g w , where there is pressure from an exudation, or where there is a change in the nerve-centres accompanying blood-poison, e. g. t in Uraemia. The pause between the inspirations may last ten, fifteen or even thirty seconds, and the breathing be even shorter than the pause. The deadened state of the brain does not perceive the need of respiration, and there is an accumulation of Carbonic Acid. This accumulates until it finally arouses the lethargic brain, but this energy soon dies, and the brain lapses back until there is another rally. This breathing is a very ominous sign. After recovery is very rare. XIV. The Circulatory System is affected where a tumor presses on the brain ; the Pulse may be slowed. It is often irregular or intermittent. Where we find these changes without heart trouble, we should think of the possibility of brain lesions. XV. Derangement of the Digestive Apparatus. Vomiting is often produced by centric irritation. Where we do not have enough Gastric trou- ble to account for its occurrence, we should think of brain tumor as a possi- bility. Where there is brain trouble we may have Constipation. On the other hand, we may have, as in Spinal Palsies, Incontinence of faeces, or the patient may be unable to void them, and then we have Retention. XVI. The Urinary Organs are Involved. We find Incontinence with involuntary constant dribbling, or there may be Retention. A central lesion near the floor of the Fourth Ventricle may give rise to Saccharine Diabetes. Causes which lead to Functional and Organic Diseases of Nerves: — I. Heredity. With the exception of Phthisis, in no other diseases is there a greater hereditary tendency. The children of Epileptic parents will have either Palsy or some form of mental derangement. Pseudo- hypertrophic paralysis runs in families. Several cases have been noted in a group of relations, and not so many in a million outside these. II. In no other class of disease does Traumatism have such effects. Epilepsy may often be traced to an old injury, which may be only revealed by trephining or at the post-?nortem. III. Over- Exertion, exhausting excessive labors. IV. Prolonged and Depressing Emotions, e.g., excessive indulgence in venery. V. Inordinate Use of Alcohol and Tobacco. VI. Atmospheric Influences. The Nervous System is liable to be influenced by violent vicissitudes of temperature, but still more by long exposure to cold. VII. The brain is especially liable to Syphilitic Disease, but the chord and nerves are also affected. Lesions from Syphilis will always yield to large doses of Iodide of Potassium. This distinguishes them from other similar lesions. By proper treatment a Syphilitic Gumma will be dispersed. This is not so with other tumors. VIII. Atheroma of Arteries is a fruitful source of Nerve Disease, lead- ing to Softening of the vessels. In the study of any Nervous Disease all the above causes must be looked for. In making our Diagnosis the first point is to distinguish Functional from Organic disease. We should study the History, Symptoms and the Mode of Development. Next we localize the disease. This is more im- portant in nerve diseases than in any others, except perhaps those of the heart. We then study the special function that is disturbed, and, having localized it, we determine its Pathological nature. Diseases of the Membranes : — Meningitis may be Cerebral, Cerebro-spinal or simply Spinal. The membranes are liable to Inflammation, under the names of Pachy-menin- gitis, Arachnitis and Lepto-meningitis. These are the accepted divisions. The First is inflammation of the thick outer membrane of the brain or Dura. It is especially met with in Trauma and disease of the bone, as in Caries. The Second, or inflammation of the Arachnoid, is rare as a separate affection. The Third may present itself as Tubercular Meningitis, or it may be Idiopathic. I. Tubercular Lepto- Meningitis is an inflammation of the Pia or Arachnoid space, accompanied with a deposit of tubercles. Its Causes are: i. Age. It is a disease of infancy, being comparatively rare after puberty. It is most frequent in the first three years, but occasionally occurs in adult life. It is influenced — 2. By Heredity. 3. By Tuberculous Diathesis. 4. By a Tendency to Nervous Diseases. Especially does it occur in infants whose mothers are delicate or have a tendency to Phthisis. Such children should never be suckled by their mothers. 5. It is brought on by Dentition ; or 6. By a blow on the head. The essential lesions consist in the formation of grey, round, tuberculous granules in the meshes of the Pia Mater. These are found chiefly in the course of the small vessels con- nected with the sheaths. They seem to prefer the base of the brain, par- ticularly the Fissure of Sylvius, and back of the Crura of the brain and the Pons. Their formation is associated with congestion, inflammation and the production of lymph. At times this is copious. The lesions may extend into the Spinal Tract and involve the Chord. The Substance of the brain is congested. The outer layers show degeneration, and the lining of the ventricles is often roughened or softened with the too great effusion therein. Tubercles are often found in the Lungs, Spleen and Lymphatic Glands. In adults Tubercular Meningitis is never Primary, but always follows tubercles somewhere else. In children, however, it may be primary. The Symptoms are very characteristic indeed. We consider those of — 1. The Invasion. 2. The Fully-Developed Disease. 3. Co?na. There may be some Prodroities. The child is irritable, has a headache, and is listless. Unless the Headache is very constant, there is nothing definite. Children do not often have headache. When they complain of it day after day it is very alarming. It may be Local or General. It may wake the child from its sleep, with a Cry which is so peculiarly shrill that it has been designated the Meningeal or Hydro-Cephalic Cry. Fever ensues — at first slight; then the temperature may run up to 103 F. and 104 F. The Pulse is small and tense. The Special Senses are very acute. The child wants the room darkened. The noises of the street annoy him. There may be Wandering Delirium or simply Insomnia. This lasts three or four days, then the Fully-Developed Stage is reached. This is marked by Flushing of the Face and local Sweating about the head. At times there may be Convulsions or spasmodic twitching. There is a tendency to Delirium and to starting out of sleep with a cry. The Headache persists, the Pulse continues frequent, but may present little halting in its character. There is Vomiting without nausea, which is strictly Reflex in its character. Constipation is marked. The Belly is sunken and scaphoid. The Ilia and Ribs stand out. There is apparently no room for the intestines. It will now be noticed that if the finger is drawn over the brow or the skin of the face a red streak or Cerebral Tache will result. If the eye is examined there will be found Optic Neuritis and Cerebral Tubercles. The Pulse now becomes slow. It falls from 120 to 10 90, to 70, or even 60. This with fever in a child is very important. Squint may now develop. The child lapses into a state of Coma ; the Pulse becomes irregular and often increases beyond the power of counting ; Breathing be- comes of the Cheyne-Stokes type. There are still local Sweats and Cerebral taches, Flushed cheeks, Local spasms, Squint or occasionally General Convulsive Movements. The child wastes rapidly, Vomiting stops, Constipation continues, swallowing becomes difficult and Death ensues from paralysis of nerve-centres and Inanition. The case may last twenty-eight days, but fourteen or fifteen is the average duration. Diagnosis. There are few diseases with which this can be confounded. 1. It may be mistaken for Typhoid Fever. Typhoid is often anomalous in children, and is wanting in nose-bleed, diarrhoea and what we regard as its characteristic temperature. It is often not fully developed in children. If tubercles have attacked the membrane of the bowels, Meningitis is very liable to be mistaken for Typhoid, for then the belly is distended instead of being scaphoid, and there is diarrhoea instead of constipation. We can easily distinguish Meningitis from Typhoid by the change in the Optic Nerve. The course of the fever is more characteristic in Typhoid. There we have no squint, no local palsy, no tendency to local spasm, and the peculiar halting pulse does not appear. At the end of four days there should be no doubt as regards the diagnosis. 2. The question may come up to distinguish it from Si?nple Meningitis. Here we would be guided by the existence of a hereditary tendency and predisposition, the occurrence of a similar case in brothers and sisters as they reached the same period, the existence of tuberculous formation elsewhere, tenderness of the spleen and enlargement of the lymphatic glands, and by the results of Ophthalmoscopic examination of the Retina. Prognosis. As long as you can cling to hope, do so. When you see advancing exudation and the approach of coma, you may inform the parents that the prognosis is utterly hopeless. All cases of recorded recovery have been where Idiopathic Lepto-Meningit'is has simulated the Tubercular variety. Treatment is purely palliative. The indications are to allay the fever by the use of a hot foot-bath and the application of ice to the head. We may give small doses of Aconite with Bromide of Potassium. This febrifuge and sedative treatment we pursue only to await results. The diet should be of the simplest kind ; light liquid food should be given and the bowels gently moved by an Enema or simply by laxative food. No purgatives should be ordered ; the chance of it being Typhoid fever should warn us against them.. When the true nature of the disease is seen, continue the light diet as the child is willing to take nourishment. Keep up the Bromides to control spasm. Treat the case as though it might be Simple Meningitis. Give Iodide of Potassium from the first in positive doses, but still graduated to the age of the child. For a child of two years old give one-half grain every two hours,, increased to one or two grains ; this would be equivalent to ten grains in an adult, and would do as much good as any amount in a non-syphilitic case. With the Iodide we may combine Fluid Extract of Ergot, giving of the latter three, four or five drops to a child of two years, making in a day one-quarter to one drachm of the extract. Blisters are of doubtful utility; if the evi- dences of inflammation are high and there is great pain, we may apply one to the mastoid region of the scalp, but not to the nape of the neck, as has been recommended. II. Idiopathic Meningitis occurs most commonly in children. The ordinary Causes are : 1. Atmospheric Disturbances. Sudden changes of temperature have been known to produce it. 2. It may occur as a 13 Secondary Complication in Pneumonia, Typhoid Fever, Erysipelas and Rheumatism. The Symptoms of Meningitis when arising in these dis- eases is puzzling, especially because we have marked brain symptoms from other causes, as, e. g., from Pyrexia, and we may hesitate as to whether there is any actual organic affection of the brain or not. If, without intense Pyrexia, we have — i. Acuity of the special senses. 2. Headache. 3. Flushings of the head and face. 4. A disposition to muscular spasm, tremor or actual convulsions. 5. Squint or other local palsy. 6. Neuritis of the optic nerve. 7. The Pulse halting, rapid, then slow and irregular, we know we have a Meningitis. Prognosis. It is very fatal, but not inevitably so, except in the tubercu- lar form. We may have recovery with impairment of some member. Treatment. Absolute rest in bed. The exclusion of all light. The application of cold to the head and of a blister or mustard plaster to the calves of the legs and soles of the feet. We must use sedatives, as Bromide of Potassium and sometimes Opiates to relieve pain. Ergot is useful com- bined with Iodide of Potassium in proper doses. If life is preserved, as the disease passes through the acute stage, we may omit Ergot, and put in Bi- chloride of Mercury to absorb the exuded lymph. A light unstimulating diet should be given throughout. Chronic Cerebral Meningitis is most commonly met with as an ac- companiment of injury to the bone, as the result of Syphilis, or as a result of Tumor. Its diagnosis is often obscure. The Symptoms are localized pain referred to nearly the spot of inflam- mation. Evidences of irritation of the surface of the brain as shown by Insomnia or disturbed sleep. Subjective sounds. Disordered vision. Sometimes a little giddiness of gait and then evidences of irritation or of pressure on the nerve trunks going from the brain centres, so that we may have creeping sensations in the auditory or optic nerves or in the motor nerves of the eye-ball. There is a loss of flesh and general ill health. Diagnosis. The greatest difficulty consists in distinguishing it from tu- mor of the brain; this can only be decided by the result of treatment. It may arise from rheumatism. If Syphilis is present elsewhere this may put us on the right track. If it came on with an injury it may have hurt the Dura and then spread to the interior membranes. The Prognosis depends on the exact cause and duration. It is most favor- able in Syphilis. It is hopeless in the case of Tumor or an affection of the bone. Treatment. It may be cured by local counter irritation — the use of the Cautery applied as near as possible to the seat of pain every eight or ten days. If it is a syphilitic accompaniment Iodide of Potassium is indicated associated with a Mercurial Salt. Cerebro-Spinal Meningitis is chiefly met with in constitutional conditions. Frequently spotted fever is characterized by inflammation of the spinal chord. Spinal Meningitis is considered under the three divisions of: 1. Pachymeningitis. 2. Lepto-Meningitis ; and 3. Arachno-Meningitis or Arachnitis. As in the brain, Spinal Pachymeningitis is associated with Fracture, Caries, Wounds and the like. More interesting is Spinal Lepto-Meningitis, i. e., inflammation of the Pia Mater of the chord, which sometimes spreads and becomes basic. Causes. 1. Rheumatism. 2. Exposure to atmospheric changes. 3. It may follow shock or concussion. 14 The Symptoms are: i. Pain in the back, aggravated by motion. 2. Pain radiating from the spine round the sides and down the arms and legs. These are very marked. 3. Muscular Hypersesthesia. 4. Increased Reflex Irritability. 5. Limited breathing. 6. Retention of urine. 7. Constipation. 8. The Pulse is frequent and we have fever. If it creeps up and involves the base we have an implication of the brain and of the nerves coming from it, and hence we should have symptoms of Cerebro- spinal Meningitis. Diagnosis. We might confound Spinal Meningitis with — 1. Acute Rheu- matism, but there we have stiffness of the joints. In children, however, inflam- mation of the joints may be absent. In rheumatism we do not have Reten- tion of the urine. There is not so much Pain nor so much Hyperesthesia, but there is a copious acid sweat. The urine is intensely acid, and there is more Fever than in Spinal Meningitis. We should remember, however, that Rheumatism may be complicated with Spinal Meningitis. 2. With Teta- nus. Tetanus however generally follows a Traumatic cause, and is associ- ated with Tonic Spasm and Contraction of the Buccinators, causing Lock-jaw, and gradually spreading lower down. Tetanus developes more gradually. There is not so much fever. The bladder is not so apt to be affected. The Course of acute Spinal Meningitis is irregular. It usually lasts from ten to fourteen days. The Prognosis is doubtful. If it is limited to the chord it is favorable. It is apt, however, to leave thickening of the chord. If it creeps up and de- velopes Basic or Basilar Meningitis it may terminate fatally. The Treatment should be on the same plan as that adopted in Idiopathic Cerebro-Spinal Meningitis. 1. Leeching and cupping along the chord where the girdle pains indicate intensity of inflammation. 2. Internally, give Quinia, Opium, Ergot, Belladonna and Iodide of Potassium. Quinia is useful in lessening the exudation by its influence on the crasis of the blood vessels. Full doses should be given. Opium is essential for subduing irri- tability of the system and promoting quiet sleep. Ergot is beneficial for its special action on the vessels of the chord, and for absorption of such exuda- tion as may occur. Give three to ten grains of Quinia twice daily, and give Opium per rectum or hypodermically. Apply liniments over the track of the painful spinal nerves and along the spine. This affection is more com- mon than is generally believed. Tumors of the spinal chord are rare. The food for a patient suffering from Spinal Meningitis should be light and simple. Hydrocephalus. The expression acute hydrocephalus was formerly em- ployed to designate Tubercular Meningitis, because there is an effusion into the ventricles of the brain. The presence of effusion into the ventricles is, however, a purely accidental concomitant. There are two kinds of hydro- cephalus: 1. External, or meningeal 2. Internal, or ventricular. In the one the effusion lies between the brain and the skull ; in the other the brain is distended, its substance thinned out, and the ventricles filled with the effusion. The external form of the disease is rare, but is sometimes produced by a meningeal hemorrhage which sets up slight meningitis. The brain does not develop properly. The condition may come from the transformation of a meningeal clot, or, because the effusion breaks through the Corpus Callosum. The Internal is the more common form of hydro- cephalus. In the internal form the ventricles are greatly distended. The Serum comes from an inflammation of the lining membrane of the Ventricles or from pressure on the veins of Galen. As the effusion increases it spreads out the substance of the brain. The furrows in the brain disappear and the 17 convolutions are flattened. The bony case grows in proportion to the dis- tension ; the vault of the cranium is increased in size ; the Fontanelles are increased in area ; and the Sutures become very wide. New centres of ossifi- cation appear in the wide sutures. This development brings about a strange disproportion between the head and face. The orbit is very flat and is pushed from the horizontal to the oblique position. The cranium is very voluminous. Various parts of the brain may be imperfectly developed ; some centres of the brain may be wanting, or, we may have occlusion of one of the veins. Causes. Hydrocephalus is a disease of infancy. It may begin before or soon after birth. It may begin the second year of life or as late as the seventh year. Infancy, then, is a strong predisposing cause. The disease may come from an injury to the mother during gestation. But it may come from inflammation set up by a tumor. There are cases in which the disease is brought about by causes which we are not able to detect. Symptoms. First, the head of the child is noticed to be growing to a larger size than is usual, while the child may apparently be in perfect health. Secondly, as the disease advances there may be feverish spells with heated head, disturbed sleep, sudden cries, and in forty-eight hours these symptoms subside and the child appears to be all right again. Often the tongue is coated. The head gets bigger by spells. The axes of the eyes are directed downward. The child cannot walk well, the head falls to one side, or the child sits or reclines constantly. The functions of the brain do not develop, and the child is often dull. The special senses are impaired, or the child may keep up with other children in its lessons at school ; the head alone may indicate the trouble. Prognosis. The duration of this disease is very variable. Some children are hurried off by convulsions, especially where tumor is present. Others may be carried oft by Bronchitis from injury to the Pneumo-Gastric Centre. Nutrition may fail. Diarrhoea sets in and can't be checked. In some cases the children regain the power of walking, and the muscles develop. Cases are on record of patients living to be thirty, the head containing gallons of water, but thi's is rare. Diagnosis. We should never express our suspicion of the existence of this condition until we are perfectly sure. It may be confounded with simply an abnormally large head. In Rickets a big head is one of the morbid conditions. The Rickety skull is square and chunky, showing persistent thickening. Changes in the wrists, ankles, etc., are indicative of Rickets. The peculiar feverish spells and the interference with the mental functions make the Diagnosis easy. The Rickety skull again is entirely ■different in appearance. The Treatment of Hydrocephalus is very unsatisfactory. The Lesion is incurable, but we should resort to all the means within our power as though the Lesion were curable. Adhesive strips of plaster should be applied round the head so as to exert a uniform pressure. These should be loosened if brain symptoms come on. But even this is unavailable. Prolonged use of Mercurials, Iodine, and of the Iodides has proved futile. If the child's functions are good, and we think it is an inflammation of the membranes, we simply put him on the use of alteratives to absorb effusions. We can treat special symptoms as they arise. We combat feverish symptoms with Opium, Aconite and Quinine, Digitalis and simple Febrifuges. Wheeled crutches, such as are made in Newark, are very useful. To them is attached a jury mast, so as to keep the head erect, and treadles to work the wheels. By means of this a child may develop strength for a time. The idea may i8 occur to let the fluid out. This is useless in the internal form. Where the water is between the brain and its membranes it is useful. A pint may be drawn off, and complete recovery take place. Where the accumulation is inside the Ventricles the conditions which give rise to it are such that mere operation would not remove them. Affections of the Cerebrum: Anaemia, Congestion, Thrombosis, Embolism, Softening, Hemorrhage, Apoplexy. The connection between the above is not so close in theory as it is seen to be in practice. Anaemia implies a diminution of blood in the cerebral mass. It may be due to obstruction in any part of the arteries or to enfeebled power of the heart. The chief cause of obstruction is Atheroma accompanied by a thick- ening of the walls and a diminution of the blood supply. We have either a depressed function of the whole brain or of only the part which is anaemic. The Symptoms are Vertigo, a tendency to syncope on sudden exertion, and impairment of the Intellectual powers, memory, perception, and the like, and of the special senses. When the anaemia is intense and prolonged, the nutrition of the brain suffers and softening may be induced, especially if the disease of the vessels is extreme. We may have Rupture and Apoplexy. Thus we have a pathological chain from Anaemia to Apoplexy. Cerebral Congestion is that state in which there is an excess of blood in a part or in the whole of the brain. It is an undue fullness of the vessels of the brain. This may be active and then there is arterial blood from hypertrophy of the heart, but more commonly it is passive and is due to an undue accumulation of venous blood. We meet this frequently and in intense degrees. Causes. It is produced by anything which prevents the return of venous blood into the chest, e.g., wearing tight collars. A state of Plethora with a feeble heart which allows the blood to accumulate in the Sinuses. Pressure of a tumor on a vein. Passive Congestion is a common occurrence. Sometimes it is Acute and sometimes Chronic or Persistent. The acute form occurs in those who have a predisposition. A man with, plethora and a weak heart gorges himself with strong food and then under- goes exertion, Acute Congestion results. There is fullness and dull pain in the head, confusion of mind, or full unconsciousness with stertorous breathing. The face is flushed. The veins of the face are distended. The Pulse is full. The heart's action and the breathing is labored. The patient feels numbness and loss of power in the arms and legs, which may be hemiplegic or only affect one limb. If he has been unconscious, when he comes out he finds weakness of the part not amounting to actual palsy. There is very little use of Temperature. Attacks may last three or four days or three or four hours, and if there is no rupture of the blood-vessels the patient comes out and gets well because there is no lesion. It is impossible to draw the line between acute congestion and slight hemorrhage. Chronic Congestion is a continual fullness of the vessels of the head. The patient suffers from obtusive head- aches, is restless, sleep is disturbed with dreams. He feels oppressed when he lies down and is better when he sleeps semi -recumbent. There is confu- sion of mind. Changes of temper are noticed. The patient is irritable, is easily tired. The secretions are disturbed. Congestion of the stomach 21 and Liver may exist too. A sudden increase of pressure may give rise to Apoplexy. Nutrition may be interfered with. Softening may result, and from it may spring Hemorrhage. Thrombosis is coagulation of blood in a vein, artery or sinus. It is connected with changes in the walls of the vessels or Atheroma. Cerebral Embolism is the plugging of an artery in the brain by a clot driven from a distance. This may have come from the heart, or may have gathered on the rough lining of Atheroma. Its size, if large, will often stop it at the Circle of Willis. If small, it may get into the small vessels. If it stops at the Circle of Willis it will not cause Softening, because the anastomosis is so complete. If it is very small it will not cause Softening, because the other vessels supply the place of the vessel which is plugged. Cerebral Softening is a very common and important condition. It is a loss of consistency of some portion of the cerebral substance, owing to interference with its circulation. Anaemia is a long step on the road to softening. Atheroma, or acute obstruction, may so hinder the passage of blood through the Common Carotid or the Innominate, that we have impaired circulation and malnutrition of the part. Long-continued Anaemia or Con- gestion, continued over-taxing of the brain, exhausting its vitality, impairing its nutrition and producing Anaemia, finally causes softening. We find it in the neighborhood of a tumor, or around local meningitis. Anatomically, the softened part is whiter than the surrounding matter. It varies from a cream-like liquid to a barely perceptible softening. If we examine it micro- scopically, we find the nerve fibres broken, and globules escape something like oil drops and compound granular cells. The extent of the softening varies from a very minute point to a whole hemisphere. Symptoms of softening are very varied, according to the part affected and its extent. W T e notice a failure of motor power, though the patient may be very restless. His gait grows shambling. He trips. He does not lift his feet and put them down regularly. Sometimes we have staggering, and Vertigo. Intellectual Changes take place. Memory fails. There is often a change of disposition. He becomes restless, peevish, irritable and even quarrelsome. In later stages we find a complete perversion of the moral nature. There be total depravity. With this we have changes of other functions. The appetite is often capricious and voracious. The patient bolts his food. The circulation is weak. The pulse small. The bowels costive. The flesh may be well maintained, but grows soft and flabby. In this condition the patient is carried off by apoplexy. Acute congestive attacks make the patient feel worse, and then he may get better ; but the disease has advanced. It may last three, five, or even ten years. The patient becomes childish, and is carried off by some accident or by hemorr- hage. The Prognosis is altogether unfavorable. The disease advances slowly, and terminates fatally. Apoplexy is a rupture of a vessel within the cranium, attended with hemorrhage into or upon the cerebral mass. It may be Meningeal, i. e., when the apoplexy is on the membranes; or Cei'ebral, i. e almost uncontrollable. Bleeding Piles are not rare. Apoplexy may occur. III. Paralysis may result from vegetations of the valves being carried off as emboli. IV. As the result of Cardiac disease, Embolism may give rise to Gan- grene. Prognosis. A double valvular lesion is more unfavorable than a single one. The occurrence of Dilatation in place of, or out of proportion to, the Hypertrophy is bad. When it develops rapidly, and the heart does not respond quickly, it is a bad sign. The existence of rigid arteries, " Arcus Senilis," or previous ill nutrition, renders the prognosis unfavorable. In persons of strongly rheumatic diathesis, or where a complication of Kidney affections exist, it is bad. Treatment. I. General Principles. Rest is absolutely necessary in order to reduce the strain upon the heart. It is not wise to endeavor to bring up the heart to the full work of the system ; but we should rather endeavor to bring the amount of work within the power of the heart. If possible, the patient should lie down for a greater part of the twenty-four hours. All strains upon the arterial system must be avoided, such as those caused — i. By going up hill or up stairs. 2. By the contraction of the capillaries of the surface, as the result of chills; or, 3. By the congestions of internal organs, etc. II. Medicines : Digitalis, Belladonna, Convallaria, the Bromides, Aco- nite and Veratrum Viride will be considered in detail, the latter being less frequently indicated than in the acute. 1. Digitalis regulates, slows and strengthens the heart. No injurious effects result from its accumulation. It does not rapidly lose its effects, and it may be used for years. The best preparation is the tincture. A good infusion is reliable, but inconvenient to administer. Digitalin is often a convenient form of administration. We should begin with small doses, as it sometimes irritates the stomach. When this is the case abandon its use or change the form of administration. 2. Belladonna is good where the action of the heart is irregular and rapid from some reflex cause, e. g., the stomach. It does not increase the heart's force. 3. Convallaria is inferior to Digitalis in range and certainty, and is disagreeable to the taste and to the stomach. It may be used where Digitalis fails, and where there is a tendency to dropsy, as it is a Diuretic. Long courses do no harm. The dose of the fluid extract is gtt v-vii ter die. 4. The Bromides are useful where there is irritation, irregularity, and excitement, but where there is little or no organic lesion. They must not be pushed for too long a time, as they lower digestion and the tone of the system. 5. Aconite ; and, 6. Veratrum Viride, are indicated where there is simple hypertrophy which is too great for the lesion of the valves. Small doses may be given, extending over a long period of time. Treatment of Special Symptoms. For Dyspepsia and Kidney trouble improve the general health by tonics, vegetable bitters, and iron. Where the stomach is irritable, hydrocyanic acid, bismuth, and Argentic Nitrate lessen the irritability of the stomach and consequently of the heart. In venous congestion of the liver, especially with oedema, restrict the diet and give small doses of blue mass, together with the use of mineral acids. In cases associated with Rheumatism order prolonged courses of Potassium Iodide and Alkalies in small doses. Cardiac Dropsy indicates that the §9 heart is weak or that some organ is obstructed. Enjoin rest in bed and study the cause. Diseases of the Great Vessels. The arteries are subject to — i. In- flammation or Arteritis. 2. Degeneration or Atheroma. 3. Aneurism. 4. Narrowing or Occlusion. Aneurism may arise from — 1. An injury to the coats of the vessels. 2. Previous syphilitic Arteritis. 3. Chronic Atheroma forming an atheromatous ulcer. Termination. 1. It ruptures either from chafing against some hard sub- stance, or its walls may become so attenuated that it bursts from blood pres- sure. 2. It heals by clotting, owing to the coagulation caused by the slowing of the current from pressure. Thoracic Aneurism. Symptoms. Deglutition is impaired. A pulsating tumor, or a thrill is apparent. There is dullness on percussion over the point of contact of the aneurism with the chest wall. An aneurys- mal murmur may be heard or the heart sounds be changed. There may be a prominence or bulging of the ribs. Aneurism of Abdominal Aorta. We may often feel the tumor. There is a prominence either anteriorly or posteriorly, but percussion may not show dullness on account of the tympany of the ribs. None of these symptoms may be present if the aneurism be small or deeply situated. This is especially true of small aneurisms in the thorax. Peculiar Symptoms. There is Pain referred to the spot of pressure, or it may radiate along the nerve pressed upon. If very severe, Paralysis may occur, e. g., Aphonia from pressure on the recurrent laryngeal. The Pupils may be unequally dilated. If it is situated in the abdomen it may press upon the abdominal sympathetics, and profuse sweating of one or both sides be produced, the intestinal secretions being modified. When situated on the abdominal Aorta it seldom presses on anything else than the nerves. Previous to the rupture of these aneurisms, a valve may be formed which allows a leakage to take place for some time before the final opening. Paralysis may result from the erosion of the spinal cord, or asphyxia, or starvation from pressure on the CEsophagus. Prognosis depends on — 1. The patient's age. 2. The state of the arteries. 3. The time the condition has existed. 4. The rapidity of its growth. 5. The ability of the patient to carry out the requisite treatment. Diagnosis from — 1. Aphonia arising from other causes ; and 2. CEso- phageal stricture. The conditition of the aorta must be carefully studied. 3. In Aortic valvular disease the murmur may be the same, and there may be concurrent hypertrophy. We must consider the line of transmis- sion, the point of greatest intensity of the murmur, and dullness in unequal spots. 4. From other forms of Tumors, by the pulsation, the murmur's location, and the course of the case, and by the presence of causes of aneurism. Other tumors may pulsate and have a murmur, but this is not transmitted. Put the patient in the "Knee and Elbow position," and the mass, if it is not aneurismal, will not pulsate. There will also be a loss of dullness in the back while the patient is in this position. Treatment. 1. Abdominal Aneurisms are within the reach of Surgical aid. If the tumor is near the bifurcation of the Abdominal Aorta, the application of a tourniquet will slow the current and hasten coagulation. Internal treatment in these cases is of little or no use. Ligation of the Ab- dominal Aorta has met with no success in twenty cases. 2. Thoracic Aneurisms. If the Aneurism is in contact with the chest walls and has re- sisted treatment, we may use Electrolysis, one needle being placed in the 9 o sack, and from twelve to twenty-four contacts made. Absolutely immovable rest must be enjoined at the same time, for weeks and months, and with this, starvation of the patient within the limits of safety. If there is a history of syphilis, Potassium Iodide should be pushed to its fullest extent. Cardiac Sedatives, Aconite, Veratrum Viride, Hydrocyanic Acid, Bromides and Digitalis, when the accompanying heart trouble demands it, should be used. Exophthalmic Goitre. We have a neurosis of the ganglia controlling the action of the heart and the great blood-vessels arising from it, particu- larly the thyroid axis and its branches. Causes. All depressing influences, Prolonged anxiety, Debauches, Sudden shocks, Too frequent Pregnancies, Exhausting Hemorrhages, Chronic Diarrhoea, Exhausting Uterine disease, Irritation of the Sexual organs. Symptoms. We have a palpitation of the heart, which is difficult to control. Goitre and protrusion of the eyes, either of which may precede the other, but after a time both exist together. The Thyroid Enlargement is often enormous. It varies in size, rapidly increasing and again decreasing. It presents a feeling of elasticity, but not fluctuation. The thyroid arteries are tortuous, enlarged, and throb violently, the superficial veins being very prominent. The tumor is the seat of pulsation and thrill, and a strong arterial murmur is heard, more prolonged than that heard over the other vessels. The function of the larynx and pharynx may be interfered with, but the dyspnoea is due rather to the irritation of their muscles than to actual pressure. Protrusion of the eyeball is due to a want of perfect harmony in the ascent and descent of the lid and ball. The Cornea is dull, dry, and may be ulcerated. Tne globe of the eye appears sometimes to be very hard. General Symptoms. Patients are highly neurotic and emotional, and there are marked changes in temperament. Indeed, they may often seem to be deranged. They are pale, weak, and anaemic, and are easily fatigued. The appetite is sometimes poor, and may very often be greatly perverted. The digestion is weak and the stools ill formed, consist of undigested food, and are too frequent. The Course of the case is prolonged, often lasting many years. Termination : If no effect is obtained from the use of medicine, dilata- tion of the heart occurs with congestion of the lungs, dropsy, and death. The symptoms may all disappear under proper treatment, but are liable to return. Undue rapidity of the pulse may remain, together with a slight enlargement of the gland. Prognosis is generally favorable, except in very long standing cases and where we cannot remove the cause. Diagnosis. In Uncomplicated Goitres the heart's action is different. The gland does not pulsate, nor does it vary in size, and there is neither thrill nor murmur. Treatment is largely dietetic and hygienic. The cause must be dis- covered, and, if possible, removed. Special attention must be given to the dwelling, occupation, and diet. Sometimes an absolute milk diet is best, at others, a carefully regulated and restricted diet of cereals and milk. The nasal and other catarrhs must be treated. Argentic nitrate is very useful in these gastro-intestinal catarrhs. At other times the treatment must be directed to the ovaries. Among drugs Digitalis is very useful to control the heart. Caffein is used where there is a marked emotional condition. Iron should be used in all cases and extensively. It must be given in acceptable 93 forms, e. g., Tincture of the Chloride, Dialyzed Iron, or Iron by Hydrogen. Iodoform may be given with digitalis or with Iron. R Iodoform, Iron bv Hvdrogen, aa gr. i, M. ft. Pil. No. i. Ergot is useful when the condition of the stomach does not contra-indicate it. It is not wise to use more than two remedies at one time. Plethora is an undue increase in the total quantity of the blood or of its solid ingredients, so that it is either Qualitative or Quantitative. Causes are an excessive ingestion of highly nourishing food, combined with a lack of exercise, or it may be brought about by the sudden arrest of habitual discharges, e. g., of the Menses, Bleeding Piles, etc. Symptoms. The patient has a tendency to fullness in the head which is increased by sitting in a close room, stooping, etc. The color is heightened, with a tendency to become bluish. The action of the heart is heavy and labored. The Impulse is strong, and its Sounds long and heavy. There is a throbbing and distension of the vessels. The breathing is labored, and dyspnoea is easily excited. There is a tendency to conges- tion of the liver and lithaemia. Hemorrhoids are apt to form. The urine is of too high color and specific gravity. There is a general increase in the adipose tissue of the body. Prognosis. This condition disposes to Hemorrhage, Apoplexy, Pul- monary Complaints, and Hemorrhoids. Treatment requires a careful attention to diet and regimen. Scales for determining the weight of the body should be frequently resorted to, to ascertain what articles of diet bring about the desired effect. Drugs, such as salines and mineral waters are required to regulate the secretions and for meeting the indications as they arise. Anaemias are conditions of the blood in which its normal composition and quantity suffer. There are several varieties: i. Simple. 2. Toxic. 3. Those which are associated with organic disease. 4. Idiopathic. Under the last we consider — (a) Progressive, (b) Pseudoleucsemia. (c) Leucaemia. I. In Simple Anaemia we have a deficiency in the amount of blood and a diminution in the number of red blood corpuscles, or the red blood corpus- cles alone may be diminished. Normally, a cubic millimetre contains five millions of blood corpuscles, the proportion of white to red, being one to four hundred. Causes of Anaemia are — 1. Want of proper food and sleep, the latter being just as important as trie diet. The regeneration of red blood corpus- cles is much more active during sleep. 2. Excessive discharges, e. g., hemorrhage from the Nose, the Uterus, or from Piles. 3. It frequently fol- lows fevers, inflammations, etc. 4. Anxiety or over-work, and depressing excitement. 5. Impure atmosphere and general mal-hygiene. Symptoms. The skin and mucous membranes are bloodless. The eyes and the nails assume a white pearly appearance. The heart becomes weak and irritable, and dyspnoea is easily excited by exertion. The sleep is light, disturbed and easily broken. The brain soon becomes tired, and the patient loses the power of concentration. The digestive system is weak, and dyspeptic distress is common after eating. The urine is pale and of low specific gravity, unless the liver or stomach are at the same time out of order, when it may contain urates and lithates. Anaemic patients are very prone to have neuralgia. It is among them that we find the most typical cases of neurasthenia and hysteria. The temperament very frequently undergoes changes, the patient becoming petulant, irritable and nervous. 94 Physical Examination reveals a soft blowing systolic murmur over the heart, and low continuous musical sounds over the great vessels. The Prognosis is always favorable when we can remove the cause. The Treatment consists in the removal of the cause, whether moral or dietetic, and the improvement of the patient's hygiene and surroundings, plenty of sunshine and fresh air being absolutely necessary. This may be all that is needed. Usually, we must at the same time restore digestion by the use of Bitter Tonics, Pepsin or Pancreatin, Malt and Mineral acids. It may be necessary to cure the gastro-intestinal inflammation before striking at the original disease. Iron, Arsenic and Cod-liver oil are all invaluable. II. Toxic Anaemia may be either Malarial or Metallic. i. Malarial may occur in those who have had malarial fever, or it may- appear at first as an anaemia without there having been apparently any previous malaria. Symptoms. We have a destruction of the red blood corpuscles by the poison. The spleen is enlarged, assuming the form known as "Ague Cake." The liver is apt to suffer, and a granular black pigment is found in the blood. There is a greater tendency in this form to neuralgia. At various times patients exhibit other signs of malarial poisoning. Diagnosis is made by its occurrence in malarial districts and by our inability to obtain a history of any other cause. Treatment consists in the persistent use of arsenic and quinine, which, in combination with iron, have a peculiarly marked effect. 2. Metallic. Under this head we consider poisoning by copper and lead, that by lead being most common. We base our Diagnosis on — i. History of the occupation, habits, etc., of the patient. 2. The previous occurrence of colic. 3. The presence of a "blue line" on the gums; and 4. The reaction of the skin, when moistened with sweat, to the hydro-sulphuret of Ammonium, black spots of sulphuret of lead being deposited. III. Anaemias Associated with Organic Disease. In incipient Cancer of the stomach, incipient Cirrhosis of the liver, Bright's disease, and Intestinal cancers, we may have anaemia long before the appearance of the usual symptoms. IV. Idiopathic Anaemia is associated with changes in the blood-making organs, viz., the spleen, lymph glands, and lymphoid tissue wherever found throughout the body. We have an abnormal increase in the colorless blood corpuscles, which is known as leucaemia, or a decrease in both, pernicious anaemia. In Leucaemia the blood may look normal, but is more frequently like thin pus, coagulates poorly, and its clots are soft. The red blood cor- puscles are pale and poorly developed, and are deficient in number. The colorless blood corpuscles are large and have several nuclei, and their pro- portion to the red may be increased to one to ten or one to six. Perverted globulins may also be found in the blood. The Spleen is firm, heavy, and enlarged. It may be six or more pounds in weight. The pulp is dark and studded with grayish bodies, which are enlarged Malpighian corpuscles. These may run together, forming blocks one-half to one inch in diameter. Lymphoid Tissue elsewhere enlarges. The glands are painless and movable, and the skin over them is not reddened. The lungs, liver, etc., all contain spots of this hypertrophied lymph tissue. The marrow of the long bones, which seems to have the power of elaborating red blood corpuscles, has its normal structure changed in this anaemia. Hence we have the three forms, Splenic, Lymphatic, and Medullary. 97 Symptoms. We have an apparently causeless, extreme, progressive anaemia, the patient often having a waxy appearance. At first loss of flesh may not be marked. Shortness of breath and palpitation of the heart follow exertion. The mucous membranes are pale, and the sclerotic white. Hemorrhages from the nose, gums, or bowels, or into the retina, are common ; this latter causing a dimness of vision. Some- times excessive sweating and fever are common. On long standing, oedema of the feet and legs comes on. The lymph glands are enlarged, and give rise to Lymphadenoma, or Hodgkin's disease. If it is of the sple?iic type, the spleen is enlarged. If lymphatic, pain is felt in the seat of the glands, either superficially or deeply placed. Those in the abdomen may be so large as to press upon the aorta and simulate aneurism. Prognosis. It is always a fatal disease, lasting from six months to six years. Treatment is merely palliative. The patient goes on from bad to worse, and death occurs from Syncope, Diarrhoea, Asthenia, Hemorrhage, or some intercurrent attack, the most common cause being Epistaxis. Pseudo-leucaemia begins in the same way as the above, with a progressive failure in health, with a tendency to hemorrhages. The spleen and the gland may or may not be enlarged. If there is no enlargement of the glands, the marrow undergoes changes. At first there is no increase in the colorless blood corpuscles, but towards the last this Pseudo-leucaemia may change to Leucae- mia, at which time we do find an increase in the colorless blood corpuscles. In Leucaemia the blood-making glands are irritated and a great abundance of colorless blood corpuscles, which do not develop fully, is produced ; and, as the red are destroyed, anaemia results, because the unformed colorless blood corpuscles cannot circulate to advantage. The Prognosis in a fully-developed case, seems to be fatal. The dura- tion may be from a few months to two or three years. In the progressive form life ends in a few months. Diagnosis. We recognize an intense anaemia without any apparent cause, and, as far as we know, no organic disease of any viscus. If there is no enlargement of liver, spleen, or lymph glands, we should turn our attention to the rarer form of Medullary. Treatment is merely palliative and symptomatic. The indications are to regulate the diet and relieve pain. Iron, Arsenic, and nutrients act only in a general way, and should not be regarded as specific. Transfusion of blood should be condemned. Chlorosis is an affection most frequently seen in young girls, but may occur in males also. It is associated often with derangements of the sexual apparatus, especially with menstruation. Hysteria and perverted temperaments are very often associated with it. The face assumes a pale, yellowish, green tinge, almost like a faint trace of jaundice, but is distinguished from it by the appearance of the conjunctiva, which is pearly white. The red blood corpuscles are reduced in number, but the colorless blood corpuscles are not increased. There is some pigmentary alteration in the blood, but it has, so far, eluded chemical test. Symptoms. At first there may be no loss of flesh. The extremities are cold, and there is a feeling of great fatigue, with a tendency to palpita- tion on the slightest exertion. The digestion is more markedly disturbed than in ordinary anaemia. The appetite is lost or may be perverted. There is a great tendency to neuralgia. Sleep is disordered, and the patient grad- ually becomes morbid in temperament. We have here associated a disorder of the mind, digestion, and the menstrual function. 93 The Prognosis is very good, but cases are often obstinate on account of the difficulty of removing the cause. Treatment consists in attention to diet and hygiene. The exercise of moral influences, such as change of scene, occupation, etc., and the removal of local disorders, such as ovarian, uterine, and prostatic irritation arising from masturbation ; and the administration of remedies to restore the condition of the blood. Iron is indicated, but its administration is attended with difficulty owing to the great digestive disturbance. We should endeavor to effect a judicious concealment of the Iron, and persist in its use until we are perfectly assured that it does harm. It may be given with dilute phos- phoric acid or in pill-form. R Iron by Hydrogen, and Phosphorus in minute doses. Strychnia and mineral acids should also be given. All sedatives must be avoided. IV. DISEASES OF THE SPLEEN. The Spleen is subject to — i. Rupture. 2. Enlargement from Malaria or Chronic congestion. 3. Inflammation of Capsule, or Substance with the formation of abscess. 4. Degeneration. 5. Cancer. 6. Hydalid Cysts. 7. Leucaemia. 1. Rupture is usually the result of traumatism, but may be spontaneous in the swollen spleens of Relapsing and Typhoid fevers. 2. Enlargement, very common in Typhoid fever, of which it is a characteristic symptom, and also in Relapsing and Typhus fever and Malaria. It is particularly common in chronic Malaria, in which it attains the large form known as " Spleen Cake," or Spleen tumor. It is also common in heart disease. It is recognized by — (a) Percussion and Palpation, (b) By a history of Malaria; or (c) A dull pain in that locality may call our attention to it. 3. Inflammation may be limited — (a) To the Capsule, when it becomes a local Peritonitis, which is very common in this situation in relapsing fever, less so in Typhoid. Syphilitic and Tuberculous Peritonitis are very apt to be located here. The Symptoms are: — Pain and tenderness, and evidences of enlarge- ment. They are, of course, merged in those of the disease* causing it, where there is a history of the fever or of Syphilis. The Treatment would be the same as for any other local peritonitis. (b) Primary inflammation of the Substance of the Spleen is rare. Secondary is more common as the result of Pyaemia, or the lodgment of Emboli, causing an infarct which goes on to organization or suppuration. 4. Degenerations. Amyloid is the most, common. The spleen becomes very large, and it is associated with amyloid degeneration of the kidney or of the liver. The Symptoms of the degeneration are referred more to the degenera- tion of the liver or kidney. We should suspect it where there were causes for the disease, or from the disease appearing in the kidney as shown by copious urine and presence of epithelial cells, giving the mahogany-red reaction. Prognosis is fatal. Treatment is merely palliative and symptomatic. Cancer of the Spleen is rarely primary, and is accompanied by a can- cerous cachexia. The organ is nodular and not uniformly enlarged, and is the seat of great pain and tenderness. IOI In Our Diagnosis we should eliminate Amyloid Degeneration and Leucaemia. Hydatids of the Spleen. The morbid Anatomy is the same here as elsewhere. There may be a single or multiple cysts which may be situated in, or only attached to, the organ. The spleen has a peculiar parchment-like feel on Palpation, giving a distinct sense of fluctuation. It contains a pel- lucid liquid of a low specific gravity, with no albumen. The tumor is painless and grows slowly, the health being but slightly affected. Diagnosis. There are scarcely any other kinds of cysts to which this organ is subject. We base our diagnosis on the absence of signs of other splenic diseases. Prognosis, if it is recognized, is good. If left alone there is danger of its rupturing or a pyaemia being set up. Treatment is purely Surgical, and consists in the evacuation of the cyst. A single puncture may suffice, but if it refills it must be again punctured and injected. If it obstinately recurs, a fistula must be established and the cyst injected and drained until it finally closes, or laparotomy may be per- formed and the tumor enucleated. V. AFFECTIONS OF THE RESPIRATORY TRACT. I. THE NOSE. The Nasal Cavities are subject to Catarrh, which may be either Acute or Chronic. The word Catarrh is applied to all inflammations of mucous membranes. Acute Nasal Catarrh is not of very great importance; but owing to its great prevalence, its study possesses considerable interest. Its Causes are those which generally produce " a cold in the head," e.g., atmospheric changes, damp and cold feet, exposure to draughts of air or irritating vapors. The tendency to " take cold " (as it is called) is associated with a lowered tone of the system, and also with an individual weakness of the Mucous Membrane. Thus, Scrofulous subjects are peculiarly liable to it. It may also be brought about by a defective shape of the Nostrils. Symptoms are both Local and General. The Local Symptoms are — i. Smarting pain in the nasal cavities. There is a stage of Watery Secretion. This becomes gradually thicker, and finally muco-purulent. The General Symptoms consist in a feeling of Languor and Dullness, aching across the brow, a "creepy" sensation throughout the system, and pain in the limbs. The voice changes, and is apt to be lost. The Temperature may run up to ioo^° F., or in a sensitive child to ioi° F. Prognosis. With little children only is the disease serious, in so far as it may offer an obstruction to breathing. The Diagnosis is very plain. When we meet with Coryza, we should be on the lookout for Measles. Treatment. The patient should, if possible, stay indoors and take rest. We may order a Dover's powder and a warm foot-bath. A cap or handker- chief should be worn on the head at night, or we may adopt a Tonic Treat- ment, giving viii-xii grs. of Quinine, and paying attention to the clothing, 102 etc. A snuff of Sub-Nitrate of Bismuth is often of service. A person tending to " take cold in the head " should be subjected to Systemic Treat- ment, special care being taken of the skin. Nutrients, as Cod-liver Oil, and regular Gymnastics should be recommended. When a cold in the head runs on for some time we have what is known as Chronic Nasal Catarrh. This either arises — i. From repeated attacks of the Acute; or, 2. May begin as such from the outset. This is especially the case in persons of relaxed tone and in Syphilitic and Scrofulous subjects. 3. Injuries of the nose may produce it. This Affection may be in the Nasal Cavities or in the upper part of the pharynx. The mucous membrane is thickened and hypertrophied. Symptoms. The discharges from the nasal cavity in chronic catarrh vary in quantity, consistence and color. They may fall backwards into the throat and cause hawking. This is unfavorable, as it induces congestion of the mucous membrane there too. The voice is altered, owing to suppres- sion of the nasal sound. A habit of mouth breathing is developed, owing to the accumulation of mucus in the nasal cavities. A chronic Pharyngitis may be brought about. The General health, too, suffers indirectly. The Diagnosis of Chronic Nasal Catarrh presents no difficulty, but its exact location by means of the Laryngoscope requires practice. It is only recently that this has come into vogue, and the Prognosis is thus rendered more favorable than before. Treatment. Hygienic Treatment is essential. We must pay attention to the habits, dress and tone of the patient. All taint of Syphilis or Scrofula, when they exist, should be eradicated. Locally we may use Solutions of Sul- phate of Zinc and Nitrate of Silver, or an astringent powder may be blown into the parts. The condition of the mucous membrane may be such as to demand the application of the Cautery. A bone may have to be sawn away, as from Exostosis, or there may be a displaced Septum, requiring special treatment. We should, however, always try mild local measures first. II. THE LARYNX. Laryngitis and Croup. Laryngitis may be 1. Catarrhal. 2. (Edematous. 3. Ulcerative. Of the Catarrhal form we have — 1. A Mild; and 2. A Severe type. I. Ordinary Catarrhal Laryngitis affects all ages. Causes are Atmospheric Changes. The Larynx when heated is suddenlv cooled. Teachers, Public Speakers, Preachers, and all persons who use their voices much, persons of relaxed fibre, are prone. Symptoms. There is — 1. Pain in the Larynx of a smarting or burning character, which is increased by coughing or laughing. 2. Cough, which is hard and dry, and causes pain. 3. The Voice is altered, becoming hoarse, rough and weak. 4. There is General Malaise and slight Febrile symptoms. 5. The Laryngoscope shows Redness and Slight Swelling. In two or three days the Secretion of Glairy Mucus begins, thin at first, becoming thicker, and gradually diminishing in quantity, the attack lasting from five to ten days. In nervous children with acute Catarrhal Laryngitis there is more or less Muscular Spasm and Symptoms of Croup. But grown persons as well may have Symptoms of Croup. When we speak of Croup Symptoms, a coarse, hard, brassy, ringing Cough is meant, e. g., a Croupy Cough is noticeable is Bronchitis. 105 Diagnosis is easy, and the Prognosis is favorable, but attended with some anxiety, as in children ordinary Cartarrhal Laryngitis may run into something else The Treatment is simple. The voice must not be used. The air of the patient's room must be kept warm and moist. Counter-irritation over the front of the neck by means of Iodine. We may use Fomentations, or simply cold water, protected with Rubber or Oil Silk. Local applications of water, Lime Water, Weak Ammonia, or Lime Water with a little Carbolic Acid, are useful. Internally we give some Sedative and Laxative as the following : R Morph. Acetat. grss., Syrup Ipecac f3iij, Sol. Acetat. Amnion, f^iv. Mft. Sign. : Two Teaspoonfuls every four hours. We may use besides Spirits of Mendererus, and about 8 grains of Quinine along with the above. Children bear large doses of Quinia bv the Rectum well. Severe Acute Laryngitis is dangerous to the child ; much more so than to the adult. Its Causes are the same as those of ordinary Laryngitis, but usually there are predisposing causes, as former attacks. Symptoms. Fever of unusual severity. The Temperature running up to io2° F. to 103 F. The Skin is hot and moist. The Pulse is rapid, strong and excited, the breathing hurried. There is severe pain in the Larynx. The Voice is reduced in volume to a mere whisper sometimes. Cough is frequent and painful, and is reduced in force to a wheezy sound. The child is restless. There is a sense of oppression and obstruction. Sometimes the child sits erect in order to breathe. Examination of the Fauces and Larynx shows no pseudo-membrane, but there is intense congestion of the Mucous Membrane. This reaches its height in two days. The Duration of the Disease is generally from seven to nine days, but it may last fourteen. The Diagnosis is easy as to the presence of Laryngitis, but in a child we are always anxious about the existence of a pseudo-membranous deposit. Indeed, we can often only determine its absence by the fact of its not being discharged, and the child getting well. The Prognosis is favorable, but anxious. Treatment. Put the child to bed. Keep the temperature of the sick 'room humid and even. Apply counter irritation to the affected region. If the symptoms are very severe, a few leeches may be applied to the throat, followed by a fomentation. Blisters are not recommended. Cold packs kept on night and day are preferable. Frequently steam the throat by the atomizer from a funnel over some hot sedative liquid. Internally, give Calomel with Dover's powders in pill form to suit the case, e.g., y^ gr. Calomel with 2 or 3 grains of Dover's powders for three or four days. Also, give full amounts of Quinine at different times. When the symptoms sub- side, use alkaline solutions, as Ammonia, etc. Croup is the name applied to an acute febrile disease, attended by obstruc- tion of the Larynx with Spasms, causing a peculiar sound of the voice and a Cough. There is always present an element of inflammation and spasm. When the Spasm is the chief element we speak of it as Spasmodic Croup ; on the other hand, we may have Pseudo-Membranous Croup, in which the spasm is a minor element. Spasmodic or False Croup is a mild or Catarrhal Laryngitis with a high degree of spasm of the Muscles of the Larynx and an inflammation of a light degree. io6 Causes, i. Childhood ; and 2. An individual predisposition which is very marked in some families. 3. It occurs mostly in children before the close of the first dentition. Indeed, it would seem as though there is a tendency in the first dentition to bring on this disease. 4. Digestive Disturbances. 5. Some adults have Croup, but such cases are rare, and generally occur in persons of a highly neurotic temperament. Symptoms begin with those of a slight cold. They point to irritation of the Throat and Larynx, but are often overlooked, and the onset of Croup is sudden, frequently awakening the child after midnight. The child is alarmed and agitated. The skin is covered with sweat. The child is febrile. Its expression anxious and face flushed. Breathing is difficult, and at each inspiration there is a loud stridulous croupy sound. The supra- sternal notch sinks. The chest recedes. The cough is hoarse, weak, and croupy. Speaking is impossible, and the voice is reduced to a whisper. The Spasm is relaxed by the very thing it brings about, viz., the accumula- tion of Carbon Dioxide in the system, and soon the attack is over. They generally last a few moments. Rarely does the child have a second attack that night. Next day the child is feverish and croupy, and there is danger of a recurrence of attack the next night. The Laryngoscope shows no congestion. The Diagnosis is easy, if we bear in mind the Suddenness of the Attack, the Constitutional Disturbances, and the way in which it yields to treatment. The Prognosis is altogether good. The Treatment is simple. The principal point is to guard against future attacks. We should instruct the parents as to the care of the child when it has a cold. Such children are very sensitive. When they have a cold they should be kept in bed, in a warm room, and on light diet. Some- times a sponge dipped in hot water and applied to the Larynx does good. A hot bath will often break up a Spasm. Sprup of Ipecac causes vomiting and relaxes the spasm. Mouth-breathing is apt to bring on an attack. During sleep the throat gets dry, and this throws the child into a spasm. Hence, a child subject to croup should be waked up at intervals of a few hours during the night, and a teaspoonful of gum-water, or something similar, administered to keep the throat moist. Membranous or True Croup bears a close resemblance to Diphtheria as regards its Pathology. We may have Membranous Croup either Idiopathic or associated with Diphtheria. It is hard to say what is the relative frequency ( of True Membranous Croup and Diphtheritic Croup. In a large number of cases it is not Idiopathic. Membranous Croup develops gradually, and is called " Creeping Croup." Symptoms begin with Fever, Languor, Lassitude, Sore Throat, Cough, Hoarseness, and alteration of the voice. These last for two, three, or four days, but may be so slight that they are overlooked, and Membranous Laryngitis appears suddenly. Then come Obstructive Symptoms. The Breathing grows more and more difficult. The voice becomes more and more whispering. The hoarse character of the cough is suppressed. It becomes a mere effort at coughing. The Chest cannot be distended, the Lungs cannot be filled, and the base of the Chest is pressed in at each inspiration. The Supra-sternal Notch is sucked in from the same cause. These symptoms are attended with a weakening of the Pulse, Livid lips and Features. There is interference with Oxidation, and spasms of Dyspnoea, which threaten and sometimes cause sudden Death. The child is Restless and tears at its Throat. We have an accumulation of Carbonic Acid, and Death comes from Apnoea. In some cases there has been Membrane 1 09 in the Fauces before the Laryngeal symptoms. There may be no Membrane in the throat. The Tonsils are red and the Pharynx injected. The Glands at the angle of the jaw may be tender and swollen, but when the Membrane is in the Larynx first we have very little lymphatic enlarge- ment, whether it be Diphtheritic or Idiopathic. When Diphtheritic we have more adynamic symptoms. But we cannot base our Diagnosis on Constitutional Symptoms. They both run into extreme Debility. Obstruc- tion may become complete and death take place on the third day, but more commonly the case lasts from six to nine days. Morbid Anatomy. We find a deposit in the Larynx, beginning at the vocal cords. We have a cast of the Larynx, or it may be broken at points. This membrane is whiter and tougher than it is in the Pharynx. It may reach down to the Bronchi. The mucous membrane beneath is raw, con- gested, and excoriated, but is not ulcerated. The Post-Tracheal and Bron- chial Glands are enlarged. The Lungs have Patches of Catarrhal Secondary Pneumonia. Diagnosis of Membranous Croup is easy. Simple Catarrhal Laryn- gitis may have severe symptoms. Where Spasmodic Croup occurs there is no difficulty. Its sudden onset, and the fact of its yielding suddenly to treatment, would at once reveal simple Laryngitis. The Diagnosis is greatly assisted by a patch of membrane on the tonsils. The child may vomit a portion of membrane, and this reveals the true nature of the case, whether it be of the Idiopathic or Diphtheritic type. Prognosis is very grave. Many cases die. Treatment. Use prompt, strict treatment in apparent trivial diseases. Anticipate serious developments by Restraint in Bed and Attention to Hygiene. Regulate the Diet. Keep off Draughts. During the first day or two use Muriate of Ammonia and Ipecac with Squill and Opium, but as soon as local trouble appears give a steady course of Calomel. We may associate Chlorate of Potassium with Muriate of Ammonia, on account of liability to Faucial Irritation. For this- early stage use something like the following : R Ammon. Muriat., Potass. Chlorat. aa Z\, Mist. Glycyrhiz. Comp. f 3 i i i . M. ft. S. : f£i every three or four hours. For very young children substitute Syrup of Ipecac for Potash. If this has no effect give gr. iii of Calomel, to purge, and after this gr. x /> every one, two or three hours. It is well to give the Calomel with an alkali, as Carbonate of Potash. It never salivates. If it is a case of Putrid Laryngitis in Scarlet Fever, this treatment would be futile. Meanwhile give Quinia by the Rectum, and apply Iodine over the neck. Protect the surface by light batting of cotton. Give inhalations of Lime Water or Boracic Acid, or Pepsin and Lactic Acid. Put a couple of grains of Pepsin and a few drops of Lactic Acid into the cup of the Atomizer. Nourishment must be kept up. Heart failure is a great danger. Give Alcohol ; it is well borne. But the Symptoms of Obstruction may go on. There is danger of sudden death from Heart Clot, or Pulmonary Collapse. Perform Tracheotomy where the symptoms persist. It is a hard operation in a child, but there can be no apology for not performing it. The Fatal results are due to delay. The Temperature of the room must be high and the Air moist. The surface of the tube must be covered with Glycerine, and the tube cleaned from time to time. Chronic Conditions of the Larynx. Under this head we have two conditions. Chronic Laryngitis may be simply Catarrhal or Ulcerative, under which head we have — 1. Tuberculous. 2. Syphilitic. 3. Cancerous. no Chronic Laryngitis follows repeated Attacks of Acute Laryngitis. It is most common in those who have abused their voice. It may come on from the start as Chronic. We have Redness of the Vocal Cords, Epiglottis and Lining of the Larynx; Enlargement of the Follicles, Accumulations of Morbid Secretions; but the muscular movements of the Larynx are well preserved. Symptoms are Local. There is Smarting and Fullness in the Larynx. The Epiglottis, if swollen, may cause a disposition to swallow. There is Cough of a hard, Laryngeal character. The voice is hard, harsh and hoarse in tone. Mucus expectoration is great. The general health may be well preserved. Diagnosis. We recognize the disease by the Laryngoscope. We see an absence of any Bronchial or Pulmonary Disease. The Maintenance of the General Health is an important thing in the Diagnosis. Where it is Syphilitic or Tuberculous we have impairment of health. Prognosis is good if the patient breaks up the Habit of Life inducing the Disease. Treatment. The patient should learn how to use his voice rightly; not abuse it. Local Treatment can be employed by puffing Powders into the Larynx, guided by the Laryngoscope. Internal Remedies are Alkaline Salts, as those of Potash and Soda, and Copaiba. R Ammonii Muriat., or Brom., gr. c, Ext. Eriodyc. f^i, Mist. Glyc. Comp. f^iii, M. ft. S. : fgii ter. die. If there is soreness we add Bromide of Ammonia. Exte?-nal Counter-Irri- tation is useful here. I. In Tuberculous Laryngitis we find a remarkable degree of Swelling over the Arytenoid Cartilages. This is so often met with that it has a Diagnostic value. The Cartilages are rounded. In Ulcerative Laryn- gitis we may or may not find Tubercles. They may be at the base of the Lungs. The Lungs may be involved first, or the Larynx may. Tuberculous Laryngitis may be Primary or Secondary to Tuberculosis elsewhere. Symptoms are Troublesome Cough, Expectoration of Glairy Mucus and some Pus, and severe Pain in the Larynx. Before long there is Difficulty in Swallowing, owing to the Inflammation of the Arytenoids. Death may be hastened by taking food. The Voice is altered, being reduced to a whisper. There may be complete Aphonia. The General Health may fail. Some cases last only a few months; others several years. Diagnosis. Extreme care is necessary. It is important to know whether the Lungs are involved or not. This is often difficult. Rales are formed, and there is a complication of sounds. The Chest must be ausculted, both when the mouth is open and closed. The determination of the existence of the disease in the Lungs has an important bearing on the Laryngeal trouble. If the Lungs are healthy, and there is no Syphilis, yet at the same time obstinate Laryngitis, we are led to regard it as a Catarrhal Laryngitis. Prognosis is bad but the case may undergo temporary Improvement. The Treatment should be directed to the Improvement of the General Health, to the Pulmonary Trouble, and to the administration of Local Remedies, for the Laryngeal Trouble by the use of Inhalations. The appli- cation of Iodoform in solution, paste or powder. The Alkalies and Nitrate of Silver are not so safe. Food should be taken by a tube. If Dyspnoea or Dysphagia threatens life, tracheotomy may be indicated. II. Syphilitic Ulceration of the Larynx is a constitutional expression of syphilis. The Anatomical Characters differ from Tuberculous. Here the H3 Perichondrium is swollen, the Cartilages break down, and the Ulcers are superficial and deep. They are irregular and extensive, — all parts of the Larynx being affected. Not rarely ulceration of the Fauces is associated. Prognosis is favorable as regards life, but if not recognized early, Deformity is left behind, Cicatrices form, and fibrous bands encroach on the aperture. The Voice is often prematurely affected, and also Deglutition. This Stenosis causes obstruction. Treatment. Internal Constitutional Medication works wonderful results. External Counter irritation should be made over the Cartilaginous portion of the Larynx with the Laryngoscope. Nitric Acid, Caustic, or Sul- phate-of Copper may be applied locally to the ulcers. Sometimes Trache- otomy is necessary in Stenosis. Tumors of the Larynx may be — i. Simple. 2. Malignant. Mostly they are Papillomata. They may occur at any age or may be congenital. They are met with late in life. In shape they are sesile or pediculated. Their rate of growth differs. Causes are obscure. They seem to occur in persons who are predisposed to such growths. Symptoms are apt to be overlooked. There are alterations in the voice, it grows weaker, is unreliable, loses volume, cracks or breaks, is sometimes whistling — the tumor being between the Vocal Cords. There is Pro- gressive Dyspncea complicated with spasms from time to time. This Dyspnoea in a typical case is permanent. Pain and Cough are not very com- mon. The Cough, when it exists, is hard and spasmodic. The General Health does not appear to suffer. Diagnosis must be made with the Laryngoscope. This will reveal whether there is one Tumor or many. The absence of Syphilitic History and Tuberculosis must be taken into consideration. Prognosis of simple tumor is good. But if treatment is postponed, Tracheotomy may have to be performed, owing to sudden spasm. Treatment consists in the removal of the Growth. If it cannot be reached through the mouth Tracheotomy must first be performed. Cancer of the Larynx. The History of Cancer is a painful one. Cancer appears in elderly Subjects. It may be Primary or Secondary to growths 'in the Neighborhood. There is excessive Pain. Swallowing is difficult. There is more or less extinction of the Voice, Cough, and Expectora- tion. The Diagnosis by means of the Laryngoscope and the History is easy. Prognosis is hopeless. Treatment can only be Palliative, and consists in supporting the patient's system. Diseases of the Bronchi and Trachea. Bronchitis is — I. Acute. II. Chronic. Under Acute forms come — 1. Simple. 2. Capillary. 3. Mechanical, with Hypostatic Congestion. 4. Secondary. 5. Fibrinous. I. Simple Acute is an inflammation of the lining Membrane of the Bronchial tubes. It is excessively frequent. Causes. 1. Climate. The disease is more common at severe seasons of the year and in rough climates where there are sudden changes. In most climates it is not so bad unless Cold winds exist. High winds, much Dust, and a Dry climate favor Bronchitis. 2. A lax, atonic state of the sys- tem predisposes to it. 3. Age. It is most common in early life. 4. Ex- isting Cardiac Disease. 5. Occupations in which the person is exposed to irritating vapors or dust as in Mines. 6. It is an attendant on H4 Certain General Diseases, as Measles, Typhoid Fever, and most Blood diseases. It frequently complicates Phthisis and Emphysema. 7. In rare cases it is connected with the Gouty and Rheumatic Diathesis. Morbid Anatomy. At first there is a state of dryness of the parts; then Injection, Swelling and Redness of the Bronchial tubes. The Swelling is very variable, and may amount to Obstruction. There are patches of inflamed areas, and the swelling completes the closure of the small tubes, after which there is a Morbid Secretion. This condition is called Capillary Bronchitis. Sometimes we have a Fibrinous Formation, which may fill up the tubes of one side. Usually this Fibrinous Formation is a true morbid Product of a Pseudo-Membranous character. In a child we may have little patches of collapsed Lung, from occlusion of the bronchial tree where the lesions are symmetrical and bilateral. Symptoms — General. There is a Rigor, followed by more or less Fever, attended with aching Pains in the back, limbs and head. Often the Febrile Symptoms are not marked. There is pain in the Chest and hard Cough, increased by talking or using the voice. Pain under the Sternum is often complained of. Otherwise the symptoms are very slight. After this condition has lasted for about two days the cough grows softer, and there is a free, soft, muco-purulent expectoration. The General Symp- toms subside in a few days, and the attack terminates in from seven to fourteen days. Physical Signs. We observe no change on Inspection or Percussion. Auscultation reveals sonorous and sibilant Rales behind and down to the root of the Lungs. Later on Mucous Rales are heard at the base of the Lungs. These mark the two stages of — 1. Dryness; and 2. Secretion. II. Capillary Bronchitis is more common in children. It may be Primary or Secondary. When it is Primary it is acute and severe. The Temperature may be 102 F. or 103 F. The Pulse rapid. The Face flushed. The Breathing very rapid. In a child the respirations may be 60, 80, or even 100 per minute. In an adult 45 to 50. In children the base of the chest recedes. The respirations are shallow. There is Restlessness and Discomfort, which is not relieved, because there is no Expectoration. Later the Expectoration becomes soft and more muco-purulent, and then the Symptoms subside. Physical Signs. In general there is no impairment of Percussion Reso- nance. Auscultation gives very extensive Sub-crepitant Rales, most marked over the antero-posterior portion of the Lungs. With these may be mixed some Sonorous Rales. Respiratory Murmur is in many places weak. Over the upper portion of the Lung there may be Supplementary increase of Respiratory Murmur. After a few days Nervous Symptoms may appear. We have Jactation, Failure of Peripheral Circulation, Engorgement of the Lungs, and Death from Carbonic Acid Poisoning. It is often fatal in four or five days ; but it may last ten or twelve. Convalescence is apt to be pro- tracted. The whole Duration may be fifteen to twenty-one days. It is very different from the ordinary Bronchitis. Collapse is a term applied to Subjects who have fully expanded Lungs which have afterwards collapsed. It is more common in children as a com- plication — their respiratory muscles are weaker — but it may occur at any period of life, and especially when the System is exhausted. Explanation. A Bronchial Tube has been partly closed by the Swelling of the Mucous Membrane, and then by the thick Secretion. A thick plug is formed. The act of Expiration, when violent efforts are made, is more powerful than inspiration. Thus, from parts of the Lungs where the Obstruction is greatest, the air is pumped out and not replaced. A certain amount of air is absorbed, and we have a return to the Fcetal state. Either a spot may be affected the size of a cherry or a pin's head, or an entire lobe may be involved. The portions most liable to collapse are where the bronchitis is worst, and where it is difficult for the air to get back, e.g., the Intervertebral Gutters, and along the attenuated anterior margins of the Lung. It also may extend into the Mediastinum. Morbid Anatomy. The collapsed part of the Lung is sunken below the surrounding surface. It has a purplish color and is hard to the feel. It does not break down. If we inflate the Lung this collapsed portion will expand. This process of Collapse is inseparably connected with Bronchitis. It is rare as we have said, except in very attenuated systems. Symptoms. The occurrence of this Complication would be recognized by Dyspnoea. Frequency of Pulse and Respiration, without rise of Tem- perature as in Pneumonia, by the appearance of areas of impaired Dull- ness on percussion, and Distant Respiratory Murmur. There is not that intense Dullness of Consolidation of the Lung. Mechanical Bronchitis is simply Bronchitis in a person subject to Venous Stasis in heart disease. In these the Bronchitis is apt to be Subacute, but we may have spells. The chief point is there is a constantly marked ten- dency to Congestion and CEdema of the Lungs. We have a combination of pure Subcrepitant Rales with the ordinary Rale of Bronchitis. It may run into Subacute. A high degree of disturbance of breathing is caused with very little fever. Disorder of breathing and pulse is due to Cardiac disturb- ance. These are apt to be overlooked as the physician may only regard the Heart. Secondary Bronchitis ensues in other acute diseases, blood disorders, Measles, and the like. It may be secondary to Pulmonary Phthisis. Some of these forms are inevitable. We hardly pay attention to it if moderate, e.g., in Typhoid, Measles and Whooping Cough, the bronchitis is apt to be troublesome. It assumes more of the Capillary type especially in Whoop- ing Cough, Diphtheria, and Measles. The gravity of any disease is increased by Bronchitis. It may run into Catarrhal Pneumonia or be associated with extensive Hypostasis of the Lung or Collapse. Fibrinous Bronchitis is rare. It usually occurs in adults. There must be a predisposition. Symptoms. There will be Fever of an irregular character for an indefinite time. The Pulse is rapid. There is a disposition to Debility. The Cough is hard and troublesome. There is violent hawking, but little expectoration. Physical Signs show Ordinary Bronchitis, but it is peculiarly limited to one side, contrary to the rule of ordinary Bronchitis. Expiratory murmur is weak. The expulsion of a plug of fibrinous material gives great relief. Frequently we have a common chronic form. The patient is worn out, and dies of exhaustion. Plugs are found in the Bronchi after death. Rheumatic Bronchitis is not merely Bronchitis in rheumatic subjects, but is a Rheumatism of the Bronchial Tubes. The patient has a history of Rheumatism. Great pain attends acts of Coughing, which is very frequent and harsh. The Secretion is clear and mucus, and continues so a long time. It will not break up into a purulent effusion. This form is singularly connected with changes of Temperature. It is rebellious to treatment. It is cured only by Anti-rheumatics, together with Bronchial Treatment. It may present Metastasis. Under it we include the Bronchitis of gouty subjects. u8 Diagnosis of Acute Bronchitis. We must observe certain precau- tions. There is danger of recognizing bronchitis but overlooking the Disease of which it is a Symptom, e. g., in Typhoid and Measles. We must ask ourselves is this Primary or Secondary ? Again, Acute Bronchitis may be confounded with Acute Tuberculosis of the Lungs. This may present a great deal of embarrassment, but its Bilateral Character, Mild Symptoms, will set us right. We may find Bronchitis limited to one side. This is the case generally when Bronchitis is Secondary in Malaria or Typhoid, or where there is some local weakness of the Lung, which may afterward develop Tuberculosis. It indicates a local vulnerability. The Prognosis in the ordinary form is good. In Capillary grave. In the Mechanical form it depends on the condition which it has followed. Treatment. Every patient demands Restriction to bed. He must not even be allowed to go about his room. A mild attack may thus be converted into a Severe. Talking and Excitement must be avoided, especially in old persons. Nervous Exhaustion may turn it into Capillary Bronchitis. Coun- ter-Irritation of a mild diffused character, e. g., Tincture of Iodine painted over each chest six or eight inches square or repeated Mustard Plasters applied twice or thrice a day. Turpentine Liniment. The yolk of an egg to a wineglassful of Turpentine and thinned with a Tablespoonful of Vinegar is good, but it is too strong for a child. It must be diluted with Cream or Water. Place this over the Chest. Then a layer of raw Cotton which may be stitched to the under shirt. If it is Capillary Bronchitis stitch oil skin outside. If there is a moderate Cough promote Expectoration. Fever should be met by Aconite or Veratrum Viride. Give Aconite in divided dose. For an adult gtt i every hour for seven hours. By the time gtt v are taken, we should have a marked effect. For a child five years old, give gtt iii in nine spoonfuls of water. Stop during the night and begin next day. We may combine a moderate amount of Quinine. If there is a tendency to run into the Capillary Form give Strychnia and Nux Vomica. The strain on the muscles of respiration must be relieved. Give Opium to stop the Cough or Chloral or Bromide of Potassium or Ammonium. It is best to pre- scribe the Opium in a separate form as the Deodorized Tincture or the Offi- cinal Solution of Morphin or for children, Paregoric. We may combine Opium, Ipecac, and Liquor Ammonii Acetatis or Citrate of Potash. This is relaxing sedative and alkaline. When the fever is subdued, we substitute Muriate of Ammonia and Brown Mixture. R Morph. Sulphat. gr. i, Syrup. Ipecac f^ii ss., Syrup. Scillas fgvi, Syrup. Prun. Verg. f^iss, Glycerin, ad fjiii. M. ft. In the Capillary form give Quinia, Carbonate of Ammonia, Nux Vomica. We must not use Opium. Various demulcent drinks, Rock Candy, etc., may be given. In the Fibrinous form give Carbonate of Ammonia and Iodide of Potassium to its fullest extent. In Rheumatic bronchitis try Salicylate of Soda, Iodide of Potassium, Carbonate of Potash, Vinim Colchici, Salts of Ammonia, Squill, Ipecac and Senega. i. Chronic Bronchitis. 2. Winter Cough. 3. Emphysema. 4. Bronchiectasis. 5. Asthma. 121 Chronic Bronchitis is a Chronic Inflammation of the Bronchial Tubes. Causes, i. It has a Geographical arrangement. The American climate favors it. Inhalation of irritating vapors. It is common in workers in mills, knife grinders, and persons who have to carry hot iron into the open air. It may be Chronic from the start, or arise from repeated acute attacks. Attacks of Winter Cough may each year last longer. Then the patient has it the whole year round. We have a Con- stitutional Susceptibility, which predisposes to congestion of the Mucous Membrane. All agencies which impair lung circulation, weak right heart, etc. Symptoms are Local and General. General are Cough, which is very troublesome, and is increased by change of Temperature, exertion of the voice, the inhalation of cold air, but not occuring like phthisis, in fixed spells for the removal of accumulations. This cough is more troublesome than that of Phthisis. The Expectoration may be stringy or tenacious. Hemorrhage is rare, yet when we have Emphysema it may occur. Respiration is not much quickened. The Pulse may be rapid and weak. Exertion produces shortness of breath and acceleration of the pulse. The effect on the General health varies. Some persons remain fleshy and plethoric, keeping the cough up many years. This is true of those subject to gouty Bronchitis. Others grow anaemic and lose flesh and strength. This varies with the spells of bron- chitis. We may have a series of changes extending over years. If there has. been dilatation of the bronchial tubes and purulent expectoration, we may have Night Sweats, great debility, and extreme Anosmia. Physical Signs, if it is Simple, are largely negative. Palpation is normal. Respiratory Murmur but little changed. There are Sibilent and Sonorous Rales, or large Mucous Rales, extremely variable in position.. Other changes are induced at length, e. g., Vesicular Emphysema. In Emphysema we have a globular chest, Exaggerated Vesiculo-Tympanitic Resonance, and Sonorous Mucous and Sibilant Rales around the base of the lung. Inflammation of a tube often extends to the tissue around the tube, and a hard mass is formed, which tends to dilate the Bronchial tubes. This Dilatation is of two kinds, Uniform or Saccular, i. In Diffused Dila- tation we find the Respiratory Murmur rough and blowing, both in Expira- tion and Inspiration. A lung may be Emphysematous or it may be thick- ened. 2. If Saccular Dilatation has been developed we have the signs of a deep-seated Cavity, Wooden Tympany, Exaggerated Vocal Resonance, Tubular, hollow, blowing murmur, both on expiration and inspiration. Quite often, from acute attacks of cold, the patient has asthma, i. e., spasm of the bronchial tubes. It depends on the nervous mechanism of the Bronchi. Duration varies from several months to fifty years. When there is puru- lent expectoration it may only last a few years. Diagnosis. A knowledge of the exact state of the Lungs is necessary. The disease with which Chronic Bronchitis is most commonly confounded is Phthisis, where the spots of Disease are small and scattered through the Lungs. We distinguish Bronchitis from Phthisis by — The age of the patient and the history of the case; the marked alterations from time to time; the rarity of hemorrhage; the absence of Bacith from the Spula; its amenability to treatment ; the absence of infiltration in the Lung tissue ; the absence of signs of softening or Cavity; the bilateral involvement. The physical signs of Bronchitis are very shifting. The Prognosis is uncertain, but not grave. Life may be prolonged indefinitelv. 122 Treatment is very complicated. The dress, residence, occupation, cli- mate, need attention. In all congested and inflammatory conditions change of climate can be recommended. The detection of the cause and its removal goes far towards putting the Treatment on a scientific basis. Remedies. Inhalations are most valuable. They may be made with an Atomizer using Carbolic Acid, Muriate of Ammonia, and Sulphate of Zinc. If the expectoration is foetid, Chlorinated Soda may be used. R Tinct. Iodine f^ii, Acid Carbolic f^ss, Spirit Chloroform f^ss, Tinct. Conii f^ss. M. ft. Put a few drops on the sponge of an Inhaler or we may use Pumice Stone which can be washed with Alcohol afterwards. Where we have reason to suspect Emphysema, let the patient breathe into an Exhausted receiver. Several kinds of Apparatus for this purpose can be procured. Internal Remedies. Order Cod Liver Oil, Arsenic, and Colchicum in gouty cases. Ammonia and the Alkalies favor Expectoration. Iodide of Sodium and Ammonium combined with Carbonate of Potash. Vegetable remedies such as Senega and Squills, which are stimulating, and Copaiba which is alterative as well. If we desire to stop the Expectoration, we use Sedatives such as Stramonium, Belladonna, Hyoscyamus, and Opium. Opium, however, should be avoided as much as possible. Strychnia and Mineral Tonics are useful to give tone to the System. Dilatation of the Bronchial Tubes may, as we have seen, be Uni- form or Saccular. Causes are those of common Bronchitis. The expectoration is copious, and if the Dilatation is Sacculated is foetid. Gangrenous Bronchitis is often associated. It is of long standing. Physical Signs. There is Diffused Blowing Respiration. Not rarely in the Sacculated form we find leaks at the roots of the lungs. Often the Lung itself may be contracted and Cirrhotic. This may impair the Resonance, but there is generally Emphysema, and consequently Exaggerated Resonance over the affected area. Prognosis. The lesion is incurable. Treatment is that of Chronic Bronchitis with the addition of Inhalations according to the character of the Expectoration. Emphysema occurs in many forms. In real Emphysema the air cells are permanently over-distended. It is usually associated with degeneration — the walls being often broken down. We have Atrophic and Hypertrophic forms. By Emphysema, we mean Vesicular Emphysema. It is inseparably connected with Chronic Bronchitis. Causes. Repeated violent efforts at Coughing. It may become asso- ciated with Sub-Lobular and Sub-Pleural Emphysema from Rupture of the Vesicles, and the entrance of the air to the Pleura. Morbid Anatomy. The Lung is very much enlarged. Its outline is altered. It is irregular. The distended vesicles may hang like Cherries from the sides. When grasped, it does not crepitate, but has a Cottony feel. It is paler than normal. The Circulation being impaired, we have an enlargement of the Right Heart. Atrophic Emphysema is where the Lung is contracted and indurated. Sometimes the Vesicles break and we have as a sequel Pneumo-Thorax. The air may make its way round and give rise to an Emphysema of the cutaneous tissue of the whole body. Violent efforts of Labor have caused it. It is a rare Complication of Emphysema. 125 Symptoms, i. The patient has had Chronic Bronchitis, but all evidences of Bronchitis may be wanting. We must not confound Emphy- sema and Bronchitis. Cough is not a symptom of Emphysema ; nor is Expectoration. 2. Habitual Dyspnoea, which is progressive and finally extreme. It is increased by talking, excitement, etc. There are no lesions of the Lung to account for the dyspnoea. The Explanation is easy. The Lung is so inflated that no new air can get in, and there is only just enough oxidation to supply the simplest wants of the body. The Chest is globular, and the Sterno Cleido Mastoid Muscle prominent. Respiratory Move- ments are changed. We have the up and down movement of the chest, but expansion and retraction are wanting. Percussion gives Exaggerated Resonance. The Apex is higher ; the base lower. This leads to the Liver being pushed aside. The Heart is overlaid and pushed to the right. The Spleen is displaced. Auscultatory sound is changed. There is a weak Inspiratory Murmur and prolonged expiration. Resonance and Fremitus are weak. Atrophic Emphysema. We find the same progressive Dyspnoea, but the Chest is Alar and Phthisical. The Lung is retracted. If the thickening is considerable, and the Emphysema in patches, we may have Impaired Resonance. There is a diffused blowing sound. No change in the adjoin- ing organs. As the Emphysema goes on the Heart and Circulation grow weak. Dropsy ascends from the feet. We have Congestion of the Kidney and transient Albuminuria. Rupture of the Vesicles may give Hemorrhage of moderate extent. The disease is unattended with Fever. There is distressing Pain in the Chest, and often Diaphragmatic Dis- tress. From time to time Spells of Asthma occur. Phthisis is often a complication. Diagnosis. We should look out for it in Chronic Bronchitis. When there is Dyspnoea, exclude Heart Trouble, Pneumo-Thorax, and Pleurisy. Fatty Degeneration of the Diaphragm is very rare. Prognosis. Emphysema progresses with fluctuations. If taken early, it may be cured. Treatment. Should be begun at once. The Indications are — 1. To cure the Chronic Bronchitis. 2. Allay the Spasmodic Condition. 3. Put the patient in the best general condition. 4. Aid the acts of respiration by some apparatus, which will give additional rarification to the air several times a day. 5. Associate with this careful Calisthenics. Young children may be cured by the adoption of Pulmonary Gymnastics. 6. Give ascend- ing doses of Strychnia and Arsenic as Respiratory and Muscular Tonics. Asthma is a name applied to paroxysms of Dyspnoea with wheezing. It is not Dyspnoea. A patient with Emphysema or Fatty heart may have Dyspnoea, but not Asthma. It is Spasmodic and is sometimes called " Spas- modic Asthma." It is divided into Bronchial, Cardiac, and Renal. This is only for Pathological clearness. It may occur with either. Symptoms. The attack is sudden. The patient is seized with Dysp- noea amounting to Apncea. He cannot lie down. The pupils are dilated. He is bathed in sweat. There is a terrible play of all the Respiratory Muscles. The Veins are distended. Expiration is prolonged and dim- cult, and accompanied by wheezing. The Pulse is rapid and weak. There may or may not be Cough. Inspiration is very feeble. There are Rales mostly sibilant, but if Bronchitis is present they may be moist. An attack may last from half an hour to seventy-two hours. An intense degree of Muscular and Nervous Exhaustion follows a prolonged attack. 126 Bronchial Asthma. There may be no evidences of Bronchitis in the interval. Some atmospheric change brings it on. Some take it on top of Bronchitis. It may occur in Emphysema. Renal. Any little increase of the malady, if there be a predisposition, gives rise to Asthma. The term Asthma has reference solely to the paroxysm. Asthmatics may present the tendency from childhood. It is sometimes inherited, and may be outgrown. It may be an idiosyncrasy. Some patients are thrown into Asthma by certain smells. Some can't live in the city ; others cannot live in the country. The most trivial Disturbances of Health may produce it, e. g., Eating Condiments, Shellfish, etc. The Diagnosis is easy. The Prognosis depends on the nature of the associated condition. Treatment of Asthma. We must consider the underlying condition. i. The Attack. In General the indications are to relax the spasm and relieve the Congestion and Catarrh. Spasm may be relieved by the Inhala- tion of Stramonium in Cigarettes. Espec's cigarettes are the best. These are composed of Belladonna, Hyoscyamus and Stramonium. Breathing the fumes of burning Nitre is a cheaper method. Internally, Lobelia, Bromides, Opiates, or Hoffman's Anodyne maybe used. R Tinct. Lobeliae gtt. cc, Amnion. Bromid. gr. cc, Spirit ./Etheris Co. f^x, Glycerin fSjss, Aquam, ad ff v, M. ft. S. : f£ii as required. This presents an Antispasmodic action and diffusible agents. If very severe give Opium separately, in Suppositories preferably, or as the Deodor- ized Tincture. Among inhalations we may mention Chloroform and Nitrite of Amyl. Belladonna or Atropia is valuable in Cardiac and Renal Asthma. In Renal we must avoid any remedy such as Opiates which would check Secretion. A minimum amount of Morphia with Atropia is valuable. Externally. Irritation by Dry Cups, Iodine, or Iodine and Croton Oil if there is much Congestion, followed by hot fomentations. Where Gastric Irritation is the cause, an emetic will break up the spell, and when there are large amounts of Mucus to be brought up. The Respiratory Muscles undergo partial paralysis, hence we give full doses of Nux Vomica and Strychnia, keeping up this for its tonic action. In the Interval treat for Cardiac or Bright's Disease. It may be, only Tonic Regimen is required. Iodide of Potassium in long courses, Arsenic in moderate doses, and Tartar Emetic in minute doses, have an alterative effect on the mucous membrane and remove morbid susceptibility. In true asthmatics, change of climate is most potent, and in the young it alone may be successful. This change is controlled by personal idiosyncrasy. Large cities do well for some, North Colorado for others. Sound Hygiene and Regimen are required. Atelactasis, or Pulmonary Collapse, is a Term applied to a retention of the Foetal condition. Carnification is where, from long pressure, air is driven out by a pleural effusion, and yet there is no inflammation. This is a good term. Hypostatic Congestion is a name applied to an import a7it clinical con- dition of the Lung, affecting chiefly the postero-inferior parts, where there is Engorgement, with or without infiltration, determined by Gravitation and Cardiac failure. It is seen in Low fevers and in Typhoid. The Lungs are purplish, heavy, very slightly crepitant, yet not hard. On section, bloody 129 serum, with bubbles of air, exudes. Compression removes it, and the Lung is not friable or softened. It is often mixed with Catarrhal Pneumonia or Bronchitis, Severe or Capillary, and we have the symptoms of Bronchitis. There may be more than Congestion. There may be a low form of Pneu- monia and an Exudation. This is Hypostatic Pneumonia. Causes. It occurs in weak, exhausted systems at the close of long dis- eases. It commonly follows Typhoid and Typhus, in the very old and very young. Symptoms. Respiration is more embarrassed. The hue of the face is dusky. The Pulse is frequent and weak. There is impaired Resonance over the postero-inferior part of the Lung. Respiratory murmur is weak, and Sub-Crepitant rales are heard on inspiration. If the Hypostasis is slight, putting the patient erect and making him take long inspirations may remove it ; the Crepitant Rale entirely disappearing from nervous exertion and pres- sure of the vesicles. Prognosis. In any condition in which it occurs it adds danger, and is sometimes the cause of death. Treatment is that of the disease which it accompanies. In Typhoid, it is due to a feeble condition of the heart. The tone of the branches of the Pneumo-Gastric going to the Lungs is lowered. Give Carbonate of Ammonium and Strychnia. The patient should not lie long in one position, Gravitation being a powerful factor. When the hypostasis is threatening and persistent, Electricity may be applied to the Respiratory Muscles. Pneumonia, i. Catarrhal. 2. Croupous. Catarrhal Pneumonia affects a group of cells. Hence it has been called Lobular or Insular. From its association with Bronchitis, it has been termed Broncho-Pneumonia. It is an inflammation of the alveolar walls, with an exfoliation of their [Epithelium. It involves scattered patches of Lung tissue on one or both sides, attended with a high grade of Mortality, occurring specially in the young and weak. Morbid Anatomy. It does not involve a whole Lung, but there are Nodules of inflamed tissue. The wedges are broader at their apex than at the centre. The inflamed patch is hard and stands out. There is often a little Pleurisy over it. On incision it is red. On pressure, friable. Under the microscope we see that the exudation is in the vesicles, and consists of Epithelial Cells, coagulated fibrin and leucocytes. The cells are variously changed, and the walls are affected by morbid processes. The Bronchial Tubes are inflamed, and lesions of Bronchitis co-exist. The tubes contain Mucus and Muco-Pus of different degrees of tenacity. With this we find patches of Collapse. The collapsed patches are dark, swollen and sunken. When inflated with a blow-pipe, the collapsed areas are restored. As the disease progresses, under favorable circumstances the exudation slowly softens, and Expectoration takes place. The Cells cease to proliferate, and the lung returns to its natural state. This is termed Cure by Slow Resolution. But the inflamed patch may soften and form abscesses under the pleura looking like Small Pox, or the exudation dries up and becomes granular, and we have a Chronic Induration, with cheesy change in the Exudation. There may be the formation of Tuberculosis through absorption of Septic material. Causes are those of Catarrhal Inflammation. 1. Exposure to damp and Cold when the system is run down. 2. Age. It occurs in the very old and in children. 3. A large proportion of cases are Secondary and con- nected with Measles, Typhoid, Whooping Cough, and Diphtheria. There may be very slight attacks. It may only be revealed at the Post-Mortem. 130 Symptoms in a Mild Case. We have Moderate Fever lasting for a few days which is generally higher in the morning. 101-5 F., or 102-5 F. Coated Tongue. Loss of Appetite. Heavy Urine. Some pain about the chest and Cough which is dry, severe, and bronchial. After a day or two there is grey expectoration. The Cough softens, and the expectora- tion becomes muco-purulent and then purulent. This may last fourteen days. If the lobules are few and but little affected, there would be no change in percussion or premitus. No blowing Sound. Perhaps a few spots of weakness and a few Crackling Rales which may only be heard on forci- ble expiration. If the patches are deep, as they often are, there are no physical signs. If the patient is not treated, the lesions extend and become unmistakable. Such attacks run into the distinctive changes of true Pulmo- nary Phthisis, and even Tuberculosis in those so disposed. A great many cases of Phthisis are of an inflammatory origin — slow Septic processes being set up. True Catarrhal Pneumonia usually arises in the course of severe Bron- chitis, but may arise primarily. Symptoms. Respiration is very rapid. Pulse rapid and disposed to weakness. Cough becomes more frequent and painful, and there is less Expectoration. Fever is very high, and presents remissions between day and night. The Skin may be moist. The Eyes are often congested from the fever, circulation, and Cough. There is Catarrh of the Intestinal tract and discomfort about the Epigastrium. The Tongue is foul. The Stools are irregular, costive, or loose. There is not that Flush on the cheek which we observe in Croupous Pneumonia. Physical Signs. Bronchitis has extended. Instead of Sonorous Rales, we have fine Sub-Crepitant Rales heard both on expiration and inspiration. Respiratory Murmur is weak, diffused, and blowing. Resonance is impaired, but there is not that flatness of Lobar Pneumonia. Vocal resonance has a Bronchophonic character. The consolidation is less extensive than in Croupous. In weak children we may have Collapse of the Lung. In a few days Nervous Symptoms appear. There is broken sleep, slight delirium, constant jactation. The appearance grows worse ; the lips livid ; features pale. The extremities are cool, though the central Temperature is high. The breathing is rapid and shallow; the pulse running and feeble. The heart is labored in its action, and its sound is weak. The skin is moist. The Physical Signs indicate extending Capil- lary Bronchitis and passive filling of the Lungs. We have a paralytic engorgement, as in Pneumo-gastric palsy. Vitality fails and Coma ensues. The patient dies of prostration and impeded Circulation and Respiration. The Duration of a case depends on its extent and gravity. A fatal case lasts four to five days, or it may run on to three or four weeks. Death may occur on the twenty-first day. Complications are not numerous. 1. Collapse is frequent. 2. Heart Failure from the prolonged High Temperature and interference with respiration. 3. Albuminuria is rare, and depends on the complication of Renal Catarrh. 4. Gastro-intestinal trouble — the mucous membrane sympathizing. Diagnosis. The chief point is the recognition of the possibility of its occurrence in Bronchitis and Blood diseases. It may be mistaken for irregular Malarial or Typhoid fever, with Bronchial complications. Give the patient the benefit of the doubt. Prognosis is very bad. From twenty-five per cent, to sixty per cent, die. The mortality, however, can be lessened if its onset is noticed and treated early. 133 Treatment is very unsatisfactory. It is difficult to lay down fixed rules. The indications are to relieve the Bronchitis, to maintain the circulation, to treat the stomach, and to favor resolution of the patches of exudation. As soon as its approach is discerned restrain the patient to bed. A mistake of two days may spoil the result. Put raw cotton' around the chest, and over it Oil Silk. Adapt the diet to the stomach. In order to limit the fever give moderate amounts of Quinine, if the stomach bears them well ; also Strych- nia and Mineral Acids. Avoid all weakening and nauseating remedies. Muriate or Carbonate of Ammonia for children, should be administered in Emulsion or Simple Solution. If there is a tendency to Heart failure, stimulants are called for. Turpentine is a valuable alterative expectorant and diffusible stimulant. It may be combined with alcohol. The disease is too diffused for counter-irritation. Iodine may be used over the whole chest. In children where there is great retention of mucus, an emetic as Sulphate of Zinc, or Ipecac, may be used ; but this should be avoided as far as possible. Croupous Pneumonia is an acute febrile disease connected with an inflammation of the Substance of the Lung, involving a considerable extent in which an exudation rich in fibrin, and red globules occurs in the vesicles without affecting the walls. The exudation is composed largely of coagu- lated Fibrin. It resembles the False Membrane of Croup. We have four stages. i. Congestion. 2. Red Hepatization or Consolidation. 3. Grey Hepatization or Softening. 4. Evacuation. It terminates in Resolution, Abscess or Death. It usually affects the lower lobe of the Lung. It may involve only the posterior part of a lobe or may affect the whole lung. It may be double, and is then known as Double Pneunionia. I. Stage of Congestion. The Lung is acutely congested and full of red blood. The vesicles have a little exudation in them. II. Stage of Red Hepatization. The Lung is heavy. No air is admitted. It cuts like flesh on Section. If we press it with the blade of the knife a thick fluid comes out. It breaks down on pressure. If put into water it sinks. The exudation is from the blood vessels into the vesicles. It is composed of Globules, Leucocytes and a few Epithelial Cells. III. Stage of Grey Hepatization. The Lung is pale. On section the granulations disappear. There is Softening, and the exudation is less tenacious than during the first stage. The lung has undergone fatty degen- eration. IV. Stage of Evacuation comes on when the exudation is partly absorbed and partly expectorated. An abscess may form. There may be Thrombi, and Necrosis or Gangrene result from obstruction to the circula- tion. Nature and Causes. Some hold that Pneumonia is merely an Inflam- mation, others maintain that it is a Specific Disease. Pneumonia runs a definite course and terminates in a crisis, whereas, Inflammations generally subside gradually. In rare instances, it may follow violence, inhalations, etc., but this is not the case with Croupous Pneumonia. The peculiar dis- tribution of Pneumonia does not accord with the Climatic changes which are believed to produce it. On the other hand, Specific diseases are Symmetri- cal and Bilateral in their manifestations, e. g. t Small-Pox, whereas Pneumo- nia is most frequently unilateral. Pneumonia does run a Specific course, but 134 we find many variations. No positive opinion can be given. There is as much to be said in favor of one side as the other. Causes, i. Some assume a poison not yet separated. 2. Others, a Bacillus. 3. Others, the existence of a preparatory state of the system, e. g., Depression of nerve force. 4. Sudden climatic changes, Wet, Cold, Damp, etc. 5. Age. It is more a disease of adult life; old persons are very prone to it, yet children often have it. Varieties. Ordinary, Bilious, Cerebral, Malarial, Typhoid, and Sec- ondary. Ordinary. There is an abrupt onset, with Chill, followed by pain in the side, sharp and severe, from the association of Pleurisy. If there is less pleurisy, the pain is duller. It is increased by movement, pressure and coughing. There is a rapid rise of Temperature. It may reach 104 ° F. or 105 ° F., with only a moderate drop in the morning. At the close of the stadium it may drop 3 ° or 4 ° in twenty- four hours. The disease may gradu- ally terminate by defervescence. The Pulse is not so great as to accord with the Temperature. It is 96-115. Breathing is very rapid and labored. The nostrils play. The alae nasi move forcibly. The patient may have Orthopnoea. There is a great disproportion between the Respiratory and the Pulse rate. In an adult there may be 40, 48, 60 respirations per minute. Those of children may be 48, 72, or even 80. The ordinary ratio of Breath- ing to the Pulse is 18 to 72, or 1 to 4. Here it is 1 to 2, or even 1 to 1^. The patient seems ill from the start. The Expression is troubled. The Countenance flushed. The Flush on the cheek is on the same side as the Lesion. We have a dry, painful Cough, with at first no sputa. Then we have a little tenacious, glassy sputum, which soon becomes specked with points of blood. It looks like Iron rust. Fibrin is being brought away. It is so sticky that everting the cup which contains it does not empty it. As the disease advances and consolidation takes place, the Cough may stop and the Sputa again be dry, or fresh parts may be attacked and blood specks be brought away the whole time. When the disease is at its close, the expec- toration softens and becomes greyish. It ends in a soft muco-purulent fluid, and the Cough, at first hard and dry, becomes softer, looser and easier. Nervous Symptoms vary. Restlessness and wandering are common. The disease verges on a Typhoid type, with a tendency to twitching of the tendons, desire to leave the bed, muttering delirium. In children, when the upper lobe is involved, there may be active brain symptoms, followed by Coma. In children, Convulsions may occur at the onset or in the course of the disease. The Tongue is coated with yellow. There may be a little Vomiting. The Bowels are torpid, except there is Catarrh of the bowel, when there may be loose, bilious stools. The Urine is scanty, and has a heavy sediment, but there is an entire absence of Chlorides, Argentic Nitrate giving no precipitate. Physical Signs of Pneumonia. First Stage. Respiratory Murmur is feeble, partly from the pain caused by breathing. There is no change in Resonance or Fremitus. We hear a fine Inspiratory Murmur from the opening of vesicles coated with a fibrinous, sticky material. Second Stage. The Lung is hepatized and travelled by open bronchial tubes. Percussion is very dull and follows the course of a lobe or a lobe and a half. It is uninfluenced by any change in position. Vibrations in the Bronchial tubes come through to the hand better than normally. Thus we get increased Vocal Resonance and Fremitus. Auscultation reveals pure Bronchial respiration. There are no Rales. The exudation is too solid for 137 air to break it up. The chest movements are restricted. There is no push- ing away of the Liver, Heart or Stomach. Third Stage. Grey Hepatization. There is the same Dullness on Per- cussion. Vocal Fremitus and Resonance are increased ; but now we have Sub-Crepitant Rales, much coarser, larger and moister, heard both in expira- tion and inspiration. Fourth Stage. The Dullness lessens, the Bronchial breathing softens, and gradually th;e Lung returns to its normal condition. The Physical Signs do not disappear as quickly after the crisis as the Constitutional Symptoms do. Bilious Pneumonia. We have here a Complication of Gastro-Hepatic Catarrh. There may be little Jaundice with it. It occurs in the Tropics in the Spring and Fall. Cerebral Pneumonia may simulate the symptoms of Meningitis. It is generally associated with apicial Pneumonia. It is common in children and those disposed to Phthisis. Malarial is Pneumonia in a subject with Malarial Fever. A remittent or intermittent type is impressed on the Pneumonic Symptoms. Typhoid Pneumonia is where the symptoms run into a Typhoid char- acter. We have a marked prostration of the Nervous System. We find Flatulent distention of the bowel, Slipping down in bed, dry grey tongue, Muttering delirium. It occurs especially in the old and weak, or where there is some serious disorder of excretion at the same time, e. g., Nephritis. Secondary Pneumonia may occur in Typhoid and Rheumatic Fever. Diphtheria, etc. Diagnosis. Croupous Pneumonia may be mistaken for I. Catarrhal. We should remember the abruptness of Croupous ; Catarrhal Pneumonia being preceded by Bronchitis. Croupous affects a whole Lobe. In Catarrhal Pneumonia the Lesions are scattered. Croupous runs a definite, Catarrhal, an indefinite course. Catarrhal is three times as fatal as Croupous. The Chlorides are not absent from the urine in Catarrhal Pneumonia. They are in Croupous. Sputa are present in Croupous, absent in Catarrhal. Physical Signs in Catarrhal are not well marked except when the patches coalesce. II. Pleurisy. Pneumonia is more severe and the patient more ill. The alteration in the pulse is greater and the Fever higher. Physical Signs. In the First Stage of Pleurisy we hear a Friction Sound instead of the Fine Crepitant Rales of Pneumonia. In the Second Stage of Pleurisy, we have an enlarged chest, great difficulty of movement, and displacement of the Vis- cera. Effusion changes its place in Pleurisy. Vocal Fremitus and Reso- nance are weakened or lost. Prognosis of Croupous Pneumonia is good. An adult gets well in 90 to 95 cases out of 100, if there is no complication. If the Pneumonia is Double or complicated with Pericarditis or Pleurisy, or if it occurs in drunkards or broken-down systems, and very aged people, it is very fatal. Yet, patients of 80 have recovered. Sometimes there is a tendency to Hyperpyrexia, e. g., above 105 F. This may arise from the violent inflammatory acuteness of the disease, or from the morbid condition of the Nervous Centres. Hence, heat is retained and accumulated. It is a dangerous Complication. Treatment. We do not follow any one plan. We speak of an ideal case, for which we can lay down certain rules. If we believe it to be a Specific Disease, we can only conduct our patient through its course. We can only break up an attack when there is Acute Congestion — not after that, /. e., once Consolidation has set in. The patient should be seen early. If there is high arterial tension in a person of good health, Venisection from the arm or copious Leeching to the side of the chest is advisable. This 138 should be followed by the immediate application of a cotton jacket inside the shirt, with Mackintosh outside. Push Veratrum Viride and Aconite to the point of positively affecting the Volume Force and Frequency of the Pulse. We should get a Softening of the Pulse and a relaxation of the surface. Give Fluid Extract Veratrum Viride, gtt. iii-v every two hours ; also Tincture of Aconite, gtt. iii. Moderate this the moment an impression begins to be produced, by lessening the dose and increasing the interval. There is a tendency to effusion into the Vesicles. Whether the nerves are palsied or not we do not know, but by checking the vis a tergo we stop the Exudation. Throw in full doses of Quinine. If the Stomach is irritable, give it per Rectum. If there is any absolute necessity give Quinine hypodermically. These measures, with absolute rest and rigidly restricted diet, may enable us to restore vitality to, and perhaps even cure a part of a lobe. The Diges- tive System must not be broken down. This treatment should not extend over two days. Then the area of Consolidation is known. The patient is now in for a siege of Fever and slow resolution. The treatment must now be directed to softening and hastening Resolution. Use at once Carbonate of Ammonia. It acts more quickly than the Muriate. Senega, Squills and Ipecac, nauseate. Give Carbonate of Ammonia, gr. v, or Muriate of Ammonia gr. vi-viii every two hours. Cough should be checked by Opium. This is also needed for Rest and Sleep. Do not mix it with the other medicine which is to be taken continuously. Quinine need only now be given in tonic doses, gr. vi-viii every three hours. Under the Cotton Jacket we may apply Tincture of Iodine. The diet should not be improved ; give Milk, Broth, etc. Continue this until the crisis comes and the Febrile Stadium is passed. Under this treatment 90 per cent, to 94 per cent, of cases recover. The fewer the drugs the better. Complications. In the very old and weak, and in children, we must avoid Venisection. Existing debility contra-indicates Cardiac Sedatives. Use Aconite alone, as being more controllable. Bilious symptoms make it necessary to attend, for the first few days, to the Stomach. Give Calomel, Bismuth and Soda; Aconite by the mouth and Quinine per Rectum. Push the Calomel in fractional doses till three liquid stools are obtained. Then use it only when there is Hepatic trouble. There may be Diarrhoea. This must be checked by the continuous use of Opiates. Sometimes Pain in the side is so severe that we must apply a blister over the spot under the Cotton Jacket. Poultice, and follow it with a greasy rag. It is better to reserve Blisters for the later stages. Nervous symptoms are often alarming, the patient being restless and not able to sleep. The cautious use of graduated doses of Opium prevent their appearance. Sometimes, however, it seems to increase them. Then use the Bromide Salts and Chloral. The Bromide of Potash is best : dose, gr. xv, at intervals, or gr. x with gr. v of Chloral. An Enema of Chloral in active Nervous symptoms together with Stomach trouble, is good. For a child, gr. v. ; an adult, gr. xv. If there is excess- ive Hyper-Pyrexia, we can scarcely hope to beat it down much. Our Remedies may increase it. If the Nervous symptoms are moderate, let the fever alone and go on with ordinary Treatment. In Pneumonia, Cold baths do not give favorable results. It is better to give colossal doses of Quinine, gr. xv, every three hours. Other drugs, notably Anti-Pyrene, have a won- derful effect, yet evidence so far does not enable us to say whether other results do not follow its use worse than the remaining Fever. The fever is only one Symptom of a complicated case. Cold applications to the head are good. A coil of rubber tubing with ice-water running through, ice bags, etc., may be left on several hours, and the effects watched. 141 Stimulants in Pneumonia. Alcohol is not required, but if it does not interfere with digestion, small amounts at short intervals with food, may be given to both old and young. Heart failure is thus less apt to occur. If there is marked weakness of the heart, the pulse weak and small, give first small and then large doses, to tide the patient over till the crisis comes to his relief. Children bear stimulants very well. Old persons require Wine Whey, Champagne, etc. Digitalis will suggest itself in connection with Heart failure. Give pretty full doses, with Ammonia Mixture and Quinine. We must not expect the same result on the Pulse as when Cardiac trouble is treated. Gtt. xii-xv of a good tincture, or f^i-ii of the Infusion will be enough. Pulmonary Phthisis is a term applied to a varying and complex set of symptoms, viz. : Cough, Expectoration, Hemorrhage, Fever, Sweats and Emaciation, associated anatomically with Ulcerative or Suppurative changes i?i the Lungs, which have been infiltrated by a peculiar Inflammatory product. The term Phthisis should not be applied to conditions till established organic disease of the Lungs exists. As to its nature views differ. It is mixed up with the obscure question of Tuberculosis. Some maintain that the areas of suppuration are areas of Tuberculous formation ; but we have no definition of Tuberculosis. Some authorities, like Koch, say nothing is Tuberculous in which Bacilli are not found. Opinions differ as regards the action of Bacilli, as to whether they are a cause or an effect, or whether the product of Tuberculosis offers a favorable nidus for their development. We do know, however, that there are areas of Lung infiltrated, and involvement of the peri-bronchial sheaths and alveolar walls. A new form of Lymphoid Tissue developes and infiltrates the area; then there are proliferations of the cells, after which Bacilli are found. The affected areas may be like Millet seeds, or quite extensive retrograde changes occur. There is very little blood supply. Cheesey Metamorphosis, Softening and Ulceration ensue and in the cavities thus formed Suppuration is kept up. We first have Infiltration, and when the areas coalesce, Consolidation. The ulcers often communicate with the walls of the Bronchi, and these may soften and ulcerate. The blood vessels of the diseased portion of the Lung are unpro- tected, and Aneurisms may form on their weakened walls. The Lung may be riddled by these areas, or one Lobe may be hollowed out into a large cavity with fibrous partitions. These changes begin at the Apex, usually involving only one Lung at first. They are nearly always associated with Pleurisy. Phthisis. Chronic, i. Catarrhal. 2. Fibroid. Acute. Croupous, Cheesey Pneumonia, Infiltrated Tuberculosis. In speaking of the varieties of Phthisis, we divide them clinically, and not according to the strict Pathology of each variety. Catarrhal is not neces- sarily a purely Catarrhal Inflammation. We have Tuberculous deposits in Catarrhal Products. So too in Fibroid, we find Tuberculous processes mixed with Fibroid products. Acute is simply Phthisis running only a few weeks or months. It is often called Galloping Consumption. It is not to be confounded with Acute Miliary Tuberculosis. Croupous Pneumonia may run into Phthisis, soften- ing, etc. Causes of Phthisis. We clearly recognize a state of preparation some- times inherited. To children a low form of Vitality is often transmitted, which renders them liable to phthisis. This state may also be acquired by all influences which depress the system. Early youth and early adolescence are times of formation. New tissue is being formed. Those who grow too 142 fast and who are precocious, are peculiarly liable. It often follows Im- paired Digestion and any exhausting Drain on the system. Those who are in this state get Phthisis from any inflammation. Where a subject has had old hard inflammatory products as scrofulous glands, absorption from these excites Phthisis. Some hold Phthisis to be Contagious. It may develop in a wife after the death of her husband from Phthisis, or in a mother after the death of the daughter, but such cases can be explained apart from Contagion. Whether it is contagious or not, is a momentous question, Clinically, Pathologically, and Socially. There are Local and Climatic Causes. Excessive Soil Moisture is a powerful agent. The character of the house and the ground on which it stands have a positive influence. Symptoms are — i. Early. 2. Late. 3. Physical signs. Chronic Catarrhal Phthisis. The Early Symptoms are paleness, impairment of appetite and nutrition, and slow loss of flesh. These may last for years before any Cough comes on. This is called the Stage of Incipient Phthisis. This is a bad term, as the phthisis may be broken up by proper means. Symptoms of Local Disease of the Lung may be called into play by a mere cold. The Cough is at first just slight and hacking. Then it becomes more troublesome. There is pain about the chest. The Tem- perature may rise one-half a degree in the afternoon. There is a slight acceleration of the Pulse. The Tongue is red at the edges and coated. Digestion is somewhat impaired. Sleep is disturbed, and the patient is restless. There may be a little Moisture at night. The patient loses flesh, gains a little, and then drops in 'weight. He becomes pale, and flushes easily in the cheek. The Temperature rises in the night, drops in the early hours of the morning, and rises in the afternoon. Night Sweats come on. The Cough is looser, and the Expectoration muco- purulent. The Pulse rises in rate, and the Breathing is accelerated. Not rarely the Extremities are cool, while the centre of the body is hot. There may be slight attacks of Diarrhoea. The Advanced Stage comes on when a Cavity has formed, and round it are spots of disease in various stages. The Temperature is always ele- vated. It runs up high on slight causes. The patient gets out of breath very easily. The Pulse is small and rapid. The Cough changes its char- acter and only comes on when the Cavity is full. There may only be a Coughing spell in the morning. Haemoptysis may be small or copious. Digestion breaks down more and more. The appetite fails and Diarrhoea is set up by slight things. Termination. The case ends in Tuberculous or Colliquative Diarrhoea. A patient may be cut off by a clot from sudden failure of the heart or by Dropsy. The Course varies from one to fifteen years, the average being two or three. There may be many fluctuations, which may be associated with acute Catarrhal attacks. Generally they accompany serious organic changes. Physical Signs. The Lesions of the early stages are generally found at the Apices of the Lungs, but not always. A patch may be even down below the root of the Lung. Percussion gives a slight relative impairment of Resonance. Auscultation shows that the Elasticity of the Lung is impaired. There is weak inspiration, prolonged and blowing expiration. Vocal Resonance is slightly increased.' If the patient coughs, and then takes a long breath, there may be a few scattered, crackling Rales. The Infiltra- tion progresses and we have the stage of Consolidation. Percussion shows marked Dullness. Auscultation reveals Bronchophony. We find both Increased Vocal Fremitus and Crackling Rales, because the process is not uniform. Then comes the Stage of Softening. Over the area of Con- solidation we now have moist Rales, which muffle the Bronchophony. Lastly we have the Stage of Evacuation. Cavities are formed, with Consolidation. On Percussion there is Tympany and the cracked pot sound. Auscultation gives Amphoric breathing. The Rales are large, mucous and bubbling. We hear Metallic Tinkling. The voice is pectoriloquous. In the stage of Consolidation and Softening there is Retraction of the Chest and Impaired Movement. The General Symptoms change more than the Local do. Fibroid Phthisis differs from Catarrhal in its longer duration, and in the absence of acute Catarrhal Inflammatory Spells. There is little fever for months. There may be none. Cough is apt to be extreme and wearying. Expectoration is white and copious Hemorrhage is by no means rare. Digestive disturbances and Night Sweats are not so common. The affected Lung has a large area. It undergoes Contraction. Cavities form round the centres of inflammation. The chest gradually retracts. The patient looks as if he had had Adhesive Pleurisy. Its mobility is much impaired. Physical Signs. Percussion gives hard wooden Resonance, with areas of tympanitic Resonance. Auscultation reveals a diffused blowing sound, with here and there cavernous breathing. In spots the Pleura is so much thickened that transmission of fremitus is interfered with. Vocal Resonance is increased and pectoriloquous, or it may be decreased. Rales are heard in the dilated bronchi. The Pleura may be so much thickened — one-quarter to one-half inch — that the transmission of Fremitus is interfered with. Vocal Resonance is increased and pectoriloquous, or it may be decreased. Acute Phthisis, or Galloping Consumption, is met with in Miliary Tuberculosis. We have an extensive Pneumonic infiltration, which takes on cheesey degeneration. Symptoms are its Duration — from one and a half to three or four months; the Course of the fever, which is high and continued, marked at times by breaks. The Breathing is weak ; the Pulse rapid. Cough may be very troublesome, or almost absent. Expectoration at times may be absent when the tubercles have not softened ; again it may be copious. Hemorrhage may or may not be present. Physical Signs, where the Lungs are studded with Tubercles, are obscure. Percussion reveals no dullness, Vocal Fremitus no change. The movements of the chest may be almost normal. Respiratory Murmur is altered and feeble. So many Lobules are obstructed that the amount of inspired air is small. There is consequently very little expansion. At times Vesicular Murmur may be shrill or hissing. Usually we have Crackling Rales at certain points, but the physical signs are out of proportion to the general symptoms of respiratory disturbance. When there is infiltration undergoing extensive changes we have signs of Consolidation breaking dozen, marked in either lung. Where the physical signs are very pronounced we have those of disseminated Tuberculosis. Special Symptoms. Cough is extremely important. It varies at different times as the disease advances. Patients will often deny that they have a cough. On interrogation we find that they raise mucus. This may be brought up by a very slight effort. On the other hand, Cough may be a most prominent symptom, and the amount of mucus raised be very small. Of course it is right that what pus is formed should be brought up. Cough for the removal of pus must not be checked, but a cough which wearies the patient, and is fruitless, must be stopped. As the disease advances cough 146 may only occur in spells, i. e., when the cavities are to be evacuated. Fre- quently the cough is aggravated by irritation from the larynx and pharynx. Troublesome cough helps to break a patient down rapidly. Sometimes we meet with cough which excites Vomiting. Patients will insist that it is a stomach cough. The stomach demands careful treatment, which will be followed by improvement in the cough. In the same way Expectoration should be studied carefully. In the First stage there is scarcely any. When softening begins it is muco-purulent, and finally becomes purulent. Expecto- ration may be absent. There may be extensive rales, and no mucus raised. In other cases, with small physical signs, there may be bronchial secretion in excess and copious expectoration. The sputa assumes what is known as the nummular form, solid, flat, heavy, round masses, which sink in water. This is more particularly met with in the later stages, when there is disintegration of Tissue. The Sputa of Phthisis have acquired an importance. The study of them after boiling with Potash is significant. The elastic tissue of the lung resists the action of the alkali, and its presence proves that the walls of the alveoli are undergoing disintegration. This diagnoses the case from chronic bronchitis. The presence of bacilli has a diagnostic value. In proportion to their number and growth is the progress and bad character of the phthisis. Hemorrhage repays careful study. It is a frequent symp- tom. Few cases go on without it. Some few do. Some bleed often and freely. The haemoptysis is easily recognized as coming from the Lungs by the character of the blood raised. It does not come up in gulps, like vomit- ing, but the mouth fills, and it is quietly spit out. The amount raised is generally very small. The Blood is arterial, fully oxidized, and frothy. Crimson froth lies on the top of the mucus. The amount is always exag- gerated. The mere amount rarely does harm. It indicates some fresh disease, which may result in more sputa and fever. It does no injury at the time. It comes from congestion around a spot already congested. This may occur at any period of phthisis, or the hemorrhage may arise from weakness of little pockets. Hemorrhages of these two kinds are followed by relief, especially the latter kind, after a hard, racking cough and fever. The patient feels better, the appetite returns, and the fever improves. In many cases of phthisis which bleed easily during the first stage the progress is good r and the case is slow and amenable to treatment, and the lesions do not advance rapidly. The vessels relieve themselves by hemorrhage, and not by exudation, which would fill up the lung and cause more disturbance. Other kinds of Hemorrhage may be dangerous. Small Aneurisms often form on the blood vessels along the walls, and cause death by bursting. Some blood stays, and if the lung is irritable, we have a sub-acute pneumonic con- dition set up. The Question arises, Can hemorrhage start phthisis itself? While it is true that hemorrhage from the Lung indicates organic disease, in a person strongly disposed to phthisis a blow on the chest may cause hemorr- hage and set up phthisis. People may have bronchial hemorrhage, in which lung tissue is not involved. It may come from the Larynx or Bronchial tubes. Their Mucous Membrane is thin, and the vessels break easily. Con- gestion following changes in atmospheric pressure may cause hemorrhage. In general, however, it is a symptom of evil omen. Pulse Rate is often accelerated before the physical signs are manifest. A continued acceleration and hacking cough justifies serious apprehension and radical measures. The absence of acceleration of the Pulse and elevation of Temperature is a very favorable symptom in phthisis. It means that Re- flex Irritability is not as great as usual; and, secondly, by the tendency to absorption of Septic material is not prominent. 149 Body weight should be studied carefully and regularly. When we add to elevation of Temperature and acceleration of pulse, body weight declin- ing, and a little hacking cough, we have dangerous symptoms. Nothing is more favorable than to find the body weight keeping equal. Diagnosis of Phthisis is easy with care. We might confound it with Chronic Bronchitis or Clironic Catarrhal Pneumonia. From Chronic Bronchitis we would diagnose it thus : The symptoms of Phthisis indicate greater constitutional disturbance. There is more weakness, fever, anaemia, Indigestion, Diarrhoea, Dyspepsia, etc., Night sweats and headache. Still with a large amount of Purulent Discharge and dilated bronchi, there may be the above symptoms. Physical signs are more reliable. There is no con- solidation in bronchitis, but dilated bronchi and Emphysema. Percussion Resonance is hardly affected, and may be exaggerated in Bronchitis. In Bronchitis, Vesicular Murmur is unchanged, and there maybe diffused blow- ing sound 'from general bronchial dilatation. In Bronchitis, we have feeble, inspiratory, and prolonged expiratory murmur. These are in both Lungs and diffused, but in Phthisis, it may be one-sided, or only in one spot. Hence, Localization is an important point. At one part there may be evi- dences of infiltration, Cavernous breathing, and change in vocal resonance. Rales in Chronic Bronchitis are Sibilant. In Phthisis they are at first Crackling, and in consolidation there are none. Again, they may be mucous, then bubbling, and then limited to one spot and spreading gradu- ally from it. If we have a case of phthisis where there are small centres of disease not running together to give consolidation to any extent, it may closely resemble Chronic Bronchitis. In the Diagnosis Elastic fibre and bacilli must be sought for. A very Important question is Recognition in the Early Stage. We may think it is only dyspepsia, anaemia, Malaria, and thus explain away the Symptoms. We diagnose by considering the Heredi- tary Tendency or evident acquired Constitutional weakness, Family history, age, Loss of flesh, Acceleration of Pulse, Temperature, Hacking cough, and then if there is repeated and critical examination of the chest, and it shows change at any point, though we cannot diagnose phthisis, we should keep the patient under observation and treat him carefully. This is the stage for Radical cure. After catarrhal pneumonia, minute areas remain, which may run into phthisis. We find a little impairment of Percussion Resonance after a coughing spell. On deep inspiration we may hear slight Rales. Prognosis varies enormously in different stages. It is fairly good in the very early stage if we can secure full control of the patient. After this, the Prognosis is bad. Life may be prolonged, but eventually the disease wears the patient out. Yet, even after positive Lesions are found, the Prognosis is not necessarily wholly bad. Consider — i. The Family History. 2. The Extent of the Lesion. Existence of any disease on the opposite side is very bad. A case is always worse if bilateral as indicating a tendency to Generalization. If the Stomach remains unimpaired, the patient can fight for a long time. Pecuniary means are of great service. Occupation, Climate, Mode of Life, must be changed, and all depressing circumstances avoided. Treatment of Phthisis. The most important part of the Treatment is Prevention, which should be both Individual and Municipal. Sanitary reform is needed in the Ventilation of Factories. Marriages should be prevented between phthisical persons, or coitus and conception prohibited. In the early stage health may be entirely restored. The Subject must be brought into physical vigor. Drugs should only be used as nutritives, or to check functional disturbances. We must recommend pulmonary Proper i qo gymnastics, and teach our patients to use the deeper parts of their Lungs, and to cultivate abdominal breathing. Drugs when used at all, should be adapted to the promotion of Secretion and Digestion, and to give tone to the system. Cod Liver Oil, Hyposphites, Iron, are all serviceable. Fully Developed Stage. Consider the tone of the patient, whether — i, to use a cautious conservative plan; or, 2, whether he is the stronger or the disease. If he is too weak for the above, let him either change his climate or start a protective plan. Rest in bed determined by his weight and tempera- ture, In-door exercise, Marriage, Artificial Feeding. Guard against Changes of Temperature. Use baths, gradually cooler and cooler, and friction. Insist on Out-door exercise. Stop his occupation, i. e., break the conditions which have led to the disease. Very often Phthisis will yield entirely to Gastric Treatment, by studying the Digestion and the Diet. Often the appetite is capricious. Here give acceptable food. Guard against the least tendency to diarrhoea. Cough is the patient's chief complaint. As a matter of fact, this is of no value. If it is fruitless and dry, we should attend to the Larynx and Fauces. Avoid Expectorants which are laxative and irritate the stomach, and use the simplest things. For Cough we give the following — R Morphise Sulphatis gr. i, Acidi Sulphuric Diluti, f«Jii, Syrup Pruni Vergin, fjiv. M. ft. S. A Teaspoonful in water two or three times a day. Or, instead of Morphia, we can use — R Potass. Cyanid, gr. iii, Acid. Muriatic Diluti, f^ii, Glycerin, f^ss, Syr. Pruni, Vergin : f^iss, Syrup Scillae, q. s. ad, f^iii. M. ft. Sign : A Teaspoonful in water two or three times a day. Avoid Expectorants in Phthisis. Mixtures of Senega, Squill, Tolu, etc., nauseate the patient. Night Sweats. We should endeavor to remove the cause by stopping Meat food and lessening the bed clothes, etc. Sometimes they depend on the irritation of the fever. Here give Atropia, y-L to -y-J-g gr., or join with the former prescriptions gtt x or xv of Aromatic Sulphuric Acid two or three times a day, or Gallic Acid 3 gr. and Quinia 2 gr., three or four times a day. Jaborandi in minute doses will tone up the Sweat glands, given in doses of gtt v three times a day. So will Sponging with Whiskey and Alum, or Alcohol, and rubbing with a dry salt towel. Change to a dry climate often breaks up Night Sweats. Haemoptysis need not excite solicitude. Huge doses of drugs to check it break the digestion down. Prescribe cool air in the bed-room, rest, a little Opium to tranquillize circulation, and a few drops of Ergot or Gallic Acid. If the stomach is irritable, give Ergot by hypodermic injections over the affected part or in suppository. Forbid all excitement. Digitalis is valuable as sustaining the heart's action and being itself an astringent. In cases of protracted Hemorrhage we may use Inhalations of Salts of Iron and Zinc by an atomizer. Do not push Opium too far. If Ergot does not stop the Hemorrhage within forty-eight or seventy-two hours, substitute Gallic Acid or Lead Acetate. Give Lead Acetate in gr. iii doses every three hours, and watch for Lead poisoning. In unusually protracted cases, Sulphate of Copper, gr. }i to gr. }£ does g°°d, aR d so will dry Sulphate of Iron. The 153 application of Ice over the Chest should only be given when large amounts of blood are being lost and where we want a powerful result. Fever. A moderate amount is to be expected. Apyretic cases are mod- erate. We can't get rid of it. It improves with the system, but sometimes may be exhausting. It may be associated with night sweats, and checking the fever may stop them as well. Keep the patient very quiet and restrict his diet. The effect should be prompt. We can't keep them in or on poor diet too long. Then give remedies, such as Quinia, Digitalis, Opium and Belladonna. Xiemeyer's pills are as follows : R Ouiniae Sulphatis gr. xl, Pulv. Digitalis, gr. x, Pulv. Opii gr. iii, Extract Belladonna? gr. iiss. Mft. Pil. xx. S. One three times a day. Break down the fever with Aconite in five doses of one drop each, or An- tipyrene, x or xii grains each, during the evening and afternoon. Some- times patients bear fever well and may go out with a temperature of 103 F. or 104 F., but we have rapid wasting of Tissue all the time. It shows a more intense infection of the system. Give Opium and Quinine to check it. We can't stop it, and other remedies only do harm. Don't give too many drugs. Only give them to meet special emergencies. Combine Extract of Malt, Cod Liver Oil, etc., with the food. Change of Climate. Some- times — 1. It is desirable to bring about a radical change in general state of of the System. 2. It may be required for relief of some special symptom. 3. Simply for Euthanasia. Mere change of climate will lose its effect if the patients don't keep up same treatment as before. Forced Artificial Feeding has been recommended, but is no good. Rest, massage, and forced feeding may be good in a very simple case. Atmospheres of different densities and medicated seem to give some help. Local Treatment. Inhalations or Hypodermic injections into the dis- eased lung, are good where the disease is circumscribed, and there is a good deal of irritable coughing. THE PLEURA. Pleurisy is an Inflammation of the Pleural Membrane, which invests the Chest and covers the Lungs and Pericardium. It is a Serous Membrane, forming two closed sacks. We may consider it under the two forms of Acute and Chronic. Anatomically we consider — 1. Plastic Pleurisy. 2. Pleurisy with Effusion. We may further regard it under the two heads of — 1. General ; and 2. Local Pleurisy. Of the latter Diaphragmatic is a very interesting form. Under Special Forms we consider 1. Idiopathic. 2. Traumatic. 3. Rheumatic. 4. Latent. 5. Tuberculous. 6. Cancerous ; and 7. Secondary. Acute Pleurisy may affect one or both sides. Sometimes the First Stage is followed by Plastic formation. There may be hardly any Serum. The whole Lung may be covered with plastic lymph, and present a reticu- lated appearance, with layers of false membrane. This lymph organizes, new vessels form in it, and we have what is known as Organized Lymph. 154 The layer may be one-qurter of an inch in thickness. Sometimes we have a large amount of yellow Serum, with little flocculi floating in it. It may fill the chest. The Lung is squeezed flat and the heart pushed to one side, or only two lobes may be compressed in the right lung, while the upper may resist the effusion. Encysted Pleurisy. The adhesions form partitions. In cases where the Diaphragm is bound to the under surface, the anterior margin of the Lung may come entirely around the Diaphraghm. Sometimes the effusion is so rich in lymph that pockets are formed all through the Lung. The effu- sion may be purulent from the beginning, or at first serous, and then the Pleurisy be converted into an Emphyema. After pleurisy has existed some time, if only a moderate amount of Lymph has been exuded, the Lung absorbs it, and the case recovers ; but if the Lung has been matted in the chest is drawn in, and we have the Deformity known as Retraction. Still worse is Purulent Effusion where a large collection of Pus has escaped. The Lung cannot expand, and we have permanent alterations, forming perma- nent inability to expand the Lung. Causes, i. Atmospheric Changes. Exposure to Changes of Tempera- ture. 2. It often follows blows, bruises, wounds, etc. This is Traumatic. 3. When it develops in Rheumatism, it is known as Rheumatic. 4. It may come from so slight a degree of Inflammation that it is Latent. 5. The development of a Neoplasm or Carcinoma or Sarcoma, gives rise to Cancer- ous. 6. In Scarlet Fever, Pyaemia, etc., we have Secondary Pleurisy, and also in Bright's Disease. I. Simple Acute Pleurisy with Effusion. Symptoms. There may be slight Rigor followed by moderate fever 102 F. to 103 F. Sharp Stabbing Pain in the side which is increased by moving, coughing, etc. It has given rise to the name Pleuritic Stitch. The Breathing is interfered with — is jerking and somewhat rapid. It is con- fined to one side. Constitutional Symptoms are Slight. The patient neither looks nor feels very ill. In reclining, he leans to the Injured Side. As the disease advances, the patient has less pain and lies on the Affected Side. The Effusion has occurred and separated the two layers of the Pleura. These layers do not rub against each other. In the first stage, Auscultation gives a dry brushing, Crackling, Superficial Friction sound, attended with sharp pain. Vesicular Murmur is impaired. In twenty-four hours, we may have signs of liquid Effusion. The Chest is enlarged. The Movement is exaggerated on the healthy side. Expansion is reduced over the affected spot. The intercostal spaces are prominent. Percussion gives a flat note over the affected area. This dullness varies with position. If the effusion is only moderate, instead of finding, as in Pneumonia, an oblique line corre- sponding to a lobe of the Lung, we have a wavy " S " shaped curve, or gen- erally it is horizontal. We have Flatness which varies with Position, and rises from the base. The upper line is horizontal. Vocal Fremitus is im- paired or lost. Vocal Resonance is Feeble or Absent. Fully Developed Stage. The affected side is filled entirely with the Effusion. The semi-circumference of the affected side, from the sternum to the Spine, is increased. The Intercostal Muscles are paralyzed, and the Intercostal Spaces are prominent. Percussion is Flat from base to apex. On the other side the Vesicular Murmur is Exaggerated. Now the Pleural Cavities are full, and change of position has no effect. The adjoining Vis- cera are displaced. On Auscultation there may be no breath sounds. There is much Dyspnoea, and with this we may have Tracheal Sniffling. Over Extreme Effusion we may hear a distinct sniffle, which may make us think it 157 is Bronchophony under our ear. Cases have been treated for Consolidation owing to this. If the patient breathes softly, we see there are no voice sounds at all. Vocal Fremitus is gone, and Resonance is feeble. The Dura- tion of the stage of increased Effusion closes in ten to fifteen davs ; then it is absorbed if it is serous. If the fluid has been purulent, there is no Absorp- tion. If Absorption takes place the Fever declines. The Pulse is slower, and the Breathing easier. During the stage of large Effusion there has been no pain ; now there is slight pain. The Viscera return to their Normal position, the size of the Chest is reduced, the line of Dullness fails, the Vesicular murmur returns, and we have a returning Friction Sound where the Costal and Visceral layers are rubbed together. Transmission of Voice is wholly abolished in Empyema, not entirely in Hydrothorax. Vocal Reson- ance gauges the progress of the Effusion. Where the Lung is partially Col- lapsed, we have coming through the thin layer of liquid a bleating, quavering sound called Aigophony. It is peculiar to the period when there is a thin layer of fluid. It is best caught over the Inter-Scapular region. The stage of Absorption lasts a week or ten days in favorable cases, but generally longer. It may run into a Chronic state and not be absorbed. These cases of Pleurisy are modified by the various forms mentioned above. We may have a considerable Effusion which is locked up in a sack and has a false membrane around it. This is Cystic Pleurisy. The general symptoms will not be Severe, for there cannot be much Effusion, but Physical Signs are modified, i. The upper line of Dullness is not horizontal, but follows the shape of the sack. 2. The Area of Dullness is not changed by position. Where we have a Multilocular Pleurisy we have pockets, uniformlv small, with Serum in them. We notice that the amount of Serum is small. 1. The Side is not swollen; and 2. The adjoining Viscera are Undisturbed. 3. The Area of Dullness is irregular. 4. It is not influenced by change of position. 5. There is Flatness on percussion and Feebleness of Vocal Resonance and Fremitus, but they are not so entirely absent as in a large Effusion. 6. Vesicular Murmur is often feeble. 7. We have a transmitted Blowing Sound. The Duration of Encysted and Multilocular Pleurisy is uncertain. They are both Unfavorable to Absorption. In them we find an easy tran- sition to Plastic Pleurisy. Here we have the same General Symptoms, but the Area of Dullness is very irregular. We have a patch of Plastic Pleurisy, irregular in size and shape. There is much more persistent Crackling Friction. There is only Modified Dullness, not Flatness. Rarely is there great Dullness. Vocal Fre7?iitus and Resonance are not wholly lost, but of course they are impaired. Respiratory Murmur can be heard as a Weak, Blowing Sound. There is often associated with Plastic Pleurisy a slight Pneumonia of the Lung. Then there is Bronchial Breathing over such an Area, and the Vocal Resonance, as it comes to the ear, will be modified in character. The Course of Plastic Pleurisy is slow. Diaphragmatic is where the effusion is caught within the Diaphragm and base of the Lung. The Pain is extreme and referred to the base of the Chest and Diaphragm. It is associated with extreme Spasm of the Dia- phragm. It seems as if the patient would die of Suffocation. Hiccough is a most distressing Symptom. It may last ninety-six hours. The patient cannot sleep. The Heart may not be displaced, but its action is disor- dered in an unusual degree. The Inflammation may extend to the Vena Cava where that vessel passes through the Crura, and then we have ''Milk Leg." Physical Signs. If the Lung is entirely held down the effusion is con- cealed. There is no expansion. There is moderate displacement of the i 5 8 Heart, and Lowering of the Liver and Diaphragm. There may be no Dull- ness on Percussion, as the Lung covers the effusion. There is no Friction Sound. There may be just a little relative Dullness. Vesicular Murmur may be present down to the Diaphragm. This is often overlooked. If the effusion involves part of the Costal Pleura we can get at the effusion. Purulent Pleurisy. The differences are rather in the General Symp- toms than in the Physical signs. The Physical signs are pretty much the same as in Encysted Pleurisy. The Pus may be free to move, or be in a pocket. We recognize Pus by the General Symptoms, i. The Fever does not subside ; it progresses, and rises higher and higher ; is hectic in type. 2. We have sweats at night. 3. The patient wastes ; is weak and sallow. 4. The Breath is sweetish and pyaemic in odor. These symptoms may come on any time. Diagnosis of Acute Pleurisy. We must Distinguish — 1. Myalgia of the Muscles of the chest Walls. The Patient is in pain, bends over, holds his side, etc. The Pain is increased by a Cough, by Movement, and by Breathing, but there is little Fever. The Pulse is not so frequent. On Auscultation there is no friction sound. There is no effusion to produce Dullness. Watch for a day and no Effusion occurs. 2. Pneumonia. There is more Chill ; more abrupt rise of Temperature ; more disturbance of breath- ing ; more flushing of the face. There is Crepitus on inspiration only, while the friction of Pleurisy is heard both on expiration and Inspiration. Yet, we sometimes cannot distinguish Crepitus from Friction Sound. In Con- solidation of Pneumonia, dullness follows a lobe of the Lung. Over the effusion we have a horizontal or (in case of Encysted Pleurisy) an irregular line of Dullness which changes with position. There is absence of Reso- nance or great weakness of Vocal Fremitus over the Effusion. When the Effusion fills the whole Chest and there is a transmitted sniffle, we might be misled. But we consider, the — 1. Absence of Vocal Fremitus. 2. Displacement of the Viscera. 3. Enlargement of the Chest. 4. Disappearance of Intercostal Spaces. These points Pneumonia cannot imitate. However, Multilocular Pleurisy and Encysted Pleurisy are more difficult. There is weakness of Respiratory Murmur as contrasted with the Broncophony, and Dullness is irregular, as compared with the regular lobar form of Pneumonia. In Pleurisy, there is an absence of Expectoration and no rusty Sputa. In order to make sure of our Diagnosis, we can use the exploratory needle. It does not hurt to run a needle into a Consolidated Lung ; therefore, we can use a Capillary needle and get enough fluid to satisfy our Diagnosis. The Prognosis of Acute Pleurisy is very good. In the encysted form it is doubtful as to duration. In the Multilocular Form it is doubtful. Some- times cases die from exhaustion if the amount of effusion is great. Acute Purulent Pleurisy is always dangerous. Our Prognosis should therefore be guarded. Treatment. Absolute rest in bed and protection of the surface. Restrict the diet. The disease is not wasting. The danger lies in the amount of the effusion. Give very little liquid. Venisection is never needed. In vigorous persons, where the patient is in very great pain, it might be advantageous, but generally local depletion by leeches or wet cups is sufficient. Then envelop the chest with cotton, oiled silk and Mackintosh. This must be arranged so that we can get careful Physical Examination every day. Opium is needed to relieve pain. Give hypodermic injections of i6i Morphia, with or without Atropia. We may administer Calomel, Opium and Digitalis for several days during the formation of the effusion. When it is clear that an effusion is formed stop this and use Alterative treatment. Iodide of Potassium with Digitalis, Acetate of Potash and Digitalis, or Iodide of Potassium and Jaborandi in the intervals; not enough, however, to produce Sweating. When the effusion is very large put on a Cantharides Blister 5x5, and let it "draw." Prick it and withdraw the Serum, and in ten days repeat it. This will generally bring an acute case to an end in three weeks. If the Pleurisy is plastic continue Calomel ; then Iodide of Potassium alone. Use smaller and smaller and more frequent Blisters. With Iodide of Potassium you may join Bichloride of Mercury, after stop- ping the mild Chloride. If you suspect Pus, puncture and aspirate at once. If Pus remains, bands are formed and a Pneumo-thorax may be produced. If Effusion increases in spite of treatment, distends the Chest, and displaces the Viscera, we may have sudden failure of the Heart. Therefore the existence of large Effusion, whether Serum or Pus, demands withdrawal. Sometimes the patient has Paroxysms of Dyspnoea, owing to encroachment on the Aorta, or from some Nerve being influenced. Operate at once in this case. If Effusion has been a long time, and will not go away in five or six weeks, then operate. All this time the Membrane is getting thicker and thicker, layers of plastic lymph are more numerous, and expansion will not be regained. Chronic Pleural Effusion. Hydrothorax is a term applied toa Watery Effusion where there is scarcely any inflammation. It is applied to a passive Dropsy in the Chest, connected with Heart and Kidney disease. Sometimes we have a Serous Effusion from a slight affection of the Pleura without inflammation. An acute case of Serous Effusion may not terminate in Absorption. Generally we get Pus, or, in other words, an Empyema. We meet with Chronic Pleurisy where Treatment has been faulty, and where there have been several attacks. Where the Patient's constitution is poor, or where we have a Tubercular Diathesis, Pleurisy may be secondary to Tuberculosis. The Effusion in Cancerous Pleurisy is apt to be blood-stained. The Effusion in Chronic Pleurisy may be free to move or encysted. Symptoms. 1. It may be Latent. It comes on insidiously. The patient gets tired from breathing. He may not even mention his Chest when he calls for medical aid, though the heart may be pushed to one side. People have fallen dead with the Chest filled to the Clavicle, yet never sus- pected it. While the symptoms are thus latent the Physical Signs are demon- strable : 1. The Affected Side is Enlarged. 2. The Intercostal Spaces are filled out. 3. Respiratory movements are abolished. There is, 4. Shifting Flatness. 5. Absence of Resonance and Fremitus. 6. The Viscera are nearly always pushed to one side in Chronic Pleural Effusion. The General Symptoms are well marked : 1. There is Shortness of Breath. 2. Pain on the affected side. 3. Inability to lie on the opposite side. 4. Dry Cough increased on talking or movement. 5. Some Fever, which is moderate in Serous, but Hectic and considerable in Purulent Effusion. 6. Failure in health, strength and color. 7. If the effusion has been long, oedema of the feet may come on from Heart Failure. W T e judge of the nature of the effusion by the amount and character of the Fever. Where there is Pus of long standing, the thoracic wall is cedematous. There is apt to be more severe pain and tenderness on pressure. Use the exploratory needle. The Course of the Case depends on the character of the effusion and on the condition of the chest. If the effusion is Serous, it may remain indefi- nitely. If Pus, it discharges itself by opening into the Bronchial tul>e> or 1 62 by an external Fistula. It may be vomited by the CEsophagus or perforate the Diaphragm. If the Lung is diseased, sometimes the effusion compresses it, and putting it at rest, has retarded the advance of the lesions. Hence we may be reluctant to disturb an effusion where the Lung is diseased. Diagnosis. It may be difficult to diagnose a Circumscribed effusion close to the Liver. We may mistake it for enlarged Liver. The history of the case, the conformation or otherwise of the Dullness to the shape of the Liver, the exploratory puncture, etc., will settle it. Sometimes it simulates Pericardial enlargement. However, a careful study of the Apex beat, the character of the Breath sounds, Dullness, etc., will set us right. Prognosis of Chronic Effusion if serous, is serious \ if Purulent, is dan- gerous. In Cancerous and Tuberculous pleural effusion, it is hopeless. Treatment. In Acute Pleurisy with effusion, even if it be Serous, and has lasted a long time, operate, i. e., where it has gone on for five or six weeks. Sometimes, of course, the symptoms demand early withdrawal of liquid. Put on a blister of Turpentine and confine the patient to bed. Give Iodide of Potassium and Digitalis, also a few sweats with Jaborandi, order rest and restricted Diet. If Phthisis is present, of course, give nothing to reduce the strength. If you have given a fair trial and no good results have followed, then perform Paracentesis. Paracentesis is usually performed by an Aspirator. If the Apparatus be dirty, it may turn a serous into a puru- lent effusion. Sometimes we have to tap five or six times before final absorp- tion takes place. Stop instantly when cough comes on, and the patient catches his breath. Do not be too anxious to obtain every drop of the fluid. After two or three tappings, if Pus still returns, pull out the Trochar and insert an India Rubber tube. Do this under Antiseptic Spray. Dress with Antiseptic Gauze, and outside put Mackintosh not only for the exclusion of Septic Material, but it enables Pus to be expelled with expiration, and no air can get in with inspiration through the Mackintosh. As the Lung expands towards the chest, withdraw the Rubber gradually and cut some off. In children, owing to the amount of Lymph and the thinness of the chest walls, we may have Retraction and Curvature of the spine. This will rectify itself in later years. Sometimes Secretion will not stop in Adults. Cutting out pieces of the Ribs so that the side caves in, has been tried, but this is an extreme measure. The best place for operation is outside of the Angle of the Scapula and as far down as we can without injuring the Diaphragm. The General Health of the Patient requires care. Tonics, Alteratives, Nutri- ents, etc., must be given. In Chronic Disease, as Bright's, we must remove the effusion. In organic Heart disease and Kidney disease, we, of course, keep up their own specific treatment. In Tuberculous Disease, complicated with Pleurisy, Operative Meddling avails but little. Pneumo-thorax. This condition is connected with Chronic Pleurisy. The Morbid Anatomy is Simple. It may be general or restricted to a very small area by bands of organized lymph. Pneumo-thorax often exists before Pleuritis, this being from an Empyema. An Empyema may burst into the Bronchi and air get into the Pleural Sack. Pneumo-thorax is a condition in which there is Pits and air in the Cavity of the Pleura. The Pleural Membrane presents symptoms of Inflammation, and with the Lymph we find an effusion of either Pus or Pus and Serum. The Lung is either totally collapsed or only one Lobe may be. If air has come from an ulcer- ated opening in the Pulmonary Pleura, a Fistula is found. In order to detect this condition, put a tube into the Trachea and blow into it, we find bubbles coming out of the Pleura and the point of injury is known. The adjacent viscera are displaced and the Diaphragm is pushed downwards. i6 S Causes, i. Wounds of the Chest. 2. A Fistula from an Empyema opening outside. 3. Rupture of the Pleura and the establishment of a Pulmonary Fistula. 4. It may come on in Phthisis where Sub- Pleural abscesses have formed and perforate. Phthisis would be a common cause for it, were it not for the adhesions formed between the Lung and Chest wall. Symptoms are those of a large Pleural Effusion of any kind. Dyspncea, pain in the Chest, Cough, without expectoration, coming on suddenly. Physical Signs. Distension on the affected side. The Intercostal Spaces are filled out. Displacement of adjoining viscera, especially the heart. There is altered or absent respiratory movement. Percussion gives very large tympanitic Resonance and Amphoric Sound, either circumscribed or general. Auscultation shows complete absence of breath sounds. There is no respira- tory murmur. But where we have a Pulmonary Fistula we have tubular Blowing and amphoric Breathing. If the hole is large, we may have large Cavernous breathing, and with this Rales and also Metallic Tinkling, caused by drops of Pus falling on the liquid below. The Rales are peculiar which are heard chiefly in this affection. If we sway the Trunk abruptly, we have a " succussion splash" which is characteristic. Vocal Fremitus and Reson- ance are lost. Only when we have a very large opening would we have Amphoric resonance. When Pneumo-thorax reaches a high degree, we have displacement of the Heart, with resulting Cyanosis, with Orthopnea and feeble pulse. Diagnosis is simple if the condition is not complicated with something else. The only trouble in Diagnosis is in Circumscribed Pneumo-thorax, especially on the left side. It may simulate Dilated Stomach. The tym- panitic note is hard to distinguish. In the Stomach we may have drops from the oesophagus falling on the liquid in the stomach. But the History of the case clears the matter up. There is here a history of Gastric symptoms. A very careful study will show that the quality of the tympany changes as we go from the Pneumo-thorax to the stomach. In the stomach the Resonance is the same throughout. Again, in Pneumo-thorax the tympany does not follow the shape of the stomach. Prognosis is good, if from a broken rib or a stab it gets well. In Empy- ema the prognosis depends on the primary disease. This is also the case in Phthisis. Treatment. We must stimulate the Heart and Respiratory organs. Strap the Chest from the Sternum to the Spine, and put that side at rest. When the Pneumo-thorax is very large, aspirate a moderate quantity of gas, and repeat this whenever alarming symptoms appear. VI. DISEASES OF THE DIGESTIVE TRACT. I. THE MOUTH. I. Stomatitis. 1. Aphthous Stomatitis is a disease of the mouth, characterized by little ulcers which form on the tongue, or cheeks, and lips. They are the size of small split peas, with slightly reddened rims and whitish surface. There may be only a few or many may be present. They are very painful, and may interfere with taking food in children. Apthse may be Idiopathic or occur at any period of life in connection with any disease of a grave cachectic character, as Cancer, etc. There are no complications. 1 66 They are easily recognized. The ordinary Apthae of children are easily treated by attention to diet. This is often sufficient for a cure. Or, a tonic, as small doses of Hydrochloric Acid and Pepsin may be given, or a powder of the Subnitrate of Bismuth and Pepsin; and if gastric irritation is marked, Nitrate of Silver in very small doses. Locally, dusting of Iodoform and Accacia is very useful. Light contact with Argentic Nitrate stick, or Sulphate of Copper may be made. In Cachectic Apthae we rely on local treatment. Diagnosis. We must distinguish it from Thrush which is a Fungus or Parasitic Stomatitis. It is a disease of childhood and is favored by indiges- tion and poor nutrition, but its special cause is Oidium Albicans. Its favorite seat is the mucous membrane of the mouth, but it may extend to the (Esoph- agus. There is much pain in aphthae. The dead white color and the elevated patch, and the use of the microscope would at once distinguish it from apthae. Its Treatment requires attention to diet, Tonics and local remedies calculated to destroy this fungus. The spots may be touched with Sulphur or a Saturated Solution of Iodoform and Ether. Prognosis. The disease is only serious when it is low down in the throat. Ulcerated Stomatitis. This appears in ill-nourished children, often in asylums, rarely in children of cleanly and well-to-do classes. Symptoms. The child is irritable, there is fever and great fetor of breath. There is dribbling of fetid saliva and great heat in the mouth. The gums assume a grayish hue. They are swollen and separated from the teeth. It suggests diphtheria and diphtheritic exudation, but it is not a true diphtheria. The glands under the jaw may be swollen. This is a very easily cured disease, but shows no tendency to heal of itself. Sometimes in true Diphtheria the exudation may appear to come from the mouth but it is really in the fauces. Treatment. Chlorate of Potash exerts a specific action. R Potassae Chloratis Z], Tr. Cinchonae Comp. f ^i, Syrup, Zingib. f^ij. M. S. : Teaspoonful every three hours. Give Tinct. Chloride of Iron and Quinia, Brandy and Port Wine. Local applications, as Chlorate of Potash and Borax, may be made with a swab, or the throat touched with a weak solution of Zinc Sulphate or acids. Gangrenous Stomatitis belongs to ill-fed, ill-nourished and depressed children. It follows on ill-nourished convalescence from Measles and Whooping Cough. The Symptoms are easily recognized. The disease attacks one cheek and there is a hard swelling. The exterior is glossy and red at the most prominent part. On the inside is an Aphagadenic ulcer, with indurated base, gray and sloughy. Its base is the thickened part of the cheek. The tendency of this ulcer is to perforate. It may spread and denude the bone, leaving a gangrenous hole, exposing the roots of the teeth. The constitu- tional symptoms are like those of gangrene. There is horrible fetor of the breath, loathing for food, decided pallor. The pulse is running and feeble. There is nervous prostration and decided pallor. Prognosis. This disease is generally fatal, or if recovery takes place, it is attended with shocking deformity. Local Treatment is most important. This consists in removing ulcerated portions by the application of pure Nitric, Hydrochloric or Carbolic Acids, so as to promote healthy granulations. The surrounding parts should be protected with lint soaked in oil. Mild applications will 169 not do. Pure Bromine has been used with success, but fuming Nitric Acid is best. Stimulants, such as Iron, Quinine and Turpentine, which has a healthy action in inflammations, should be given. II. THE THROAT. Acute Tonsilitis appears in three forms chiefly, Simple, Herpetic and Phlegmonous, but, as a matter of fact, we consider them under one heading practically. Causes are — 1. Early age. 2. Family; or 3. Personal Disposition. Some individuals have dozens of attacks. 4. Rheumatic; 01-5. Gouty Diathesis. 6. A run-down state of the system arising from Bad Air, Mai-Hygiene, Overwork, etc. The Morbid Appearances are seen by a direct Inspection of the Throat. For this the Tongue need not be thrust out. All that is necessary is to depress it with a spoon. Children frequently make no complaint, hence we should always examine the throat, even with entirely different symptoms. 1. In the Simplest Cases we have Deep Redness and Swelling. There may be viscid mucus over the inflamed surface. 2. Sometimes we have one or twenty White Points. This is called the Herpetic Form. There is no true False Membrane. The name of Folli- cular, or Herpetic, Tonsilitis is a good one. The points may be Unilateral or Bilateral. 3. These points may or may not be present. We have Redness and Violent Inflammation, and we see little patches of False Membrane on the Mucous Membrane. This may complicate Tonsilitis. We give to it the name of Pseudo-Membranous Tonsilitis. It is a rare occurrence, but should be distinguished from Diphtheria. We may have Resolution — the little Follicles bursting and healing, or the Swelling may increase and Sup- puration may take place, and then the Tonsil is hard and unyielding to the Finger. This is known as Quinsy. There may or may not have been White Points. Chronic Enlargement may remain. The only associated lesions are those of the Pharynx and Lymphatic Glands at the angle of the Jaw. Those who have had one attack of Suppurative Quinsy are disposed to another. This is also the case with those who have had Herpetic Ton- silitis. Symptoms. There is often a Chill and General Malaise. High Fever up to 103 F. and 105 F. The Pulse is rapid. There is Severe Headache. Pain on swallowing. Tenderness and Pain at the angles of the Jaw. The Swelling may constitute a Distinct Tumor. The Tongue is coated and the Appetite lost. Vomiting is rare. In children the Ner- vous System is sometimes affected. Sleep is disturbed. The mind wan- ders, and there are Convulsions. In rare cases Temporary Erythrema is not extensive. There may be a temporary trace of Albumen in the urine. Disease lasts three or four, or may last seven to eight, days. It is longest when it terminates in Suppuration. The Abscess may not break of itself for ten days. The Symptoms grow worse till this Pus is discharged. The Case may look alarming. The Patient may be unable to swallow. Prognosis. This Disease always terminates in recovery. Suppuration might open the Carotid, or the patient might die from want of nutrition. Diagnosis. 1. We must exclude Scarlet Fever. This comes on with High Fever, Sore Throat and Swelling of the Glands. For a few hours the two are indistinguishable. Our doubt would be increased if there was a little rash. The throat symptoms of Scarlet Fever, however, don't generally I/O come on till the third day. Here the Swelling of the Tonsil is more rapid. The Fever is not so high, nor the Pulse so rapid, nor are the Nervous symp- toms so marked. Herpetic Patches do not appear in Scarlet Fever. Albu- men in the urine would be against Scarlet Fever. It is not found during the First Stage of Scarlet Fever. We must not be precipitate in our Diagnosis. If it is Scarlet Fever, the whole family is broken up ; and if it be in a school, a panic may spread. 2. Distinguish it from Diphtheria. Here we have a true False Membrane, not a distention of the membrane of the Follicles. In Tonsilitis the lesions are confined to the Tonsils. In Diphtheria the glands at the angle of the jaw are more swollen. Our diagnosis should be very cautious. The Term Diphtheritic Sore Throat should be abandoned. Treatment. In cases of Rheumatic Diathesis, Salicylate of Soda is a Febrifuge and Anti-rheumatic. Quinine is undoubtedly useful. It should be given in moderate doses. For a child five years old, gr. v., for an adult gr. xii. If the stomach is irritable give gr. ix. by Suppository. Where there are Herpetic Patches, Guiacum is useful in Emulsion or Lozenges. We may combine Chlorate of Potassium, or we may safely trust ordinary cases to Chlorate of Potassium. Tincture of Iron and Quinine at intervals of three hours. R Potass. Chlorat. gr. lxxx, Tinct. Ferri Chlorid, gtt. clx, Acid. Muriatic. Dil. f 3i, Syrup. Zingib. f ^ii, Aquam, ad f ^iv. Mft. Sign. : Teaspoonful in water every three hours. Locally we may use Externally, Iodine, and Internally Astringent and Sedative applications, as Tincture of Iron, and Glycerine, and Iodoform, dissolved in Ether. Both of these possess positive curative powers. Where there is plenty of Herpes, Iodoform is preferable. Gargle the throat with a saturated solution of Chlorate of Potash. Let pieces of ice dissolve in the mouth. Use the Steam Atomizer with Lime Water, Chlorate of Potash, Borax, Brocacic Acid. As soon as suppuration is expected puncture the Tonsil. An exploratory puncture is often serviceable as helping the Pus to reach surface. Hypertrophy of the Tonsils is quite common. It may come on suddenly, without any distinct symptoms. It is apt to develop in Rickety and Scrofulous children and patients disposed to Acute Tonsilitis. Symptoms. The movements of the soft palate are interfered with. The voice has a muffled, nasal and disagreeable character. The patient is apt to become a mouth breather. The entrance of the air to the Pharynx leads to Post Nasal Catarrh. It may interfere with chest development. The Treatment should be Dietetic and Hygienic — Dyspeptic derange- ment often lies at the bottom of this disease — and Local. The Tonsils may be painted with Iodine or a saturated solution of Iodoform in Tincture of Guiacum. Light applications of Nitrate of Silver, gr. xxx to an ounce. In acute cases we may inject Ergot, Acetic Acid or Iodine into the substance of the Tonsils, If it is hard and riddled with Sinuses it may be necessary to extirpate it, but we should try to save it if possible. After extirpation the base is frequently the seat of inflammation. To build up the strength give Cod Liver Oil with Lime, Iodide of Potassium and Syrup of the Iodide of Iron. Retro-Pharyngeal or Post Pharyngeal Abscess is frequent in children. Its Cause is sometimes Idiopathic Inflammation. More frequently it results from some deep-seated trouble, e.g., of the Cervical Vertebrae. 173 The Symptoms are Local pain and Inability to swallow. More or less interference with breathing, which is less if the abscess is above the glottis. There is swelling of the neck. The disease may continue some time before our suspicions are aroused. The finger may recognize the Fluctuation, or it may be so high up that we can see the abscess itself. Treatment consists in opening up the abscess with a curved bistoury guarded by adhesive plaster. The condition of the patient may be dan- gerous till it is cut. Death has resulted from delay. Diagnosis is easy. We should exclude mere laryngeal trouble and Spas- modic (Esophagus. We can hardly, however, make any mistake except where the abscess is very low down. P'haryngitis is Acute or Chronic, i. The Acute occurs under the forms of Simple Catarrhal, Follicular, Ulcerative, Phlegmonous, Gangrenous, and Tuberculous, and the special forms which occur in Scarlet Fever and Diph- theria with Pseudo-Membrane. Catarrhal. The parts are swollen, red, injected with viscid mucus, adherent in strings or patches. The Tonsils often sympathize, and the Folli- cles may be prominent or studded over. Causes are Atmospheric Changes. Exposure to Draughts. Over-straining •of the Voice. The sudden checking of perspiration. The Symptoms are Local Soreness, increased by swallowing and some- what by talking. A local sense of fullness causing an ineffectual effort at swallowing. Hawking and Removal of Viscid Mucus. There is a little swell- ing of the glands of the face and neck, but they are not so swollen as in Tonsilitis. There is moderate fever and some disturbance of the pulse. The Diagnosis in adults is easy but in children it may be overlooked from our attention not being directed to the part, and secondly, sore throat is an initiatory symptom of many specific diseases. Caution and reserve are, therefore, imposed upon us for a little time. At the start it is difficult to ■distinguish Pharyngitis and Diphtheria. The Treatment is very simple. Impress on the patient the necessity for remaining in the house. Young and sensitive children should be restrained to one room or even to bed. Externally, various applications may be of ser- vice, e. g., Wrapping the throat with a pack of wet cloth covered with Oil Silk or Mackintosh. This relieves the pain and subdues the swelling, or we may bathe it with Chloroform Liniment. Internally we may paint the throat with Nitrate of Silver (gr. v to the ounce) or with Tincture of Iron (25 per cent, strength) or we may atomize it with either Lime or plain water. If the fever is pronounced give Saline doses and Tincture of Aconite followed by Quinine and Tincture of Iron. We may give a prescription of Chlorate of Potash and Iron. Where there is not much swelling, but great pain, we might suspect Rheumatism, and we could describe a Rheumatic Pharyngitis. Here use Iodide of Potassium with Potassium Bromide, also Salicylate of Soda. Acute Follicular Pharyngitis is only an aggravated form of Catarrhal Pharyngitis, but is more apt to run into a Subacute or Chronic form. In' Phlegmonous Pharyngitis, suppuration is apt to occur. It is really an acute Post Pharyngeal abscess. It is very rare. Ulcerative Pharyngitis is one of the Chronic diseases of this part, and is connected with Syphilis, Scrofula, etc. Syphilitic ulcers may occur in any part of the Pharynx, Tonsils or half arches. They are irregular and often quite large. They eat into the tissue and cause destruction. After- wards they may heal, leaving white puckered Scars with deformity. The Diagnosis is important. We may detect Syphilis by old Scars in the throat. Patients will show other and Constitutional sign>. 1/4 Prognosis. If left to themselves, they may eat away the entire Tonsil and both half arches. They may be followed by Cicatrization and union all the way across, producing occlusion ; or the posterior wall of the pharynx may be puckered, and the (Esophagus shut up. As they are not very pain- ful, they are likely to be overlooked. Treatment, Internally, should be a full course of Anti-Syphilitic remedies, e. g., Doses of a Salt of Mercury with Iodide of Potassium or Sodium in moderate doses. Locally we require powerful applications of Iodoform, in the form of powder or in a saturated Solution. Next come the Mineral Acids. Then Sulphate of Copper and Nitrate of Silver (gr. xx.-lx. to an ounce), or a few touches with the solid stick. Surgical measures are some- times necessary, and we must open the ulcers with a Galvano Cautery. Tubercular Pharyngitis. In a case of tuberculosis, ulceration of the Pharynx may occur. It is apt to be associated with Tubercular Pharyngitis. Generally, Pulmonary Tuberculosis precedes it. We have miliary Tubercles with a shallow, round, irregular, white base, resisting treatment, and very painful. It is rarer in the larynx than in the pharynx. Treatment. Apply Iodoform and other Alteratives. This relieves the pain and produces an alterative action, which is very useful. Other Altera- tive applications are useful to relieve pain and prevent progress of the ulcers. Prognosis. They may heal, leaving a scar; but generally they advance with the condition of the lungs, and terminate fatally. The commonest Pharyngeal troubles are the Catarrhal and the Follicular. II. Chronic Sore Throat. This arises from repeated attacks imper- fectly cured, or it may result from long-standing inflammation. The most frequent cause is Mouth-breathing from Nasal Obstruction. This may be Congenital, or arise from over-use of the Voice. It goes by the name of "Clergyman's Sore Throat" and " Singer's Sore Throat." If the sys- tem is relaxed and run down this cause acts with double intensity. The American climate is irritating to the throat. The Symptoms are : A feeling of fullness and discomfort in the back of the throat, accompanied by frequent hawking and the discharge of mucus amounting to a considerable quantity in a day. The voice becomes guttural, coarse and thick. There is morbid sensitiveness and inability for prolonged speaking. The Diagnosis is easy. There is no difficulty of recognizing it by the enlargement of the follicles and the excessive secretion of glairy mucus. Prognosis. It is not a grave disease, but in some cases, if it runs on, it may necessitate abandonment of work. Treatment. We must search for the exciting cause. This may be a nasal hypertrophy or a post-nasal catarrh. Study the patient's elocution, peremptorily forbidding scraping of the throat. This alone often cures it. Gymnastic exercise, friction, sponging, and attention to ventilation are of inestimable benefit. We may take this affection as an admirable text for relieving general pharyngeal troubles. Administer Tonics, such as Quinine, Mineral acids, and Strychnia, for Systemic relaxation. Where there is much swelling and infiltration, the local application of Mineral Astringents, such as the Sulphates of Zinc and Copper, and Tannic Acid, are useful. The Faradic Current will restore tone to the muscles. III. THE CESOPHAGUS. The CEsophagus is not subject to many affections. The most common are Spasm, Obstruction and Paralysis. *77 i. In Spasm we have a Functional Condition brought about by a slight scratch or by swallowing things too hot, or it may be Reflex, as in Uterine and Gastric troubles, or it may be an accompaniment of Hysteria. Its Symptoms are an Inability to Swallow. The patient finds him- self suddenly unable to swallow nourishment. The act of deglutition brings on a spasm. Diagnosis. This condition is recognized by the General History, but more particularly by the fact of an ([Esophageal Sound or Bougie passing easily into the stomach. During the spasm the oesophagus grasps it, but lets it pass upon pressure. "We can never make a mistake. The Prognosis is favorable. The Treatment consists in the removal of the cause and the administra- tion of Antispasmodics and Tonics ; Regimen to get rid of any Hysterical tendency, and the gradual dilatation of the oesophagus by the constant passage of the Bougie. If it is associated with Uterine disease, Counter- irritation over the Ovaries, Uterus, 8 Location is determined by watching the effect of swallowing, and by the careful use of the (Esophageal Bougie. The Prognosis depends on the cause. »Even in the case of Cancer life may be prolonged by appropriate treatment. Treatment is Dietetic. Strict attention must be paid to food. The proper use of judiciously prepared Enemas to maintain the strength. If dependent on syphilis, we should endeavor to check this disease. In all other cases Internal Treatment is not indicated. Dilatation must be prac- ticed. Where the obstruction is from a Neoplasm we can only retard it by keeping the channel patulous. Even in Cancer we may thus obtain in- creased ease in swallowing. In some cases the use of a false oesophagus made of rubber has been found useful for the administration of peptonized food. The mere pressure of the tube favors dilatation. When the obstruc- tion is very high up, Excision has been performed. Such an operation requires extreme skill, and is often useless. However, the establishment of a Gastric Fistula has been successful in some cases, and promises to consider- ably prolong life. III. Paralysis of the (Esophagus, i. e., loss of power, arises from a Failure of Vitality at the end of Low and Brain Fevers. It exists as a symptom in Labio-Glosso Pharyngeal Paralysis which arises from an affection of the root of the Glosso-Pharyngeal Nerve. Here it is only a part of a hopelessly progressive condition. Sometimes articulate speech is lost while the (Esophagus still retains its power. After Diphtheria we often find Paralysis of the (Esophagus very troublesome. It may also be present in Hysterical cases. Symptoms. Food enters the Larynx and induces a fit of coughing. This may be so marked that it is impossible to feed the patient. Sometimes a litttle food may go down. The Diagnosis is made by first excluding obstruction, and then studying the history of the case. Prognosis. At the end of Brain Fevers patients are rarely saved. Treatment. Electricity and Rectal injections of food may retard death. The application of insulated conductors to the walls of the chest is important. ( Continued in Part II )