» ^ 'a ♦ . . « • aT !>*• *i, A* •* •/ \Wy \4&y xm-Y ■* V *o -%. ^V r ^**. •"VIVAS' * K 1 > A SYNOPSIS OF THE PRACTICE OF MEDICINE BY WILLIAM BLAIR' STEWART, A.M., M.D. |l lecturer on therapeutics, late instructor in the practice of medicine, in the medico-chirurgical college of philadelphia; demonstrator in the philadelphia school of anatomy; etc., etc. V/762^ „— Z***~ r NEW-YORK E. B. TREAT, 5 COOPER UNION 1894 Copyright By E. B. Treat, Medical Publisher, 1894. LC Control Number tmp96 028668 INSCRIBED TO MY FATHER, WILLIAM GRAHAM STEWART, M.D., NEWVILLE, PA., IN APPRECIATION OF HIS UNTIRING EFFORTS IN MY MEDICAL TRAINING. PKEFACE. Several years of instruction on the subject of the Practice of Medicine have led the author to prepare and present to the profession a brief synopsis of the subject, not with the view of replacing our elaborate text-books, but to give to the busy practitioner and student concise, accurate, and brief descrip- tions which will suggest outlines and practical thoughts upon etiology, symptomatology, pathology, diagnosis, prognosis, and treatment. All of the prominent authors have been re- viewed in text-books and medical journals, and the most ap- proved methods of treatment have been given prominence. Many drugs and systems have not been considered at length, not on account of their inutility, but from the fact that better forms of treatment have taken their place. The classification of diseases is open to severe criticism, but the author has considered it best, for the present, to adopt the regular arrangement and distinctly state under each subject its own peculiarities. The action of organic extracts and nuclein in pathological conditions has not been considered, as this subject is still under investigation. In conclusion, let it be remembered that the Practice of Medicine does not consist in the administration of drugs only, 5 6 PREFACE. but also in the exercise of good physiological, hygienic, and dietetic measures, combined with a deep mental impression and influence. The author desires to thank those members of the profes- sion who have given valuable advice and assistance in the preparation of this work. N. Carolina and Pacific Aves., Atlantic City, N. J. September 1, 1894. INTEODUCTIOK The science of medicine comprises every method used in the healing art, and includes the practice of surgery, obstetrics, and general medicine. The term practice of medicine is very broad in its meaning, but, as used in this work, will be lim- ited to such diseases and conditions as do not come prop- erly under the field of surgery, obstetrics, or specialism. No one has any moral or legal right to treat disease, nor can he properly understand or grasp the subject, until he is well versed in anatomy, physiology, histology, general pathology, and therapeutics. Any departure from the normal physiological condition is termed disease, and is either functional or organic. It is func- tional when the structure of the organ affected has not under- gone pathological changes which are of a permanent character. It is organic when the organ has undergone permanent patho- logical changes. Every disease is dependent upon some dis- tinct cause, and the removal of it will ameliorate untoward symptoms or produce a cure. Diseases are contagious when their causes are reproduced within the body and communicated b}^ direct or indirect con- tact j infectious when reproduced out of the body and com- municated through air, water, or food, but not reproduced in 7 8 INTRODUCTION. the body ; endemic when a certain number of cases occur peri- odically or constantly in the same limited territory ; epidemic when they spread promiscuously from one place to another, but not limited j sporadic when a single case occurs without distinct history of exposure, or independent of other con- ditions, and not spreading. When the onset is sudden the disease is acute ; when the symptoms are mild and ill-defined it is subacute ; and when its duration is prolonged indefinitely it is chronic. Synonyms. — Every disease or condition is known by two or more distinct names, and it is wise for the practitioner to familiarize himself with the leading terms of each as given. Definition. — When asked for a definition or brief descrip- tion of a disease, the essential or pathognomonic symptoms are all that is required. The definitions here given, although brief, will designate the condition readily. Etiology. — A study of the cause of disease. Certain per- sons are more subject to disease than others, and are said to have a predisposition to it which has existed from birth (hered- itary) or has been acquired. The children of phthisical, nerv- ous, insane, rheumatic, and gouty parents have a diathesis, predisposition, or tendency to the development of the same disease. Age, sex, modes of living, duties, habits, and race 1 all influence disease. The exciting or direct causes are spe- cific germs, exposure, improper food and drink, dissipation, intemperance, excitement, worry, passion, and allied condi- tions. A period of incubation is the time that elapses between the exposure to a contagious or infectious disease and its acute onset. INTRODUCTION. 9 Symptoms. — Those conditions which arise during the course of a disease and serve to demonstrate its presence, progress, and decline. Those symptoms which are recogniz- able by the patient only are subjective, and those recognized by the physician are objective. It frequently happens that the patient will not be entirely at ease for an indefinite time before the onset of the disease, but will present certain signs which are called prodromal. Pathognomonic symptoms are those which serve to distinguish a disease from others. Symptoms may subside suddenly (crisis), gradually (lysis), or suddenly leave one organ and appear in another (metastasis). Disease may terminate in death, which is recognized by a cessation of vital function. Complications are transitory or permanent symptoms which intervene in the natural course of a disease, and are usually unfavorable. Pathology. — This term, as used here, embraces a study of all morbid processes, their development, course, and morbid anatomy. It is considered from the general and special stand- point without long detail. Diagnosis. — The art of distinguishing one disease from another. When made directly from the symptoms and his- tory it is called a direct diagnosis. If made from the history and a detailed account of another it is an indirect diagnosis. A close differentiation between two intimately related or simi- lar diseases is termed a differential diagnosis. Diagnosis by exclusion is made by proving what the case cannot be, until only one condition is left, which is the real disease. A good diagnostician must be a thorough anatomist and physiologist, and be familiar with the minutiae of physical signs. 10 INTRODUCTION. Prognosis. — The act of foretelling the course or termina- tion of a disease. Unless you are positively certain of what you speak, it is best to give a guarded prognosis, for the ways of nature are very peculiar, and untoward symptoms often arise in the most favorable cases. Treatment. — This subject has been considered from every possible side, and it is your duty to study well hygienic, die- tetic, and physiological methods before you rush to drugs. Many pathological symptoms will subside under proper care and a minimum of medicine, but always stand ready to use such remedies as the occasion demands. Let elimination (carrying off excrementitious products through active emunc- tories) form the foundation of all treatment. Treatment is preventive or prophylactic when it is directed to a prevention of the spread or communication of disease to others, and is accomplished by isolafon, disinfection, and keeping the bodily functions active and in physiological con- dition. Abortive treatment comprises the methods used to check the course of or abruptly terminate a disease. When treated symptomatically from day to day it is called expectant. Palliative treatment is the application of remedies for tem- porary relief in chronic diseases or pending a radical cure. AllopatMc treatment is a form in which drugs are used upon the principle that unlike cures ; that is, a drug must be given which produces a condition contrary to the disease. Very few physicians hold to this theory, and the word "allopathic" as applied to the regular system is incorrect and narrow. Homoeopathic treatment, a system founded by Hahnemann, INTRODUCTION. 11 with the motto, Similia similibus curantur, administers drugs which produce symptoms like the morbid condition if admin- istered in health. Regular treatment is founded upon the broad base of clinical experience, and binds itself to no motto, theory, ism, pathy, or sect. This work is written from this broad view, and no method, be it introduced by any sect, is given upon a sec- tarian basis, but with a full knowledge that it will give certain results at the bedside independent of theoretical considerations. It is our duty to theorize in the office, society, or laboratory j but the sick-room demands clinical experience and knowledge. This should not discourage experimental research, for when conducted properly many new methods may be evolved. CONTENTS. PAGE Introduction 7 Fevers. — The Spread of Contagious Fevers — Prophylaxis of Con- tagious Diseases — Antipyretic Measures — Cold Baths 17 Continued Fevers. — Ephemeral — Influenza — Eelapsing — Epi- demic Cerebrospinal Meningitis — Typhus — The Plague — Ty- phoid 23 Periodical Fevers. — Yellow — Malarial (Intermittent, Remittent, Pernicious, and Chronic) 44 Eruptive Fevers. — Varicella — Variola — Scarlatina — Morbilli — Rotheln — Dengue — Erysipelas 54 General Infectious and Contagious Diseases. — Cholera — Diph- theria — Pertussis — Parotitis — Tetanus — Hydrophobia — An- thrax — Tuberculosis (Acute, Chronic) Tuberculin — Syphilis — Beriberi 73 General Non-Infectious Diseases. — Myalgia — Gout — Rachitis — Acute Eheumatism — Polyuria — Diabetes Mellitus 103 Diseases of the Circulatory System 119 Diseases of the Heart. — Introduction — Cardiac Murmurs — Hypertrophy — Dilatation — Fatty Degeneration — Myocarditis — Acute Endocarditis — Chronic Endocarditis — Mitral, Aortic, Tricuspid, Pulmonic Insufficiency and Stenosis — Palpitation Angina Pectoris — Exophthalmic Goiter 119 Diseases of the Pericardium. — Pericarditis — Hydropericar- dium 139 Diseases of the Blood-vessels. — Aneurysm — Phlebitis 142 13 14 CONTENTS. PAGE Diseases of the Blood. — Introduction — Ansemia (Symptomatic, Essential — Chlorosis and Progressive, Pernicious) — Leucaemia — Pseudo-leucaemia — Sapraemia — Septicaemia — Pyaemia — Purpura — Scorbutis — Haemophilia 145 Diseases of the Suprarenal Capsule. — Addison's Disease 162 Diseases of the Mouth. — Stomatitis — Aphthae — Cancrum Oris — Ulcers of — Thrush — Glossitis — Noma — Hemorrhage from — Cancer in — Salivation 164 Diseases of the Pharynx. — Pharyngitis (Acute, Chronic, Follicu- lar, Tubercular, Herpetic, Sicca) — Pharyngeal Croup — Quinsy — Syphilis of — Herpes of Tonsils — Eetro-pharyngeal Abscess — Angina Ludovici 177 Diseases of the GEsophagus. — Oesophagitis — Stricture of — Dilata- tion of 189 Diseases of the Stomach. — Acute Gastric Catarrh — Chronic Gas- tric Catarrh — Gastritis Phlegmonosa — Toxic Gastritis — Gastric Ulcer — Gastric Cancer — Dilatation of — Hypertrophy — Haema- temesis — Gastralgia — Dyspepsia — Stomachic Vertigo 193 Diseases of the Intestines. — Diarrhoea — Intestinal Catarrh — Duo- denal Catarrh — Typhlitis — Perityphlitis — Proctitis — Periproc- titis — Cholera Morbus — Cholera Infantum — Ileo-colitis — Acute Dysentery — Chronic Dysentery — Ulcers of — Cancer of — Intes- tinal Obstruction — Hemorrhage — Enteralgia — Constipation — Intestinal Worms 213 Diseases of the Peritoneum. — Peritonitis — Ascites 239 Diseases of the Pancreas. — Pancreatitis — Cancer of 244 Diseases of the Liver and Appendages. — Introduction — Jaun- dice — Hepatic Hyperaemia — Acute Suppurative Hepatitis — Interstitial Hepatitis — Syphilis of — Amyloid — Fatty — Hepatic Cancer — Hydatids of — Acute Yellow Atrophy — Pylephlebitis — Catarrh of Bile-ducts — Hepatic Calculi 245 Diseases of the Spleen. — Hyperaemia — Splenitis — Hypertrophy — Amyloid 261 CONTENTS. 15 PAGE The Urine. — Urine — Qualitative Urinary Analysis — Chemical Tests 263 Diseases of the Kidneys. — Uraemia — Hyperemia — Acute Tubal Nephritis — Chronic Tubal Nephritis — Chronic Interstitial Nephritis — Amyloid — Pyelitis — Hydronephrosis — Perine- phritis — Floating Kidney — Eenal Cancer — Tuberculosis of — Eenal Calculi — Parasites (Filaria, Echinococcus, Bilharzia Haematobia) 266 Diseases of the Bladder. — Cystitis — Hyperesthesia — Anaes- thesia — Haematuria — Paralysis 283 Physical Diagnosis. — Introduction — Inspection — Mensuration — Palpation — Percussion — Auscultation — Succussion 289 Diseases of the Nose. — Acute Rhinitis — Chronic Ehinitis — Hay- fever 295 Diseases of the Larynx. — Acute Catarrhal Laryngitis — (Edema of the Glottis — Chronic Catarrhal Laryngitis — Tubercular Laryngitis — Laryngismus Stridulus — Catarrhal Croup — Mem- branous Croup 300 Diseases of Bronchial Tubes and Lungs. — Bronchitis (Acute, Plastic, Chronic) — Catarrhal Pneumonia — Haemoptysis — Pul- monary Hyperaemia — Apneumatosis — Vesicular Emphysema — Bronchial Asthma — Pneumonia — Chronic Pneumonia — Fi- broid Phthisis 311 Diseases of the Pleura. — Acute Pleurisy — Chronic Pleurisy — Pneumothorax — Hydrothorax 335 The Nervous System. — Introduction — Motion — Sensation — Electri- cal Eeactions — Trophic Changes — Reflexes 342 The Neuroses. — Chorea — Epilepsy — Hysteria — Thomsen's Dis- ease — Neuralgia — Migraine — Paralysis Agitans — Writers' Cramp 346 Diseases of the Nerves. — Neuritis — Multiple Neuritis — Sciatica — Facial Paralysis 365 Diseases of the Spinal Cord and its Membranes. — Spinal Meningitis (Acute, Chronic, Pachymeningitis) — Acute Mye- 16 CONTENTS. PAGE litis — Poliomyelitis Anterior Acuta — Paralysis Aseendens Acuta — Spinal Sclerosis (Antero-lateral, Posterior, Multiple, Hereditary Ataxia) 372 Diseases of the Brain and Membranes. — Acute Cerebral Menin- gitis — Tubercular Meningitis — Cerebral Pachymeningitis — Cerebral Hyperemia — Concussion — Cerebritis — Cerebral Hemorrhage — Cerebral Embolism and Thrombosis — Cerebral Abscess — Cerebral Tumors — Insolation 385 The Psychoses. — Introduction — Mind — Insanity — General Etiology — Classification — Mania (Acute Delirious, Acute, Chronic) — Acute Dementia — Chronic Dementia — Melancholia — Moral Insanity — Idiocy — Cretinism— Dementia Paralytica 402 Index 421 A SYNOPSIS OP THE PRACTICE OF MEDICINE. FEVERS. Fever, or pyrexia, is a symptom of some general or local pathological process, recognized by an elevation of the normal body temperature, quickened circulation, increased catabolism, and disordered secretions, together with a -disturbance of the physiological functions of the part or parts affected. Temperature. — The average temperature of the human body in health is 98.6° F. or 37° C. This temperature is not constant in the same individual, but varies a fraction of one degree according to the hour of the day, the amount of exercise or excitement, and the character of diet. Tempera- ture receives various terms, according to its height : Subnormal temperature varies from 96° to 97.5° F. Subfebrile " " " 99.5° " 100.4° F. Slight fever " " " 100.5° " 103° F. High " " " " 103° " 105° F. Hyperpyrexia includes all temperatures above 105° F. Temperature is taken with a self -registering mercurial ther- mometer, by placing it in the axilla or groin in close contact with the skin j more commonly by placing the bulb under the 17 18 A SYNOPSIS OF THE PRACTICE OF MEDICINE. tongue, and closing the lips upon it, or by inserting the bulb into the rectum for several inches {rectal temperature). The last method is most reliable, but objectionable in many cases. To insure accuracy, allow the thermometer to remain five minutes before removing it. During fever the heart's action is accelerated, but soon be- comes depressed and weak ; respiration is increased ; there are nervous symptoms, such as headache, drowsiness, languor, in- somnia, delirium, coma, subsultus, and general nervousness; gastro-intestinal disturbances ; derangement of the functions of the skin, which may be hot, dry or moist ; profuse perspira- tion, eruptions, flushing of the face ; urine is usually high- colored, scanty, or profuse. Fever causes a change in the physiological action of every organ in the body. It is usually preceded by malaise, chilly sensations, a chill, rigor, or convul- sions, in children, lasting from a few minutes to several hours. If temperature is taken during a chill or rigor it will show pyrexia, and not subnormal temperature as would be expected. The acme of a fever is the highest point or critical stage. The fasti 'gium represents that period during which the fever pursues a typical course, at its height, for a long or short period. Defervescence is the period of fall or decline, and occurs by : (a) Crisis — a sudden fall of temperature to normal or sub- normal within twenty-four hours. (?>) Lysis — a slow fall of temperature to normal in three or more days. Convalescence is a slow or rapid return of strength after defervescence. A simple continued fever is one in which the temperature continues above normal for an indefinite period, with varia- tions of not more than one and one half degrees from day to day. FEVERS. 19 Intermittent fever has a fall of temperature to normal for a short period, then rises, and thus intermits indefinitely. Remittent fever is paroxysmal, with distinct remissions of several degrees, but never intermittent. Idiopathic or specific fever is one which is not dependent upon a local affection, but upon some pathogenic microor- ganism whose action is not definitely known. Symptomatic fever is dependent upon some local trouble, and is caused by the absorption of ptomaines. Neurotic fevers are caused by a lack of inhibition in the nerv- ous system, nerve-lesions, and hysteria. Eruptive fevers are self -limited, self-protective, contagious, and accompanied by a rash of a specific character, always ap- pearing at a definite time during the course of the disease. Infectious fevers are dependent upon a specific germ that flourishes without the body; hence not communicable from one person to another by direct contact. Malaria ; influenza. Contagious fevers are caused by a specific germ which repro- duces itself within the body and is capable of infecting others by direct contact, or indirectly by contact with the germs car- ried on clothing, books, etc. >■ Variola ; scarlet fever. Epidemic fevers spread over a whole section of country, run for a long or short period, disappear, and may appear in some other neighboring community. Not stationary for any pro- longed period. Endemic fevers exist in certain communities at all times, limited in extent, and liable to become epidemic ; in fact, they are sometimes termed native fevers. Sporadic fevers are those isolated cases that arise independ- ent of epidemic or endemic causes, and are always traceable to some preexisting case, as they never arise spontaneously. 20 A SYNOPSIS OF THE PRACTICE OP MEDICINE. THE SPREAD OF CONTAGIOUS FEVERS. Every contagious and infectious disease, according to mod- ern pathologists, is caused by a specific microorganism or germ which enters the body through the respiratory, gastro- intestinal, or genital tract, or some abrasion of the skin. The germ grows and reproduces itself at the expense of the white cells and albuminoids either in the blood or some localized part of the body, and produces a poison or waste product pe- culiar to itself, called a ptomaine. Some time, varying from a few days to several weeks, must elapse before the actual onset of the disease, during which the germs are coming into activity, constituting the period of incubation or invasion. These living germs constitute the actual means of contagion, and always originate from that special disease. Contagion is most active during the height and decline of a disease, as at that time the excreta, urine, expectorated matter, exhala- tions, desquamating epithelium, or discharges from vesicles, pustules, or open sores contain the germ in its most active state. Thus it is possible to convey the germ, by direct con- tact with the sick, on clothing, articles of furniture, books, and other things that ha ye been used by or about them. It must be remembered that the germ of scarlatina, variola, and some other diseases will lie dormant in clothing for many years, and still retain its full power of infection. All persons are susceptible to contagious diseases, but more especially children and those debilitated by sickness, confinement, and bad hygiene. One attack usually affords immunity from a second ; hence self-protective to a degree. Second and third attacks may occur in the same person. FEVERS. 21 PROPHYLAXIS OF CONTAGIOUS DISEASES. There are certain definite rules applicable to the prevention of all contagious and infectious diseases, which will be sum- marized in this section. Isolation. — The first imperative measure. If possible, select a large, well- ventilated room at the top of the house — south- ern or western exposure preferable. Remove all unnecessary and upholstered furniture, curtains, clothing, rugs, pictures, and heavy carpets. Put the patient in this room and allow no one to enter except the nurses and physicians — always instructing them to avoid contact with other members of the family, and to stay in that part of the house, unless clothing has been previously changed and an antiseptic bath taken. Disinfection. — All excreta, vomited and expectorated mat- ter must be thoroughly and freely mixed with chloride of lime, Piatt's chlorides, or concentrated carbolic acid, and either buried or thrown into the sink after standing for one hour. As far as practicable use cotton and old linen for the discharges, and burn at once. Soiled clothing and handkerchiefs should be placed in an antiseptic solution before removal from the room, and then boiled for six hours before they are used again. It is a wise precaution to wipe the floor and furniture daily with an antiseptic wash. A sheet, wetted with an anti- septic solution, is often hung over the door as an additional safeguard. Unused food should always be destroyed. Keep the windows open to afford free ventilation, taking care to avoid direct draughts. Bathe the patient frequently with anti- septic washes (acid bichloride of mercury, jjp). During convalescence, a daily scrub-bath should be given, and, as a final means, before going into other parts of the house, thor- 22 A SYNOPSIS OF THE PRACTICE OF MEDICINE. ouglily shampoo the hair with antiseptic washes and change all clothing. Disinfect the room by scrubbing the floors, washboards, fur- niture, and walls with acid bichloride of mercury; scraping, calcimining, white- washing, or papering the walls and ceiling ; thoroughly boiling all bed-clothing and linen for six hours ; and destroying, by fire, books and toys used by the patient. The fumes of burning sulphur are frequently used, but it must be remembered that sulphur vapor is antiseptic only in the presence of moisture; hence it is well to have the room filled with steam when this method is used. ANTIPYRETIC MEASURES. Fever is diminished by hygienic and dietary means, internal medication, and the local application of cold. Hygiene and Diet. — All persons with slight or high fever should be placed in bed in a cool, well-ventilated room, and be freed from all business and family cares and worries. Light, nutritious diet (milk, broths, and refrigerant drinks) at regular intervals. This is the physiological method, and fa- vors Nature in her cure, but does not in itself lessen fever. Internal Medication. — Aconite, veratrum, antimony, digi- talis, colchicum, gelsemium, and strophanthus act upon the circulatory system. Quinine, cinchona salts, salicjlates, car- bolic acid, camphor, and phenacetin reduce fever by lessen- ing active catabolism. Acetanilide, nitrous ether, alcohol, and antipyrin act by dilating the capillary vessels of the skin, thus increasing radiation of heat. Local Application of Cold — Sponging. — In cases of mode- rate or high fever the body is sponged all over with cold or tepid water, prolonging the operation as long as it is comfort- FEVERS. 23 able to the patient, exercising care not to chill. This is a convenient and efficient means, in mild cases, to reduce tem- perature one or two degrees. Wet-pack. — This consists of wringing sheets out of ice-cold water and wrapping them around the whole body, and repeat- ing the process every minute or more until the condition of hyperpyrexia is overcome. Some wrap patient in a wet sheet and pour cold water over it. Ice-hags or cracked ice are often applied to one or more parts of the body, and allowed to remain until the desired local results are obtained. Cold Baths. — The Germans use this method very extensively in treating typhoid fever. The water is prepared in a bath at a temperature of 60° to 80° F. ; the patient is gently immersed in it for five, ten, or twenty minutes, according to indications. Sometimes iced water is gradually added to water at 80° F., until it falls to 60° or 70° F. When patient is removed he should be rubbed gently with a soft, coarse towel, covered warmly, aiid, if weakened, stimulants must be given. A cold bath is used whenever the temperature reaches 102° F., and reduces temperature three to five degrees. Patients threatened with pneumonia, hemorrhage, or collapse should not be placed in a cold bath. Repeat baths as often as necessary. CONTINUED FEVERS. EPHEMERAL FEVER. Synonyms. — Simple continued fever ; febricula ; simple es- sential fever ; irritative fever ; synochus. Description. — Children and adults are subject to the influ- ences of mental and physical exhaustion, over eating and drinking, excitement, exposure to heat and cold, and often de- 24 A SYNOPSIS OF THE PRACTICE OF MEDICINE. velop a slight fever with no definite or constant pathological lesion. It begins with a slight chilly sensation, chill, rigor, or convulsion, together with general malaise, slight headache, anorexia, thirst, and coated tongue. Temperature gradually or quickly runs from 101° to 104° F. ; pulse rapid ; urine scanty and high-colored ; slight delirium if the temperature is high. These symptoms continue from one to ten days, and subside by lysis or crisis. Treatment. — Rest in bed : a light diet of milk, meat broths, rice-milk, sago, and acidulated drinks. Sponge the body fre- quently with tepid or cold water and alcohol. Triturated calomel, one-tenth grain, every hour, until free action is ob- tained. In addition, you may give a mild fever mixture. Tr. aconiti radicis fll. xvj. Liq. ammonii acetatis f 1 jss. Syrupi aurantii floratis . . . q. s. ad. f I ij. M. Signa. One teaspoonful every two hours, as necessary. Remove every possible cause, and, during convalescence, ad- minister tonics of iron and quinine if indicated. INFLUENZA. Synonyms. — Epidemic catarrh; la grippe; "the grippe"; Russian influenza. History and Etiology. — Influenza is a disease that has been known to man from most ancient times, occurring among all nations at irregular intervals. No definite records of these epidemics exist previous to the sixteenth century. Fagge re- cords eleven epidemics in the sixteenth century, sixteen in the seventeenth, eighteen in the eighteenth, and ten between the years 1800 and 1850. A very severe epidemic spread over Europe, America, and Asia during the winter of 1889 and the FEVERS. 25 spring of 1890, causing a great mortality, and leaving thou- sands of people with its sequelae. In 1891 and 1892 the dis- ease was mildly epidemic in parts of the United States, China, and Japan. It seems to affect cattle as well as man, and the great epidemic of epizootic in horses, in the year 1872, in New York, is claimed to have been due to this poison or a similar one. Each epidemic seems to differ from the preceding one in course, sequela?, and mortality. There is a prevalent idea that influenza is always a fore- runner of Asiatic cholera, from the fact that the latter has fre- quently followed the track of influenza. In July, 1892, cholera was epidemic in Russia, and followed the track of the recent epidemic of influenza and made its appearance in Paris. These are given only as facts, but no reliable deductions can be drawn from present statistics. Influenza is undoubtedly caused by an aerobic germ which is transmitted by the air. It is infectious and, possibly, slightly contagious. Some pathologists claim that they have found the germ of influenza, and that it is the smallest known, and flourishes in the mucous membrane of the respiratory tract ; but it remains to be confirmed. All persons, strong and weak, are attacked, but more especially those suffering with chronic diseases. Heat and cold do not appear to influence the spread of influenza, for it exists in the coldest parts of Russia and in the warmest tropical climates. Symptoms. — Onset is sudden with a distinct chill, an attack of syncope, or may be preceded by slight headache, giddiness, anorexia, and general malaise. Temperature rises rapidly in a few hours from 102° to 104° F. ; intense aching pain in the head, back, arms, and" legs ; skin may be dry and hot, or cov- ered with profuse perspiration ; mild delirium in cases with high temperature ; great lassitude ; photophobia ; conjunctivae are congested and lachrymation is profuse ; free, clear, watery 2G A SYNOPSIS OF THE PRACTICE OF MEDICINE. discharge from the nose ; occasional epistaxis ; sneezing and a dry, hacking, irritating cough ; hoarseness j tongue is coated with a heavy white fur; pulse increased, with a tendency to weakness • skin is often hyperaesthetic. Stomach is irri- table j nausea or vomiting • epigastric tenderness or pain ; may be slight haamatemesis ; bowels constipated or in state of diarrhoea. These symptoms continue four or five days, and subside by lysis or crisis, leaving the patient in a condition of extreme prostration and debility, out of all proportion to the duration of the disease. Convalescence is slow, and lasts from one week to one year. In many cases, just as in typhoid fever, the nor- mal strength or power of endurance is permanently impaired. Pneumonia is the most frequent complication, either lobular or lobar. The joints often become inflamed in certain epi- demics (1889-90). Peculiar Manifestations. — The onset is usually the same, but certain symptoms are more marked in some than in others. It assumes a catarrhal form when the respiratory tract is affected ; a gastro-intestinal form when that tract is most in- volved ; a nervous form when the manifestations are principally nervous, with slight involvement of gastro-intestinal and re- spiratory tract. Any of these forms may exist alone or in combination. Diagnosis. — Made from its being epidemic : sudden onset ; peculiar catarrhal, gastric, and nervous symptoms ; extreme prostration ; sequela?, and slow convalescence. Prognosis. — In previously health} 7 persons influenza, if prop- erly guarded, is not fatal. Complicated cases are uncertain. Among old and debilitated persons, chronic cases of Bright's disease, tuberculosis, cancer, heart-diseases, and in very young children the mortality is high — often fifty to seventj'-five percent. An epidemic of influenza always leaves its after- FEVERS. 27 effects so thoroughly impressed on a community that it takes years to regain its normal condition of immunity from other diseases. Treatment — Prophylaxis. — As in all diseases, attend to hy- giene. It seems that no precaution will prevent an attack, not even the much-abused daily dose of quinine and whisky, which seems to favor rather than retard its invasion. Dur- ing an epidemic be regular in hours of sleep, work, and rec- reation. Avoid all unnecessary stimulation and drugging; eat nothing but substantial, nutritious, wholesome, and easily digested foods ; avoid carousals, unnecessary fatigue, worry, and venereal excesses ; keep the bowels active every day, and avoid a sedentary, indoor life ; sleep in well- ventilated rooms. If any preventive measures will avail, these will ; if they do not you will be in the best possible condition to abort or en- dure an attack. Active Treatment. — Put the patient in bed and keep him there until convalescence is well advanced ; darken the room ; bathe frequently with tepid water. Pain is the leading symp- tom, and can be relieved by two or five grains of phenacetin every two or three hours, given with hot water ; or pill acet- anilide comp., every half -hour until relieved ; or the salicylates. Pill acetanilide comp : Acetanilide. Quininse bisulphatis aa. gr. j. Cocainge hydrochloratis gr. t§-. M. Fiat pilula vel tablet., compress., No. 1. Sodii salicylatis 3 jss. Liq. ammonii acetatis f I jss. Syr. aurantii nor q. s. ad. f § ij. M. Signa. One teaspoonful every two hours until relieved, then every three or four hours as necessary, 28 A SYNOPSIS OF THE PRACTICE OF MEDICINE. These combinations relieve pain, reduce fever, are antisep- tic and favor diaphoresis. Apply ice to the head, if desirable. Follow the relief of pain by the administration of triturated calomel, one-tenth grain, every hour until free action is ob- tained. Calomel will also relieve nausea and irritation of the stomach and bowels. Cough and catarrhal symptoms are treated as acute laryn- gitis and bronchitis. Avoid all depressants, and administer tonics as indicated. Let the diet be most nutritious, liquid and non-irritating albuminoid products — milk, wine-whey, broths, beef -extracts, boiled rice, or rice-milk. During conva- lescence give tonics of cinchona, iron, arsenic, and strychnine. For a persistent cough, following an attack, nothing is better than malto-yerbine, one dram, three or four times daily. Com- plications must be met as they arise. RELAPSING FEVER. Synonyms. — Febris recurrens; famine fever; bilious re- lapsing fever. Definition. — An acute, contagious, self-limited, epidemic fever, recognized by a sudden onset with chill, high fever, pains in the head and muscles, jaundice, and vomiting. Lasts for seven days ; has a distinct remission of six or seven days, and a return of all symptoms as at first. Etiology. — Caused by the Spirocliceta Obermeieri. Conta- gious. Development is favored by filth, crowding, bad hy- giene, and lack of proper diet. Period of incubation is one to fourteen days. Symptoms. — Onset is sudden, without prodromal symp- toms. Chill or rigor followed by high fever, 102° to 106° F. ; violent headache ; sharp, shooting pains in the muscles of the legs, back, and arms ; nausea and vomiting ; epigastric tender- FEVERS, 29 * ness ; liver and spleen are swollen and tender to pressure j anorexia, great thirst, and insomnia ; tongue is coated with a thick white coating. As temperature increases, pains and other symptoms are aggravated. Jaundice frequently occurs on the third or fourth day and is often pronounced. Urine contains bile-pigment, decrease of the chlorides, and may show a trace of albumin. Herpes labialis is a frequent complication ■ delirium is a late symptom. On the seventh day crisis comes suddenly with profuse perspiration and rapid fall of temperature to normal or subnormal. Patient feels well, except weak. Convalescence takes two or three days, and is apparently complete. On the fourteenth day from the onset the attack repeats itself, and all symptoms return. Crisis occurs in three to five days. Relapses may occur four or five times, or not at all. Complications. — Pneumonia ; pleurisy ; intense hyperemia or rupture of the spleen; jaundice, acute or chronic; in- flammation of the salivary or cervical glands ; epistaxis or hamiatemesis. Pathology. — Undoubtedly due to the Sjriroclueta Obermeieri, a spiral or corkscrew-shaped filament found in the blood dur- ing the height of the fever, and entirely absent during the interval. These spiral filaments multiply rapidly, possess a rotary spiral motion, and are about -5^0 to toVo i ncn m length. Spleen and liver are enlarged and hyperamric. Diagnosis. — The positive diagnostic sign is a microscopical demonstration of these spirilla? in the blood. Prognosis. — Not commonly fatal; death is most common during the height of a first attack or at crisis. Convalescence is prolonged and slow. Treatment. — Rest in bed, with free ventilation, isolation, and best hygienic surroundings. Give a diet such as is given in typhoid fever, during the attacks ; but in the intervals give 30 A SYNOPSIS OF THE PRACTICE OF MEDICINE. good, rich milk, rare beef, soft boiled eggs, and ripe fruits. Begin treatment with a free calomel purge. Sponge the body with tepid water and alcohol every few hours ; give cold water and cracked ice. Infusion of digitalis, f 3 j, with acetate of potash, gr. v, every four hours. Pill acetanilide comp. (form, p. 27), every hour for five or six hours, often relieves muscular pains and head- ache. Cold baths for hyperpyrexia. If pains are very severe, administer morphina sulph., gr. x, and atrophia sulph., gr. y^o, hypodermically, to be repeated in half an hour if necessary. Carbolic acid, iodine, sulphocarbolate of zinc, and salol are claimed as excellent antiseptics and of possible use when in- ternally administered. Stimulate freely during crisis or as demanded. Avoid all depressants. During convalescence give tonic treatment. Enforce prophylactic measures to prevent contagion. EPIDEMIC CEREBROSPINAL MENINGITIS. Synonyms. — Spotted fever ; cerebrospinal fever ; cerebro- spinal typhus 5 apoplectic cerebral typhus ; epidemic meningi- tis. The Germans call it Geniclckrampf and Nackenstarre. Definition. — An acute, specific, epidemic, malignant, infec- tious fever, recognized by spasmodic muscular contractions of the muscles of the neck and back, hyperesthesia, together with a peculiar eruption (not constant). Etiology. — It is due to a round micrococcus called Micro- coccus intracellulars meningitidis, usually occurring in groups of two (diplococci). Epidemic and not contagious. Most com- mon in winter among young adults. Acute diseases predis- pose one to attacks during epidemics. Period of incubation is nearly seven days. Symptoms. — Prodromal symptoms are headache, loss of appe- tite, malaise, and general pains. Onset is sudden, with a severe FEVERS. 31 chill or rigor, violent pain in the head, persistent vomiting, and a feeling of giddiness. Photophobia and intolerance of noise j pupils are contracted at first, but dilated later. Con- vulsions often appear early ; delirium. Headache is so severe that the patient cries out with it. There is stiffness and sore- ness in the muscles of the neck and back during the first and second days, which soon assumes a severe form, with tetanic convulsions, in which the head is drawn back, and frequently accompanied by oposthotonos. The body may assume a straight, rigid state — orthotonos. Patient lies on side, with legs flexed, on abdomen. Pains in the joints are often severe; skin is hyperaesthetic ; quantity of urine is profuse. Temperature varies from 102° to 107° F., and assumes no regular type. Deafness, loss of sight and smell, temporary or permanent. Eruption appears from the third to the sixth day, and is either herpetical, on the face and ears, or a diffuse urticaria, erythema, or purpura. The only peculiarity of the eruption is the fact that it occurs symmetrically on different parts of the body. Disease reaches its height about the tenth day, and declines by lysis or assumes a more serious form, resulting in death. Convalescence is long, and often extends over many months. Among serious sequela? are loss of hearing, sight, and smell ; deaf -mutism ; headache that persists for years after- ward ; progressive emaciation ; epilepsy or special paralyses. Fulminant or foudroyant cases are those malignant attacks where the patient dies a few hours after the onset, and occur most commonly in the early part of epidemics. Abortive cases are those whose symptoms are not well de- fined, and are followed by recovery after a few days in bed, or a short period of indisposition ; most common during the decline of an epidemic. Hysterical cases occur in excitable, nervous women and chil- dren, are never fatal, and are easily distinguished by physical examination. 32 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Pathology. — The disease is caused by a diplococeus called Micrococcus intracellular is meningitidis, which, by some unknown selective action, produces an inflammation of the meninges at the base of the brain and medulla oblongata, involving the ventricular structures. Post-mortem examination shows an exudation of lymph and pus on the pons, chiasma, sulci, large vessels, posterior part of the medulla, and the ventricles. Congestion of the base of the lungs ; hyperemia of the liver, spleen, and kidneys. Rigor mortis is prolonged, and staining of the body marked. Diagnosis. — Typhoid fever does not begin so abruptly ; has no high rise of temperature during the first and second days • time and character of eruption are different, and it runs a different course. Simple sporadic meningitis has no loss of special senses; symptoms less marked; no muscular contractions of severe type ; absence of peculiar eruption, and is not epidemic. Prognosis. — Must be guarded. Simplest cases often be- come most severe. Relapses are very common. A mean mortality is given as forty percent. Always advise as to possible sequela?. Treatment. — Treat on the same principle as simple menin- gitis, q. v. Observe best hygienic surroundings to prevent its spread. Treat complications and sequela? as demanded. TYPHUS FEVER. Synonyms. — Camp fever; jail fever; ship fever; putrid fever ; stupid fever. Definition. — An acute, contagious, epidemic fever, recog- nized by a sudden onset, high fever, great depression, stupor, and the appearance of a petechial eruption on the fifth day. FEVERS. 33 Etiology. — The primary cause is a distinct germ. It is both epidemic and endemic. Close crowding, close confine- ment, filth, decomposing vegetable matter, nncleanliness, im- proper diet, and general debility are predisposing causes. It often breaks out in overcrowded, poorly ventilated jails, ships, and tenement-houses. Most common among the poorer classes. It is highly contagious. Symptoms. — For several days prior to the onset there are tired feelings, headache, loss of appetite, dizzy and chilly sen- sations. Onset is heralded by a chill, nausea, vomiting, and high fever, 102° to 104° F., on the first or second day. Pulse and respiration increased; tongue coated with a yellowish- white coating ; constipation ; throbbing headache, face flushed, and photophobia. Urine is scanty, high-colored, and often contains albumin. On the fifth day a petechial or mulberry rash appears on the abdomen, chest, arms, and legs j little or no eruption on the face and neck. The eruption consists of petechial spots which do not disappear on pressure and do not come out in separate crops ; most pronounced from the seventh to the tenth day, when it begins to fade, and finally disappears between the fourteenth and twentieth days. A characteristic symptom is the peculiar blank facial expres- sion ; contracted pupils ; absolute indifference to conversation and surroundings. All symptoms reach their height about the second iveek, when there is continual delirium of a low muttering type, or it may be wild and maniacal. Coma may supervene, together with subsultus tendinum, involuntary passage of urine and faeces. Tongue, during later stages, is dry, brown, and fissured ; teeth and lips covered with sordes. There is a peculiar mouse-like odor about these cases, most marked during the second or third week. Bed-sores are com- mon. Crisis comes about the fifteenth day, when the temperature 34 A SYNOPSIS OF THE PRACTICE OF MEDICINE. falls nearly to normal or subnormal in twenty-four hours. All other symptoms subside, leaving the patient very weak, pale, and emaciated. Death may ensue at crisis from paral- ysis of the heart or complications of pneumonia, coma, or relapses. Pathology. — Typhus fever is due to a germ the exact nat- ure and action of which are not determined. There are no constant pathological lesions by which to determine where the disease is central. Post-mortem examination shows the general muscular tissues, including the heart, in a state of fatty degeneration and quite friable. Blood is thin, dark in color, and forms imperfect clots. Liver, spleen, and kidneys are enlarged and friable. DIAGNOSIS. TYPHUS FEVER. Short prodromal symptoms. High fever during first day, irregu- lar in course. Constipation. Slight general abdominal tender- ness. Petechial eruption on fifth day ; not in successive crops ; not influ- enced by pressure ; covers whole body. Ends in three weeks by crisis. Peculiar mouse-like odor present. Highly contagious. Early delirium and cerebral symp- toms. No involvement of Pyer's patches. TYPHOID FEVER. Long prodromes, with epistaxis. Fever rises slowly and regularly for seven or eight days. Persistent, pea-green diarrhoea. Marked tenderness in right iliac fossa. Eruption on seventh day ; comes in crops ; disappears on pressure ; limited to abdomen, chest, and back. Ends in five or six weeks by lysis. No characteristic odor. Infectious ; possibly slightly con- tagious. Late delirium and cerebral symp- toms. Pyer's patches the seat of disease. Prognosis. — Occurring in hearty, strong individuals, it is good. Quite fatal in young children, aged and debilitated persons. Treatment. — Isolation and the strictest antiseptic measures are imperative. Ventilate the sick-room freely, destroy all FEVERS. 35 excreta by fire, and follow prophylactic measures as indicated on page 21. Constantly watch patient to prevent accidents during delirium. Establish free action of the bowels by full doses of calomel and ipecacuanha. No known remedy will abort or shorten the disease. Soldi, gr. v, or sulphocarbolate of zinc, gr. iij— v ? every four hours through the whole course, seems to mitigate unfavorable symptoms by its possible antiseptic action. Reduce fever by cold baths, cautiously ad- ministered as often as necessary. Avoid depressants; stimu- late freely. Quinine is of doubtful utility. Feed at regular intervals with milk, beef -extracts, whites of eggs in cold water, or good broths. Carbonated or alkaline waters can be used at liberty. Sponge the body several times daily with cold water and acid bichloride of mercury. Admin- ister carbonate of ammonia at crisis to prevent heart-failure. Watch the bladder closely to avoid retention of urine. Ice applied to the head will relieve headache. Chloral is the best remedy for coma vigil. Meet complications as they arise. THE PLAGUE. Synonyms. — Oriental plague ; Levantine plague ; bubonic plague. Etiology. — Due to some specific microorganism 5 conta- gious; self -protective. Virus is carried on clothing and merchandise; warm, damp weather favors its development; occurs principally in low, marshy districts. Filth, poverty, overcrowding, and bad hygiene favor it. Period of incubation is from three to seven days. Description. — The plague was most active during the mid- dle ages, but has since occurred in Oriental countries as an epidemic at irregular intervals. During 1892 it was present 36 A SYNOPSIS OF THE PRACTICE OF MEDICINE. in some parts of the East, and at this time (1894) is epidemic in China, and the mortality is very great. There is a short prodromal period of malaise, depression, headache, anorexia, attacks of giddiness or syncope, and slight fever. Onset is preceded by chilly sensations or a chill, fol- lowed by rise of temperature to 103° to 107° F. ; rapid pulse, 120 j tongue moist and red at first, but soon becomes covered with a brown coating as in typhoid fever ; a general typhoid condition soon follows. Death may occur in one or two days, and is frequently preceded by a petechial eruption, haematuria, and heematemesis. About the third day buboes form in the groin, axilla, or neck, and vary in size from a pigeon's egg to a hen's egg. When buboes form, fever and delirium lessen ; skin is covered with perspiration • pulse falls to 90 or 100. Buboes often break spontaneously, and pursue a long course of suppuration. Carbuncles not infrequently appear in large numbers on the nates, neck, back, and arms. Convalescence is very slow and tedious. Pneumonia, dropsy, paralysis (gen- eral or local), pyaemia, or mental troubles may complicate or follow. Pathology. — Due to a specific germ which seems to develop best in low, marshy districts during hot, damp weather. The germs have a selective action for the lymphatic system, in which they cause inflammation and suppuration. After death the spleen is enlarged, soft, friable, and dark in color. Serous membranes are blood-stained and ecchymosed. Internal lym- phatic glands are enlarged, swollen, and in a state of suppura- tion. Diagnosis. — An epidemic of the plague is diagnosed by the high fever, appearance of buboes and carbuncles in large numbers, and the great mortality. It is frequently mistaken for typhus fever, to which disease it bears some resemblance. Prognosis. — The mortality during past epidemics ranged FEVERS. 37 from sixty to ninety percent. Modern antiseptic treatment may diminish mortality. Treatment. — Isolation and preventive treatment, as given on page 21. Most nutritions, stimulating, and sustaining diet. Avoid depressants. Pill acetanilide comp., every half -hour or hour (form, p. 27) ; salol, gr. v, every four hours ; sulphocarbo- late of zinc, gr. v, every four hours, with a view to antisepsis. Infusion of digitalis and acetate of potash as indicated. Cold baths to reduce temperature. Constant applications of anti- septic lotions to "buboes and early incision. Meet complica- tions and give tonic treatment from first until convalescence is complete. TYPHOID FEVER. Synonyms. — Enteric fever; entero-mesenteric fever; ab- dominal typhus. Definition. — An acute, infections, self -limited fever, recog- nized by long prodromes, epistaxis, abdominal tenderness, diarrhoea, enlarged spleen, marked nervous symptoms, a petech- ial eruption appearing in crops on the abdomen on and after the seventh day, and a characteristic temperature-chart rising gradually by regular intervals for seven days, remaining sta- tionary for one or two weeks, and declining by lysis. Etiology. — It is caused by a specific, pathogenic germ called the bacillus typhosus, which is capable of reproduction in de- composing vegetable or animal matter, or within the large and small intestines, when in a condition of lowered vitality. Among predisposing causes is the use of infected drinking- water, milk, vegetable and animal food ; overcrowding, filth, prolonged hot and diy weather following or preceding a wet spell. May be derived directly from the excreta of patients. 38 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Epidemic at times. Never originated de novo — spontaneous ■ generation is impossible. Young adults are most susceptible. It is not self-protective, and may occur an unlimited number of times in the same person. Period of incubation varies from one to four weeks. Symptoms. — One to four weeks preceding the onset, an uncertain period of incubation, there are certain characteristic prodromal symptoms. Patient complains of a general tired feeling with slight muscular soreness, pain in the back and bones, headache, lack of usual energy, loss of appetite, and restless sleep, disturbed by dreams ; attacks of vertigo or gid- diness ; occasional mild or profuse epistaxis ; nervous and irri- table ; cold, creepy feelings ; tendency to diarrhoea (at times marked constipation) • a flushed, feverish appearance toward evening, and floating spots before the eyes. Onset is variable. Patients sometimes take to their beds from exhaustion or debility when the temperature begins to rise. Others have a distinct chill or rigor followed by a slight rise in temperature, severe headache, and diarrhoea. Pulse is quick, soft, and may be dichrotic • respiration increased ; short, hacking, unsatisfactory cough; tongue is red at the tip and edges, with a brown coating in the center. Evening tempera- ture rises one and one half to two degrees every day, and, in the morning, falls one degree below the temperature of the pre- vious evening. This continues for six or seven days until 104° or 105° F. is reached, when it continues about the same height for seven or ten days, with about one degree between morning and evening temperature. Between the seventh and tenth days the disease assumes its typical form. Patient is dull and listless ; picks at the bed- clothing for imaginary objects; has low, muttering delirium; headache ; tongue is dry and red on sides and edges, a red line running down its center, and a white coating on each FEVERS. 39 side. Teeth and gums are covered with thick sordes ; profuse epistaxis may occur. Diarrhoea continues, and assumes a con- dition similar to green-pea soup, and is very offensive ; spleen is enlarged and tender ; abdomen prominent, tympanitic, with gurgling, rumbling, and crepitation, and marked tenderness in the right iliac region. Eruption. — About the seventh day a characteristic eruption appears on the abdomen, chest, and back in the form of rose- red spots, varying from one to four lines in diameter, isolated, and disappearing on pressure. These spots come in successive crops of five to twenty, each crop fading in about four days, and so continuing until the twenty-first day of the disease, or disappearing at death. At the end of the second week intestinal hemorrhages are most prone to occur, usually indicated by a sudden fall in temperature, great pallor or syncope, and a discharge of clotted or bright-red blood from the bowels. Sloughed portions of the intestines may be passed. Urine is scanty, high-colored • specific gravity high j late increase of urates • albumin may be present ; retention or passed involuntarily. SubsuUus is a marked late symptom. Temporary or permanent deafness. Between the twelfth and fourteenth days, it declines by lysis. Temperature falls regularly. The morning temperature falls one degree each day, but the evening temperature remains about the same for several days, and then declines as it rose. Fever is liable to intermit and remit before convalescence begins. The fastigium or height of the disease lasts from the seventh to the twelfth or fourteenth day, but there are cases where it appears to run for several weeks. Such cases enter what Wunderlich calls an ambiguous period. Relapses are prone to recur. Pneumonia frequently complicates typhoid fever, and is heralded by a sudden fall in temperature, followed in a few 40 A SYNOPSIS OF THE PRACTICE OF MEDICINE. hours by a sudden rise. Perforation is usually attended by profuse hemorrhage, collapse, and peritonitis. Bed-sores are common in later stages. Convalescence is long, tedious, and slow. Walking typhoid fever is a term applied to those cases which pursue an apparently mild or insidious course during the first and second weeks, in which time the patient goes about busi- ness in a listless way, not feeling sick enough to consult a physician. These cases often terminate fatally or with most serious consequences, owing to a lack of proper diet during the earlier stages. Walking typhoid does not imply mild typhoid by any means. Pathology. — Typhoid fever is caused by the bacillus typho- sus, which flourishes in the large and small intestines, when in a state of lowered vitality, attacking the solitary glands and glands of Pyer. These germs grow at the expense of sur- rounding tissues, produce ptomaines, and act as irritants, caus- ing congestion and inflammation of the structures named. As a further result of irritation, intestinal secretions are increased, and, when mixed with ptomaines and waste products, cause pea-green, offensive diarrhoea. Furthermore, these ptomaines are absorbed, carried into the general circulation, and by their action on the various nerve-centers produce systemic condi- tions — fever, delirium, stupor, and headache. Pyogenic germs soon complicate the action of the bacillus tyj)hosus (a mixed microbic infection), and the simple inflammation of Pyers glands assumes an ulcerative type, often resulting in perfora- tion of the intestine, with hemorrhage from eroded capillaries or vessels, and peritonitis. Post-mortem shows Pyer's glands swollen, elevated, red, and ulcerated ; mesenteric glands en- larged, inflamed, and ulcerated ; enlarged, dark-red, friable spleen; kidneys and heart are soft and granular; lungs are congested. FEVERS. 41 Diagnosis. — There are seven diagnostic points, viz. : (1) long prodromes ; (2) epistaxis ; (3) peculiar temperature ; (4) ab- dominal symptoms — gurgling, tympany, tenderness in right iliac region, and diarrhoea ; (5) characteristic eruption on sev- enth day j (6) nervous symptoms ; (7) prolonged convalescence. From Typhus Fever, see p. 34. Prognosis. — Must always be guarded. Mild cases usually recover in four to six weeks. Convalescence is slow, and lasts from four weeks to a year. Latent tuberculosis is often brought into activity by an attack. Hemorrhage, perfora- tion, and complications are bad signs. Treatment. — Follow strictest prophylaxis and antisepsis, as indicated on page 21. Rest in bed during the whole course of the disease. Patient should use a bed-pan and not be allowed to rise. Excitement, noise, and worry must not be permitted. A nurse should be in constant attendance day and night ; temperature should be noted two or three times daily, and the greatest care taken to properly dispose of all excrementitious products. Watch the bladder to detect retention of urine. Diet — Probably no more important subject demands our attention than that of diet. Solid foods must be absolutely for- bidden, as they irritate the intestinal mucous membrane and produce ulceration and perforation. Let diet consist of milk and lime-water ; animal broths ; beef-extracts ; corn-starch, soft boiled rice, tapioca, or sago, provided they have been passed through a line sieve to remove solid particles ; white of egg given in ice- water with a pinch of salt. Avoid oat- meal. Feed at regular intervals of four hours, and never give large amounts at one time. Brandy may be given with milk if desired or indicated. Pig's-feet jelly (provided it has been strained to remove solid particles), given with vinegar, affords slight variety. Wine-whey is good. The general rule for 42 A SYNOPSIS OF THE PRACTICE OF MEDICINE. diet is to avoid all solid, indigestible, or irritating articles, and give liquids or jellies of a bland, nutritions, nnirritating quality. If seen before or at the onset, administer a free cathartic of calomel (one-quarter grain triturate, every half -hour, until free catharsis results) or a full dose of castor-oil. Never ad- minister active cathartics after the first week of the disease. There is no specific for typhoid fever, but the rational method of treatment is based on the principle of intestinal antisepsis. To this end, sulphocarbolate of zinc, given in one to five grain doses every three or four hours, through the whole course of the disease, lessens fever, delirium, diarrhoea, and changes the character of intestinal and nervous symptoms. Given in three to five grain doses in the prodromal stage it has checked many cases that might idtimately have terminated in typhoid fever. Sixty grains of the drug daily will cause no toxic symptoms. Salol, gr. v, every four hours ; beta-naphthol, gr. j-v, every four hours, and salicylic acid are advocated as intestinal anti- septics. Hydrochloric acid dilute, gtt. x-xx, every three hours, is astringent, antiseptic, and is used during the whole course. Bichloride of mercury is not reliable as an intestinal antisep- tic, for it is converted into the inert albuminate of mercury in the stomach. Tincture of iodine and carbolic acid are of service. Many other remedies have been used, but the above list will suffice as a reliable working-outline from a medicinal standpoint. Special Symptoms. — Fever is a symptom only, and not the disease ; it is nature's method of resisting disease. As long as temperature is below 103° F., little damage will occur. Quinine, acetanilide, phenacetin, and other drugs, in antipy- retic doses, are too irritating and depressing. Give a sponge- bath with cold water and alcohol, every two to six hours, to FEVERS. 43 remove secretions from the skin and rednce temperature. In hyperpyrexia, or high fever, use cold baths (p. 23) to reduce temperature, rather than antipyretic drugs. Intestinal hemor- rhage, collapse, or pulmonary congestion contra-indicate cold baths. Diarrhoea. — Usually controlled by the sulphocarbolate of zinc or salol. If profuse, administer bismuth salicylate or other astringents, exercising care not to stop secretions and excretions entirely, for these products act harmfully if re- tained in the intestines. Hemorrhage. — Acetate of lead, zinc salts, tannic acid, and oil of turpentine are most commonly employed. Oil of tur- pentine (five to ten drops in an emulsion every three or four hours) is indicated in extreme tympany, tenderness, or actual hemorrhage. Headache, a common symptom, is lessened by applications of ice or the administration of the bromides, acetanilide, phenacetin, or pill acetanilide comp. (form, p. 27). Convalescence is slow. Avoid solid food and active cathartics for several weeks. Perforation has taken place more than one month following convalescence — one case is recorded at three months. Stimulants, best nutritious diet, freedom from all business care, and an out-door life for six months or a year. Observation. — Typhoid fever will run its course in spite of all medicinal remedies (so-called specifics), and best results are to be obtained from efficient nursing, proper attention to diet and hygiene, and the avoidance of the system of dosing with medicines. 44 A SYNOPSIS OF THE PRACTICE OF MEDICINE. PERIODICAL FEVERS. YELLOW FEVER. Synonyms. — " Yellow Jack " j typhus icterodes ; malignant bilious fever ; sailor's fever ; Mediterranean fever. Definition. — An acute, contagious, malignant, epidemic or endemic, paroxysmal fever, occurring in warm climates, and recognized by sudden onset with high fever, a remission, fol- lowed by deep jaundice, black vomit, and collapse. Etiology. — Caused by a specific germ, as yet not discovered, which flourishes best at a temperature above 72° F., and is rendered inert by frost or heat of 225° F. Primarily it is a disease of tropical climates, usually along the coast, but fre- quently invades temperate climates of high altitude. In South America, the West Indies, and along the shores of the Mediter- ranean it is endemic, not spreading rapidly among the natives, but attacking strangers who are not acclimated. It is dis- tinctly non-malarial in character. Self -protective. Very con- tagious from infected clothing, merchandise, and the body of the sick. Period of incubation varies from six to ten days. Symptoms — First Stage. — Prodromes of headache, general malaise, uneasiness, anorexia, and feverish tendency. Onset is sudden, with a severe chill (occasionally prolonged), followed by high fever, 102° to 105° F. 5 dry, hot skin ; quick, tense pulse ; eyes unusually bright and liquid j severe pains in fore- head, back, legs, and epigastric region • general muscular soreness ; no delirium or loss of consciousness except in very severe cases ; bowels constipated ; tongue coated, moist, and flabby. A peculiar odor exists with these cases. Urine con- tains albumin. In thirty-six to forty-eight hours fever remits, and the disease assumes a different phase. Second Stage. — Temperature varies from 97° to 101° F, ; all FEVERS. 45 symptoms subside ; stomach is irritable ; conjunctivae assume a yellow hue and the skin is tinged with yellow. Patient feels well and desires to be up. Bowels move freely, and passages are dark and biliary. Convalescence may begin here, and patient recover in one or two weeks. On the other hand, about one to four days following the remission, he passes into the last stage. Third Stage — Collapse. — All symptoms return ; pulse falls, is irregular and compressible ; skin is dry, cold, and deep yellow or bronzed, with livid spots here and there • hemor- rhages from the nose, ears, lungs, stomach, and internal or- gans are quite characteristic. Vomiting is frequent, and is black and grumous — black vomit. Urine is dark, albumi- nous, and often suppressed; consciousness is retained until death. Convalescence is very slow and tedious. Pathology. — The pathogenic germ has never been isolated, nor is it known how or where it is most active. Many symp- toms seem to point to the gastro-intestinal canal as its habitat. Post-mortem examination shows that the heart has under- gone granular degeneration ; fatty degeneration of the liver ; stomach and intestines congested and ecchymosed, and mu- cous membrane soft and friable. Kidneys are soft, granular, and show a condition of tubular nephritis ; hemorrhages into various serous cavities. Diagnosis. — Yellow fever is recognized by being epidemic or endemic; sudden onset, high fever, black vomit, albumi- nuria, one remission, deep jaundice, and running its course in a few hours or one week at most. Prognosis. — A very fatal disease. Mortality varies from ten to fifty percent, in different epidemics. Treatment. — Follow prophylactic measures strictly as in- dicated on page 21. Patient must be put in bed at once and entirely isolated. If possible, administer a full dose of calo- 46 A SYNOPSIS OF THE PRACTICE OF MEDICINE. mel, gr. x, and socla bicarbonate, gr. x, and follow at once with snlphocarbolate of zinc, gr. v, every three honrs, or salol, gr. v, every four hours. Use cold baths for hyperpyrexia. Drink freely of alkaline, carbonated waters. Ice should be taken freely. Carbolic acid, gr. }, every two hours, is recommended. Cleanse lower bowel frequently with injections of cold water and snlphocarbolate of zinc (one dram to the half -pint). Avoid depressants, and stimulate from first. Diet. — Let it be liquid, consisting of beef-extracts, milk, and lime-water, or prepared infant food, given at regular in- tervals of three or four hours in small quantities. MALARIAL FEVERS. Malaria (Italian for "bad air") is a term applied to a group of fevers or toxaemia which are endemic in tropical and tem- perate regions, and produced by a miasmatic poison or bacil- lus called the bacillus malarke, isolated by Lemaire, Klebs, and others. Malarial poison develops in low, marshy flats, mead- ows, swamps, and damp forests where a large amount of decomposing vegetable matter is exposed for a long period to the heat of the sun; is most active during the hot, dry months of summer, in tropical climates, between the hours of sunset and sunrise, and rises with the fog several feet from the ground ; hence is capable of dissemination by currents of air. Malaria also exists in high elevations where temperature and conditions of the soil are favorable. Malarial poison usually enters the system through the respiratory tract, but may be taken in drinking-water and vegetable food. People who have not lived in malarial districts are very susceptible, and contract it readily. Colored people seem to possess a peculiar immunity, but may have it. One attack predisposes FEVERS. 47 to another, and the disease may become active in the system many weeks after exposure, when the patient has moved to a non -malarious district. Period of incubation is very uncertain, and varies from a few days to two or three weeks. Malarial Types. — (I.) Intermittent fever; (II.) remittent fever; (III.) pernicious malarial fever; (IV.) chronic malaria. I. Intermittent Fever. Synonyms. — Ague ; chills and fever ; mild malarial fever ; paludal fever. Definition. — An acute, infectious, paroxysmal malarial fe- ver, recognized by a distinct chill, lasting about one hour, followed by" a period of great heat, and declining by profuse sweating, leaving the patient without fever and in an appar- ent state of health for an uncertain period of time, only to return again. Symptoms. — There may be slight headache, general indis- position, anorexia, nausea, and uneasiness preceding the onset. Onset or cold stage begins suddenly with a decided and pro- longed chill ; skin is rough, pale, and cold (cutis anserina) ; nails and lips are blue ; teeth chattering ; great thirst ; intense headache ; vomiting ; urine pale and copious ; pulse small and tense ; temperature is 101° to 105° F. This continues for about one hour, and is followed by a hot stage. Hot Stage. — Chill gradually ceases, and patient begins to feel hot and flushed ; skin assumes a dry, burning feeling ; pulse is full and rapid ; temperature varies from 103° to 107° F. ; urine is scanty and feverish ; face puff ed ; headache in- tense ; spleen enlarged. This stage varies in duration from three to four hours or longer. Sweating Stage. — The dry, hot condition of the skin gives 48 ' A SYNOPSIS OF THE PRACTICE OF MEDICINE. way to profuse sweating, which continues for several hours and soaks all the bed-clothing ; tongue is moist ; temperature falls gradually to normal, and all symptoms disappear, leav- ing the patient weak and nervous for a short time, when there is a distinct intermission, during which he enjoys appar- ent health. Varieties. — Quotidian ague has a distinct paroxysm every day ; tertian ague, every other day, and is the most common form; quartan ague, every fourth day; double quotidian ague, two attacks daily; double tertian ague, one paroxysm every day, the alternate ones being most severe. One type may change to another or assume a remittent form. Masked in- termittent or dumb ague does not have three stages; one stage may be replaced by facial neuralgia, or, in fact, no other symptom may exist except periodical neuralgia dependent on malarial poison. II. Remittent Fever. Synonyms. — Bilious remittent fever ; marsh fever. Definition. — A paroxysmal malarial fever of hot climates, recognized by a high rise of temperature, with active symp- toms, followed by a short remission, in which temperature never falls to normal, and a return of all symptoms in a few hours. Symptoms. — Onset is sudden, with a slight chill, headache, restlessness, aching pains in the arms and legs, thirst, nausea and vomiting, high fever, 102° to 107° F. ; pulse full, tense, and rapid ; constipation ; delirium ; conjunctivae congested ; epigastric oppression or soreness. Remission in six to eighteen hours after onset, when sweat- ing begins and all symptoms lessen. Headache, nausea, and general pains cease, and temperature falls to 99° or 100° F. FEVERS. 49 (but never reaches normal during a remission), when patient sleeps calmly. In a few hours fever and all symptoms return with renewed vigor, but without an initial chill. Spleen is swollen and tender. Disease usually runs its course in one to three weeks, is quotidian in type, and may assume a typhoid form. Occasionally these cases run into chronic malaria, leaving such nervous symptoms as severe headache or local palsies. Jaundice often occurs, and may be mild or quite severe. III. Pernicious Malarial Fever. Synonyms. — Pernicious fever ; malignant, intermittent or remittent, fever 5 congestive fever. Description. — A malignant malarial fever, pursuing the same course as intermittent or remittent fever of the tertian or quotidian type, with the addition of intense congestion or hemorrhage from one or more internal organs, and general aggravation of all symptoms. Symptoms vary according to the organs affected. Fatality is mobt liable to follow second or third attacks. Cerebral Variety. — Intense congestion of the brain, effusion of serum into the ventricles, or cerebral apoplexy. There is delirium, stupor, or coma; pulse is slow and full; skin is either dusky or quite flushed ; delirium may be very violent and maniacal. Death is due to coma, meningitis, or compli- cations. Gastroenteric Variety. — Nausea, vomiting, bloody diarrhoea, anorexia, and intense thirst. Abdomen is not tender, but there is a sense of fullness or oppression in the epigastric region ; skin is cold and clammy. Symptoms may remit or intermit, and death ultimately ensue from exhaustion. Parox- ysms last about six hours. 50 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Thoracic or Pulmonary Form. — Great dyspnoea ; congestion of the kings, with all attending symptoms ; weak pnlse ; skin is dnsky and cold. Most fatal form. Algid Form. — Cold stage appears to be prolonged, even though the temperature is high, until pulse decreases and is finally lost ; body becomes cold ; temperature falls to 85° or 95° F. 5 voice is very faint ; expressionless face ; absolute clearness of the mind until death ; great thirst. May have vomiting and serous discharges from the bowels. Hemorrhagic Form. — It is closely allied to the congestive, and occurs in those who are subject to malarial attacks. Begins with a prolonged chill, epigastric distress, nausea and vomit- ing, headache, uneasiness, and deep jaundice. High fever soon follows ; great thirst ; pains over region of liver, stomach, and kidneys ; urine is smoky, and contains red blood-corpuscles. Epistaxis and intestinal hemorrhages, with signs of cerebral congestion. Uraemia ma}^ develop. During remission or intermission, all symptoms lessen or disappear. Liver and spleen are enlarged. Convalescence is very slow. Usually of the quotidian type. IV. Chronic Malaria. Description. — Persons who have been exposed to the mala- rial miasma for several years gradually become accustomed to its influences, and are not often seized with acute attacks. Such persons complain of general malaise, indigestion, ane- mia, high-colored urine, insomnia, headache, dizziness, ringing sounds in the ears, no fever, sore, tired feelings in the muscles and bones. The skin becomes brown or bronzed. Morris says, " The skin looks like an old, dirty buckwheat-cake." Spleen is enlarged, hard, tender, and occupies a large portion of the abdominal cavity j this enlarged spleen is called ague- FEVERS. 51 cake. Liver is often enlarged. In fact, the patient possesses a general cachectic appearance peculiar to malaria. General Pathology. — All forms of malarial fevers arise from the same cause, namely, a miasmatic poison or germ called the bacillus malarice. It is possible that this germ is most active in the lymphatic and circulatory systems, but its method of action, reproduction, and growth still remains in obscurity. Why the disease assumes a quotidian type in one person and a tertian in another is not known. Direct trans- fusion of blood from malarial to healthy patients during the active stage of the disease will reproduce the disease in the latter, although it cannot be transmitted by any other means from the sick. The cold stage is caused by a temporary con- traction of the superficial arterioles of the skin, causing poor circulation. Hot stage is produced by a relaxation of the cap- illary vessels and an unusual engorgement of the superficial vessels. Profuse sweating depends upon a lack of vaso-motor power and temporary loss of inhibition of the sudoriferous glands. Post-mortem examination shows an enlarged, hard spleen with thickened capsule and trabeculae [ague-cake) ; slight enlargement of the liver; blood contains pigmentary masses which adhere to the blood-corpuscles (melanamiia), most marked in remittent and pernicious fever; hyperaemia of the brain and other organs; general discoloration of the skin, spleen, and liver, from pigmentary deposits from the blood. Diagnosis. — Pyamiia is distinguished by peculiar hectic fever, irregularity of chills, causation and formation of ab- scesses. Intermittent fever has normal temperature during the intermission, while the temperature and symptoms of remittent fever never become normal during the course of the disease. Yellow fever is epidemic ; short in duration ; has one parox- ysm only; black vomit; clean or slightly coated tongue; 52 A SYNOPSIS OF THE PRACTICE OF MEDICINE. peculiar expression of the eyes ; delirium is mild or absent ; albuminuria • is self-protective ; does not respond readily to treatment. Prognosis. — Intermittent fever terminates in recovery or chronic malaria. Remittent fever affords a favorable prog- nosis. Pernicious fever is fatal in a large percentage of cases in a few hours to four days — death usually ensuing in the second or fourth paroxysm. Chronic malaria is amenable to treatment, but relapses very easily. Treatment. — Prophylaxis. — Avoid malarious districts ; or, if compelled to live in them, do not go out of the house dur- ing the night and early morning hours until the sun has cleared away fogs, for these afford an easy method of infec- tion. Do not drink water that is at all doubtful unless it has been previously sterilized. Keep the bowels active, and observe regular habits of diet, work, and rest. Avoid all unwholesome food. Thorough drainage and cultivation of marshy districts have done much toward eradicating malaria. Eucalyptus trees are said to absorb and destroy malarial poi- son, but modern research tends to disprove this, as their only virtue lies in absorbing moisture and breaking currents of wind which might disseminate the poison. Shrubbery and foliage of any kind will have the same action. Diet. — Vary diet according to symptoms, but it should gen- erally consist of liquid and farinaceous foods — beef broths and extracts, chicken-broth, baked potatoes, soft-boiled rice, milk, junket, tapioca, corn-starch, sago, boiled fish in mode- ration, soft-boiled egg. Medicinal Treatment. — During the Paroxysm. — If called immediately before or daring the chill, administer a hypoder- mic injection of morphina sulph., gr. }, and atrophia sulph., gr. t!o> which will abort or greatly mitigate a chill; put patient in bed ; cover him with blankets, and use hot- water FEVERS. 53 bottles. A full dose of spts. chloroformi, f 3j, or pilocarpine, gr. --re to i, hypodermically, will often answer. Hot Stage. — Greatest relief is afforded by a cold sponge- bath, cold, acid drinks, or a regular cold bath. Antipyretic drugs are too slow in action. Sweating Stage. — Cold sponge-baths with cold water and alcohol, or some mild astringent ; cold, acid drinks. Atropine, hypodermically, if sweating is profuse. Curative agents are useless during a paroxysm of intermittent fever. Intermission or Remission. — Induce active catharsis with calomel and salines. Cinchona and its preparations are the accepted remedies, and in order to prove efficacious must be pushed until the full physiological effect is produced, and that at least two hours preceding the anticipated attack. Quinine bisulphate or sulphate, administered by the stomach or per rectum, in doses varying from five to forty grains, beginning four to six hours before the anticipated paroxysm, and con- tinued every one or three hours until its full effects are pro- duced. When a paroxysm is aborted, give small doses of quinine until next day, when it must be increased as before at the time for the paroxysm. Continue this method every two, four, or six days until the twenty-first day is passed, when it is not likely to return unless patient is still exposed to the poison. Irritability of the stomach is lessened by calomel, gr. x^-, every hour ; arsenite of copper, gr. -^j-q, every fifteen minutes to half an hour, in solution ; small doses of morphina or cocaine. Hyperpyrexia requires cold baths and not antipyretic drugs. Headache is relieved by pill acetanilide comp. (form, p. 27), every half -hour. Congestive and hemorrhagic symptoms require symptomatic treatment as given in other parts of this work. 54 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Convalescence. — Give tonics of iron, quinine, strychnine, arsenic, and cod-liver oil, with, good, nourishing diet. Chronic Malaria. — Change residence to a non-malarious dis- trict ; keep bowels active every day with cathartics. Quinine is not of much benefit. Arsenic is the best remedy, and should be pushed to the point of tolerance and used for long periods of time. Salts of mercury and iodides are sometimes given with advantage. Enlarged spleen (ague-cake) is reduced by inunctions of red iodide of mercury and lard, baked in before a hot fire ; cold douches over the spleen are beneficial; galvanism is some- times used. [Note. — Many remedies are recommended in malarial dis- eases, but none yet mentioned will take the place of quinine, which may be termed almost a specific if properly adminis- tered. Malaria can never be wholly eradicated from the sys- tem as long as patients live in malarial districts.] ERUPTIVE FEVERS. VARICELLA. Synonym . — Chicken-pox. Definition. — A specific, infectious, eruptive disease, mani- festing itself by slight febrile reaction and successive crops of smooth vesicles on all parts of the body, at the end of twenty- four hours, which desiccate rapidly and leave a small scab. Etiology. — Due to a specific germ, that is communicated by direct contact. Often epidemic. A disease of childhood. Symptoms. — Slight malaise ; low fever ; pulse slightly in- creased ; loss of appetite ; thirst ; constipation. Disease may begin with a rigor, chill, chilly sensations, or a convulsion, followed by a temperature of 103° F. The eruption, pri- FEVERS. 55 marily, is erythematous, and changes in a few hours to a soft papule. At the end of the first twenty-four hours, distinct vesicles, filled with a clear or white serous fluid, appear. When punctured these vesicles collapse. It may come in crops, during several days, on the face, trunk, and extremities. Vesicles sometimes form in the mouth and throat. In three or five days these vesicles rupture spontaneously, and small scabs form and fall off in six to ten days. A few isolated vesicles may become pustular, but this is most common in cases where there is uncleanliness. Cicatrices are not the rule, but may follow severe cases. A mild attack may be overlooked by careless parents. Diagnosis. — May be confounded with variola during onset or vesicular stage, but the mild constitutional symptoms, time of eruption, complete collapse of vesicles when punct- ured, absence of general pustules, and secondary fever serve to characterize varicella. Prognosis. — Death is extremely rare, and is caused by com- plications. Treatment. — It is wise to put the child in bed and isolate him until the disease is past, even though the case is very mild. Administer a mild cathartic, and follow with some mild fever mixture, such as aconite, liquor ammonii acetatis, and simple syrup. Light diet. Watch for complications. If pitting is feared, treat locally as in variola (p. 60). VARIOLA. Synonym .—Smallpox. Definition. — An acute, epidemic, specific, eruptive, conta- gious fever, recognized by the sudden onset of fever and the appearance of a papular rash over all parts of the body on the third day, which becomes vesicular, then pustular, and 56 A SYNOPSIS OF THE PRACTICE OF MEDICINE. finally forms a scab that falls off about the twenty-first day, leaving a pitted cicatrix and always accompanied by second- ary fever during the stage of pustulation. Varieties. — Discrete variola ; confluent variola ; malignant variola ; mitigated variola, or varioloid. Etiology. — The exciting cause of the disease is undoubtedly a germ, as yet not isolated. Contagion, directly or indirectly, is its only means of origin, for the disease never arises de novo. Debilitated and unvaccinated persons are most sus- ceptible to it. One attack usually prevents another. Negroes have a peculiar susceptibility to variola. Incubation is twelve to fourteen days. Symptoms. — Discrete Variola. — Onset is sudden, with a chill or rigor; great pain in the lumbar region, head, arms, and legs ; nausea ; and fever varying from 102° to 105° F. Tongue is coated; anorexia; constipation; occasional delir- ium ; and full, tense, rapid pulse. Eruption. — On the third day, following onset, erythematous spots appear, first on the forehead, face, and neck, and, later, on all parts of the body. On the fifth day these spots become papules, which feel like shot under the skin. At this period the fever and acute symptoms lessen, or, in some cases, sub- side entirely. On the sixth day the papules become vesicles which are depressed in the center (umbilicated) and do not collapse when punctured. About the eighth day the vesicles become pustular, and are soon surrounded with a band of dark-red, swollen skin. On the eleventh or twelfth day pus begins to exude from the pustules, and soon forms a hard, in- spissated mass or scab which does not fall until the eighteenth or twenty-first day. A red, depressed or pitted cicatrix re- mains for several weeks or months, and ultimately becomes white. Secondary fever of a severe type and general aggravation FEVERS. 57 of all symptoms begin on the eighth day, when the eruption becomes pustular, and continue three to five days. There is a peculiar, indescribable odor present in all cases of variola, most marked during the stage of pustulation. Confluent Variola is a more severe form, and is character- ized by an aggravation of all symptoms, but more especially the eruption, which is so abundant that the vesicles and pus- tules coalesce in many places, causing intense swelling, pain, fever, and large cicatrices. Mucous membranes are more liable to become involved and complications are greater. Eruption may appear a few hours earlier than in discrete variola. Malignant Variola, black smallpox, or hemorrhagic variola is recognized by a sudden onset with hyperpyrexia, delirium, convulsions, and slight or very severe and fatal hemorrhages from the mucous membrane of the stomach, nose, lungs, kidneys, or uterus. Eruption appears within twenty-four or forty-eight hours ; is very thick and dark in color ; whole body is covered with petechia?. Recovery from malignant variola is rare. Mitigated Variola, or Varioloid, is a mild disease occurring in those persons who have been protected by previous vacci- nation or second attacks of variola. All symptoms are mild ; eruption is scattered and does not generally become pustular j hence secondary fever is rare. Complications and sequelce are pneumonia, ptyalism, pleu- risy, erysipelas, purulent conjunctivitis, keratitis, otitis media, obstinate diarrhoea, pyasmia, abscesses, caries, and paralysis of the bladder, larynx, or extremities. Pathology. — The exact pathological process of variola is not understood. It is undoubtedly due to a specific germ, which is most active in the vesicles, pustules, and scabs formed, The characteristic lesions of variola begin in the 58 A SYNOPSIS OF THE PRACTICE OF MEDICINE. papillary layer of the skin, and are frequently situated over a hair follicle or glands, which may account in part for um- bilication of the vesicles. Each vesicle is subdivided into small compartments (loculated) by bands of fiber, and will not collapse when punctured. Fatty degeneration of the liver, heart, and kidneys is found post-mortem. Diagnosis — Measles, acute syphilis, and varicella may be mistaken for variola in the onset, but the characteristic symp- toms of the latter, already described, and the presence of an epidemic will serve to differentiate. Prognosis. — Discrete variola usually terminates in recovery. Confluent variola is fatal in nearly fifty percent, of the cases. Malignant variola is almost invariably fatal. Varioloid rarely causes death, and is short in duration. Unfavorable signs are hyperpyrexia, wild delirium, high secondary fever, multi- ple abscesses, pneumonia, or any grave complication. Treatment. — Prophylaxis. — Isolation must be enforced, and the most stringent restrictions adopted to prevent spread of the disease (see p. 21). Vaccination is probably the safest prophylactic measure. Vaccination consists in inoculating the body with virus taken from the vesicle of a cow suffering with cowpox, or from the scab or virus taken from the vesicle of a healthy person who has been vaccinated. The best method of inocu- lation consists in scraping away the upper layer of the skin on the arm or leg, rubbing in the moistened virus, and allow- ing it to dry. If it is successfully inoculated it begins to grow red, and, on the third day, a small vesicle forms at the point of inoculation, which becomes umbilicated or depressed on the sixth day. About this time there is some fever, rest- lessness, anorexia, and a general sick feeling in most cases. About the eighth day the vesicle becomes a pustule, sur- rounded with a distinct, pink or red areola ; the arm some- FEVERS. 59 times swells to enormous size, and is very painful. From the tenth to the twelfth day the pustule begins to dry, and by the fourteenth day a hard, brown scab is formed, which falls off on the twenty-first or twenty-third day, leaving a distinct cicatrix which persists for life. Vaccination is often accom- panied or followed by a papular eruption, which will soon disappear and need cause no alarm. Persons who are vacci- nated are afforded immunity from true smallpox, and when it is contracted it is usually varioloid and rarely fatal. This is not an absolute preventive, for true variola may occur in those who have been vaccinated previously. The patient shoidd be kept in bed in a dark, well- ventilated room. No known remedy seems to shorten or mitigate the course of variola. Begin treatment by the administration of a free calomel purge. Full doses of salicylate of soda, gr. v-xv, every two hours, will relieve pains and fever during the onset. Hypodermics of morphina must be given in extreme pain. Salol, gr. ij-v, or sulphocarbolate of zinc, gr. j-v, every four hours, is frequently given during the whole course of the disease with benefit. Insomnia is met by full doses of chloral or the bromides. Hyperpyrexia requires the cold bath, to be followed by a mild fever mixture, pill acetanilide comp. (form, p. 27), or any other desirable antipyretic. Three or four sponge-baths should be given during the clay, with a cold antiseptic solu- tion of acid bichloride of mercury. Watch the heart, and begin to stimulate freely whenever it shows signs of weak- ness. Tonics of iron, quinine, strychnine, and arsenic. Full doses of cocaine are said to prevent the violent form of erup- tion, confluence, and pitting : this is questionable. Diet should be bland, nutritious, and liquid, and must be given at intervals of three or four hours. Milk, bovinine, scraped beef, soft-boiled egg, animal-broths, oyster-broths,, 60 A SYNOPSIS OF THE PRACTICE OF MEDICINE. and beef-exteacts. Water should be given in small amounts at frequent intervals ; cracked ice is permissible ad libitum. Sore throat requires astringent, antiseptic washes and gar- gles. Peroxide of hydrogen, glycerine, and water. Diarrhoea is usually controlled by salol or sulphocarbolate of zinc, but may require more astringent medication. Open large abscesses, and treat antiseptically without poul- tices. To avoid disfigurement and jutting, the room must be kept dark and the exposed parts covered with some antiseptic unguent, powder, or wash. My own preference is given to the constant application of a cold antiseptic solution of acid bichloride of mercury, one to five or ten thousand, or peroxide of hydrogen, one to four, exercising care to keep the parts thoroughly cleansed and the cotton dressing changed fre- quently. Collodion, carbolic acid, ung. zinci oxidi, and boric acid are recommended as local applications to prevent pitting. SCARLATINA. Synonym. — Scralet fever. Definition. — An acute, specific, contagious, self-limited, self-protective disease of childhood, manifesting itself by a sudden onset with a chill, rigors, convulsions, or vomiting, followed by high fever, sore throat, and the appearance of a bright-scarlet, uniform rash over the whole body, at the end of the first twenty-four or thirty hours, gradual defervescence, and desquamation of the epithelial layer of the skin at the end of the seventh or tenth day. Varieties. — Scarlatina simplex ; scarlatina anginosa ; scar- latina maligna. Etiology. — Due to a very active, specific germ, not yet iso- lated. It is the most contagious of children's diseases, and can be carried to any distance by books, letters, clothing, and FEVERS. 61 careless persons. One epidemic in England was caused by milk from one cow where the disease existed. The vitality of the germ is not lessened by age, for cases originate from toys, books, and clothing that have been used by infected persons years before. Most common among children. Very young infants and adults are not so susceptible ; women who have recently been confined show a peculiar susceptibility to it. Period of incubation is about one week. Symptoms. — Scarlatina simplex. — Patient may be peev- ish, cross, restless, and complains of slight sore throat and headache for a few days before the onset. Invasion is sudden, with a chill or rigor, intense headache, nausea or vomiting • a temperature of 103° to 105° F. ; rapid pulse and quickened respiration; skin is dry and hot. Throat is sore, dry, and red ; tongue is coated, red at the tip and edges, and papillae prominent. In twenty-four or thirty hours after the onset a scarlet eruption appears on the face and neck, and spreads rapidly in a few hours to the whole body. This eruption consists of minute points, with a distinct areola around each point, which coalesce and form a uniform redness with no interven- ing healthy skin. Parts of the body may be entirely free from the eruption. On the fourth day following the onset the rash begins to fade, and on the seventh or tenth day des- quamation begins. The skin is first scaly or rough in appear- ance, and soon large flakes or pieces of epidermis can be peeled off — especially so on the hands and feet. Desquama- tion continues until the fifth or sixth week after onset. Soreness of the throat and tongue is most severe after the third day; tongue presents a strawberry appearance, and is often fissured and dry • lips crack, and are covered with a thick, hardened sordes and epithelium ; temperature remains high, 103° to 107° F., for three days ; delirium is a common 62 A SYNOPSIS OF THE PRACTICE OF MEDICINE. symptom. Diarrhoea may supervene. As the rash fades, the temperature and all symptoms subside by lysis. Scarlatina anginosa pursues the same course as the sim- ple form, except that the throat symptoms are greatly aggra- vated. Throat is very sore, ulcerated in patches, and covered with a thick, offensive, tenacious, yellow or white exudation. Cervical glands and tonsils are swollen, and abscesses often form in them. Deglutition and breathing are quite difficult. Inflammation not infrequently spreads to the middle ear, producing a suppurative otitis media with permanent loss of hearing. The Schneiderian mucous membrane, conjunctivae, and cornea are often involved through extension of the in- flammation by continuity of structure. Scarlatina maligna is a fatal form of the disease. Onset is violent and sudden, with convulsions, great prostration, a purple, petechial eruption, hyperpyrexia, and death in one to four days. Complications. — Acute tubular nephritis is the most com- mon complication, and may occur at any stage of the dis- ease. Urine is smoky; contains albumin, red blood-cells, and tube-casts. It is liable to assume a chronic form with dropsy. Latent tuberculosis is often brought into activity by an at- tack of scarlatina. Endocarditis and rheumatism often accompany or follow scarlatina. Diagnosis. — Must be distinguished from morbilli, rotheln, and variola. Typical cases are so distinctive that mistakes in diagnosis are inexcusable. Care must be taken not to confound scarlatina anginosa with time diphtheria, Prognosis. — A positive prognosis is impossible, as mild cases often assume the worst forms. Mild, uncomplicated cases usually recover promptly. Always caution parents of FEVERS. 63 possible sequelae and complications. Puerperal cases are mostly fatal. Treatment. — Isolation and prophylactic treatment as given on page 21. It is questionable whether any known remedy will limit the course of scarlatina. Objectionable symptoms and complications can be greatly mitigated. Begin treatment with a good cathartic. Triturates of calomel, gr. ^ every half-hour, will relieve nausea and vomiting and produce cathartic action. Follow this with : Infus. digitalis f 5 iij. Liq. ammonii acetatis f 1 ss. Syr. aurantii floratis q. s. ad. f ? iv. M. Signa. One teaspoonful every three hours. Digitalis must be pushed to its full extent to produce good results. It is diuretic, a heart-tonic, lessens fever, and aids in preventing complications. In addition to this, give the following to reduce fever and favor the appearance of the eruption : Tr. aconiti radicis. Tr. belladonnae aa. gtt. xxx. Tr. rhois toxicodendron gtt. x. Aquas q. s. ad. f I iv. M. Signa. One teaspoonful every hour until the rash has properly appeared, then every two or three hours. If the temperature remains above 103° F., give cold sponge- baths at intervals of two or four hours in preference to anti- pyretics. For the sore mouth and throat, use a wash of chlorate of potash and boric acid ; or a very desirable com- bination is : 64 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Hydrogen peroxide. . (15-volnme sol.) f?ij. Sol. cocainae hydroeliloratis . . . .(4 %) gtt. x. Mel. despumati vel mel. rosae f I ss. Aquas q. s. ad. f J iv. M. Signa. Use freely as a mouth-wash, gargle, or spray. If too strong, dilute with pure water. When the tongue is dry and parched, apply borax and glycerin several times daily with a soft brush. For the dry condition of the lips apply tallow, 3 j, and spts. camphorae, gtt. x. Ice and carbonated waters for thirst. During exfoliation use some good antiseptic ointment or wash. Bathe several times daily with a good antiseptic wash. Follow, during convalescence, with tonics of iron and strych- nine. Meet complications as they arise. Diet should be light, nutritious, and unseasoned. Milk, butter-milk, vegetable and animal broths, rice, tapioca, sago, and small amounts of game and fish. Orange- juice may be used freely at all periods. MORBILLI. Synonym . — Measles. Definition. — An acute, contagious, self -protective, self -lim- ited, epidemic fever of childhood, recognized by sudden onset, marked catarrhal symptoms of the eyes and respiratory tract, and the appearance of a diffuse rash on the fourth day. Etiology. — A disease of childhood, but may occur in the adult. Young children are not very susceptible. Always caused by direct or indirect exposure to some previous case. The germs of morbilli are often carried by physicians, nurses, and visitors to other children. There seems to be no special FEVERS. 65 predisposition on the part of delicate children. It is most contagious during the catarrhal stage and period of desqua- mation. Period of incubation is about ten days. Symptoms. — Child is restless, peevish, flushed in the face, nauseated, and has little appetite. A chill, rigor, convulsion, or chilly sensations herald the onset. Temperature is 102° to 104° F. ; eyes are red, swollen, and have a suffused, liquid appearance ; photophobia ; catarrh of the nasal mucous mem- brane, with profuse, watery and irritating discharge ; tongue is covered with a white fur ; pharynx is red and congested ; a very annoying, dry, hacking cough. Diarrhoea may occur. On the second or third day the temperature may fall to nor- mal, but rises suddenly at the end of the third day or the beginning of the fourth. Eruption, on the fourth day, appears on the forehead and neck, and gradually spreads to all parts of the body. It con- sists of slightly raised, crescentic, and irregular erythematous red spots, with healthy skin intervening. It begins to fade in three days, assuming a brown, a pale-yellow, and then a light color, and disappears from the face first. All symptoms begin to subside when the rash reaches its height, and by the ninth day disappear. Rash is followed by a desquamation of fine, bran- like scales, accompanied by mild or intense itching of the skin. Varieties. — Malignant, hemorrhagic, or black measles be- gins suddenly with great aggravation of all symptoms and hyperpyrexia. The rash becomes petechial, hemorrhagic, and of a dark-purple or black color. Haemoptysis is common. These cases are usually fatal. Morbilli sine catarrho vel sine eruptione — measles without catarrh or eruption — is very doubtful, although such cases are described. Complications and Sequela?. — Conjunctivitis ; ophthalmia ; 66 A SYNOPSIS OF THE PRACTICE OF MEDICINE. otitis media ; chronic nasal catarrh ; chronic laryngitis ; acute catarrhal pneumonia ; tuberculosis ; noma ; parotitis j stoma- titis j hypertrophy of the tonsils ; and general debility. Pathology. — No distinct pathological process has been dis- covered, but the disease is undoubtedly dependent on a germ for its activity. Diagnosis. — No disease should be mistaken for morbilli after the characteristic eruption occurs on the fourth day. Scarlatina is ushered in by a very high fever, no catarrhal symptoms about the eyes and nose, and the appearance of a uniform scarlet rash at the end of twenty-four hours. Morbilli in the colored race is diagnosed by the catarrhal symptoms, time of the eruption, and the appearance of patches of irregular, crescentic form, not red, but of a coppery color, and much different from the natural black skin. Prognosis. — Uncomplicated cases recover promptly. Ma- lignant cases terminate fatally. Latent tuberculosis may be brought into activity by an attack. Treatment. — Specific medication is entirely out of the question, as nothing appears to limit its course. The main treatment lies in regulating hygiene and diet, preventing complications, and relieving objectionable symptoms. Keep the room dark to prevent eye-complications. The following combination relieves cough, lessens fever, and prevents tend- ency to congestions : Tr. aconiti radicis. Tr. rhois toxicodendron. Tr. belladonnse aa. gtt. viij. Morphinaa sulpha tis gr. j. Aquae q. s. ad. f 1 iv. M. Signa. One teaspoonful every two or three hours as needed. FEVERS. 67 Bathe frequently with some cold or tepid antiseptic solu- tion. During desquamation, use an unguent or antiseptic wash to relieve itching and prevent spread of the scales. Malignant morbilli must be treated symptomatically, and free use made of cold baths and stimulants. In all cases keep up a free action of the bowels. Check diarrhoea with appropriate remedies. In marked nervous symptoms or convul- sions immerse the child's body to the neck in hot water, and apply ice to its head. Continue this for any length of time necessary to give relief. Best diet and tonics during conva- lescence. If the eyes are greatly affected, use an eye-wash of boric acid, gr. x, in water, 1 j, frequently. ROTHELN. Synonyms. — Rubeola ; roseola ; rubella ; false measles ; German measles; French measels. Definition. — An acute, contagious, epidemic, eruptive, self- limited f ever, recognized by sudden onset with a chill or slight catarrhal symptoms, and the appearance of an irregular dis- crete eruption, from the first to the third day, similar to morbilli. Etiology. — Is certainly caused by a distinct germ, not yet isolated. Contagious. Rotheln is not a hybrid variety of morbilli and scarlatina. Adults are frequently affected by it. Period of incubation is about ten days. Symptoms. — Prodromal symptoms are usually absent. Onset is marked by a rigor, chill, convulsion, or chilly sensa- tions, nausea and vomiting. Throat is slightly sore; eyes are red ; lachrymation is profuse ; coryza and sneezing. The cervical lymphatic glands are swollen and tender ; slight or severe cough; headache. Fever is very slight or entirely absent. 68 A SYNOPSIS OP THE PRACTICE OP MEDICINE. Eruption appears on the first, second, or third day on the face, neck, and chest, gradually spreading to other parts of the body, and lasting about two or three days. Eruption is composed of numerous very small, rose-colored or pink, round or oval spots, distinctly isolated, and rarely coalescing to form crescentic patches. It is slightly elevated, very itchy, and, when it subsides, fine scales desquamate. The eruption may fade away and reappear again without harm. Compli- cations are not common, pneumonia and nephritis being the principal ones. Diagnosis. — Morbilli has severe catarrh, higher fever, ap- pearance of a crescentic rash on the fourth day, longer in duration, more severe sequela?, and extensive desquamation. Scarlatina has very high fever, absence of catarrhal symp- toms, a confluent scarlet rash, desquamation in large patches, severe sequelae, and great prostration. Prognosis. — Most cases recover in one week or ten days. Treatment. — Pursue the same general symptomatic treat- ment as in morbilli. DENGUE. Synonyms. — Break-bone fever ; dandy fever. Description. — It is a disease of tropical and hot climates, whose distinct cause is unknown. Some authors claim it to be of the malarial type, but this is very doubtful. It is an acute, infectious, epidemic disease, whose period of incubation varies from three to six days. Onset is sudden, with severe pains in one or more of the joints and back ; a severe, boring pain in the shafts of the long bones, shifting from one part of the body to another ; high fever ; headache ; nausea ; stiffness of the muscles ; and severe pains in the eyes. Sometimes a uniform red rash appears with the primary fever, and sub- FEVERS. 69 sides in one or two days with the fever, by lysis or crisis, leaving the patient weak, anxions, or exhausted. In two or three days fever returns as before, and a diffuse red rash similar to scarlatina appears on the face, neck, and hands, and spreads to the whole body. It often resembles the eruption of urticaria, and is very itchy. Fever subsides, pains dis- appear about the eighth day, and desquamation of the skin ensues. Relapses are of frequent occurrence; some cases pursue a chronic course for months or years, leaving the joints deformed or anchylosed. It is rarely fatal except in very young or old people, or persons suffering with old chronic diseases. It is differentiated from acute rheumatism and scarlatina by its short duration, relapses, character of the eruption, and the epidemics. Treatment. — Stimulate the emunctories by a free purge, free diaphoresis, and diuresis. For the pains, give full doses of the salicylates, salol, acetanilide, phenacetin, or pill acet- anilide comp. (form, p. 27). Avoid opium unless absolutely necessary. Antiseptic, carbolated washes or unguents to the skin to relieve pruritis. Frequent cold baths ; good, stimulat- ing diet ; and, during convalescence, massage and inunctions of hot olive-oil or lard, two or three times daily, around the affected joints. ERYSIPELAS. Synonyms. — St. Anthony's fire ; the rose. Definition. — An acute, contagious, specific, eruptive fever, manifesting itself by sudden onset with a chill, high fever, and. local or diffuse inflammation of the skin and subcuta- neous tissue of the face or other parts of the body. 70 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Etiology. — It is caused by the entrance of the Micrococcus erysipelatis into the blood or lymphatics through some abra- sion of the skin, be it a slight scratch or a severe surgical wound. Medical and surgical erysipelas are one and the same disease, due to the same cause ; the latter occurring after surgical operations, and is more extensive. It is contagious, and often becomes epidemic in surgical and obstetrical wards. Very young and old people are most susceptible to its influ- ence. Those who are debilitated by chronic or acute dis- eases, those subject to exposure to severe cold, bad hygiene and diet, are most susceptible. The face is most commonly affected. Period of incubation varies from three to seven days. Symptoms. — Onset. — There may be a feeling of uneasiness or general malaise for one or two days, followed by a rigor or chill, high fever, headache, nausea, anorexia, and, possibly, diarrhoea. A few hours later there is a stinging, burning, or itching sensation at one spot on the face, nose, or ear, at the point of inoculation. On examination this spot is red, swollen, and tender. A small vesicle or papule forms. Inflammation soon spreads to the whole face and scalp j skin is swollen, red, tense, hot, shiny, and covered with small vesicles. It is much darker red in the central area, and shades off in color to a dis- tinct line of demarcation between the affected and healthy skin. Pain, burning, itching, and throbbing are very severe at times ; glands of the neck are swollen ; throat is sore ; and general depression is marked. In five to seven days inflam- mation and severe symptoms begin to subside, and exfoliation of the epidermis ensues on the affected area. Small or large a,bscesses not infrequently form. Temporary albuminuria may be present. Phlegmonous Erysipelas is a more severe type of the sim- ple variety, and is accompanied by more severe constitutional FEVERS. 71 symptoms, delirium, and coma. Multiple or single abscesses form in the cellular tissue, and the local manifestations are more severe, although confined to a limited area. Death is caused by general depression, exhaustion, pyaemia, oedema of larynx and pharynx, or meningitis. Pathology. — The primary lesion in every case is some abra- sion of the skin through which the Micrococcus erysipelatis gains entrance. The germ grows, reproduces itself, and forms ptomaines which act as a local irritant, causiug inflammation. As a result of the irritation and inflammation, small vesicles form j swelling results, together with redness and pain. The virus travels through the lymphatics to the subcellular tissues and lymphatic glands, where it is checked. Ptomaines are carried into the geueral circulation and produce constitutional symptoms. Abscesses are due to a mixed microbic infection — that is, the introduction of pyogenic germs in addition to the germs of erysipelas. Diagnosis. — Easily distinguished from all other affections by sudden onset, fever, local inflammation with a shiny, tense skin covered with small vesicles, a distinct line of demarka- tion, and possibility of contagion. Prognosis. — Simple erysipelas is rarely fatal. Phlegmonous erysipelas requires a guarded prognosis, and is very fatal. Puerperal erysipelas usually terminates in death. Treatment. — Local Measures. — The disease being due to a germ, local applications should be antiseptic and non-irritat- ing. Poultices should be avoided, as they favor suppuration. Make constant applications of acid bichloride of mercury (1 to 3000) and never allow the parts to become dry. Peroxide of hydrogen acts admirably if applied constantly, either in its purity or diluted. A one-percent, solution of fuchsin, painted over the parts, forms a coating impervious to gases and liquids. Cures are reported from a few applications. Open vesicles as 72 A SYNOPSIS OF THE PRACTICE OF MEDICINE. they form, and pursue most scrupulous cleanliness and anti- sepsis. Applications of iodine, solutions of iron, nitrate of silver, and others act as local antiseptics, but are objectionable on account of discoloration of the skin. If seen early, when it amounts to a mere point or very small area, multiple incisions around the outer zone of demarkation, made sufficiently deep to sever the lymphatic vessels leading from the part, and local antisepsis often cut it short. Open abscesses freely, and treat antiseptically without poultices. Constitutional Measures. — Administer a saline cathartic, and see that it acts freely. Establish diaphoresis with fluid extract of jaborandi, gtt. xx, every two to four hours, admin- istered with hot drinks. The jaborandi treatment is claimed to cut every case short if continued several days. Pilocarpine, gr. J, hypodermically. Tonics of iron and quinine, every four hours, aid materially in cimng the affection. Give most nutri- tious, stimulating diet, and insist on rest in bed. Antipyretic measures are unnecessary except in high fever, in which case use cold baths. Use every measure to prevent contagion, and do not attend cases of confinement at the same time you are treating erysipelas. GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. CHOLERA. Synonyms. — Asiatic cholera 5 epidemic cholera; sporadic cholera. Definition. — An acute, specific, epidemic or endemic, infec- tious, malignant disease, recognized by sudden onset, profuse vomiting, severe cramps, rice-water stools, collapse, and death in a few hours or days. Etiology. — The direct cause of the disease seems to be the Spirillum cholerw or comma bacillus of Koch, which is an aerobic germ and is carried by drinking-water, milk, food, and the stools of the patient. Decaying vegetable matter, intense heat of a dry season, bad hygiene, over-crowding, summer complaints, and carelessness predispose to its development. Although hot weather favors its development, some of the worst epidemics have occurred in Russia in midwinter. The germs may be carried in rags, merchandise, and letters. It is not self -protective. Period of incubation varies from two to seven days. Symptoms. — Cholera is usually preceded for a few hours or days by a feeling of lassitude, uneasiness, slight headache, lack of appetite, occasional dizziness, slight diarrhoea, and weakness. There is a distinct chill or chilly sensations, accom- panied by epigastric and abdominal pain, nausea, coated tongue, bad taste in the mouth, and profuse diarrhcea. At 73 74 A SYNOPSIS OF THE PRACTICE OF MEDICINE. first the diarrhoea contains fecal matter, but it changes in quality to an opaque, copious, or colorless fluid which is passed every few minutes or seconds. These so-called rice- water stools are alkaline in reaction, have a specific gravity of about 1009, contain albumin, and deposit a fine mass of leucocytes, mucus, epithelium, shreds of tissue, salts, and bacteria. These passages are accompanied by gurgling and rumbling sounds, but with little tenesmus or pain. Blood may be mixed with them. Vomiting is slight, but soon becomes obstinate, and consists of clear " rice-water" fluid. Little effort is required in vomit- ing. The tongue is dry and covered with a heavy white coating. Severe cramps of the legs, feet, hands, and body accompany the latter stage of vomiting and purging. Urine is scanty or suppressed and contains albumin. Pulse is rapid and there is slight fever. Collapse (Algid Stage). — At any period from one hour to several days after the onset the temperature in the mouth and axilla falls from 89° to 80° F. ; the skin is cold • breath feels cold ; respiration is rapid and shallow ; great restless- ness 5 diminution or loss of voice ; continued vomiting ; eyes sunken and hollow ; general wasted appearance ; purging may cease, and the mind remains perfectly clear. Vaginal or rec- tal temperature may be 103° F., during collapse, while that of the mouth and axilla may be 90° F., or lower. Collapse may last from six to twenty-four hours, when death comes or reac- tion sets in. Reaction. — Temperature begins to rise, and may reach 105° F. j pulse strengthens; vomiting and purging cease; skin begins to get warm, and assumes a more natural appearance ; urine is increased in amount, and may show albumin and casts ; msij be a rash of erythema or urticaria on the trunk, arms, and legs, which lasts for several days. Rapid recovery GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 75 or slow convalescence with a typhoid condition for several weeks. Complications may occur at this time — bed-sores, pneu- monia, parotitis, and abscesses. Pathology. — The weight of medical testimony points to the comma bacillus of Koch as the true cause. It develops in the gastro-intestinal canal, and produces the various symptoms by a process which is unknown. Rigor mortis persists for a much longer time than usual. Decomposition is delayed. Lungs and serous membranes are congested and red. Intes- tines are congested and swollen. Pyer's glands are promi- nent, and contain an opaque fluid. All glands in the intes- tines are enlarged, and the tissues relaxed. In prolonged cases the mucous membrane of the bowel is eroded and ulcerated. Kidneys are enlarged as in acute Bright's disease. Spleen is diminished in size. Diagnosis. — Cholerine consists of a choleraic diarrhoea or the symptoms of the onset of true cholera • absence of intense muscular cramps and collapse ; short in duration ; absence of albuminuria and ursemic symptoms. Arsenical poisoning is distinguished by the history; short duration; presence of arsenic in dejecta; not epidemic, and absence of comma bacillus of Koch. Prognosis. — True Asiatic cholera is mostly fatal within six hours to seven. days. Epidemics vary in mortality and sever- ity. Convalescence is prolonged and tedious. Treatment. — Prophylaxis. — During an epidemic use noth- ing but thoroughly sterilized water, milk, and food. Light wines may be used, but not the stronger alcoholics. Excesses of all kinds must be avoided. Bowels should be kept active by mild salines if necessary. Daily exercise in the open air. Close confinement must be avoided. A daily, cold sponge- bath before retiring is beneficial. Every case of diarrhoea, even if mild, must be treated at once by mild liquid and 76 A SYNOPSIS OF THE PRACTICE OP MEDICINE. farinaceous diet, and intestinal antiseptics every two to four hours. (Sulphocarbolate of zinc, gr. iij ; salol, gr. iij • beta- naphthol; salicylate of bismuth.) If there is purging use copious injections of warm water containing an astringent. Thoroughly disinfect all stools, isolate patient and attendants (see p. 21). Active Treatment. — Never resort to the use ofmorplmia or opium hypodermically or by the mouth, except as a last resort to relieve intense pain. Camphor gives best results and is used in the form of a wine. Pulv. camphorae gr. Ixxv. Alcoholis q. s. Vini rubri O j . M. Signa. One small wineglassful, to an adult, every hour. This often limits vomiting, diarrhoea, and cramps, and pro- duces diuresis. Salol or sulphocarbolate of zinc, gr. v — x, every hour, are the best remedies, and should be pushed to their full extent. Dilute sulphuric and hydrochloric acid should be used in the water that is given. Enteroclysis or thorough washing out of the bowel. Use a fountain syringe, without much pressure, and inject two to four quarts of water (100° to 105° F.) to which have been added tannic acid, 3ij, and wine of opium, ffij to Oij. If possible make the injection, which should always be given in the recumbent position, pass the ilio-caecal valve. Repeat the process hourly, or keep up a constant flow if necessary. The use of antiseptics in enteroclysis is objectionable on account of toxic symptoms. When the skin becomes inactive and cold, and collapse is threatened, rub the body for a few minutes with a rough towel GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 77 and cold water, and follow at once with a hot bath (118° F.) for ten or thirty minutes, using the camphor- wine and other stimu- lants as indicated. Intravenous injections of a normal aseptic, saline solution (seven parts to one thousand, at 102° F.), or Irypo- dermic injections of saline solution into the subcutaneous tis- sues (hypodermoclysis). Harkins recommends the " application of blistering fluid behind the ear and along the course of the pneumogastric nerve as far as the angle of the jaw." It has been shown to stop purging and other characteristic symp- toms and tide the patient over the worst stage of the disease, cure or abort it. As soon as stomach and bowels react, ad- minister concentrated, predigested meat juices and milk at intervals of three or four hours. DIPHTHERIA. Synonyms. — Malignant sore throat ; membranous angina j putrid sore throat ; synache maligna. Definition. — An acute, systemic, specific, contagious, epi- demic or endemic disease, recognized by constitutional symp- toms, albuminuria, and the presence of a tough, ashy or gray- ish-white false membrane on the mucous membrane of the fauces and throat, and terminating with characteristic sequela?. Etiology. — Caused by a germ whose identity is not posi- tively demonstrated. Most common among children from the second to the tenth year, but may occur in adults. A disease of cold weather, and is epidemic. Directly contagious from saliva, breath of patient, or from soiled clothing. Filth, made ground, bad hygiene, and crowding favor its development. The germs may be conveyed in water, milk, food, or ice. Cats and pet animals frequently carry it. Period of incuba- tion varies from two to six days. 78 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Symptoms. — Onset may be gradual, with loss of appetite, headache, muscular soreness, slight fever, and to all appear- ances an ordinary sore throat. It may begin suddenly with a chill, chilly sensations, headache, backache, rise of tempera- ture to 102° F., enlarged cervical glands, sore throat, painful deglutition, great prostration, and coated tongue. During the first few hours or days the throat is red, congested, and swollen, and shows one or more white points on the tonsil, fauces, or palate. These spots may enlarge rapidly, and cover half of the throat in twelve or twenty-four hours, or spread slowly. This exudation ov false membrane is an ashy or gray- ish-white ; quite thick and tenacious ; is hard to detach ; leaves small bleeding points and soon reforms. In one or two days the throat begins to ulcerate ; breath is very offensive j bits of the membrane are coughed and spit up. A part or the whole of the throat may be involved. Lymphatic glands, at the angle of the jaw, enlarge and are very tender ; temperature rises to 104° to 105° F. ; pulse is weak, and prostration marked. Urine is scanty, high-colored, and contains albumin and casts. The membrane may extend to the nasal cavity (nasal diphtheria), and is recognized by an excoriating discharge, occlusion of the nose, epistaxis, great fetor, and frontal headache. It may extend to the larynx (membranous laryngitis; membranous croup), and is recog- nized by hoarseness, loss of voice, and croupy symptoms. May extend to bronchi ; Eustachian tube to the middle ear ; through the lachrymal duct or forward into the mouth. Scratches, blisters, and sores on the patient soon become covered with a frosty, ashy-white exudation, and ulcerate freely. Lymphatic glands may suppurate. Resolution may begin on the third to seventh day ; the mem- brane gradually disappears ; fever and headache lessen, and patient convalesces very slowly. Relapses are frequent. En- GENERAL INFECTIOUS AND CONTAGIOUS DISEASES. 79 docarditis may develop. Sudden death from cardiac embolism, paralysis of the heart-muscle, or asphyxia. Diphtheritic paraly- sis, temporary or permanent, always follows typical cases, and may affect the muscles of deglutition, with inability to swallow and regurgitation of the food ; loss of voice, with strabismus 5 hemiplegia or paraplegia j paralysis of the bladder ; and local anaesthesia. Duration of diphtheria is two to three weeks. Pathology. — Diphtheria is caused by a germ which seems to nourish best in the mucous and submucous membranes of the throat, nose, and bronchi. The false membrane is com- posed of mucus, epithelium, leucocytes, new fibrous tissue, pus-corpuscles, micrococci, and bacilli. It is tough, tenacious, ashy-white in. color, when detached leaves bleeding points, and soon reforms. This membrane grows in successive layers, and spreads from one or more focal points to the pharynx, larynx, lungs, mouth, ears, eyes, or nose. The submucous tis- sue is infiltrated with leucocytes and germs. Absorption of ptomaines produces all constitutional symptoms. Diphtheritic endocarditis is due to the introduction of the germs into the circulation. Paralysis is probably due to multiple neuritis. The enlarged glands show bacteria and inflammatory changes. Heart and kidneys are more or less degenerated. Albuminuria is always present in typical cases. Diagnosis. — Scarlatina is abrupt in onset, with very high fever, sore throat, no tough membrane in the throat, and the appearance of the characteristic eruption in twenty-four hours. Follicular tonsillitis is recognized by small yellow plugs, fill- ing the follicles of one or both tonsils, which do not spread to the palate and mucous membrane ; different course, dura- tion, and sequelae ; few constitutional symptoms, and no gen- eral glandular enlargement. Prognosis. — Must always be guarded, as most favorable indications are often replaced by severe and fatal symptoms. 80 A SYNOPSIS OP THE PRACTICE OP MEDICINE. Always advise patients and parents of possible endocarditis, cardiac paralysis, Bright's disease, or local paralysis. Laryn- geal and nasal diphtheria are very unfavorable. Treatment. — Isolation is imperative. Rest in bed from the onset nntil all traces of the disease disappear. Avoid all de- pressants, and give nothing bat stimulating and tonic treatment. Dietary Treatment. — Nourishment must be given at regular intervals of four hours, day and night, regardless of sleep. Milk is the best diet. With it you may give beef-extracts and beef -juices, brandy, or an egg. Administer brandy (gtt. x-lx) each time milk is given, if there is much prostration. Scraped beef, in small amounts ; boiled rice, tapioca, and sago j light puddings ; wine-whey, wine- jelly, chicken- jelly, baked potato, soft-boiled egg, and juice of oranges. Avoid all heavy, indi- gestible diet. Rectal alimentation may be necessary. Internal Medication. — Hydrargyrum chloridum corros., gr. to 30 , and tr. ferri chloridi, gtt. x-xx, every three to six 60 hours, pushed to a point short of mercurialism. Infusion of digitalis may be given at four-hour intervals for its stimulating and diuretic effects. Potassii chloras, gr. j-v, every three or four hours, with tr. ferri chloridi, is an old method, but rather depressing, irritating to the stomach and kidneys, and unsatis- factory in many cases. Hydrargyri ioclidum rubrum, gr. T J- - to - or powdered opium and soap in pill form. Cocaine and iodoform are of little benefit. Oxide of silver, gr. }, with oxide of zinc, gr. ij, in pill form, before meals and at bedtime, gives great relief. Nitrate DISEASES OF THE STOMACH. 203 of silver, gr. \- ; bismuth subnitrate, gr. xx ; glycozone, f 3 i-ij • or liq. potassii arsenitis, gtt. i-ij, do good. Do not give silver too loug on account of argyria. Blisters and local irritation over the epigastrium often relieve. The Germans use the alkaline carbonates or sodium sulphate. Sodium is not suit- able in anaemic cases, but will answer in plethora. Carlsbad water will check acid secretion. Vomiting must be controlled and cathartics cautiously used. Rectal injections of cold water. Salts or compound licorice-powder should be given the preference to open the bowels. In hcematemesis give ice internally and apply it over the epigastrium. Acetate of lead, iron, alum, turpentine, or tan- nic acid internally, or ergotine, gr. i-ij, bypoclermically. Zinc sulphocarbolate, gr. v, every three hours, stopped severe hem- orrhage in a number of cases. When due to vicarious men- struation, give emmenagogues before the period. Marriage is said to cure some cases. In perforation, put patient on opiates and keep quiet in bed. When there is a syphilitic history, potassium iodide will relieve when all other remedies fail. Lavage is highly recommended by later writers and clini- cians. Use a solution of sodium sulphate, chloride, biborate or bicarbonate, 3 i-ij in Oij of warm water. Antiseptic solu- tions are resorcin, one percent. ; boric acid, one percent. ; creo- sote, carbolic acid, or creolin, one percent. Surgical interfer- ence may be necessary in perforation. GASTRIC CANCER. Synonyms. — Carcinoma, or cancer of the stomach. Definition. — A malignant growth in the stomach occurring after the fortieth year, characterized by cachexia, localized pain, vomiting, and tumor, and terminating fatally. 204 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Etiology. — Most common, after the fortieth year, in women. Hereditary. Gastric nicer and all irritants in those who have a tendency to it. Secondary to other cancers, bnt mostly pri- mary. Symptoms. — Sense of pressure and fullness in the epigas- trium 5 oedema of the ankles 5 dyspepsia 5 cachexia j anaemia and marasmus. Vomiting occurs immediately after eating if at the cardiac end ; or, if at the pyloric, vomiting takes place in a few hours. Regurgitation of food indicates stricture, di- latation, or ulceration of the cardiac orifice. Vomited matter consists of mucus, sour liquid, and the characteristic coffee- ground vomit. Hemorrhage is frequent and in small amounts. Profuse hemorrhage indicates ulceration. There is an ab- sence or diminution of hydrochloric acid in the secretions of the stomach.* Pain is constant, dull or lancinating, in one spot, and is independent of eating. Temperature is elevated at times. Tumor in epigastric region is the most certain sign, is the size of a pigeon's egg or larger, and is not very sensitive to the touch. A medullary tumor is nodulated. Percussion is not clear. Dilatation or involvement of other organs is common. Skin is a dirty- white or fawn color. Colloid cancer gives rise to constipation and ascites. Tongue is red and dry, and loss of flesh and strength is rapid. Death occurs from peritonitis, hemorrhage, or exhaustion, in six months to two years. * Giinzburg\$ Test for Free Hydrochloric Acid. — Mix phloroglucin, two parts ; vanillin, one part; absolute alcohol, thirty parts. Filter gastric contents, and to one drop, on a white plate, add one drop of this solu- tion ; evaporate to dryness over a flame, and a rose-red color appears at the edge if free acid is present. Free acid is also demonstrated by tro- pasolin or Congo paper. Lactic acid is shown by taking one or two drops of tr. ferri chloridi and ten or twenty drops of a five-percent, solution of carbolic acid, and dilute to an amethyst-blue with water. Add gastric fluid, and, if lactic acid is present, it is changed to a clear lemon-yellow. DISEASES OP THE STOMACH. 205 Pathology. — The stomach, is the most frequent seat of can- cer 5 is primary or secondary ; most common at the pylorus. Scirrhous is most usual, medullary next, and colloid least common. Colloid cancer causes a diffuse degeneration, and may extend to the intestines and cause atrophy of the car- diac end of the stomach. Hard, infiltrated nodules or ulcer- ated masses are found. Pylorus may be obstructed and stomach dilated. Glands of the stomach are infiltrated, and the mucous membrane is hypertrophied. Begins in submucous tissue and spreads. Vomiting is due to products of disease. Chronic Gastric Catarrh. Occurs at any age. Pain slight and con- stant ; slightly in- creased by food ; gen- eral tenderness, not localized. Vomiting at times. Hemorrhage is rare and very slight. No fever. No cachexia. Kuns long course. Cur- able. No tumor. Constipation. No dropsy. Hydrochloric acid pres- ent. Symptoms of indiges- tion. Diagnosis. Gastric Ulcer. Young adults. Pain increased fifteen minutes after eating ; localized and tender to pressure ; radiates to back and chest. May or may not vomit. Profuse hemorrhage. No fever. No cachexia. Curable. May last five years. No tumor. May have constipation. No dropsy as a rule. Hydrochloric acid pres- ent. Slight indigestion. Gastric Cancer. After forty years. Constant boring, dull, or lancinating pain, not increased by food ; not tender to press- ure. Vomiting is a constant symptom. Frequent hemorrhage in small amounts. Coffee-ground ap- pearance. Attacks of fever. Marked cachexia. Fatal in one or two years. Usually tumor. Obstinate constipation. Usually dropsy. Absence of free hydro- chloric acid. Indigestion, flatulence, and marked acidity. In examining for tumor, lay patient on his abdomen. An- eurysm and other tumors have their peculiar characteristics. 206 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Prognosis. — Bad, and all cases die in from six months to two years. Treatment. — Cundurango was recommended as a cure, bnt will only palliate. Resort to concentrated enema to sustain nutrition. Conium, Cannabis Indica, alcohol, ether, bromide of ethyl, and chloroform should be tried before resorting to opium. Give thepatient his ancesthetic, with instructions how to use it to relieve pain. Counteract acidity of stomach. Aloes or colocynth for constipation. Minute doses of carbolic acid or arsenite of copper and mix vomica to relieve vomiting. Charcoal, Fowler's solution, or mercury bichloride are good. Six surgical operations have been done to prolong life for a short time. Make patient as comfortable as possible. DILATATION OF THE STOMACH. Definition. — An increase in the normal capacity of the stomach, characterized by symptoms of indigestion, with at- tacks of vomiting at intervals of a few days. Etiology. — Pyloric obstruction. An acute form is due to over-distention by gas or liquid. Symptoms. — Marked symptoms of indigestion and gastric catarrh. Large eaters as a rule. Sense of fullness or weight in epigastrium. Vomiting every few days or oftener, and an immense quantity of partly digested food, taken days before, is thrown up, mixed with slime, mucus, or blood. Increased tympanites, and a peculiar sound on swallowing; also suc- cussion splash. Bowels constipated; patient emaciated; epi- gastric region prominent, and tumor felt at pylorus. Rum- bling of the bowels and symptoms of causative trouble. Pathology. — Walls of stomach are thickened or unusually thin. Pylorus is partially or entirely closed by a cicatrix, DISEASES OP THE STOMACH. 207 thickened mucous membrane, or cancerous growth. Normal rugae are obliterated. Glands of stomach are atrophied or obliterated. Spores of yeast-plant are found in the stomach and vomit. Condition of chronic catarrh. Diagnosis. — When cause is evident, it is not difficult. Dis- tend the stomach with gas, and note percussion-area increased. Vomiting is characteristic. Prognosis. — Not encouraging. Die of causative disease or starvation. Treatment. — In acute dilatation, remove the liquid or gas at once by a stomach-tube. Frequent lavage with antiseptic solutions is indicated and gives most relief. Dry food in small quantities, predigested, and accompanied with an anti- ferment. Limit amount of liquids. Strychnine to tone the stomach. Galvanism or faradism. Charcoal, bismuth, and antiseptics all do good. Salines such as magnesii sulphas or Carlsbad salt. Surgical interference when indicated. GASTRIC HYPERTROPHY. Synonyms. — Gastric induration ; fibroid induration j cir- rhosis of the stomach. Description. — An organic disease of the stomach in which its walls are uniformly thickened and capacity diminished. Rarely seen. Coats are from one-half to an inch and a half thick, and capacity about four or five ounces. Causation and symptoms are obscure. A diffuse tumor is felt in the epigas- trium. Commonly affects pylorus and causes obstruction. Non-malignant. It may be a nucleus from which peritonitis will start. Ascites complicates. May have slight hemor- rhage, with coffee-ground vomit. No curative treatment is known. 208 A SYNOPSIS OF THE PRACTICE OF MEDICINE. ILEMATEMESIS. Synonyms. — Gastrorrhagia ; gastric hemorrhage ; hemor- rhage from the stomach. Definition. — Hwmatemesis is a term used to designate the vomiting of blood, and is only a symptom of disease. Etiology. — Rupture of vessels ; venous congestion ; portal obstruction ; diseases of heart and liver ; varicose veins and aneurysms j hemorrhagic diathesis ; ulcers, cancer, corrosive poisons, foreign bodies, or direct injury. Anaemia, scurvy, malaria, yellow fever, vicarious menstruation, and numerous other causes. Symptoms. — Sense of pressure and constriction in the epi- gastrium ; dizziness, fluttering pulse, and sense of syncope when much blood is lest. Sudden rising causes syncope — often fatal. Vomiting of blood or contents of stomach. May be streaks of blood, bright red and clotted, or dark and like coffee-grounds. Blood may pass by bowels as black, tarry masses (melcena). Diagnosis. — Hcematemesis is preceded by faintness, pallor, fullness in epigastrium, vomiting of blood mixed with food, and black, tarry stools. ITcemoptysis, hemorrhage from lungs, begins suddenly with coughing up frothy blood, not blackened, and auscultatory symptoms. Bloody expectoration remains several days. Prognosis. — Death is not a frequent consequence, but may occur from hemorrhage or syncope. Treatment. — Treat the cause. Internally, for hemorrhage, give ice, tannic acid, alum-whey, sulphocarbolate of zinc, gr. v-x, acetate of lead, gr. i-iij, with opium, gr. 7, iron salts, dilute sulphuric acid, turpentine, or other astringents. Hypo- dermics of ergotine. Apply ice to the stomach. Give mor- phina hypodermically to quiet patient. Cannabis Indica will DISEASES OF THE STOMACH. 209 answer. Treat syncope as indicated on page 212. Congestive hemorrhage requires active purgation. Over-activity of heart must be controlled by aconite. Allow no food except per rectum. Regulate bowels. Severe vomiting is controlled by tr. ipecacuanha?, fll ii-iv, bismuth, sulphocarbolate of zinc, or arsenite of copper. After-treatment is governed by causation. GASTRALGIA. Synonyms. — Cardialgia ; neuralgia of the stomach ; gastro- dynia ; stomachic colic. Definition. — A severe, paroxysmal pain in the stomach, due to hyperesthesia of its sensory nerves. Etiology. — Chlorosis, anaemia, hysteria, malaria, lithsemia, gout, acidity of stomach, cold drinks, worms, coffee or tea, articles of diet, or may be a true neuralgia. Symptoms. — Paroxysms of severe pain, independent of tak- ing food, lasting from a few minutes to hours, with intervals of rest. Fullness or pressure over epigastrium. Extremities cold ; abdomen tense ; and pain somewhat relieved by pressure. Diarrhoea and colic. It is easily induced by the emotions. Sympathetic pain under sternum is often felt. Reflex move- ments of the abdomen • cold perspiration ; tendency to vertigo ; and a slight cough. Vomiting causes relief. Urine is high- colored. Diagnosis. — Gastric ulcer has constant, localized pain, with vomiting of blood and catarrhal symptoms. Cancer has ca- chexia, tumor, and peculiar vomiting. Myalgic pain is less severe, and increased by pressure. Intercostal neuralgia pre- sents points of tenderness along the course of a nerve ; is uni- lateral, and shows no stomach symptoms. Prognosis — Not encouraging. Not fatal or dangerous to life. Sometimes curable. 210 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Treatment. — Hysterical patients require mental impression, change of scene and occupation. Antispasmodics give tempo- rary relief, but will not reach the trouble. Leeches, electricity, and massage will do good as long as they are novel. Asafoet- ida sometimes cures. Never give narcotics or alcohol to these patients, as they easily contract the habit. When pain becomes severe, use anaesthetics. Treat any disorder from which it may arise. Regulate diet and bowels. Fowler's solution, long continued, answers nicely. DYSPEPSIA. Synonyms — Atonic dyspepsia; indigestion; pyrosis; heartburn ; nervous dyspepsia. Definition. — Dyspepsia is an indigestion of food without structural lesion. Term means primarily painful digestion. Etiology. — Improper mastication and ensalivation ; drink- ing water to moisten and wash down food; ice-water and ice-cream; improper diet and over-feeding; excessive use of coffee, tea, tobacco, and alcohol; lessened peristaltic action and exercise; hereditary; decreased or diluted gastric juice; anaemia, chlorosis, and fevers. Symptoms — Heaviness, weight, and fullness in epigastrium after eating, followed by belching wind and sour eructations (heartburn). Tongue is clean, breath is pure, and appetite uncertain. Marked nervous symptoms in some cases. Flatu- lence, and vomiting of sour and undigested food. Increased flow of saliva ; bowels constipated, or may have diarrhoea. There is a burning pain at the pit of the stomach after eating. Insomnia, drowsiness, headache, forgetfulness, palpitation of the heart, loss of flesh, and anaemia are characteristic symp- toms. There is a desire for condiments and spices. If allowed to continue, there are symptoms of catarrh. DISEASES OP THE STOMACH. 211 Diagnosis. — True dyspepsia is not a common disorder, and, too frequently, cases of gastric catarrh are treated and diag- nosed for it. Structural lesions give pain when spices are taken, while dyspepsia does not. Prognosis. — Good. It is curable. Treatment. — Regulate diet and select blandest and most easily digested foods. Insist on proper mastication of food and forbid the use of drinks at meals. Forbid diet of tea and toast. Give malt-extract for indigestion of starches, pepsin for albumens, and pancreatin for fats. Eructations of fetid gas demand pancreatin. Forbid spices or condiments. If the structure of the stomach is impaired, give wine of rhu- barb, 3ss, with quinine, columbo, quassia, or nux vomica. In the aged, where there is lack -of peristaltic action, give nux vomica. Oxaluric dyspepsia demands alkaline salts, cold baths, and restriction of the diet. Tonics, in this condition, are injurious. Anwmia should receive iron or a natural chalyb- eate water. Hydrastine will compel a peptic gland to secrete. No remed}^ will settle nerves and restore their equilibrium better than capsicum. Rhubarb is an excellent remedy to tone the stomach. Ipecac, gr. -£§ to r&, is good. Tr. lobelue, gtt. v, will dry up secretion. Hydrochloric acid, dilute, gtt. x, with meals, or hydrogen peroxide prevents lactic-acid fer- mentation. Sodium bicarbonate, magnesii carbonas, charcoal, or lime-water will overcome acidity. Best hygiene, attention to diet and mastication, and as little medicine as possible con- stitutes the main line of treatment. STOMACHIC VERTIGO. Synonyms. — Syncope ; fainting ; vertigo ; giddiness ; light- headedness. Definition. — Vertigo is a transitory loss of consciousness, 212 A SYNOPSIS OF THE PRACTICE OF MEDICINE. complete or partial, characterized by extreme pallor of the skin, a fullness in the head, sensation of falling, weakened heart-action, and sickness of the stomach. Etiology. — Over-eating, starvation, fright, fear, occupation j psychical causes ; heart, liver, stomach, or kidney disease ; gout, lithaemia, debility, over-work, defects of vision, laryngeal ver- tigo, constipation, and other causes. Loss of blood and shock. The two classes of vertigo are stomachic vertigo and cerebral vertigo. Symptoms. — Perspiration on the forehead ; great pallor of the skin j weakened heart-action j queer sensation in the head ; numbness j cloud rising before the eyes ; see sparks and hear noises j fear of falling ; thirst and a sensation of floating ; and, finally, a loss of consciousness accompanied by falling. An attack may last for one minute or longer. Dull, heavy head- ache, with symptoms of indigestion. Treatment. — Preventive. — Give assimilable diet and do not overload the stomach. Eat small amounts at frequent inter- vals ; forbid liquids and pastr} r . A little wine may do good, but you must watch habit. Regulate hygiene. Avoid all ex- citement or conditions that will cause an attack. In anaemia, give iron and arsenic. The best bitter and stimulant is tr. nucis vomicae. Aloes, gentian, or asafoetida for flatulence. Ni- tromuriatic acid for acidity, fifteen minutes before meals. Aromatic spirits of ammonia, stimulants, and rest in the re- cumbent position to avoid syncope. During tlie attack, elevate the extremities and lower the head, as fainting comes from an anaemia of the brain. Small whiff of ammonia. Cold to the face and chest. Hypodermic injections of alcohol, strychnina, or tonics. Artificial respi- ration. When due to loss of blood, use transfusion. Follow with tonics. DISEASES OF THE INTESTINES. DIARRHCEA. Diarrhoea is not a disease, but merely a symptom of local or constitutional disturbance, manifested by frequent abnormal passages from the bowels. Among the numerous causes might be enumerated: Psychical causes, such as fright, fegr, or anxiety. Reflex, from pregnancy or teething. Inflamma- tory, from ilio-colitis, typhlitis, proctitis, dysentery, cholera morbus, and cholera infantum. It also comes from heat, cold, and medicines. Accompanies such fevers as typhoid, typhus, yellow fever, cholera, acute rheumatism, and tuberculosis. It is present in gout, cancer, diabetes, anaemia, uraemia, leucaemia, and many other diseases. Stools ma}^ be watery, slimy, mucous, fatty, serous, bloody, bilious, mixed, feculent, membranous, lienteric, scybalous, diphtheritic, or purulent. As treatment, symptoms, and diagnosis depend on the cause, see appropriate headings — Ileo-colitis, Cholera Morbus, and Cholera Infantum. INTESTINAL CATARRH. Intestinal catarrh is usually limited to one part of the in- testinal canal, and rarely involves every portion at one time. The terms enteritis and intestinal catarrh are entirely too broad in their meaning and liable to confuse, even though public 213 214 A SYNOPSIS OF THE PRACTICE OF MEDICINE. use lias given them place. The terms will only be dealt with in a manner that will limit them to certain portions of the intestine involved. DUODENAL CATARRH. Synonyms. — Catarrh of the duodenum ; duodenitis. Definition. — An acute or chronic inflammation of the mu- cous membrane of the duodenum, which may extend to the gall-ducts and cause jaundice, constipation, severe pain, and symptoms of intestinal indigestion. Etiology. — Due to cold and errors in diet, such as too much fat; malarial toxaemia, germs, irritants of all kinds, and ex- tension from adjacent structures. Symptoms. — Painful digestion. Constipation — no diarrhoea. From the third to seventh day jaundice of varying degree ap- pears. Pain in the right hypochondrium and at the umbili- cus, with soreness aud tenderness on deep pressure. Liver is tender, and there may be hepatalgia. Great distress three hours after eating; flatulence and pain, especially marked after taking starches and fats. Breath bad and tongue coated. Fwces are white, putty-like, and offensive. Urine loaded with urates. Headache, vomiting, rise of temperature and pulse, and poor appetite. Pathology. — Duodenal mucous membrane is swollen, red, and inflamed. The ductus communis choledochus is occluded by the swollen membrane, or is inflamed itself, thus obstruct- ing flow of bile and causing jaundice. Pale stools mean an absence of bile. Bile is an antiseptic, and when absent there is intestinal indigestion with flatulence. Duodenal ulcers may be found. Diagnosis. — Gastric catarrh has peculiar pain and nausea soon after eating. Pain in duodenitis is three hours after DISEASES OF THE INTESTINES. 215 eating, and associated with jaundice. Hepatic colic is parox- ysmal and more severe. Hepatalgia begins suddenly, and leaves as soon without sequelae. Prognosis. — Good. It lasts two to three weeks. May be- come chronic. Treatment. — Diet. — Avoid starches, fats, alcohol, and stimu- lants. Give predigested albumens and skimmed milk, in small quantities. No pulps of meat or any irritant food. Very weak coffee with skimmed milk may be allowed. White of egg or game. A large injection of cold water, repeated, will re- lieve congestive symptoms best. It also cleanses the bowel of faecal matter. Alkalies, phosphate of soda, Rochelle salts, and taraxacum are recommended. Give three to five grains of bismuth subnitrate every hour or two. Place mustard poultices or a fly-blister over the painful spots to relieve pain. May resort to belladonna, hyoscyamus, Cannabis Indica, or opium for pain. From the first, give ox-gall, gr. iii-v, to keep the intestines aseptic, aid digestion, and supply deficiency of bile. Malarial toxaemia indicates quinine, per rectum, gr. xx- xxx, daily. If ulceration is suspected, feed per rectum, and administer silver salts, sulphocarbolate of zinc, or other anti- septics. TYPHLITIS. Synonyms. — Catarrh or inflammation of the caecum. Definition. — An inflammation of the mucous membrane of the caecum, which may involve the colon and appendix vermi- formis (appendicitis), accompanied by fever, local tenderness, constipation, and symptoms of peritonitis. Etiology. — Lodgment of foreign bodies such as seeds, but- tons, and faeces. Direct injury, extension, and exposure to cold. 216 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Symptoms. — Uneasiness, pain, tenderness on pressure in right iliac fossa and along the ascending colon, with some prominence. Legs flexed on abdomen ; obstinate constipation ; dyspnoea ; malaise ; high fever ; coated tongue ; anorexia ; vom- iting ; great depression ; cold, clammy skin ; and, at times, all symptoms of peritonitis. A tumor that feels like hard links of sausage, due to impacted fasces, is felt in the right iliac region. Great peristaltic action and vomiting of fcecal matter. May have a slight diarrhoea from the irritating impaction. Perforation is indicated by sudden collapse, high fever, and severe peritonitis. Diagnosis. — Made from the severe localized pain in the right iliac fossa ; peculiar sausage- shaped tumor ; high fever and constipation. Prognosis. — Lasts one week or more, and usually recover. Treatment. — Avoid active purgation. Rest in bed. Sul- phate of magnesium, gr. xx, with opium, to liquefy the stools, and avoid increased peristaltic action resulting from cathartics. If inflammation is not severe, rectal injections of water as hot as can be borne, every four hours, act as poultices and remove impactions. Give liquid foods and milk. Relieve abdominal tension by supporting the legs with pillows. Laparotomy is often advisable to remove impactions and sloughing tissue. Vomiting is hard to control, but a hypodermic of morphina or opium internally will relieve it and pain. Prevent impaction b}- injections ; use good hygiene, and recovery usually follows. PERITYPHLITIS. Description. — An- inflammation of the loose areolar tissue around the caecum, closely related to typhlitis and due to it or direct injury. May occur in typhoid or typhus fever. The symptoms are those of peritonitis and typhlitis. Fever, eon- DISEASES OF THE INTESTINES. 217 stipation, and tumor in right iliac region, with tenderness and severe pain. The exudation is absorbed or suppurates. Sup- puration is preceded by chills and fever. Abscess will open into the bowel, peritoneum, or on the skin. Attacks fre- quently recur. Treatment. — In the very start, treat same as in typhlitis, with hot poultices, cold compress, or leeches, and small doses of magnesium sulphate, with morphina to relieve pain. Sul- phide of calcium, gr. n,-, every three hours, will often prevent suppuration. Surgical treatment is now recognized as a cura- tive means, and when abscess is found or suspected, operative interference is advisable. Aspiration may be done, but lapa- rotomy is most certain. Cleanse abscess cavity with peroxide of hydrogen or pyoctanin (ten percent.), and give tonic treat- ment. No solid foods. Liquid and nourishing diet. PROCTITIS. Synonyms. — Catarrh of the rectum j mild dysentery ; " rec- titis." Definition. — An inflammation of the rectum, recognized by a burning pain, with frequent desire to go to stool, marked tenesmus, and passage of mucus, blood, and scybala. Etiology. — Most common in women. Due to constipation ; frequent rectal injections ; hemorrhoids ; foreign bodies ; press- ure of a retroverted uterus or tumor ; catching cold or sitting on cold, damp substances ; habitual use of aloes ; cirrhosis of the liver. Symptoms. — A burning, uneasy sensation in the rectum, with pain on defecation. The discharges consist of mucus mixed with blood or pus and scybalous matter. Great tenesmus ; frequent and constant desire to go to stool, with passage of small 218 A SYNOPSIS OF THE PRACTICE OF MEDICINE. amounts at a time. Nausea, anxiety, and, in some cases, fever. Colon is usually impacted. Headache, prostration, and ex- treme muscular soreness. Bladder is irritable and there is often retention. Chronic proctitis presents the same symptoms, not so well marked. Stools are loose, offensive, and soon become puru- lent. Ulcers form and sloughs are passed. Pathology. — That of inflammation in other parts of the intestine. Large ulcers are formed. Diagnosis. — Can hardly be mistaken, if symptoms are noted. Prognosis. — Mild cases recover in one week or less. Severe cases may become chronic ; cause periproctitis, abscess of the liver, or thrombosis of the hemorrhoidal veins. Treatment. — In mild cases, with little strangury or diar- rhoea, give small doses of castor-oil, with a few drops of lau- danum. Olei ricini f 3ij. Tr. opii "1 ij. Aquae menthae pip n L i-iij. Sacehari q. s. M. Signa. (rive every three hours. Careful injections of a pint of hot water or flaxseed-tea re- lieve greatly. Nitrate of silver, gr. xx, to eight ounces of flax- seed-tea, may be used as an injection in severe cases. Impac- tion and fever indicate a mild saline. R Magnesii sulphatis gr. xxx. Acidi sulplmrici aromatcii ^l x. Tr. opii camphoratae Tl l x. Aquae menthae pip f 3 j. M. Signa. Give every three or four hours. DISEASES OF THE INTESTINES. 219 Rest in bed and light diet that will leave no residue. Sup- positories containing oxide of silver, pyoctanin, glycozone, or cocaine are recommended. Small doses of calomel and ipecac often give good results. Correct a misplaced uterus ; relieve hemorrhoids ; and regulate habits. Treat ulcers surgically. The best application is pure nitric acid. Avoid large doses of opium in acute proctitis, as they are objectionable. PERIPROCTITIS. Description. — An inflammation of the cellular tissue sur- rounding the rectum, arising from proctitis, direct injury, or tuberculosis. Great pain attends, and an exudation occurs which is absorbed or suppurates, giving rise to a fistula. A hard or soft tumor is felt in the perineum. Patient cannot sit down, and has great pain at stools. Stricture of the rectum may result. Treatment. — Open abscess as soon as found, and treat sur- gically, observing the modern rules of antisepsis. Give tonic treatment and nourish the patient with appropriate diet. CHOLERA MORBUS. Synonyms. — English cholera ; cholera nostras ; bilious cholera. Definition. — A severe catarrh of the mucous membrane of the stomach and bowels, coming on suddenly with violent vomiting, diarrhoea, cramps, and great prostration. Etiology. — A disease principally of spring, summer, and fall. Unwholesome food, catching cold, improper hygiene. Said to be due to germs in milk, water, and food. Symptoms. — Sudden in onset, usually at night. Begins with a chill, followed by severe colic, vomiting, and purging. Diarrhoea. Stools are first formed and soon become like rice- 220 A SYNOPSIS OF THE PRACTICE OF MEDICINE. water; large, free evacuations ; body shrinks away; voice be- comes husky ; patient goes into collapse ; breath is cold and tongue dry. Violent cramps in the muscles of the arms and calves of the legs. Pulse is feeble ; great anxiety and thirst. All food is vomited. Muscles may rarely rupture from con- traction. Pathology. — Blood is thick and dark, and the serous mem- branes are dry. Muscles are granular. Muscular cramps are due to lessened fluidity of the blood. Gastro-intestinal mu- cous membrane is inflamed, sometimes ulcerated, and glands enlarged. Cases may occur in which no lesion is found. A bacillus, similar to that found in cholera, is claimed to be present. Diagnosis. — Arsenical and other mineral poisons simulate cholera morbus and can only be diagnosed by the history or post-mortem. Asiatic cholera is epidemic, is more fatal, and presents the cholera bacillus of Koch. Prognosis. — Rarely fatal in this country. Lasts from a few hours to one day. Dr. Janhaa says that "in cases of healthy persons, in this country, cholera morbus is never fatal." Treatment. — The first indication is to relieve pain and cramps. A hypodermic of morphinae sulphas, gr. J to ■§-, with atrophias sulphas, gr. T ^o- Household remedies are ginger, mustard, pepper, volatile oils, spices, brandy, ammonia, or laudanum. (See Colic, p. 209.) The Hindus use what they term a hot treatment. ft Olei cajupiti f 3 j. Tr. capsici f 3 iv. Tr. camphor® f 3ij. Chloroformi f 3 j. iEtheris fortioris q. s. ad. ffij. M. Signa. One teaspoonful every half-hour in its purity, until relieved. Do not add or follow with water. DISEASES OP THE INTESTINES. 221 This is a hot close and brings tears to the eyes, but will always relieve if given from the first. Wrap patient in good hot blankets and apply hot water or mustard over the seat of pain. When due to cold, give hot drinks. Small doses of arsenite of copper, every ten minutes, will relieve cramps. Da Costa recommends inunctions of chloral for muscular cramps. Vomiting and Diarrhoea. — Nothing will relieve better than small doses of calomel and pulv. ipecac, (gr. T o~o)> every two hours. Cupric arsenite also controls it. A most reliable and efficient combination for vomiting and purging is : Zinci sulphocarbolatis gr. ss-ij. Lactopepsin gr. i-ij. Bismuthi subnitratis gr. i-v. Misce. Fiat pulv. No. 1. Signa. Every one or two hours until symptoms are checked. If first dose is vomited, persist every few minutes until one will be retained. Salol, iodine, salicylic acid, and a host of other antiseptic and antispasmodic remedies are recommended. A large dose of castor-oil or aromatic syrup of rhubarb will often relieve, when the cause is error in diet. Always remember that in diarrhoea elimination is the main principle, and all treatment must be preceded by a saline cathartic, calomel or castor-oil, and followed with intestinal antiseptics. A broad flannel band around the abdomen will often prevent an attack. Rest in bed; care in diet and tonic treatment when the attack has passed. Acid drinks and pellets of ice relieve thirst. (See Diarrhoea, p. 223.) 222 A SYNOPSIS OF THE PRACTICE OP MEDICINE. CHOLERA INFANTUM. Synonyms. — Infantile cholera • infantile summer com- plaint. Definition. — An acnte catarrh of the mucous membrane of the stomach and intestines of young children, with marked diarrhoea, vomiting, nervous manifestations, and fever. Etiology. — Teething, improper diet, bad hygiene, heat, and disease germs. Occurs during the first two years of life in summer-time. Epidemic. Doubtful if it is contagious. Symptoms. — The child may be feverish, irritable, and have a slight diarrhoea for weeks before the onset ; or the attack may come suddenly with vomiting, retelling, colicky pains, a clear, serous, odorless, or greenish diarrhoea. Stools are frequent, and number from ten to forty in a day. Body becomes shrunken in a few hours j mouth and eyes are half open, and there is a vacant stare. Red spots on the cheek and soreness along the colon. Respiration is shallow. Fever, burning heat in the forehead and epigastrium, and a great desire for drink. Tongue is dry and brown, and pupils contracted. Shin is cold and clammy, and patient goes into collapse and dies, or slowly recovers. Convulsions often occur. Pathology. — That of any inflammation, and may involve the stomach, intestines, or both. The constitutional symptoms are due to absorption of ptomaines from the intestinal canal, where they are produced by germs. Kidneys are congested and the blood is dark and thick. Diagnosis. — Ilio-colitis is gradual in onset, and should not be confounded with the sudden onset of cholera infantum. Prognosis. — If taken at once, it is good ; later, it is more fatal. It Mils more children than any other disease. Treatment. — Preventive, — See to hygienic surroundings. Keep the child cool, and allow cold drinks in moderation. DISEASES OP THE INTESTINES. 223 Dress loosely, always with wool next the sMn. Give plenty of fresh air ; and keep it cool during the heat of the day. Sterilized milk must be insisted upon in artificially fed chil- dren. Dr. Hirst recommends the following- formula, which he lias modified from other formulae : " For a two-ounce bottle, take of cream five ounces and milk two and one-half ounces j put in a skillet, and digest with two and one-half grains of pancreatin and sodium bicarbonate, five grains. Put in each bottle six drams of the mixture, and add ten drams of sugar solution (one ounce to the pint)." Another formula, that i? like mother's milk, is : ft Cream f 3iv. Cow's milk f 3 ij. Milk-sugar gr. 1. Water f 1 j. Thoroughly sterilize, then add Lime-water f 3ij. M When diarrhoea is simple, give small doses of calomel or syr. rhei aromaticus, with a few grains of sodium bicarbonate or potassium carbonate, every two or three hours. If this fails, give the sulphocarbolate of zinc, with bismuth and pepsin (see p. 221), as it destroys germs, stops vomiting and pain, and relieves fever by its antiseptic and antispasmodic action. A favorite formula after elimination has been complete is : ft Bismuth! subnitratis 3 j. Glycerol acidi carbolici tn. xvj. Tr. cardamomi comp. Spts. chlorof ormi aa. f 3 iv. Aquae menthae pip q. s. ad. f 1 ij. M. Signa. One-half to one teaspoonful in water every two or three hours. Shake before taking. (B. Reed.) 224 A SYNOPSIS OF THE PRACTICE OF MEDICINE. If diarrhoea still proves obstinate, use a free rectal injec- tion of sulphocarbolate of zinc, gr. x to f § ij of warm water, as the poisons are active in the lower bowel and cannot be reached by the month. When the child is comatose, hard to arouse, feverish, and threatened with convulsions, place its whole body in a tepid-water hath (98° to 101° F.), and apply cold to the head and mustard to the back of its neck. This will arouse it and afford opportunity to give medicines. After a bath of this kind, wrap the child in hot blankets and keep the head cool. Stimulate with hot coffee or brandy if neces- sary. (For other treatment of diarrhoea, see p. 221.) Diet should be the mildest. G-ive whites of eggs, in water, with pepsin ; rice-water, to which may be added artificial foods. In this condition opium must be used with great caution, for its use usually means death in the severe forms. The cardinal points in treatment are elimination, diet, and intestinal anti- sepsis. ILEO-COLITIS. Synonyms. — "Summer diarrhoea"; inflammatory diar- rhoea ; improperly called catarrhal enteritis. Definition. — A catarrhal inflammation, acute or chronic, limited to the lower part of the ileum and portion of the colon, with diarrhoea, vomiting, pain, slight febrile reaction, and rapid depression. Etiology — Heat, cold, bad milk, and improper diet; bad hygiene and over-crowding. A disease principally of city, hand-fed babies under two years of age. Symptoms — Acute. — Discomfort about the belly, with diar- rhoea. There is purging of a sour, acid, curdy-like material, at times mixed with blood. Later, it is watery or greenish, and smells very bad. Vomiting of acid, curdy masses. There are from ten to twenty stools daily. Depression, weakness, DISEASES OF THE INTESTINES. 225 red tongue, skin dry, urine scanty, pulse feeble, and tempera- ture may reach 104° F. Dysenteric symptoms may supervene. Griping pains. Nephritis is a complication. Child may be- come comatose, pupils are sluggish, skin dark, involuntary stools, convulsions, and death. Spurious hydrocephalus, from thrombosis, may occur. Prolapse of the rectum comes from straining at stool. Chronic. — Follows the acute. Stools are not so frequent, but are offensive, thin, and contain mucus, pus, or serum. Skin is pale and flabby. Indigestion and vomiting. Acute at- tacks occur. It may last for months. Little or no pain. Ulceration is indicated by hemorrhage or dark clots. Flatu- lence, rapid exhaustion, and finally death or recovery. Pathology. — Acute. — Mucous membrane of the ileum and colon is thickened, red, inflamed, and coated with mucus and epithelial cells. Pyer's glands are swollen. Mesenteric and intestinal glands are swollen and dark. Chronic. — Membrane is dark red or gray, with enlarged follicles. A false membrane sometimes exists. Small, dark patches are seen, and ulcers at the seat of the follicles. Kid- ney is involved. Invagination often occurs. Diagnosis. — Easily made from typhoid fever and tuberculous ulceration of the bowels. Prognosis. — Not very good, in large cities ; but where proper precautions can be taken and treatment carried out, it is favorable. Treatment. — Absolute rest in a cool room during the heat of the day. Good, fresh, pure air of the country, mountains, or sea-shore. Clothe with flannel. Diet must be regulated, and nothing but mother's milk, or, if hand-fed, nothing but whey, with a small amount of prepared food, can be given. Sterilized milk may be given. (See p. 223.) Koumyss is often of ad- vantage as a food. Fever and stupor require tepid baths — not 226 A SYNOPSIS OP THE PRACTICE OF MEDICINE. antipyretics, as they are too depressing. If the case is seen early, give calomel in one-tenth-grain doses, castor-oil or rheum, with soda, to cleanse the bowel. Follow this with sulphocarbolate of zinc, bismuth, and pepsin. Diarrhoea is treated as indicated on pages 221 and 223. Bichloride of mercury and salicylate of bismuth have their advocates. Stimulate as much and as often as is necessary. One one- hundredth grain doses of triturated calomel and ipecac, every one or two hours, are excellent. In the chronic form, regulate diet ; give astringents, and tonics of quinine, iron, and cod-liver oil. When the lower bowel becomes involved, use injections of the silver salts. Oxide of silver, gr. -J to i, in pill form for ulceration. ACUTE DYSENTERY. Synonyms. — Bloody flux ; ulcerative colitis ; colitis. Definition. — An acute, sporadic, endemic or epidemic, infec- tious inflammation of the mucous membrane of the colon, with tenesmus, frequent desire to go to stool, and passage of scyb- alous masses, mucus, blood, and serum. Etiology. — Foul air, impure water, bad drainage and food, atmospheric changes from heat to cold. Epidemic in armies, prisons, and cities. Endemic in the tropics. It is not conta- gious, but is infectious. The varieties are acute catarrhal, ul- cerative, croupous, diphtheritic or gangrenous dysentery. Primary cause is a germ whose identity is unknown. Symptoms. — Sometimes there is a protracted diarrhoea which precedes the onset. Onset with a chill, followed by slight fever. Tenderness along the colon on pressure. Rum- bling of the bowels, and colicky pains (tormina) at the umbilicus. A burning, weighty feeling at the anus, and constant desire to go to stool, not relieved by defecation and violent straining (tenes- DISEASES OF THE INTESTINES. 227 mas). Stools are small in amount and mixed with blood, mucus, or pus, and are highly offensive, with here and there a small faecal mass. Vomiting is not a constant symptom. When the inflammation subsides, large faecal masses are passed, showing a condition of constipation. At times the stools are dark, slimy, and putrid, with pieces of sloughed mucous membrane, giving rise to the term diph- theritic or gangrenous dysentery. Vomiting, hiccup, and great depression ; tenesmus, cold skin, and weak heart. Gangrenous dysentery is most common in armies, and is attended with great prostration. Pathology. — Catarrhal Dysentery. — Mucous membrane of the colon is swollen, infiltrated, covered with muco-pus; en- larged glands, softened patches, or even desquamated epithe- lium, leaving small ulcers or cicatrices. Probably due to a germ. Diphtheritic Dysentery. — Ulcers with thick, irregular base, more or less gangrenous, with a mucous or false membranous coating like that of diphtheria, forming a cast of the bowel. Large cicatrices may remain, causing intestinal obstruction. Gangrenous dysentery is an aggravated form, with extensive destruction of tissue, involving one or all three coats and causing perforation. Diagnosis. — Inflammation of the small intestine is accom- panied with profuse diarrhoea, without tenesmus and rectal irritation. Proctitis is not so acute ; stools are not so offen- sive ; and is shorter in duration. Typhoid fever has peculiar temperature, eruption, and other symptoms. Prognosis. — Recovery takes place in one or two weeks, in mild cases. May result in stricture of the bowel, chronic form, perforation with peritonitis, abscess, or death. Treatment. — Preventive. — During epidemics, provide the best drainage, food, and hygiene. Drink only boiled water 228 A SYNOPSIS OF THE PRACTICE OF MEDICINE. and thoroughly cooked foods. Eat no fruits. Wear flannel round the abdomen, and avoid exposure to heat. Keep bowels regular, and disinfect stools of patients. During the attack, give only such nourishing food as will digest in the stomach and leave no residue. If seen early and the stools contain scybala, give castor-oil, f 3 ss-j, with tr. opii, gtt. v-x, once daily, to clear the bowels of faeces. Cleanse the bowel with one pint of hot water, and inject silver nitrate, 3 ss-j, with hot water, Oj, once or twice daily. Internally, give pulvis ipecac rad., gr. xxx-xl, in the smallest quantity of hot water possible, and make the patient lie quietly in bed to prevent vomiting. Repeat at once if vomited, and persist until it is retained. Put a hot flaxseed poultice over the abdomen. Every two hours give sulphocarbolate of zinc, gr. iv-v. Salol, gr. iij, ma}^ be given. Aconite, in small doses, is a general treatment in India. A combination of tr. Canna- bis Indica and tr. hyoscyamus is recommended. Naphthalin, gr. i-v, every two hours, with castor-oil and opium. Bismuth, Fowler's solution, and silver salts all do good. When these forms of treatment fail, give full doses of opium — these are dangerous, but often curative. Frequently cleanse the bowel by hot or cold injections. Give tonics during the whole dis- ease. In gangrenous or diphtheritic dysentery, use antiseptic injections or diluted peroxide of hydrogen, with tonic treat- ment and turpentine internally. Suppositories of opium and oxide of silver are often beneficial. CHRONIC DYSENTERY. Description. — Usually comes from the acute. The stools number from two to twenty daily, are offensive, and contain mucus, pus or blood, and scybalous masses. Stools vary from day to day. Appetite is capricious, tongue red and DISEASES OF THE INTESTINES. 229 glazed, and patient emaciates. Abscess of the liver is common. Death may be due to pneumonia, phthisis, Bright's disease, lardaceous disease of viscera, faecal abscess, or peritonitis. The disease is very intractable. There is a hectic fever j ab- domen is sunken and tender ; tenesmus and general debility. Post-mortem shows a thickened, ulcerated or cicatrized mu- cous membrane. If recovery ensues, the bowels are always very susceptible to changes or relapses. Treatment. — Change of climate, best hygiene, and woolen underclothing. Milk and foods that digest in the stomach without residue remaining. Pulv. ipecac, gr. ij, in pill form, ter die, often checks symptoms. Astringents and antiseptics. Sulphocarbolate of zinc, salol, arsenite of copper, and other salts have their advocates. Monsel's solution, trt vj the sul- phate or nitrate of iron. Rectal injections of nitrate of silver. Opium, bismuth salicylate, and silver oxide, combined, as a suppository, are good. Terebene or turpentine with opium. Counter-irritation. ULCERS OF THE INTESTINE. Ulceration may occur in any part of the intestine, and is simply a condition and not a disease of itself. It is symptomatic of such conditions as typhoid fever, tuberculosis, cancer, dys- entery, ilio-colitis, and other inflammatory conditions. It is most common in the ilium, and its main symptom is obstinate diarrhoea. (For treatment and particulars, see Causative Diseases.) CANCER OF THE INTESTINE. Cancer of the intestine is rare, and occurs after forty years of age. Scirrhous is most common, then the colloid. There is a dull, heavy, steady, or sharp periodical pain, with a tend- 230 A SYNOPSIS OF THE PRACTICE OF MEDICINE. eney to diarrhoea. Salivation, anaemia, cachexia, and emacia- tion. Death is the ultimate result. Treatment is palliative, and consists of opium and injections of hot water with as- tringents. INTESTINAL OBSTRUCTION. Definition. — Obstruction of the bowels is an occlusion, partial or complete, of any portion of the intestinal canal, which retards or prevents the normal passage of faecal matter. Etiology. — Constipation ; stricture ; congenital or acquired ; strangulated hernia j compression from tumors ; torsion j im- paction of foreign bodies such as gall-stones ; intussusception j and peritoneal adhesions. Symptoms. — Acute. — Intense abdominal pain at the umbili- cus, coming on suddenly, continuing, and increased by pressure. Vomiting of food, then bile, and finally faecal matter if the ob- struction is low down. Vomiting is persistent, and no food can be taken. Abdomen is tense, swollen, and tympanitic ; great rumbling of the intestines. Constipation is marked, and is not relieved by ordinary methods. If obstruction is high up, faeces may pass from the lower bowel. Intussusception causes a bloody, mucous passage, and, at times, a portion of sloughed gut may be ejected. Tumor in the region of invagination. Breath is bad, eyes sunken', and collapse comes early. Temperature falls ; pulse is weak ; great thirst ; tongue dry ; peritonitis ; and death in three to seven days. Chronic obstruction is due to cancers, constipation, adhe- sions, tumors, and inflammatory processes. Constipation is irregular, and can be overcome at first. Vomiting takes place at intervals, but is not faecal. Abdomen is distended, and some pain is present. Gradually the symptoms become more DISEASES OF THE INTESTINES. 231 severe 5 constipation is marked; faecal vomiting; pain is severe ; and a regular acute attack follows. Pathology. — Intussusception (invagination) is a slipping of one part of the gut into another, like the finger of a glove. The most common form is the ilio-ccecal, then the ilio-colic. Inflammation ensues, adhesions form, the invaginated part of the gut sloughs away, and there is resolution or death. Pa- thology of other affections is the same as the cause. Diagnosis. — Adhesions have a history of previous perito- nitis. Constipation has its history of slow onset. Impacted gall- stones follow hepatic colic. Hernia is readily diagnosed. In- tussusception is of sudden onset, in male children mostly, with vomiting, spasmodic pain, bloody stools, tumor, and passage of sloughed gut. Fwcal vomiting indicates an obstruction low down. In general, pain is due to colic and peritonitis. Prognosis. — Depends on the form, but is usually bad. Treatment. — Never administer purgatives. Give opium to quiet pain and peristaltic action. In the acute form, hernia must be reduced by manipulation or surgical measures. In- tussusception, in its first stages, may be relieved by gentle manipulation ; inflation of the intestines by injections of gas ; or distention with a water enema, as large as can be given. Failing in this, laparotomy must be done. Adhesions, impacted gall-stones, and cancers require laparotomy and resection of the gut. Constipation (see page 233). If food cannot be retained, give alimentation per rectum. Stimulate and support. Intestinal antisepsis sometimes overcomes tympany. Aspiration is also used to relieve tympany. INTESTINAL HEMORRHAGE. Description. — Hemorrhage is merely a symptom of a diseased condition, and may come from any part of the intestinal canal. 232 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Its principal causes are ulcers of typhoid, dysentery, and other conditions. Cancer, hemorrhoids, enlarged uterus, obstruc- tion of the lungs or heart, cirrhosis, scurvy, and purpura all give rise to it. Hemorrhage may be arterial, venous, or capillary. Blood from the small intestines is black, tarry, and mixed with faeces. From the lower bowel, it precedes or follows a stool, and is not blackened or mixed with fasces. It may be in a stream, clots, drops, or merely streaks. Treat- ment is considered in connection with the causative troubles. ENTERALGIA. Synonyms. — Intestinal colic ; tormina ; " cramp colic " ; in- testinal neuralgia. Definition. — An acute, paroxysmal pain in the region of the umbilicus, slightly relieved by pressure, due to an irrita- tion of the sensory nerves, with spasmodic contraction of the intestinal muscle, and not accompanied by fever. Etiology. — Improper diet, such as crabs, unripe fruit, spoiled meats and fish ; great changes of heat or cold ; neuralgia, hys- teria, hypochondriasis, intestinal indigestion ; copper or lead poisoning; malarial or specific infection. Symptoms. — Patient is found in great agony, with the limbs drawn up, pressing his abdomen ; features pinched ; skin cold ; a cold perspiration ; and a grinding, twisting, cutting pain in the umbilical region. Nausea, vomiting, and a desire to go to stool. Great anxiety. Pain may last for a few hours or a day, and leaves the abdomen tender and sore. No fever. Abdomen is tense and often retracted ; tympany and borborygmus. The paroxysm may come on suddenly or slowly. Lead colic comes on in connection with a history of lead-poisoning. Diagnosis. — Hepatic, renal, uterine, and ovarian colic have DISEASES OF THE INTESTINES. 233 their peculiar localized symptoms. Inflammatory troubles have fever, while ordinary colic has not. Gastralgia is localized to the stomach and is relieved by vomiting. Treatment. — For the paroxysm : A hypodermic of mor- pliinaB sulphas, gr. \ to -g-, and atropinge sulphas, gr. T |-o, is most certain. May give morphina, gr. \ to -J-, in a spoonful of hot water, for speedy relief. Chlorodyne, chloranodyne, or Hoff- man's anodyne. Volatile oils, brandy, chloroform or ether, or arsenite of copper all serve a good purpose to relieve pain. Applications of mustard, hot poultices, or dry heat over the abdomen are useful. The next indication is to eliminate. Give a large dose of castor-oil or aromatic syrup of rhubarb. The best combination is : Hydrargyri chloridi mitis gr. iij. Sodii bicarbonatis 3 j. Sacchari lactis 3 j. M. Fiat pulv. No. 10. Signa. One every hour. If they do not act freely when five are taken, give a half- bottle of liquid citrate of magnesia. Follow with light diet and tonics. Lead colic demands morphina, magnesium sulphate, and potassium iodide. (For other treatment of colic, see Cramp, p. 220.) CONSTIPATION. Synonym . — Costiveness. Definition. — A term used to denote a deficiency or absence of the normal passage from the bowels. Etiology. — Indigestion, torpid liver, articles of diet, lack of proper tone, and innervation of the intestinal muscle, causing lessened peristaltic action. Habit is a common cause from neglect. Symptomatic of lead-poisoning, obstruction, malaria, 234 A SYNOPSIS OF THE PRACTICE OF MEDICINE. diseases of the liver, stomach, and bowels. Most common in women. Symptoms. — Bowels are never moved except cathartics are taken, and then only once in every three days or a week. Normally, a person should have at least one large free passage every day. Besides these symptoms they complain of head- ache, giddiness, sluggish mental activity, lack of appetite, digestive disturbances, and sallow complexion. Palpitation of the heart, cold extremities, and great straining on defeca- tion. Stools are hard and lumpy. Treatment. — Seek for the cause and remove it. If due to retroverted uterus, replace it. Impaction of the colon requires hot- water injections and mechanical means. Correct diet and habits, and insist on a regular hour in which to go to stool every day. Instruct patients to hold the gases in the bowel and not to pass them off every time they desire it, as they keep the bowels distended and aid in the passage of faecal matter. A glass of ice-cold or hot water, with a little salt in it, before breakfast, answers in mild cases. Massage or kneading the abdomen, and exercise, constitute valuable means of relief. Mild galvanism or faradism, applied along the course of the colon or by a negative rectal electrode, will cause passages in the most obstinate and chronic cases. Cascara sagrada and other drugs answer nicely. Calomel in large doses, gr. v-x, or in small doses, gr. - f V to J, in tablet triturates, every two hours. When the stools are dry, give small doses of magnesium sulphate, or ft Ext. nucis vomicae gr. 1/4. Ext. hydrastis gr. j. Pulv. rhei gr. j. Misce. Fiat pil. No. 1. Signa. One night and morning. DISEASES OF THE INTESTINES. 235 In old chronic cases, the best results come from : Ext. aloini purif gr. x. Ext. micis vomica? gr. x. Ext. belladonna? gr. iv. Oleoresinee capsici g"r. ij. Misce. Fiat pil. No. 20. Signa. One pill thrice daily. As soon as two passages occur in one day, order one-half pill and so diminish until the habit of constipation is broken up. (Waugh.) Other conditions have their appropriate forms of treatment aud are considered with the causative trouble. INTESTINAL WORMS. Varieties. — Tcenia solium; Botlirioceplialus latus; Taenia sag- inata; Tcenia mediocanellata — all varieties of the tapeworm. Ascaris lumbr 'acoides, or round- worm. Oxyuris vermicular is, or seat-worm. Triclioceplialus disbar. Anchylostomum duo- denale. Etiology. — Worms are developed from the ingestion of their eggs into the alimentary canal with food, drink, or air. People who have pet dogs and cats in the house are most exposed, as these animals are commonly affected and drop the eggs of the worm. General Symptoms. — Some cases present no symptoms. Others have disordered digestion and pain in the umbilical region. Itching at the anus and nose, hence scratching and picking. Thirst, ravenous appetite, emaciation, palpitation of the heart, sympathetic cough, disordered senses, convulsions, fever, and vertigo in some cases ; insomnia ; passage of the worms or part of them or their ova. Three prominent classes are met, and these only will be considered. 236 A SYNOPSIS OF THE PRACTICE OF MEDICINE. TAENIA SOLIUM. Description. — The common tapeworm is developed in the small intestines from ova ingested with pork or raw beef. There is usually one, but there may be many. It measures from twenty to forty feet in length. The tapeworm is made up of joints that become detached and are passed with stools or drop away spontaneously. Average life of worm is ten years. The head is buried deeply in the mucous membrane and holds on by two or four hooks or suckers. Each joint is capable of reproduction, and contains the male and female organs. Patient has colicky pains, choreic movements, hysteria, in- somnia, intestinal catarrh, and passes segments of the worm — the only reliable point of diagnosis. Treatment. — Give light liquid diet for three or four days, and follow with a good cathartic of Epsom salts, one dram in a glass of water, to remove mucus from the imbedded head. Repeat this for several days ; follow with ethereal oil of male fern, 3 ss-j, and extract of tansy, 3 ij. Two or three hours after taking this dose give castor-oil, 1 iss, and let the bowels be opened over a bucket of hot water, so that the worm will not break when passed. Examine to see if the head has come away. An equally efficient and less dangerous remedy is pumpMn-seecl, 1 ii-iv. The seed must be administered with the greenish skin that covers it, for in it is the active principle. Pelletierine, or decoction of pomegranate, is recommended. ASCARIS LUMBRACOIDES. Description. — The round-worm measures from three to eight inches in length ; resembles an ordinary earth-worm in appear- ance, although anatomically different ; inhabits the small in- DISEASES OF THE INTESTINES. 237 testines; lives about one year. The female is the larger. Ova are taken in with food and drink. Most common in fe- males, vegetarians, and debilitated persons. Catarrh of the bowels favors its development. Worms may crawl into the stomach, throat, Eustachian tube, mouth, nares, or gall-duct. Blueness of the lower eyelids ; picking at the nose ; uneasiness and intestinal catarrh ; gritting the teeth and starting up from sleep (night terrors) ; colicky pains or diarrhoea ; or there may be no symptoms at all. Passing of worms or their ova constitutes the main and only reliable point of diagnosis. Treatment. — Precede all treatment with light diet and cathartics. Cowage down, or the spears on the pod of Mucuna pruriens, is the best remedy. Prepare by dipping the pods in molasses j scrape with a knife, and give two teaspoonfuls of the scraped product every morning, for three mornings j fol- low with a brisk cathartic. These little spears will pierce the worms, kill them, and not produce an undue amount of irrita- tion to the bowels. Santonin, gr. i-ij, with calomel, gr. i-ij, at bedtime, will bring away some of the worms. Chenopo- dium ambrosioides — American wormseed — with calomel, acts nicely. Spigelia or turpentine with mucilage will often an- swer. Treat catarrhal conditions of the bowels, anaemia, and specific troubles; build up the patient, and as the child strengthens the worms abort. OXYURIS VERMICULARIS. Description. — Thread or seat worms measure from two to five lines in length ; female is the larger. They are pearly- white, slender, and very active ; inhabit the rectum and vagina. Intense itching at the anus, with burning sensation and symptoms of proctitis. Worms are found at the anus ; 238 A SYNOPSIS OF THE PRACTICE OF MEDICINE. may enter vagina and canse vaginitis. Child is nervous, sub- ject to convulsions, and liable to practice masturbation. Treatment. — Regulate diet and hygiene. Give a purge of calomel with aloes and santonin. Injections of saturated lime- water to which tr. f erri chloridi has been added, 3 ii-Oss ; carbolic acid and warm water j turpentine or petroleum with hot water and soap • ice- water and quassia. It is well to pre- cede injections by a free purge with Rochelle salts. Glycerin with carbolic acid (one percent.) may answer. Wash anus and genitals with carbolic or bichloride solution, and use a dusting-powder to prevent external irritation. DISEASES OF THE PERITONEUM. PERITONITIS. Definition. — An inflammation of the peritoneum, acnte or chronic, local or general, with a fibroplastic exudation, accom- panied by severe pain, fever, tympanites, vomiting", and marked depression. Etiology. — Acute Peritonitis. — Direct injury; hernia; per- foration of the intestines from ulcers or abscesses ; extension from other organs j pyaemia ; septicaemia ; erysipelas ; puer- peral infection ; great heat or cold. May be idiopathic. Chronic Peritonitis comes from tuberculosis ; Bright's disease of the kidneys ; cancer ; cirrhotic diseases of the liver ; and from the acute. Symptoms. — Acute. — Idiopathic cases commence with a chill, intense fever, pain, and tenderness. Other cases come on slowly with sharp pain, gradual rise of temperature, and local tenderness. Abdomen becomes so tender that the slight- est touch causes great pain. Patient lies on his back, with thighs flexed on abdomen to relax the abdominal muscles. Cough suppressed on account of great pain ; deep breathing impossible ; abdomen swollen and tympanitic, causing com- pression of the lower lobes of lung, with dyspnoea and even cyanosis ; bowels constipated ; vomiting of food, serum, and bile ; temperature 105° to 106° F. ; mind very clear. When exudation appears, pain is not so severe. Hiccup may super- vene, with delirium, fall of temperature, and death. 239 240 A SYNOPSIS OP THE PRACTICE OF MEDICINE. Chronic peritonitis has some fever of hectic type ; local ten- derness, with a feeling of oppression and weight ; constipa- tion, alternating with diarrhoea 5 irregular appetite ; vomiting at times. May be constitutional symptoms of tuberculosis. Peritoneal cavity is filled with fluid, giving fluctuation and distention ; or there is little fluid, with a flat, resistent abdo- men and hard, irregular surfaces here and there. Rapid emaciation ; dullness on percussion, general or local. Pathology. — Acute Peritonitis. — Peritoneum is reddened from hyperemia and covered with a fibrinous exudation that causes adhesion of the parts. Exudation may fill the peri- toneal cavity and amount to several gallons ; if absorbed, adhesions remain. Chronic Peritonitis. — Peritoneum is thick and matted to- gether ; liver, spleen, and intestines are adherent ; effusion is serous ; may contain pus, and is either localized in cavities or general. In tubercular peritonitis, peritoneum is thickly studded with tubercles. Diagnosis. — Colic and hysterical pains are slightly relieved or not increased by deep pressure ; no rise in temperature. Intestinal obstruction is easily diagnosed after a few days. Toxic gastritis has the history ; constant vomiting and tender- ness, limited to stomach. Inflammatory troubles of the intes- tines commonly have pronounced diarrhoea. Prognosis. — Usually fatal, when due to perforation. Acute cases favorable ; chronic cases are usually hopeless, but some are recorded as cured. Treatment. — Acute. — Avoid active purgation in all cases. Idiopathic cases are relieved by constant applications of ice- water, applied to the abdomen every minute, with soft cloths, until temperature falls. This answers better than antipy- retics. Magnesium sulphate, 3 ss-j, with tr. belladonnae, every four hours, in plenty of water, to deplete the intestinal mucous DISEASES OP THE PERITONEUM. 241 membrane and blood-vessels, without causing peristaltic ac- tion. Opium should be withheld until it is found absolutely necessary to relieve pain ■ then it must be pushed to the point of tolerance. Hot poultices, in localized peritonitis, as well as warm compresses and counter-irritation. Blood-letting is not required. Tympany is relieved by aspirator, rectal tube, or intestinal antiseptics. In perforation, insist on absolute quiet and rest ; surgical operation if patient's condition will permit. As most cases of perforation are fatal, all we can do is to give opium to relieve pain and resort to surgical means. Vomiting is relieved by ice internally. Give blandest diet. During convalescence, potassium iodide and mercury, with iron, cod-liver oil, and the phosphates ; connter-irritation over abdomen. Stimulate freely when necessary. If local effu- sion of serum impedes respiration, draw off a small portion of it at a time. Chronic peritonitis requires flying blisters over abdomen. Diuretics, diaphoretics, and evacuants often cause effusion to absorb. Laparotomy is practiced successfully for its relief, especially in the tubercular form. Build up patient with iron, quinine, and cod -liver oil. Best foods. Cancerous or malignant peritonitis is always fatal, and treat- ment is only palliative. ASCITES. Synonyms. — Abdominal dropsy ; peritoneal dropsy. Definition. — An effusion of fluid into the peritoneal cavity, dependent upon some diseased condition. Etiology. — Chronic peritonitis ; portal obstruction ; dis- eases of the heart, lungs, liver, or kidneys ; any obstruction to the circulation. 242 A SYNOPSIS OP THE PRACTICE OP MEDICINE. Symptoms. — Local signs are enlargement of the abdomen ; dullness on percussion, that changes with the posture of patient ; distinct succussion wave, indicating presence of fluid. Intestines always float to the surface of the fluid. Percussion gives a tympanitic note at the umbilicus, with dullness in the flanks, when patient lies on his back. When standing, tym- pany is at the epigastrium and dullness below. Liver, spleen, and stomach may be displaced ; pressure on lower lobes of the lungs causes dyspnoea. Digestion impaired ; bowels con- stipated j symptoms of causative trouble. Pathology. — Peritoneum is thickened, opaque, and presents a macerated or water-logged appearance. Fluid is albumi- nous 5 rich in salts ; high specific gravity ; varies in color from a pale amber to a red ; may amount to several gallons in quantity. Diagnosis. — In ovarian cyst, dullness is in the median line and tympany in the flanks ; center of abdomen is prominent, in place of a uniform enlargement. Chronic peritonitis has pain and tenderness, with a tuberculous or cancerous history. Pregnancy and distended bladder present their peculiar charac- teristic symptoms, and should never be mistaken. Prognosis. — Depends on cause. Usually bad, as regards cure. Patients die of the primary disease. Treatment. — Strike directly at the cause and treat diseases of the heart, lungs, kidneys, liver, or other organs. Reduce effusion by hygienic, medicinal, and surgical means j dry diet, and limit amount of liquids ; guard against taking cold ; good, nourishing food. Medicines consist of diuretics, diaphoretics, purgatives, and alteratives. Elaterium, jalap, jaborandi, and Dover's powder all have their place in treatment, but de- press the patient. When these means fail, resort to surgical measures. Draw off part of the fluid at a time with an aspirator or trochar. DISEASES OF THE PERITONEUM. 243 It is not well to remove all the fluid at one time, for it drains too much albumin from the blood by refilling again. Chronic peritonitis is sometimes cured by removing all fluid at one time. Dry diet, iron, quinine, cod-liver oil, and treatment of the causative disease constitute the points in treatment. DISEASES OF THE PANCREAS. PANCREATITIS. Description. — Inflammation of the pancreas is acute or chronic, and is never positively diagnosed in life. Prominent symptoms are pain and oppression in the epigastric region ; retching, and vomiting of bilious matter ; severe salivation ; colicky pains ; pulse full, tense, and irregular ; stools contain fat and a material that resembles saliva; jaundice may be present from occlusion of the bile-duct. Pain is not altered by food, but increased by erect posture ; sugar often present in the urine. Terminates in collapse in four or five days ; or, in the chronic form, with formation of abscesses or cysts that may ulcerate into the peritoneum. Treatment. — Little can be done except to palliate. Rest in bed ; light diet without any fat ; morphina for pain ; counter- irritation and hot fomentations. In the later stages, potas- sium iodide and mercury ; quinine, iron, and supporting treat- ment. Alkaline salts are recommended. Treat symptoms. CANCER OF THE PANCREAS. Description. — Cancer of the pancreas is primary or second- ary ; scirrhous or medullary. The head of the gland is the most frequent seat. Pain is the main symptom. Cachexia; emaciation ; loss of appetite ; vomiting ; jaundice, at times j tumor in the epigastrium, in some cases. Stools are fatty. Treatment is palliative; cases rarely last more than six months or a year. 244 DISEASES OF THE LIVER AND APPENDAGES. INTRODUCTION. The liver varies in weight under conditions of age, sex, functional activity, disease, and health. Its main function is the excretion and secretion of bile. Average weight in an adult is about one fortieth of the body weight ; in children from one twentieth to one thirteenth. It is about twelve inches long, six inches broad, and three inches thick at its greatest thickness. Percussion dullness, in health, limits it between the fifth in- terspace, the lower border of the ribs, and to the right of the median line. Deep inspiration causes the liver to descend nearly one inch. Position varies in males and females, owing to the pernicious habit of lacing and corsets in the latter. Palpation reveals whether it is smooth, roughened, or nodu- lated ; whether the border is sharp or rounded ; whether it is hard or soft, large or small. Pain is generally dull, and radiates to the thorax, scapula, shoulder, and umbilicus ; is constant, and increased by deep pressure. Digestive troubles accompany hepatic affections, and vary from slight indigestion to violent gastro-intestinal catarrh. Disturbed circulation is common, and gives rise to dropsy, hemorrhoids, jaundice, hemorrhage from the stomach or in- testines, inflammatory changes in peritoneum, enlargement of the spleen, and superficial abdominal veins. Jaundice of all grades — not always present in liver-diseases. 245 246 A SYNOPSIS OF THE PRACTICE OF MEDICINE. JAUNDICE. Synonym — Icterus. Definition. — Jaundice is a symptom of some hepatic dis- order, manifested by a peculiar yellowness of the skin, con- junctiva, and mucous membranes ; the presence of biliary matter in the urine and secretions ; itching of the skin ; and white, offensive, putty-like stools. Varieties. — Catarrhal jaundice ; icterus neonatorum ; hepa- togenous jaundice ; haematogenous jaundice. Etiology. — Obstruction, partial or complete, of the bile-duct or any of its radicles in the liver, by gall-stones, hydatids, distomata, stricture, cancer, or tumors ; portal obstruction ; cirrhosis 5 atrophy; poisons, such as phosphorus, arsenic, mercury, or antimony ; concussion of the brain and nervous causes ; hyperemia and the specific fevers. Symptoms. — Conjunctiva, skin, and mucous membranes are discolored, yellow, and vary in color from a pale^ellow to a dark-brown or greenish tint. Urine contains bile pig- ment, and gives the characteristic play of colors with nitric acid. Bile is detected in the saliva and other secretions. Fceces are putty-like or whitish, and are highly offensive; pulse slow ; general malaise ; debility and stupor ; temperature subnormal. Itching of the skin is a prominent symptom ; bitter taste in mouth ; loss of appetite. A sudden blackening of the stools means a free discharge of bile. In addition, there are the symptoms of the causative trouble. Pathology. — Hepatogenous jaundice is due to an obstruc- tion to the normal outflow of bile. Bile is taken up by the circulation, produces an excitement of the nervous centers first, and soon causes drowsiness, stupor, coma, and death. Pathology of the causative affection. Hematogenous jaundice is not positively explained, but is DISEASES OF THE LIVER AND APPENDAGES. 247 supposed to be due to a failure of the liver to perform its proper function in the formation and elimination of the bile. Others claim that the blood is the tissue at fault. Icterus neonatorum, or jaundice in the new-born, cannot be explained with our present knowledge on the subject. Diagnosis. — Easily made from the symptoms. Prognosis and Treatment depend on the cause. (See Catarrh of Bile-ducts, and other diseases of liver.) HEPATIC HYPEREMIA. Synonyms. — Hepatic congestion; biliousness ; congestion of the liver. Definition. — An acute or chronic congestion of the liver, symptomatic of a constitutional or local disorder, accompanied by impaired digestion and biliary function. It is either active, when due to arterial trouble, or passive, when due to venous. Etiology. — Active hypercemia is due to over-eating ; alcohol ; spices and condiments ; fevers ; malaria ; arrested menstrua- tion ; heat and cold. Passive hyperemia arises from obstructive diseases of the heart, lungs, kidneys, or pleura ; compression of the vena cava by tumors. Symptoms. — Active Hypercemia. — Pain and feeling of weight in hepatic region; liver dullness increased; tenderness to pressure ; sense of a band around the abdomen j uneasi- ness; constipation; vomiting at times; marked indigestion; headache; slight fever ; anorexia ; and bad taste in the mouth. Conjunctiva has a yellow tinge and indications of slight jaundice. Passive hypercemia is slow in onset ; liver dullness increased ; marked symptoms of indigestion ; slight jaundice ; and symp- 248 A SYNOPSIS OF THE PRACTICE OF MEDICINE. toms of causative trouble. Hemorrhoids and ascites are common. Pathology. — Hypercemia is but the first stage of cirrhosis. A section of the liver appears like a section of nutmeg, hence the term u nutmeg liver." Liver increases in size, and finally contracts or atrophies, if the process is chronic. Headache and gastric disorders are due to improper elimination of bile. Prognosis. — Acute is good ; passive depends on cause. Treatment. — Acute Hyperemia. — Forbid all alcoholic and malt liquors, spices, condiments, and rich foods. When due to over-eating, a good dose of calomel and soda is indicated. Calomel does not increase the secretion and excretion of bile, but favors its formation and elimination. Malarial causes require quinine. Treat all fevers and digestive disorders. Leeches, counter-irritation, and cold compresses to the liver. Chronic hyperemia demands causal treatment. Sodii phos- phas, 3 i-ij, ter die, nitromuriatic acid, taraxacum, carbonated and alkaline waters are good. Stimulate when necessary; improve hygiene and diet. In all cases keep the skin active and attend to other functions. ACUTE SUPPURATIVE HEPATITIS. Synonym. — Abscess of the liver. Definition. — An acute inflammation of the cellular struct- ure of the liver, terminating in the formation of single or multiple abscesses. Etiology. — Most common in males, in malarial districts and hot climates ; seldom seen in the temperate zones. Caused by wounds ; contusions ; gall-stones ; septic thrombi ; dysen- tery ; operations for hemorrhoids; pyaemia; acute or chronic hepatitis. DISEASES OF THE LIVER AND APPENDAGES. 249 Symptoms. — Some cases are so obscure as to attract no notice until the abscess or tumor is discovered. Symptoms may be those of debility ; irritable nervous system ; and slight febrile attacks; chills; and pycemic fever; slight jaundice — not always present; loss of appetite; slight cough; vomiting; weight and oppression in hepatic region. Locally, in marked cases, hepatic region is prominent and fluctuation can be detected; local or general tenderness; throbbing, dull pain reflected to the shoulder and back. Abscess may break through the skin into peritoneum, intestines, stomach, pleura, or lungs. Pathology. — An inflammatory action sets up in the liver- cells at one or more points, from one of the causes mentioned ; the inflamed mass becomes infected with pyogenic germs ; a disintegration or breaking down of the tissues, with diape- desis of white blood-cells and formation of an abscess. One or more abscesses may form and break into the surrounding structures or become encapsulated. They vary in size from a pea to a hen's egg or larger. Diagnosis. — Presence of pus, demonstrated by an aspirat- ing needle ; sudden vomiting or coughing up of pus, or pass- ing it by the bowels, associated with local and general symptoms, constitute the positive diagnostic points. Prognosis. — Usually bad ; some cases recover. Treatment. — Symptomatic. Large doses of quinine for malaria and pyasmic fever ; most stimulating diet, with wine and supporting treatment ; cold compresses or hot turpentine stoops to the liver; morphina to relieve pain. As soon as abscess is suspected, use aspirator and remove pus ; tr. iodini or other antiseptics may be injected into the cavity. Lapa- rotomy is justifiable when abscess is demonstrable. Cleanse with peroxide of hydrogen when opened with the knife. I recently met with a case of hepatic abscess in my own prac- tice, and removed one quart of pus with an aspirating needle. 250 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Recovery complete, and abscess has not refilled. The patient is strong, hearty, and at hard work. (See Med. Bulletin.) INTERSTITIAL HEPATITIS. Synonyms. — Cirrhosis of the liver j sclerosis of liver ; hob- nailed liver; gin-drinkers' liver. Definition. — An inflammation of the interstitial connective tissue of the liver, giving rise to cicatricial bands which con- tract, canse an atrophy of the liver-cells and a local or general diminution in the size of the organ, interfering with its nor- mal physiological action. Etiology. — Principal cause is habitual use of alcohol, in frequent, small amounts ; condiments j idiopathic ; passive congestion. Fagge says, " Syphilis does not cause cirrhosis." Symptoms. — First stage of cirrhosis presents symptoms of a low grade of hypermmia ; an uneasy feeling, with now and then slight pain, in the region of the liver, most marked after eating or drinking ; slight gastro-intestinal disturbance. Grad- ually the symptoms increase until the second stage or stage of contraction occurs. Abdominal veins enlarged; marked abdom- inal ascites; persistent gastrointestinal catarrh; attacks of jaundice, becoming chronic in character; hemorrhage from the stomach and bowels; pain in the. liver ; spleen enlarged, congested, and may be involved by the same process ; hemor- rhoids. Urine rich in urates and bile pigments ; shin presents a dirty-yellow appearance ; fceces clay-colored. Palpation and Percussion. — In first stage liver is enlarged and smooth. Second stage presents a small area of dullness ; liver feels hard and nodulated. Pathology. — Constant irritation to the interstitial connect- ive tissue (Grlisson's capsule) ; increased blood-supply ; diape- desis of leucocytes; and formation of new tissue, causing a DISEASES OF THE LIVER AND APPENDAGES. 251 temporary enlargement of the organ. This newly formed cica- tricial tissue contracts and causes atrophy of the liver-cells, with diminution of the size, and nodulated appearance. A hypertrophic form, in which the organ remains enlarged, gives rise to more profuse jaundice, with tendency to fever and peri- tonitis. Gastro-iiitestinal symptoms, enlarged spleen, and dropsy come from obstruction to portal circulation. Peri- toneum covering liver is thickened and adherent. Diagnosis. — Chronic atrophy is uniform, and liver presents no nodulated feel. Cancer is more rapid, marked cachexia, age, and nodules, independent of alcoholism. Prognosis. — First stage is good. In second stage we can only palliate. Destroyed liver-tissue cannot he restored. Treatment. — All alcoholics and condiments must be stopped at once ; gastro-intestinal catarrh needs attention ; treat first stage as in hyperemia. Second Stage. — Treatment is palliative. Put on dry diet to reduce ascites. Chloride of gold and mercury will not restore destroyed liver-cells, as claimed. Oxide of zinc, nitrate of silver, or hydrastis for gastro-intestinal catarrh. Iron, bit- ters, cod-liver oil, and mineral tonics increase catarrhal symp- toms. Alkaline carbonates are too depressing. Predigested diet; sour foods, such as raw oysters with vinegar, soused pigs' feet and tripe ; peptonized milk and meat. Avoid fats and sugars. If ascites becomes severe, resort to tapping. Hemorrhage may demand astringents. SYPHILIS OF THE LIVER, Description. — Syphilis may be congenital or acquired, and causes a perihepatitis or a partial interstitial hepatitis. Gumma form in the liver, causing destruction and atrophy of its cells, and are frequently scattered through the whole organ 252 A SYNOPSIS OF THE PRACTICE OF MEDICINE. as small hemp-seeds, and cause a cheesy degeneration. Most common in children and rarely suspected until after death. Cirrhosis complicates ; ascites and jaundice may or may not be present, according to size and position of gumma. Albu- minuria is frequent ; may have fever of hectic type. Treatment. — First stage demands iodides and mercury to check the disease. Treat symptoms as they arise. (See Syphilis.) AMYLOID LIVER. Synonyms. — Lardaceous, albuminoid, or waxy liver ; scrof- ulous liver. Definition. — A waxy degeneration of the liver-cells, in which the normal cellular elements are replaced by an amy- loid or starch-like substance ; so called because it gives the same characteristic reaction with iodine as starch. Etiology. — Most common in tuberculous subjects and pa- tients suffering with prolonged suppuration of bone, syphilis, and chronic malaria. Symptoms. — Indigestion, nausea, vomiting, and diarrhoea. Jaundice rare ; feeling of fullness over liver ; pain slight or entirely absent ; liver dullness increased — may be twice the normal size ; palpation gives a hard feeling, with smooth surface and rounded edge ; spleen enlarged ; anaemia ; urine is increased, contains albumin, and, at times, may give starch reaction. Ascites is rare. Pathology. — Liver enlarged, pale, smooth, shiny, and cuts like wax. Waxy material is found in the liver-cells and capillaries. Iodine applied to a section gives a brown or blue reaction. Aniline violet stains the amylaceous matter pink, and liver structure violet or blue. Other organs undergo the same change. DISEASES OF THE LIVER AND APPENDAGES. 253 Prognosis. — Unfavorable. Treatment. — Remove the cause ; stop suppuration in bones and joints ; treat syphilis and tuberculosis. Potassium iodide, hydriodic acid, quinine, and iodide of iron. Treat symptoms. Stimulate and give good diet. FATTY LIVER. Description. — Fatty degeneration of the liver is due to cor- pulence and wasting diseases, such as cancer or consumption. Liver is large, smooth, and infiltrated with fat ; liver-cells con- tain f at-globules ; fat is deposited in the parenchyma ; liver is doughy, and pits on pressure ; edge is rounded ; cuts very easily. Subjective symptoms are not marked. Objective symptoms show an increased area of dullness over liver ; no pain on pressure ; no jaundice, except in bad cases ; obstinate diarrhoea. Treatment. — Remove cause ; treat corpulency, phthisis, or debilitating diseases. Never give cod-liver oil or fat, as it in- creases the difficulty. Treat diarrhoea with astringents ; meet all complications as demanded. HEPATIC CANCER. Synonyms. — Cancer of the liver ; hepatic carcinoma. Definition. — A malignant growth in the liver, primary or secondary : occurring after the fortieth }^ear ; accompanied by pain, cachexia, and hepatic disorders. Etiology. — Cancer of the liver is hereditary, or develops primarily under some irritating influence ; extends from other organs, and is secondary. Most common in women between the fortieth and sixtieth years. Symptoms. — During the early stages symptoms are ob- scure. Later, there is a fullness and weight in the right hypo- 254 A SYNOPSIS OF THE PRACTICE OP MEDICINE. chondrium ; severe shooting pain, reflected to right shoulder and umbilicus ; great sensitiveness to pressure ; liver enlarged, and one or more nodular tumors may be felt. Ascites, gastro- intestinal catarrh, hemorrhage, and jaundice accompany when the portal circulation and gall-ducts are obstructed by the tumor. Feet swollen ; thrombosis of femoral veins not un- common ; ascites may conceal physical signs, and requires tap- ping before satisfactory examination can be made. In all forms of cancer the red corpuscles of the blood num- ber between one and two million to the cubic millimeter, and if taken with other symptoms are almost diagnostic. Pathology. — Medullary cancer is most common, and varies from a large, soft, friable mass to a hard, lobulated, scirrhous variety. May be soft, disintegrating, and black ; marked hy- peremia ; atrophy and degeneration of the liver-cells ; local and adhesive peritonitis, if the cancer is near the surface of the organ ; whole gland infiltrated at times, or, rarely, a small, isolated epithelioma is found. Diagnosis. — Age 5 cachexia ; marked ascites ; anaemia ; blood-count; pain and local tenderness; nodulated tumor; rapid emaciation and decline of patient. Prognosis. — Always bad ; patients die within the first year. Treatment. — Relieve local pain by leeches, counter-irrita- tion, or morphina ; remove small amounts of fluid from abdo- men at a time. Clinical experience shows that arsenic, conium, mercury, and other drugs only palliate, and death will result sooner or later. HYDATIDS OF THE LIVER. Description. — Hydatids, single or multiple, are due to the Tarnia echinococciis, a peculiar form of tapeworm, and consist of cystic tumors that contain a colorless, non-albuminous fluid DISEASES OF THE LIVER AND APPENDAGES. 255 and the eggs of the worm. Most common in Iceland ; is dne to the ova of the worm, which are derived from dogs, sheep, and pigs, and are carried through the air, water, and food into the system, and develop in the spleen, liver, or kidneys. Cysts project from surface of liver as fluctuating tumors; they sometimes dry up, or continue to enlarge and ultimately rupture. Little or no jaundice ; no fever or tenderness ; ob- struction of portal circulation or bile-ducts, by pressure, causes jaundice, gastro-intestinal symptoms, ascites, and en- larged spleen. Diagnosis. — Determined by aspirator, non-albuminous fluid and presence of ova, demonstrated by microscope. Prognosis is good ; if there are multilocular cysts it is bad. Hydatids last about four years and grow very slowly. Treatment. — Draw off fluid with aspirator, and inject a so- lution of fel bovinum or tr. iodini. Electrolysis, with needles thrust into the cyst, sometimes cures. If suppuration is sus- pected, open freely and treat as suppurative hepatitis. At- tend to diet and hygiene. Multilocular cysts resist all treat- ment and are fatal. ACUTE YELLOW ATROPHY. Synonyms. — Malignant jaundice ; hemorrhagic jaundice ; acute parenchymatous degeneration of the liver. Definition. — An acute, degenerative inflammation of the cellular elements of the liver, which results in marked jaun- dice, great depression, nervous symptoms, atrophy of the liver, and terminates fatally. Etiology. — Most common in young pregnant women; syphilis ; venereal infection ; poisoning by phosphorus, anti- mony, or arsenic. Symptoms. — Prodromal symptoms are gastro-intestinal ca- 256 A SYNOPSIS OF THE PRACTICE OF MEDICINE. tarrh, tenderness of abdomen, rapid pulse, headache, and slight jaundice. Onset is heralded by vomiting of mucus and a dirty- brown or black material not unlike that of yellow fever. Pa- tient is desperate, delirious, or comatose ; convulsions or tris- mus ; dilated pupils ; temperature 104° F. ; pulse very rapid ; tongue and teeth coated; spleen enlarged; and jaundice marked. Hemorrhage from the nose, bronchi, or stomach, which ultimately results in death. Pathology. — Liver nearly one half its original size ; capsule puckered and yellow; a dirty-gray deposit between lobules, and lobules contain leucin ; fatty degeneration. Gall bladder and ducts empty ; blood thick and dark ; urine contains bile and albumin ; kidneys pigmented, and brain softened. Nerv- ous symptoms are due to toxaemia. Pathology is not posi- tively explained. Prognosis. — Duration is from twelve hours to one week, and recovery is rare. Treatment. — Since pathology is unknown, treatment is en- tirely symptomatic. A large, free purgative at onset, regard- less of pregnant condition. Mineral acids, alcohol, nux vom- ica, small doses of phosphorus, and counter-irritation are palliative measures. Ice, hydrocyanic acid, bismuth, and ar- senite of copper are given for vomiting. PYLEPHLEBITIS. Description. — An inflammation of the branches of the por- tal vein and the tissues in which they are imbedded. There are two distinct classes : the suppurative and adhesive. Suppurative pylephlebitis is due to the extension of some sup- purative inflammation to the walls of the portal vein and its branches ; or from septic thrombi, due to abscess of the stom- ach, spleen, or other organs. Inflammation begins in vessel- DISEASES OF THE LIVER AND APPENDAGES. 25? wall ; a thrombus is formed ; it suppurates, aud causes ulcera- tion of the vein, dissemination of pus into general circula- tion, and pyaemia. There is pain in epigastrium ; engorged spleen and ascites. Jaundice is absent; chills; fever; and symptoms of pyaemia. Frequent vomiting; diarrhoea, alter- nating with constipation. This is a rare condition and is always fatal. Treatment is palliative. Chronic adhesive pylephlebitis, or non-suppurating thrombus of portal vein, is caused by pressure of tumors, cirrhosis of liver, syphilis, or thickening of pylorus. Symptoms are those of congestion ; engorged spleen ; catarrh or hemorrhage of stomach and intestines ; obstinate ascites ; and marked collat- eral circulation through omentum ; liver atrophies, and is not tender. Treatment is the same as that of advanced cirrhosis of liver. CATARRH OF THE BILE-DUCTS. Synonym — Catarrhal jaundice. Definition. — A catarrhal inflammation of the mucous mem- brane of the bile-ducts, accompanied by varying degrees of jaundice and intestinal indigestion. Etiology. — Hyperaemia of liver; hepatic cancer; obstruct- ive heart-diseases ; extension from duodenal catarrh ; passage of gall-stones ; heat or cold ; malaria ; improper drink or diet ; most common in plethoric and inactive women. Symptoms. — Uneasiness and tenderness in region of liver ; gastro-intestinal disturbances; patty-liJce, offensive stools; tongue coated; little or no fever; heart slow and weak; symptoms of jaundice ; itching of skin ; urine loaded with bile and salts ; liver enlarged. Trouble leaves in a few weeks, but may become chronic and last for months, resulting in per- manent narrowing of the duct and consequent disorders. 258 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Treatment. — Rest in bed. When due to duodenitis, treat as indicated in that disease. Hot drinks, with sodium bicar- bonate, to remove mucus from stomach and duodenum ; dia- phoretics, diuretics, and Carlsbad mineral waters. Nitro- muriatic acid before meals; sodium sulphate is the best laxative ; sodium phosphate in the chronic form. Regulate diet to skim-milk and lean beef; avoid starches, fats, and sugars. When local tenderness is marked, counter-irritation, leeches, hot poultices, or fomentations. Nothing will relieve pmiritis in this condition better than large doses of pilocar- pus to produce diaphoresis. HEPATIC CALCULI. Synonyms. — Gall-stones ; biliary calculi ; liver-stones. Description. — Gall-stones are hard masses composed of bile-salts, mucus, and inspissated bile. They vary in size from a hemp-seed to a hen's egg, and usually have a nucleus of hardened mucus. They are found in the gall-bladder, cystic duct, hepatic duct, or common bile-duct. There may be one or several hundred impacted in the gall-bladder. Symptoms. — As long as the stone remains in the gall-blad- der, no symptoms may be manifested ; many impacted stones are recognized by a hard tumor on palpation. When a gall- stone enters the duct, there is an attack of hepatic colic. With- out any previous symptoms, patient is seized with violent pierc- ing and griping pain in right hypochondrium, reflected to right shoulder and umbilicus; skin cold and clammy; liver enlarged and bulging ; pulse slow ; no fever ; convulsions and syncope from intense pain ; persistent and obstinate vomiting. After one hour or more the paroxysm ceases suddenly with complete relief, indicating the passage of the stone into the duodenum. DISEASES OP THE LIVER AND APPENDAGES. 259 Jaundice comes on after the attack, from inflammation of the mucous lining of duct j liver is tender for several days. Gall-stone is passed with stool, is vomited, or may have en- tered the gall-bladder again. Attacks may occur at intervals of a few days or weeks, if other stones remain. Sometimes gall-stones become impacted and cause ulcera- tion and peritonitis. Obstruction of the common duct by a gall-stone results in fatal jaundice or ulceration. Diagnosis. Hepatic Colic. Pain always on the right side. Pain reflected to right shoulder and umbilicus. Urine shows no pathological condi- tion. Stone is found in stools or vomit. Liver very tender ; jaundice after the attack. Renal Colic. Pain may be on right or left side. Pain reflected along ureter to testi- cle and head of penis, with re- traction of same. Urine bloody and contains evidence of the trouble. Stone is often found in urine passed. Tenderness in loins along ureter, with no jaundice after attack. Treatment. — Paroxysm. — Hypodermic of morphinse sul- phas, gr. i to i, with atropine sulphas, gr. y^, relieves pain, stops spasm of muscular coat of gall-duct, and favors passage of the stone. Anaesthetics ; morphina may be given internally in hot water j chlorodyne or chloroform, gtt. xx-xxx, every ten minutes j mustard poultices j hot fomentations. Yery hot alkaline drinks often relieve vomiting and assist in relaxing spasm. Stimulate if necessary. Resulting inflammation is treated with counter-irritation and alkalies. Preventive Treatment — Exclude fat, sugars, lime salts, and malted liquors from diet ; give only lean meat and vegetables. Internally. — Sodium phosphate, 3 j, with arsenious acid, gr. a 3 ^ three times daily, for months. Sodium succinate, gr. iij-v, three times a day, long continued, often produces a cure or cessation of attacks. It is doubtful if anything except bile 260 A SYNOPSIS OF THE PRACTICE OP MEDICINE. will dissolve gall-stones in the gall-bladder. Alkalies, ether, fel bovinum, and turpentine are recommended for their so- called solvent action, but by the time they are taken into the blood and reach the liver and bile, they are so weak as not to accomplish this result. They may increase the flow and reac- tion of bile, causing it to act as the solvent. Moderate exer- cise, and all the emunctories should be kept active. Several ounces of olive-oil, given at one dose, may assist in the expul- sion of gall-stones, and has been recently recommended. DISEASES OF THE SPLEEN. SPLENIC HYPEREMIA. Synonyms. — Congestion of the spleen ; splenic fluxion. Description. — The spleen, normally, weighs about eight ounces, and its general structure favors active congestion. Acute congestion or fluxion is caused by malaria, typhoid fever, septicaemia, portal obstruction, relaxed splenic tissue, blows, injuries, exercise, and physiological enlargement after meals. Spleen becomes four times its normal size in some cases ; little or no pain ; local tenderness in left hypochondrium. Death may ensue from rupture. Area of percussion dullness is increased. Treatment. — Causal; quinine in large doses; cold douches directly over the spleen ; faradization or galvanism ; ergot hypo- dermically or by stomach ; removal from malarial districts. SPLENITIS. Description. — Inflammation of the splenic structure comes from excessive hyperemia, malaria, fevers, and embolic in- farctions. Primary inflammation is rare. Spleen is tender, swollen, and painful ; may become friable, cheesy, or result in abscess; localized peritonitis; sympathetic vomiting; chills and fever. Treatment. — Palliative. — Leeches, counter-irritation, and hot fomentations; ice and carbonated alkaline waters for 261 262 A SYNOPSIS OF THE PRACTICE OF MEDICINE. vomiting j morphina for pain. Evacnate abscess at once by aspirator or incision j quinine in full doses ; treat cause. SPLENIC HYPERTROPHY. Description. — Due to malaria, leucaemia, cirrhosis, or chronic splenitis. Spleen is broad, hard, and has rounded edges ; has a deep-brown color, or, if malarious, gray ; capsule thickened ; trabecula rigid ; pulp reduced to a cheesy mass ; anaemia ; short- ness of breath ; nasal hemorrhage ; hydraemia and dropsy. Treatment. — Quinine, in malaria ; change of residence to non-malarious district ; cold douches and electricity to spleen ; iron and arsenic for anaemia. Hypertrophy from pylephlebitis resists all treatment. To reduce ague-cake (a spleen enlarged from malaria), stand patient before a hot, open fire until the skin over spleen is red and glowing ; apply a piece of ung. hydrargyri oxidi rubri, as large as a walnut, and rub in well for several minutes ; allow it to bake in before the fire ; this process to be repeated daily. Ergot, hypodermically, may do good. AMYLOID SPLEEN. Description. — Amyloid degeneration of the spleen is asso- ciated with the same disease in the liver and kidney, and pre- sents similar symptoms. Spleen is heavy, hard, pale, smooth, and gives starch reaction with iodine. Anaemia, cachexia, dropsy, and marked increase of splenic dullness. Treatment is of little avail, and is entirely symptomatic. THE URINE. QUALITATIVE URINARY ANALYSIS. Normal urine varies under different circumstances of diet, heat, cold, and amount of liquid taken. More urine is passed when the pores of the skin are inactive. The average quantity passed in twenty-four hours is about forty to fifty fluid ounces (1200 to 1500 c.c). Color, pale amber, or shades of yellow due to presence of urobilin and indican. Reaction, slightly acid. Specific gravity varies from 1.015 to 1.020, and is determined by the urinometer. Normal constituents of urine are : urea, about five hundred grains (thirty grams) daily; uric acid, fifteen grains (one gram) ; phosphoric acid, thirty to sixty grains (two to five grams) ; chlorides, two hundred and forty-eight grains (six- teen grams) ; hippuric acid ; creatinine ; sulphuric acid ; salts of sodium, ammonium, potassium, calcium, and magnesium. Abnormal urine contains bile pigments or salts ; albumin ; glucose ; pus ; blood ; oxalic acid, or oxalates ; tyrosin ; leucin ; epithelial cells and tube-casts. CHEMICAL TESTS. ALBUMIN. Seat Test — Filter and acidify urine with acetic acid j fill test-tube nearly full of urine, and boil upper layers over spirit- lamp. If albumin is present, a coagulated mass is formed in the part boiled, and contrasted with clear urine below. Ad- dition of nitric acid will not dissolve coagula of albumin^ 263 264 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Nitric-acid Test. — (Heller's test.) Place several drops of pure nitric acid in bottom of test-tube, and allow urine to flow down sides of tube to form a distinct layer on the acid. If albumin is present, a white, coagulated ring appears at the zone of junction. Picric-acid Test. — A concentrated, acidulated solution of pure picric acid, added to urine, will coagulate albumin, and cause a precipitate if allowed to stand. SUGAR. IAquor-potassce Test. — (Moore's test.) To one part of urine, add one half as much liquor potassae ; mix thoroughly and boil upper layers ; contrast boiled part with the cold part be- low, and if sugar is present, the upper part is a canary-yellow or red. Nitric acid decolorizes it. Bismuth Test. — Treat two volumes of urine with one of liquor potassae ; add a small quantity of subnitrate of bismuth, and boil. Sugar reduces bismuth to the black suboxide. Fermentation Test. — Yeast added to saccharine urine at a warm temperature causes fermentation and generation of carbon dioxide. Fehliny's Test. — This consists of two separate preparations prepared and used as follows : No. l. Cupri sulphatis (pure crystals) 34.64 gin. Aquae destillatae ". q. s. ad. 500.00 c.c. No. 2. Potassii et sodii tartratis (pure cryst.) . . 173 gm. Sodii hydratis (solution 1.34 spec, grav.) 100 c.c. Aquae destillatae q. s. ad. 500 c.c. THE URINE. 265 Mix equal volumes of these two solutions ; add a few drops of urine, after thoroughly boiling, and boil again. If sugar is present, red oxide of copper is precipitated. This is one of the most reliable tests. PHOSPHATES. Alkalinize urine with liquor potassee or aqua ammonise, and boil. Phosphates are precipitated as a light-colored flocculent precipitate ; acetic or nitric acid dissolves them. Magnesia mixture precipitates alkaline phosphates. URIC ACID. Add strong nitric or hydrochloric acid to urine. Uric acid precipitates as small reddish-brown crystals. BILE AND SALTS. One drop of fuming nitric acid placed on a porcelain plate and allowed to blend with a drop of urine causes a play of colors from green, blue, violet, red, yellow, to brown, when bile pigment is present. CHLORIDES. Nitrate of silver precipitates as a white chloride when added to urine containing chlorides. Mucus is precipitated by acetic acid, in the shape of delicate fibrillated bands, as mucin. MICROSCOPICAL EXAMINATION. By means of the microscope, blood, pus, epithelium, casts, crystals, and bacteria are detected. DISEASES OF THE KIDNEYS. URAEMIA. Description. — A symptom of kidney-disease due to suppres- sion of the normal excretion of toxic substances (urea) from the blood through the urine. Occurs in course of Blight's disease ; albuminuria of pregnancy (puerperal convulsions) ; obstruction of both ureters ; retention or suppression of urine ; and some fevers. Acute urcemia begins suddenly with convulsions (eclampsia) similar to epilepsy; wild, staring gaze; tonic muscular con- traction, followed by twitching clonic spasms ; pupils dilated ; pulse quick ; temperature high ; and coma. Recovery is the rule, if property treated. Chronic Urcemia. — Drowsiness; headache; nausea and vom- iting ; dilated pupils ; muscular twitching, without loss of con- sciousness ; chilliness ; fever ; dyspnoea at night. This condi- tion may go on a long time and suddenly develop an acute attack. Urine scanty; urates diminished; albumin present. Prognosis depends on the cause; always grave. Puer- peral eclampsia is often cured. Treatment. — Symptomatic, and depends on cause. Vene- section is valuable in plethoric persons ; free purgation ; dia- phoresis. In convulsions, administer anaesthetics, chloral, bromides, or morphina — the first two being the most reli- able. Keep patient absolutely quiet, and avoid excitement or irritants. 266 DISEASES OF THE KIDNEYS. 267 RENAL HYPEREMIA. Synonym. — Congestion of the kidney. Definition. — An active or passive engorgement or conges- tion of the vessels of the kidney. Etiology. — Active Congestion. — Direct injury ; cold; fevers; medicines, such as turpentine and cantharides ; inflammation. Passive Congestion. — Obstructive diseases of heart, lungs, liver, or portal system; pressure of tumors on the venous trunks. Symptoms. — Active. — Xo pain or local tenderness ; little or no fever ; general malaise, headache, and sometimes vomiting ; irritability of bladder ; frequent micturition. Urine increased ; pale in color; low specific gravity. If renal veins are ob- structed, urine is scant} 7 , high-colored, contains blood, casts, and albumin. Passive. — Symptoms of cause ; urine scanty, high-colored, and loaded with urates. Pain in testicle and heavy feeling in loins ; no fever. Pathology. — Kidney is large, red, and engorged with blood ; Malpighian bodies red and inflamed ; epithelial lining of tu- bules in catarrhal state. Chronic congestion is the first stage of cirrhosis. Prognosis. — Active cases recover promptly, if properly treated. Passive cases are liable to cause Bright's disease, and depend on cause. Treatment. — Active Congestion. — Rest in bed; discontinu- ance of irritants ; mildest diet ; free use of alkaline waters to dilute and alkalinize urine ; no stimulating diuretics ; infusion of digitalis is best heart-tonic and diuretic; small doses of Epsom salts are recommended. Leeches, hot poultices, dry or wet cups over loins ; venesection in very acute cases ; free 268 A SYNOPSIS OF THE PRACTICE OF MEDICINE. diaphoresis depletes blood and relieves tension on kidneys. Irritability of bladder is relieved by morphina, liquor arnmonii acetatis, and nnx vomica. Passive congestion is treated according to cause. ACUTE TUBAL NEPHRITIS. Synonyms. — Acute Bright's disease; acute desquamative or croupous nephritis ; acute parenchymatous nephritis. Definition. — An acute inflammation of the mucous lining of the uriniferous tubules, recognized by fever, pain over the kidneys, and scanty, high-colored urine, containing blood, albumin, epithelial cells, and tube-casts. Etiology. — Scarlet fever ; high fevers ; cold ; injury ; con- gestion, drugs. Most common in the young. Symptoms. — Onset sudden; chill, fever, and vomiting; constant desire to urinate; sharp pain over both kidneys. Uraemia may supervene. Urine small in amount (f 1 i-v in twenty-four hours) ; high-colored ; high specific gravity ; albumin (one half to one third bulk) ; blood ; salts ; epithelial cells and tube-casts. Local or general dropsy soon appears, beginning by pufliness under the eyes. Patients are very susceptible to such complications as pneumonia, pleurisy, peritonitis, or pericarditis. Pathology. — Kidney enlarged ; capsule thick, opaque, and not adherent ; color deep red ; uriniferous tubules swollen and filled with epithelial cells, blood, and mucus. Dropsy is due to obstructed circulation and suppression of urine. Prognosis. — Lasts one to five weeks, and usually termi- nates in recovery. May have any of the complications. Treatment. — Rest in bed ; diet of skimmed milk and broths ; pure alkaline waters, freely used ; counter-irritation, cups, or leeches over kidneys; regulate bowels daily with saline DISEASES OP THE KIDNEYS. 269 cathartics. Tr. aconiti, gtt. j, every half -hour, often relieves acute cases. Dropsy lessened by elaterium, oleum tiglii, jalap, or mag- nesii sulphas internally; free diaphoresis by hot baths or pilocarpus jaborandi. Potassii acetas, gr. xv, with infusion digitalis, f 3 ij, every three hours, as a diuretic. Coma, con- vulsions, and dropsy indicate jaborandi. Convalescence. — Basham's iron mixture, f 3 ij, ter die. Limit foods to skimmed milk and light, non-albuminous diet ; pro- hibit all spices and condiments, volatile oils and alcoholics. CHRONIC TUBAL NEPHRITIS. Synonyms. — Chronic desquamative nephritis; chronic Bright's disease ; large white or fatty kidney ; chronic paren- chymatous nephritis. Definition. — A chronic inflammation of the mucous lining of the uriniferous tubules, recognized by scanty urine of high specific gravity in the early stages and low in the later, with granular casts, epithelium, and albumin; marked dropsy, gastro-intestinal catarrh, and frequent attacks of uraemia. Etiology. — Cold, damp, intemperance, toxic malaria, syphi- lis, and tuberculosis. Sometimes comes from acute Bright's disease ; may be idiopathic ; rare in old or very young persons. Symptoms. — If it follows acute Bright's disease, the symp- toms are more chronic ; general dropsy ; effusion into serous cavities ; urine scanty and albuminous ; cardiac hypertrophy or dilatation, and a tense, wiry pulse. Insidious Cases. — Anaemia ; loss of appetite ; headache ; nau- sea ; frequent micturition and no pain in kidneys : feet cedem- atous at night and puffiness around eyes in morning ; dropsy slowly increases and causes great dyspnoea ; gastro-intestinal catarrh ; frequent attacks of uraemia ; retinitis albuminuria. 270 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Urine scanty at first, but slightly increased in later stages ; urea diminished ; hematuria at times ; albumin nearly one half when boiled (two percent, to four percent, by weight) ; specific gravity high at first, later it is low ; tube-casts — hya- line, epithelial, and ' granular ; large masses of epithelial cells (showing fatty degeneration) ; and granular matter. Hyper- trophy of left ventricle of heart; slight fever at times. Sub- ject to pneumonia, pleurisy, peritonitis, pericarditis, bronchial and gastro-intestinal catarrh, oedema of lungs or glottis, sloughing or inflammation of skin. Pathology. — First Stage (large white kidney). — Kidney twice its normal size and weight ; capsule dull, opaque, and is easily stripped off ; color dull gray or red ; pyramids very red ; ecchymotic spots ; glomeruli and uriniferous tubules inflamed and stripped of epithelial lining, allowing transudation of al- bumin into urine. Tubes filled with epithelium, fat-globules, and granular masses. Second Stage. — Kidney rough ; nearly normal in size ; cap- sule adherent ; pale, white color ; bands of connective tissue ; degenerated kidney-cells ; tubes filled with degenerated epi- thelium and casts ; portions of kidney atrophied ; slight waxy defeneration. Diagnosis. — See Amyloid Kidney. Prognosis. — Unfavorable ; patients rarely die of the disease itself, but from one of its complications ; may be held in check many years, but is never cured. Treatment. — Absolute rest, and freedom from all business cares ; change of scene ; uniform dry temperature ; flannel next skin. Avoid condiments, volatile oils, alcohol, and spices. Diet. — Pure, sweet, skimmed milk, four to six ounces, every three or four hours, night and day — may be given hot; no other diet or drink. Vary food by adding pepsin to milk ; substitute whey or fresh butter-milk. Such diet diminishes DISEASES OF THE KIDNEYS. 271 albuminuria, clears up vision, and aids general improvement. When albumin disappears, add fresh juice of orange, apple, or peach ; later, rice, tapioca, sago, toasted bread, and, finally, rare meat, eggs, or mutton. JVb specific medication. Opium is strictly contraindiccited on account of its apparently irritating action on the urinary or- gans. Anaemia indicates iron, arsenic, and cod-liver oil. Ursemic symptoms demand pilocarpus jaborandi and hydra- gogue cathartics. Dropsy is relieved by Basham's iron mix- ture, jaborandi, diuretics, and evacuants, if patient is not too weak. Aspiration or puncture is often followed by erysipe- las. Keep bowels open and active. CHRONIC INTERSTITIAL NEPHRITIS. Synonyms. — Renal cirrhosis; gouty kidney; contracted kidney ; cirrhotic Bright's disease. Definition. — A chronic inflammation of the interstitial con- nective tissue of the kidneys, causing a diminution in their size ; little or no dropsy ; increased flow of urine, albuminous and of low specific gravity. Etiology. — Grout, syphilis, lead-poisoning, alcohol, exposure, nervousness, and an ultimate effect of gonorrhoea. Most com- mon in men after fortieth year. Symptoms. — Begins insidiously, without symptoms to indi- cate kidney trouble. Later, there is frequent urination, ver- tigo, palpitation of heart, uneasiness, dyspnoea, and dilatation of left ventricle of heart. Pulse full, tense, and bounding j in- cessant cough. Dropsy is usually absent j eyes are puffy and vision disordered. Nausea, vomiting, gastro-intestinal catarrh, diarrhoea, anaemia, debility, and headache. Ursemic symp- toms and convulsions ; apoplectic attacks common. 272 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Complications. — Pneumonia, pericarditis, endocarditis, ery- sipelas, apoplexy, carbuncles, and uraemia. Urine increased ; pale in color; specific gravity low — rarely above 1.010° ; albumin absent or extremely small in amount ; urea not decreased at first ; tube-casts few, and are granular or fibrinous molds ; fat-globules are not constant. Pathology. — Kidneys reduced in size ; capsule adherent ; surface granular ; pyramids small and dark ; cysts may exist in kidney structure. There is an infiltration of leucocytes into the interstitial substance which form new fibrinous tissue. This contracts, causing shrinkage of organ, with atrophy and obliteration of some urinif erous tubules. Malpighian capsules are thick and glomeruli crowded together. Epithelial cells in tubules and glomeruli are degenerated 5 section of kidney is tough ; heart hypertrophied and vessels degenerated, hence the frequency of apoplexy ; atrophy of optic nerve and blind- ness. Diagnosis. — See page 273. Prognosis. — -Always fatal; may continue several years; worst form of Bright's disease. Treatment. — With such a poor prognosis, treatment is not encouraging. Saline diuretics are of little use. Avoid every possible cause. When first symptoms manifest themselves, put patient in bed between blankets and keep him there until symptoms subside. Nitroglycerin, gr. T £o> or potassium io- dide, gr. xx-xxx, daily, reduces arterial tension — the latter pre- venting hyperplasia. Aconite and veratrum control the heart. Dyspepsia indicates a mild diet ; dilute hydrocyanic acid for vomiting ; tincture of iron, columbo, or quinine for anaemia. Counter-irritation is of doubtful utility. Stimulate when in- dicated. Treat uraemia. DISEASES OF THE KIDNEYS. 273 AMYLOID KIDNEY. Synonyms. — Lardaceous or waxy degeneration of kidney ; albuminoid kidney ; amyloid Bright's disease. Definition. — A waxy degeneration of the kidney-tissues, usually accompanying a similar disorder in the liver and spleen, recognized by polyuria and waxy tube-casts. Etiology. — Suppuration in bones; syphilis; tuberculosis; cancer. Symptoms. — Urine increased, pale, and specific gravity low ; albumin marked ; urea normal or slightly diminished ; few tube-casts, which are pale or transparent, giving reaction with iodine ; marked anaemia ; liver and spleen involved ; emacia- tion ; sallow face ; profuse diarrhoea ; thirst ; heart not in- volved ; dropsy at first is slight, later it is marked. Pathology. — Kidneys are large, smooth, and cut like wax ; capsule easily separated; characteristic reddish-brown reac- tion with iodine. Process begins along the vessels, involves other structures, and causes atrophy of glomeruli and tubules. Diagnosis. Acute Tubal Nephritis. Chronic Tubal Nephritis. Chronic Intersti- tial Nephritis. Amyloid Kidney. Urine scanty. Urine increased. Urine increased. Urine increased. Albumin marked. Albumin marked. Albumin small in amount or ab- sent. Albumin marked. Blood and simple epithelial casts. Granular epithe- lial casts; fatty degeneration ; no blood-casts. Few hyaline gran- ular casts. Few transparent casts; give reac- tion with iodine. Dropsy extensive. Dropsy a promi- nent symptom. Dropsy absent or slight. Dropsy little, ex- cept late. History of acute onset; pain. Antecedent at- tacks; slow on- set. Slow insidious on- set. Follows wasting diseases and sup- puration. Uraemia. Uraemia. Uraemia. Uraemia absent. Heart functionally affected. Hypertrophy of left ventricle. Dilated left ventri- cle. Hypertrophy of left ventricle. Occurs in children and young adults. Middle-aged per- sons. After forty, in men. Any age. No retinitis. Retinitis albumi- Retinitis albumi- No retinitis. nuria. nuria. 274 A SYNOPSIS OP THE PRACTICE OF MEDICINE. Prognosis. — Depends on canse ; if cause is removable and case not too far advanced, it can be checked. Treatment. — Remove cause, if possible ; build up patient, and treat as in amyloid liver. Ammonium chloride, iron iodide, and other iodides. PYELITIS. Synonym. — Inflammation of the pelvis of the kidney. Definition. — An inflammation of the mucous membrane of the pelvis of the kidney, acute or chronic, recognized by chill, fever, pain radiating to the testicle, and acid urine, turbid with mucus and pus. Etiology. — Cold; extension from bladder; gonorrhoea; balsams and resins. Complicates scurvy, typhoid, typhus, and exanthematous fevers. Symptoms. — Acute cases commence with rigors and fever; pain in lumbar region, radiating along ureter to testicle ; painful micturition. Urine increased or diminished; dark- colored ; high specific gravity ; acid reaction ; urates and chlo- rides lessened ; epithelial cells from pelvis of kidney ; pus and blood-corpu scles. Chronic Pyelitis. — Urine increased ; pale straw-color ; acid reaction; low specific gravity; marked sediment; albumin; pus-cells (often in long or oval plugs) ; blood and epithelial cells not constant, unless tubules are involved. Uraemia com- plicates pyelitis. Pathology. — Pelvic mucous membrane engorged, red, and covered with mucus and pus-cells ; epithelial cells are shed ; blood exudes. A diphtheroid membrane is often present. As the process continues, inflammation extends to the urinif erous tubules and kidney structure, causing suppuration (pyelone- phritis). Pus and urine may accumulate in the pelvis of the DISEASES OF THE KIDNEYS. 275 kidney from obstruction of the ureter { pyonephrosis), &!&& dis- charge through the kidney structure or suddenly flow into the bladder, when obstruction is removed. Urinary calculi are often found in the pelvis of the kidney. Diagnosis. — Cystitis. — Urine is alkaline ; suprapubic ten- derness ; pelvic epithelium absent. In perinephritis the urine remains normal. Prognosis. — Following fevers it is good ; chronic cases are bad ; pyonephrosis may cause death by perforation ; kidney may be totally destroyed or disabled. Treatment. — Hygienic. — Absolute rest; plenty of alkaline, carbonated waters. Avoid alcohol, condiments, volatile oils, and irritating foods ; strict milk diet. Locally. — Counter-irritation ; hot fomentations ; leeches ; dry or wet cups. Internally. — Diuretics ; salol, gr. v, ter die, diminishes fever, alkalinizes urine, and is antiseptic ; tr. benzoin, gtt. v-x, ter die. Such remedies as balsam of copaiba, quinine, tannin, pix liquida, turpentine, iron, and lead reduce discharge of pus and may do some temporary good. Opium to relieve pain. In pyonephrosis or impacted calculi, surgical means are indicated. HYDRONEPHROSIS. Definition. — An accumulation of urine and secretions in the pelvis of the kidney, due to an obstruction of the ureter, bladder, or urethra. Symptoms. — Unilateral. — A tumor is found in lumbar re- gion, which gradually enlarges ; smooth or lobulated ; tense or fluctuating ; dullness on percussion ; may suddenly dimin- ish in size, with a copious flow of urine, due to temporary re- moval of the obstruction ; it soon refills. Pressure symptoms, 276 A SYNOPSIS OF THE PRACTICE OP MEDICINE. such as pain, vomiting, disordered heart, and digestion. Urine is normal, as the other kidney performs the function of both. Bilateral. — Suppression of urine, uraemia, and death, if not relieved. Suppression of urine may not be complete. Pathology. — Ureter and pelvis of the kidney are greatly distended ; pyramids flattened ; kidney structure atrophied ; cyst may contain from one to three pints of fluid, and is sometimes lobulated and divided by septa. Fluid is pale yel- low ; contains albumin and pus, urea and uric acid — in fact, it is similar to a diluted urine. Obstruction is caused by im- pacted calculi ; tumors ; cancer ; cicatricial bands ; congenital, or due to obstruction in bladder or urethra. Prognosis. — Unilateral causes little or no trouble for years, and is not fatal unless the other kidney fails to perform its function. Bilateral is fatal from uraemia or primary cause, if not removable. Treatment. — Causal. — Remedy strictures of urethra, en- larged prostate, or retention. Tumor is lessened by aspiration or surgical operation. Excision (nephrectomy). Massage often relieves obstruction, if used over the tumor. Treat symptoms. PERINEPHRITIS. Definition. — An inflammation of the cellular tissue sur- rounding the kidney, terminating in resolution or suppuration. Etiology. — Blows, sprains, metastasis, extension, cold, sec- ondary to fevers. Symptoms. — Chill, high fever, and severe pain over kidney. Urine normal. Onset may be insidious, with a dull, sickening, aching pain, radiating to testicle and groin ; pain increased by pressure ; patient lies with leg of affected side flexed on abdomen ; when standing, body is inclined to affected side. Chills, rigors, and pj^aemic fever indicate suppuration,, with DISEASES OF THE KIDNEYS. 277 formation of abscess (perinephritic abscess), that is felt as a tumor between the last rib and iliac crest. Pus burrows along lumbar muscles and opens on the back or in the groin under Poupart's ligament. May perforate kidney, perito- neum , colon, ilium, stomach, bladder, vagina, or diaphragm. Capsulation sometimes occurs. Pathology. — Begins as a simple inflammation with exuda- tion; septic infection and suppuration follow. Kidney is infiltrated with pus, and often contains numerous sinuses ; perinephritic tissue may be one mass of pus. Pus varies in character from a pure, sweet, to a very offensive, degenerated mass. Treatment. — Rest in bed ; applications of ice over kidney ; keep bowels active by enema ; opium for pain, and chloral for insomnia. Inunctions of belladonna and mercury may pre- vent abscess. Evacuate pus at once; sustain patient with quinine, iron, cod-liver oil, and very best food. FLOATING KIDNEY. Synonym. — Movable kidney. Description. — Floating kidney is a term given to one that is freely movable from its normal position, and is congenital or acquired. Recognized by a feeling of weight or dragging in loins ; sometimes pain, aggravated by walking, running, and jumping; relieved by recumbeut position; attacks of vomiting, malaise, and great tenderness at times, but they soon subside. Palpation of abdomen reveals a kidney-shaped tumor that glides from the hand and disappears ; pressure on this tumor causes a sickening pain reflected to testicle or ovary. Treatment. — Surgical. — Application of trusses or bandages. Nephrorrhaphy or nephrectomy. Regulate exercise and occu- pation. 278 A SYNOPSIS OF THE PRACTICE OF MEDICINE. RENAL CANCER. Description. — Cancer of the kidney is primary or secondary and occurs in very young or old persons. Scirrhous and med- ullary are most common forms ; one kidney is affected and the other normal. An' irregular, nodulated, tender tumor in region of kidney ; hematuria not constant. Urine contains cancer-cells ; disorganized epithelial, blood, and pus cells ; al- bumin. Pain is variable and at times very severe, radiating along ureter to testicle or ovary, the loin and hypochondrium ; testicle not retracted. Nausea ; anorexia ; irregular bowels ; anaemia, emaciation, and cachexia. Death ensues in six months to two years, from exhaustion, hemorrhage, peritonitis, or sec- ondary involvement. Treatment. — Palliative, — Opium for pain ; tonics ; predi- gested food; local applications; and general symptomatic treatment. RENAL TUBERCULOSIS. Description. — Renal tuberculosis is not common ; primary or secondary ; most frequent in male adults. Tuberculous deposits found in cortical mass and pyramids; these break down and form large, yellow, cheesy masses. The urinif erous tubules, pelvis, and ureters become infected and ulcerate. Symptoms. — They may be latent for a time, but, com- monly, there is a dull pain in the loins, sharp and acute at intervals, due to obstruction of ureters by tuberculous pro- ducts ; kidney not enlarged. Urine contains pus, tubercular debris, blood, and albumin; may be ropy and ammoniacal. General symptoms are fever, high in evening, with morning remissions ; loss of flesh and appetite ; diarrhoea ; and general symptoms of tuberculosis. Prognosis. — Always fatal ; uraemic attacks common. DISEASES OF THE KIDNEYS. 279 Treatment. — Palliative and Symptomatic. — Open any sus- pected abscess. Nephrectomy is of little value, as both organs are usually affected. RENAL CALCULI. Synonyms. — Gravel ; nephrolithiasis ; kidney-stones. Definition. — A calcareous or stone-like concretion, having its origin in the kidney, and giving rise to pyelitis by its local irritation ; renal colic by its passage along the course of the ureter j or no symptoms, except a brick-dust deposit in the urine {gravel). Etiology. — Most common among the poor; males; early and late life. The true cause of renal calculi is obscure. Varieties. — 1. Uric-acid stone is most common, and is oval, hard, smooth, or rough, reddish in color, and varies in size from a millet-seed to a pigeon's egg. May be single or multiple. 2. Urates of soda or ammonium form soft, small stones ; most common in childhood. 3. Calcium Oxalate. — A mulberry-shaped calculus, rough, very hard, dark brown, and mostly single. 4. Calcium Phosphate. — Phosphatic stones are smooth, soft, friable, earthy, or chalky, and vary in size from a hemp-seed to a large hen's egg. 5. Mixed calculi contain various salts in alternate layers. Other calculi, not commonly found, contain carbonate of calcium, xanthin, indigo, and other debris. Symptoms. — A large renal calculus may remain in the pelvis of the kidney for a long time without symptoms. Later, there are lumbar pains, increased by jarring or motion ; hem- aturia; pyuria and all symptoms of pyelitis, nephritis, or hydronephrosis. If the stones are very small, they are de- posited in the urine and recognized by microscope. When a 280 A SYNOPSIS OF THE PRACTICE OF MEDICINE. large stone passes through the ureter, spasmodic contraction of its muscles ensues and causes renal colic. Renal colic begins suddenly with violent pain, increasing in intensity, radiating along ureter to the testicle of the same side and to the head of the penis, the groin, thighs, and flanks ; testicle of same side and the penis are retracted ; intermissions last but a moment, and pain returns with greater severity. Thighs flexed on abdomen; patient rolls and screams with agony, and often faints ; pulse quick and feeble 5 temperature slightly elevated ; nausea and vomiting ; frequent micturition ; urine scanty and bloody. Attack lasts one hour to two days, and suddenly terminates when the stone reaches the bladder. Stone is passed with urine or remains in bladder and forms a nucleus for stone. The side is tender and sore to pressure, with a dull, burning pain along ureter, for several days fol- lowing the attack. The stone may lodge in the ureter and cause obstruction, ulceration, peritonitis, and death. Pathology. — Urine becomes concentrated or greatly loaded with salts, which crystallize about a nucleus of pus, mucus, epithelium, or blood, and form a stone. When the crystals do not form about a common nucleus it causes gravel. Renal Colic. On either side. Pain reflected to tes- ticle, head of penis, with retraction ; uri- nary symptoms. Not relieved by press- ure. Passage of renal stone. Diagnosis. Hepatic Colic Always on right side. Pain reflected to back, shoulder, and no urinary symptoms ; slight jaundice. Not relieved by press- ure. Passage of srall stone. Intestinal Colic Over whole abdomen ; umbilical. Pain central over um- bilicus ; no urinary symptoms or jaun- dice. Slight relief from press- ure. Passage of indigested food. Prognosis. — Must be guarded, as many sequela^ or compli- cations arise. Simple gravel is curable. Large stones cause DISEASES OF THE KIDNEYS. 281 py elitis, hydronephrosis, nephritis, obstruction of ureter, stone in bladder, uraemia, or death. Treatment. — Renal Colic. — Hypodermic injection of mor- phina and atrophia for pain • inhalations of chloroform, ether, or bromide of ethyl for anaesthetic effect ; hot applications, posteriorly, along course of ureter. Antispasmodic and relax- ing remedies, such as tartar emetic, morphina, and anaesthet- ics, favor passage of stone. Subsequent symptoms, tender- ness and pain, are best relieved by hot applications, alkaline diuretics, and morphina. Preventive. — Limit amount of nitrogenous food to prevent formation of uric acid ; give milk, vegetables, and large amounts of alkaline, diuretic waters ; extractum pichi fluidum alkali- nizes urine, and is valuable ; keep emunctories active j frequent baths and exercise. Phosphatic and oxalic calculi require ammonium benzoate or nitromuriatic acid and free diuresis. Impacted calculus necessitates snrgical measures. The so- called solvent remedies prevent the stone from becoming larger (?), but their solvent action is extremely doubtful. Pipe- razine, gr. v-xv, daily, is the best remedy now known for calculi or gravel ; a one or two percent, solution, injected into the bladder, may dissolve a calculus if long continued. RENAL PARASITES. The three principal classes of parasites that invade the uri- nary organs deserve mention, owing to the frequency with which they are met in certain countries. (1) Filaria Sanguinis Hominis. Description. — A filiform or thread-like worm, about three inches long j indigenous to the countries of China and India, It enters the lymph-channels and blood-vessels ; affects differ- ent organs j causes elephantiasis of the scrotum, lymphangitis, 282 A SYNOPSIS OF THE PRACTICE OF MEDICINE. or chyluria. How chyluria is caused by this parasite is not positively explained. Urine is milky ; white ; fat collects on its surface ; small amount of blood or albumin ; and the filaria can often be detected with microscope. It may last for thirty years, with emaciation, great thirst, little fever, and an un- natural appetite. Treatment. — Little can be done for it. Preventive treat- ment consists in using boiled water and thoroughly cooked foods. Thymol, gr. j, increased to gr. v, ter die, is said to have cured two typical cases. (2) Echinococcus Hominis. Description. — Hydatids of the kidney are produced like hy- datids of the liver, and vary in size. The only symptom pres- ent may be a tense tumor in the loin, that gives a peculiar thrill on percussion. Rupture of the cyst is common; renal colic from passage of small cysts, pyelitis, cystitis, or suppu- ration complicate. May last many years. Prognosis is not bad. Treatment. — Aspirate cysts or perform nephrotomy. Treat symptoms. (3) BlLHARZIA ILeMATOBIA. Description. — A fluke-like worm, varying in size from one half to three quarters of an inch in length ; female is the larger; inhabits waters of Egypt, and is most common in those who bathe in the streams. Parasite invades mucous membrane of urethra, bladder, ureters, and pelvis of kidney. Heematuria, following passage of clear urine, is the leading symptom ; pain in loins, and anaemia. Prognosis is good. Treatment. — Alkaline, diuretic waters ; oil of turpentine and chloroform, internally ; salol, gr. v, ter die. Washing out the bladder is of questionable value. DISEASES OF THE BLADDER. CYSTITIS. Synonym. — Catarrh of the bladder. Definition. — An acute or chronic inflammation of the mu- cous membrane of the bladder, accompanied by scanty, alka- line, ropy urine, hypogastric pain, slight fever, and tenesmus. Varieties are catarrhal, diphtheritic, and croupous. Etiology. — Acute. — Unskillful or careless injections or cath- eterization with septic instruments ; direct injuries or blows ; cold ; foreign bodies ; calculi ; retention or acidity of urine ; new beer ; extension of gonorrhoea or pyelitis ; fevers ; diph- theria ; nervous disorders ; and irritating medicines. Chronic. — Comes from acute ; enlarged prostate ; stricture of urethra ; stone in bladder ; cancer ; tuberculosis ; tumors ; kidney-diseases ; old age ; and Bright' s disease. Symptoms. — Acute. — Weight and pain in hypogastrium and perineum, increased by pressure, and radiates to back and groins ; chills ; loss of appetite ; some fever ; irritable bladder ; vesical tenesmus 5 urine passed in small amount after great tenesmus ; burning micturition. Urine is high-colored, cloudy, ropy, alkaline, and contains mucus, pus, epithelium, and blood- cells. Chronic, — Most common in old men with enlarged prostate. Begins gradually with tenderness in the hypogastrium ; fre- quent scanty micturition, with tenesmus ; loss of appetite ; gastro-intestinal catarrh ; bad breath ; general debility. Ul- ceration is indicated by severe burning pain, hematuria, pyuria, and hectic fever. Urine scanty, alkaline, contains 283 284 A SYNOPSIS OF THE PRACTICE OF MEDICINE. offensive muco-pus, and deposits crystals of the triple phos- phates, pus, mucus, blood, and epithelial cells. When bladder becomes hypertrophied, a hard tumor is felt above the pubes j urine dribbles, and cannot be retained. Pathology. — Acute. — Hyperemia of mucous membrane, most marked in the vesical triangle ; membrane red, swollen, and oedematous ; increased glandular secretion j desquamated epithelium ; small ulcers or erosions, covered with mucus and pus. Submucous abscesses form; sinuses. A diphtheritic membrane may exist. Chronic. — Membrane is gray or bluish, thick, tough, and covered with a thick, decomposing, alkaline mucus and pus j bacteria present. Mucous membrane is ribbed, giving a co- lumnar appearance ; walls of bladder may be one-half to one inch thick. Hypertrophy is concentric or" acentric. Perforat- ing abscesses and sinuses. Diagnosis. — Neuralgia has a sharp, lancinating pain, no fever or urinary symptoms, and lasts a few hours. Uterine and vaginal troubles diagnosed by examination. Pyelitis has lumbar pains, following ureters; acid urine and no vesical tenesmus. Prognosis — Acute cases usually recover. Chronic cases drag on for years, and when hypertrophy occurs they are in- curable. Treatment. — Acute. — Remove cause. When due to cold, diaphoretics, leeches, hot poultices or fomentations to peri- neum and hypogastrium, rectal injections of hot water, hot baths, and rest in bed. Avoid condiments, volatile oils, alcohol, salt, and acids. Alkaline waters in large quantities diminish irritability ; camphor relieves catarrh of cantharides. Dover's powder, opium, belladonna, or Cannabis Indica relieve tenes- mus. Salol, gr. v, ter die, benzoic acid, infusion of pareira or extractum pichi fluidum, gtt. x, in brandy, every two hours, DISEASES OF THE BLADDER. 285 constitute valuable remedies. Milk diet is most suitable. Keep bowels open and treat symptoms. Chronic. — Empty bladder at regular intervals with a smooth, soft, elastic catheter. Absolute rest in bed. Copaiba relieves secretion of mucus and pus temporarily, but does not cure, for, as soon as discontinued, the trouble returns. Germicidal treatment is a failure, because antiseptic solutions cannot be used sufficiently strong on account of their great irritation. Large quantities of alkaline waters internally. A peculiarity with these cases is the fact that all food tires them, and the only diet that seems to be acceptable is highly seasoned terrapin. After all, the best remedy is washing out of the bladder. Bichlo- ride of mercury, sulphocarbolates, zinc sulphate, silver nitrate, and tannic acid are too irritating for injections. Creolin, one to two thousand, is recommended. One of the best and safest injections is one tablespoonful of hamamelis to a pint of warm water. Injections should be given with a douche (not a syringe), without any force. Discomfort during injections means that the solution is too hot or cold, too strong, or too much force. Wash through a two-way catheter until return- flow is clear ; always allow some of the fluid to remain in bladder. Strengthen with iron and cod-liver oil. Salol and pichi do good in some cases. HYPERESTHESIA OF THE BLADDER. Description. — A neurosis, characterized by constant desire to micturate ; no lesion to the bladder-walls. Due to acidity of urine ; sexual excesses ; increased solid constituents of urine ; onanism j gonorrhoea ; and masturbation. Flow of urine is weak, and causes straining; desire to urinate every fifteen minutes or more ; pain reflected to glans penis. Often com- plicated by pruritis ani. 286 A SYNOPSIS OP THE PRACTICE OF MEDICINE. Treatment.— Cold douches to spine; salt-water baths; Turkish baths. Severe eases relieved by balsam copaiba, or, better still, compound tincture of benzoin, gtt. xv-xx, ter die. Praritis ani relieved by penciling cutaneous margin of anus — not the mucous membrane — with benzoin. Alkalies for hyperacidity ; oxide of zinc relieves hyperesthesia of urethra. Break up habit of masturbation or excessive venereal excesses. Treat cause. ANESTHESIA OF THE BLADDER. Synonyms. — Nocturnal incontinence of urine ; enuresis. Description. — An inability to retain urine during sleep, most common in children. Caused by irritation of intestinal worms ; kidney-disease ; phymosis or adherent prepuce ; con- stipation ; uncleanliness ; excessive use of liquids before re- tiring ; and dorsal position during sleep. If not checked, it ultimately leads to confirmed masturbation ; hyperesthesia of prostate ; spermatorrhoea ; hypochondria ; insanity ; neuras- thenia ; and, finally, locomotor ataxia. Urine constantly drib- bles, and is voided during sleep. Privates are very irritable. Treatment. — Absolute cleanliness; operate on congenital defects of privates ; remove cause ; forbid drinking before retir- ing ; make child get up during night and early morning to uri- nate, and before retiring. Cause the child to sleep on its side by placing some substance on the back, such as a ball or book. Insist on out-door exercise in pure, fresh air ; athletic sports ; horseback riding ; salt baths every morning ; flannel next skin. If child is a masturbator, keep it employed and under constant observation. Iron is good in anaemia or worms. Erigeron, cantharides, or nux vomica overcome weakness of sphincters. Tincture of belladonna, bromides, and chloral may do good if pushed to point of tolerance. Tr. gelsemii, gtt. v, before re- DISEASES OF THE BLADDER, 287 tiring, and small doses during the day, is claimed to be very valuable. Electricity, applied to sphincters, increases tone, and is a means of cure. HEMATURIA. Description. — Blood in the urine is symptomatic of trouble in the urethra, prostate, bladder, ureters, or kidney j or second- ary to some constitutional disorder. It is due to Bright's disease ; active or passive renal congestion ; renal calculi ; abscess j ulcer ; cancer ; tuberculosis • entozoa ; purpura ; ma- laria ; vicarious menstruation ; use of irritant medicines. Blood from kidneys is indicated by smoky urine, with casts of uriniferous tubules and symptoms of renal colic. Blood from bladder follows the passage of urine, and is pure or clotted ; may be mixed with urine. Hemorrhage from urethra is inde- pendent of micturition. Endemic Jiwmaturia occurs in Brazil, Egypt, and Cape Colony from the parasite Bilharzia hcema- tobia. (See page 282.) Treatment. — Causal. — In general, rest in bed ; cold appli- cations ; injections of ice-water into rectum ; oil of erigeron, gtt. v, ter die ; ergot ; tannic acid ; gallic acid ; tr. f erri chloridi. Hemorrhage from these organs is rarely fatal, as the capacity of the bladder limits flow of blood. Maintain strength and treat on the general principle indicated by cause. PARALYSIS OF THE BLADDER. Description. — Paralysis of the bladder is due to cerebral disease (least common form) ; paralysis of the detursor urinae muscle ; peripheral lesions ; prolonged over-distention from retained urine ; rarely found in typhus or typhoid fever. Complete paralysis of the sphincter causes dribbling. If the 288 A SYNOPSIS OF THE PRACTICE OF MEDICINE. sphincter and detursor urina? muscles are paralyzed, the blad- der is always full, and urine constantly dribbles ; hence the term incontinence with retention. Treatment. — Use catheter at regular intervals, three or four times a day. If there is prolonged retention, never remove all urine at once, but allow a small amount to escape at a time, so that the bladder-walls may be supported until they regain their muscular tone. Galvanism to bladder and involuntary sphincter. Strychnina in full doses, gr. -^- 6 , ter die, increased to tolerance ; cold baths. Paralysis of bladder sphincter alone is relieved by oil of erigeron. Treat cause. PHYSICAL DIAGNOSIS. INTRODUCTION. Physical Diagnosis. — A method of distinguishing, fixing, or interpreting a disease from symptoms which are recognized by our senses. Differential Diagnosis. — " The qualitative distinguishing between two distinct diseases of similar character by compara- tive symptoms." (Gould.) Physical Signs. — The indications or results obtained by inspection, mensuration, palpation, percussion, auscultation, and succussion. Topographical Anatomy. — The study of external land- marks or points which indicate or determine the comparative location of the various organs and parts of the body. Certain landmarks on the chest-walls are used as fixed points, and, from these, subdivisions are made for convenience in study aud to avoid confusing terms. The clavicle, nipples, sternum, axilla, scapula, spinous processes of the vertebrge, and ribs constitute the fixed points, and all signs should be given with reference to them. To be accurate in this reference, it will be necessary for the patient to sit or stand erect with the parts in full view ; or, if lying down, to assume a natural, comfort- able position, so that none of the muscles of the parts may be brought into action and mask any important points. 289 290 A SYNOPSIS OF THE PRACTICE OF MEDICINE. INSPECTION. Inspection of the chest means simply looking at it from all sides. The normal movements of the chest vary in the sexes. The abdominal or inferior costal type of respiration is character- istic of the male sex and children. Movement of the chest in its upper portions, superior costal breathing, is characteristic of the female. The chest shonld be full, round, and nearly symmetrical. Respiratory movements in health are between sixteen and twenty per minute, and regular in rhythm. By inspection we determine whether the chest is deformed; whether the intercostal spaces are suuken or bulging j whether there is supra- or infra-clavicular depression, retracted or ex- panded chest- walls. We also note any discoloration, tumors, apex-beat of the heart, or unilateral motion of the chest. MENSURATION. The average normal circumference of the chest above the nip- ples is thirty- three inches. The difference between forced in- spiration and forced expiration (expansion) is about two inches in health. In comparing the two sides of the chest, mark the median line anteriorly and the spinous processes of the verte- brae posteriorly. The two sides vary according to a right or left-handed person. The side most used is larger, by one-half inch, than the other. Accurate measurements are taken when the breath is held between forced expiration and forced inspi- ration. Molding soft strips of lead to the side enables one to compare the chest from week to week and notice any retrac- tion or expansion. The spirometer is used to determine the capacity of the lungs, but there are so many sources of error in its use that it is not an accurate means of diagnosis. PHYSICAL DIAGNOSIS. 291 PALPATION. A method of examining the chest by the fingers or the hands. By it we learn of its movements, size, and form; points of tenderness or tnmors ; vocal fremitus, vibrations, and ronchi. Fremitus is a vibration of the chest- walls, most marked in those who have deep bass voices, consolidation, or roughened pleura. It is produced by crying, talking, cough- ing, or deep breathing. Normal fremitus is felt all over the chest, most marked at the right apex. Consolidation in- creases, pleural effusion diminishes, fremitus. PERCUSSION. The act of striking any portion of the body, with the object of learning pathological conditions by the resonance of the strokes. It is made by means of the fingers (immediate per- cussion), or by some instrument interposed, as a pleximeter (mediate percussion). Percussion is said to be clear, tympanitic, or dull ; and differs in pitch, strength, and duration. Clear sounds are produced over tissues that contain air — usually referred to the lungs — and indicate a normal con- dition. Tympanitic sounds are those produced over the intestines or cavities containing a large amount of gas or air. These sounds have been likened to a metallic or amphoric sound, be- cause they are produced in large cavities with tense walls ; and the cracked-metal or cracked-pot sound in cavities connect- ing with a bronchial tube. Dull sounds are elicited by percussion over liquids, solid matter, and such organs as the liver, spleen, or heart. Con- solidated lung-tissue gives dullness and a sense of resistance to the finger used in percussing. 292 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Respiratory percussion is practiced during forced inspiration and expiration, and is of value in detecting any points that might be overlooked in ordinary percussion. AUSCULTATION. A process of listening to the sounds produced in the various organs, with a view of comparing or harmonizing them with the symptoms obtained by other methods, and thus arrive at a more accurate diagnosis. Immediate auscultation is practiced by placing the ear directly in contact with the skin over the organ. Mediate auscultation is the intervention of some sub- stance between the ear and parts — most commonly a stetho- scope. Never practice auscultation with the head too low ; in uncomfortable positions ; through thick clothing ; nor under con- ditions of noise or personal excitement. It reveals to us the sounds of respiration 5 the voice ; coughing ; healthy and un- healthy conditions. Tubular or bronchial breathing is a sound similar to that produced by blowing through a tube, and is present in the trachea and large bronchi, both on inspiration and expiration. Vesicular murmur is heard over the lungs, marked on in- spiration, less distinct on expiration. It is soft, low in pitch, and caused by the expansion and contraction of the air- vesi- cles, cells, and small bronchi. It differs in different parts of the lungs, and is affected by disease. Vesicular murmur may be increased in duration and intensity (puerile respiration); may be very feeble, from obstruction of tubes, debility, me- chanical pressure, intervention of fluids, or consolidations ; may be absent, from complete obliteration or obstruction of air- vesicles or bronchial tubes, or the presence of large amounts of fluid. Jerking inspiration is due to the neurotic element in tuberculosis and hysteria. PHYSICAL .DIAGNOSIS. 293 Bronchial respiration alone is indicative of consolidation from infiltration, effusions, or new growths, and is tubular in character. Cavernous respiration is a blowing, hollow sound ; low pitch • circumscribed ; gurgling ; and indicative of cavities or dilated, large bronchi. Amphoric respiration is caused by a cavity with thick, tense walls, and produces a metallic sound like that of blowing into an empty bottle. Cheyne- Stokes Respiration. — "A phenomenon observed in a form of dyspnoea, in which there is a rhythmical increase of the respirations up to a certain degree of rapidity, then gradu- ally decreasing again to a temporary cessation." (Gould.) Rale. — A rattling sound produced by the passage of air through obstructions of the bronchi and lungs, either moist or dry in character. It occurs during expiration, inspira- tion, or both. Moist rales are produced by air passing through liquids in the bronchi or lungs, and cause a bubbling sound. Dry rales are the result of air passing through tough, tena- cious exudation or a partial obstruction to the caliber of the bronchi or lungs. Cavernous rales are heard over cavities containing liquid, and are caused by a bubbling of air through it. Present in last stages of phthisis pulmonalis. Crepitant or Vesicular Rales. — Fine, crackling sounds, simi- lar to that caused by rolling hair between the fingers, and heard at the end of expiration. Present in the first stages of pneumonia and incipient phthisis. Mucous Rales. — Bubbling sounds caused in the bronchial tubes by air passing through mucus. Sibilant rales are sharp, hissing, whistling sounds heard in narrowing of the small bronchi. 294 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Sonorous rales are harsh, snoring-like, low-pitched sounds due to narrowing of the large bronchi. Tracheal or subcrepitant rales are made by air passing through an accumulation of mucus in the trachea, and often termed the death-rattle. Friction-sounds arise from rubbing together of the rough- ened surfaces of the pleura on inspiration and expiration, and are dry or moist. Heard in pleurisy. THE VOICE. The voice varies under conditions of health and disease, and can be heard as the vocal resonance ; more marked on the right side of the chest. Bronchophony. — The resonance of the voice as heard in the bronchi (concentrated near the ear), indicative of consolidation of pneumonia and phthisis. Pectoriloquy. — A peculiar resonance of the voice over a cav- ity or complete consolidation, by which every articulate word can be distinctly recognized. JEgophony. — A tremulousness of the voice similar to the sound made by a bleating goat (a nasal-like twang), indicative of pleural effusion or pleuro-pneumonia. Vocal resonance may be diminished, increased, or absent. When the patient whispers, similar changes are noticed as in spoken voice. SUCCUSSION. A process of shaking or lightly striking the chest-wall with the purpose of eliciting a splashing sound or wave, which is best heard when the ear is placed against the chest, and indi- cates the presence of fluid in the pleural cavity. Present in hydrothorax or pneumo-hydrothorax. DISEASES OF THE NOSE. ACUTE RHINITIS. Synonyms. — Acute nasal catarrh ; cold in the head ; acute coryza. Definition. — An acute inflammation of the Schneiderian mucous membrane, extending by continuity of structure to the lachrymal duct, conjunctiva, pharynx, and other cavities with which it is connected. Etiology. — Exposure to cold ; irritating vapors ; chemical fumes or dust; epidemic; predisposition. Complicates and is symptomatic of measles, syphilis, and influenza. Follows the excessive use of potassium iodide. Symptoms. — Begins with repeated sneezing, chilliness, and, in children, some fever. Nose is dry, " stuffed up," and articu- lation impaired ; mucous membrane red and swollen ; nasal breathing impaired; sense of taste and smell diminished or lost temporarily. Very soon a profuse, watery, salty, thin fluid begins to flow from the nose and excoriates the upper lip and anterior nares. Headache, dull and severe, when frontal sinuses are involved ; dull, heavy feeling ; eyes suffused with tears, from extension of inflammation through the lach- rymal duct ; hearing dull, from extension or closure of Eusta- chian tube. Catarrh may leave suddenly or the discharge will assume a muco-purulent character and acute symptoms subside gradually. Severe cases involve the pharynx, larynx, and lungs, giving a u naso-pharyngo-laryngo-broncho-pul- monary catarrh." Prognosis — Mild cases recover in two days to one week. 295 296 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Severe cases may run for weeks and terminate in chronic nasal catarrh j or, by extension, diseases of the ear, lachrymal ap- paratus, pharynx, bronchial tubes, lungs, mastoid cells, an- trum, or frontal sinuses. Treatment. — Preventive. — Avoid all causes. When it is necessary to work in dust or irritating vapors, wear a wet sponge-respirator. Harden the body by cold sponging, and avoid any influence that would tend to debilitate or increase susceptibility to cold. Acute Attack. — If seen early, give pulvis ipecacuanhae et opii, gr. v-x, at bedtime, with a hot drink to promote free diaphoresis ; or a hot Turkish bath, followed by rest in a warm room. One drop of tr. aconiti or tr. veratri, every hour, until the physiological effects are obtained j tr. belladonnas or atro- pine sulphas will check excessive secretion ; quinine is recom- mended by some, but is not sufficiently active to abort acute attacks. Local applications of very dilute acidum carbolicum and sodii chloridum by means of a spray or douche j unguentum petrolii used freely ; menthol inhalations ; powders of bismuthi salicylas with morphines sulphas ; sprays of hydrogen peroxide (one to eight of water) ; four-percent, solution of cocainge hy- drochloras relieves sneezing and congestion temporarily. Symptomatic catarrh must be treated according to cause. " Sniffles n in new-born children usually indicates syphilitic in- fection, and demands specific treatment and mild errhines. Arsenic in small doses is said to relieve prolonged attacks when other remedies fail. CHRONIC RHINITIS. Synonym s. — Chronic nasal catarrh ; chronic coryza. Definition. — A chronic inflammation of the Schneiderian DISEASES OF THE NOSE. 297 mucous membrane, presenting itself in the form of a dry or moist catarrh. Etiology. — A sequel of acute rhinitis; syphilis; tubercu- losis ; constant irritation. Symptoms. — Dry Rhinitis. — Characterized by a dry, burning feeling and fullness in the nose and frontal sinuses ; obstructed nasal breathing ; little discharge, except occasional dry scabs, tough mucus, or blood ; epistaxis ; nasal voice ; impaired or destroyed sense of smell ; ulcerated patches ; slight cough ; and desire to clear the nose. Acute exacerbations are common. It is the most common cause of lachrymal obstruction. Moist Rhinitis. — Characterized by a free flow of mucus, greenish or yellow muco-pus, which is either blown from the anterior or drawn through the posterior nares, hawked, and expectorated. Constant desire to hawk and clear the throat caused by the secretions dripping from the posterior nares ; obstructed breathing ; breath offensive at times, more marked in the morning ; impaired sense of smell and taste ; occasional epistaxis. Ozena, sometimes termed chronic rhinitis ( f ), is a condition where the mucous and submucous tissues are thickened and ulcerated; the turbinated bones necrosed, and at times ex- posed. Odor is fetid, penetrating, and so offensive that it is noticed several feet from the patient. Discharge is thin, con- tains bloody mucus or muco-pus, and is very offensive. Pathology. — Mucous membrane is hypertrophied, infil- trated, dark red or grayish, and swollen ; scabs of dry, in- spissated mucus, serum, and pus; an increased glandular secretion in the moist, decreased in the dry, form; small ulcers at times, that may leave the bone exposed and cause necrosis ; veins enlarged and dilated. Occasional occlusion of nares by polypi. The tissues, being of an erectile structure, cause temporary occlusion of nares under slight irritation. 298 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Septum may be perforated. Catarrh extends to the lachrymal duct, causing stricture and epiphora. Pathology of ozena is not definitely settled. Prognosis. — Perfect cures are rare. Long, persistent treat- ment, change of climate and occupation may result in tem- porary or, possibly, permanent cure. Treatment. — Constitutional. — Treat all diatheses and give tonics. Stryehninae arsenias, gr. T io, ter die. Alteratives, potassium iodide and mercury, increased to tolerance, pro- mote absorption of hypertrophic tissues. Local. — It is impossible to make thorough applications to the entire tortuous Schneiderian mucous membrane ; hence the inefficiency of nasal douches and insufflations, which only reach the inferior, middle, and part of the superior meatus. Cleanliness is the main principle. To accomplish this, use weak solutions of sodii chloridum or sodii bicarbonas, with a douche, post-nasal spray, or, better still, snuffing it from the palm of the hand. A valuable application or spray is hydro- gen peroxide or tr. iodini comp. (see Pharyngitis). This can be followed by powders of aristol, iodoform, bismuthi sali- cylas, or morphina. Local applications to ulcers, such as dilute acidum nitricum, zinci chloridum, or argenti nitras. Mastic nasal tubes are now worn to promote absorption of hypertrophic tissues ; galvano-cautery or surgical measures are used to remove hypertrophied, turbinated bones. HAY-FEVER. Description. — A disease (?) or peculiar hyperaesthetic con- dition (neurotic ?) of the Schneiderian and bronchial mucous membranes, characterized by yearly attacks, which come dur- ing the season when the air is laden with pollen of grains, grasses, and certain flowers. Begins suddenly with constant DISEASES OP THE NOSE. 299 sneezing ; free flow of a clear mucus from the nose ; conges- tion of eyes and nasal mucous membrane ; obstruction to nasal breathing ; secretions become thick, purulent, or bloody. Catarrh may extend to larynx and bronchi, with coughing and asthmatic attacks. Lasts from one day to several weeks ; leaves patient weak and miserable. Is most common in males, after puberty, and in those who live in cities. Often complicated by bronchitis, oedema of the lungs, or pneumonia. Such terms as summer catarrh, rose-cold, and rose-fever are applied to it. Treatment. — Very unsatisfactory. Change of climate to sea-shore or mountains ; remain indoors during the middle hours of the day ; avoid passing or coming in contact with any of the pollen-bearing cereals or flowers. Free inhalations from a menthol inhaler or menthol spray greatly mitigate at- tacks of sneezing and irritation. Ammonia; cocaine, four- percent, solution ; carbolic acid, and tr. benzoini comp., locally, afford partial relief. Atropina is indicated by profuse watery discharge. Remove hypertrophied turbinated bones and mu- cous membrane by galvano-cautery or other surgical means. Quinina ; phenacetin ; acetanilide ; potassii iodidum ; arsenic ; and antispasmodics constitute internal medication, but do little good. Treat bronchial catarrh and asthma as indicated under those diseases. DISEASES OF THE LARYNX. ACUTE CATAERHAL LARYNGITIS. Definition. — An acute catarrhal inflammation of the laryn- geal mncons membrane, accompanied by sore throat, painful deglutition, dry, hacking cough; and impaired function of speech. Etiology. — Exposure to cold ; inhalation of irritating va- pors and chemical fumes; prolonged use of the voice in speaking or singing; direct injury; predisposition. Symp- tomatic of measles. Symptoms. — Begins with chill, rigors, and some fever ; or comes on gradually with a dry, burning, tickling sensation in the larynx; constant desire to cough and clear the throat; hoarseness, that gradually increases until patient cannot artic- ulate (aphonia) ; slight pain on deglutition ; some fever and dyspnoea in severe cases. Cough is first dry and harsh, but soon becomes loose — and plugs of mucus, streaked with blood, are coughed up — then muco-purulent, and gradually subsides or becomes chronic. Pathology. — Mucous membrane covering the larynx and vocal cords red, congested, and, in places, small abraded patches, with slight hemorrhage. Vocal bands do not approx- imate properly, hence the loss of voice. Secretion is first thick and tenacious, but soon changes to a muco-purulent character, and is more easily expectorated. 300 DISEASES OF THE LARYNX. 301 Prognosis. — Does not result fatally ; may become chronic ; lasts from a few days to three weeks. Treatment. — Preventive. — Harden patient by cold baths; cold sponge-baths, followed by free friction. Avoid hot baths, close confinement, sudden changes of clothing or temperature, or anything that would tend to effeminacy. Onset. — Give tr. aconiti or tr. veratri in full doses, every half -hour, until fever is broken. Hydrargyri chloridum mite, gr. to, every hour, until it opens bowels freely. Keep patient in a moist air at a uniform temperature. Inhalations of medicated steam (tr. benzoini comp., carbolic acid, or oleum eucalyptol). Limit amount of fluid taken. Pulvis ipecac- uanha et opii, gr. i-ij, every hour, until cough is broken or soothed. Apply cold or hot compresses over the throat. Small doses of codeina will soothe cough. When acute stage is passed, give small doses of antimonii et potassii tart., gr. A? syr. ipecacuanhae, or syr. scillge. Antimonii et potassii tart gr. j. Potassii bromidi 3 jss. Syr. aurantii floratis f § j. Liq. ammonii acetatis q. s. ad. f 1 iij. M. Signa. One teaspoonful every two or three hours. (EDEMA OF THE GLOTTIS. Description.— An inflammation of the mucous membrane of the glottis and larynx, accompanied by an infiltration of serum into the loose areolar tissue, causing oedema. Occurs in young adults from exposure to cold, septic fevers, Bright's disease, syphilis, and tuberculosis. Begins in a few hours with hoarseness; dry cough and marked dyspnoea; pain in the throat ; sense of fullness ; difficult and painful deglutition, 302 A SYNOPSIS OF THE PRACTICE OF MEDICINE. The swollen epiglottis often projects above the base of the tongue, or can be felt with the finger. Fatal dyspnoea may occur if not properly managed. Prognosis. — Many cases recover, but it is a serious disease. Treatment. — Scarify the swollen epiglottis freely and fre- quently : this will fulfill every indication. Tracheotomy may be indicated. Tr. aconiti for fever; brisk, drastic cathar- tics; and free diaphoresis with pilocarpine and hot drinks. Limit as far as possible the amount of water taken ; leeches to the neck. Emetics are indicated by rales in the chest. Attend to all constitutional disturbances, and treat all symp- toms as indicated. CHRONIC CATARRHAL LARYNGITIS. Description. — A chronic inflammation of the laryngeal mu- cous membrane, due to repeated acute attacks j excessive or improper use of the voice ; smoking ; alcohol ; syphilis ; all irri- tating chemical fumes ; and dust. Voice is hoarse ; dryness and tickling sensation in the throat, with a desire to cough or clear it, especially before beginning to speak. May not cause any trouble for several days, and then be aggravated by slight cause. Acute exacerbations are frequent. Laryn- goscopic examination shows a congested . mucous membrane, covered by tenacious mucus; swelling and thickening at times ; small ulcers or erosions ; improper approximation of vocal bands in phonation. Treatment. — Constitutional. — Build up the patient with tonics and good food ; abstain from smoking and drinking ; and use the voice as little as possible. Avoid every cause. Alteratives may be indicated. Strychnines arsenias, gr. T ^o? ter die. Local — Inhalations of medicated steam to remove tenacious DISEASES OF THE LARYNX. 303 mucus. Apply, with a laryngeal spray or brush, solutions of zinci chloridum, gr. xx-xxx to the 5 j of water; hydrogen peroxide ; alum ; zinci sulphas, gr. x-f 1 j ; glycerol of tannin. Topical applications of iodoform, aristol, or pyoctanin are recommended. Treat ulcers by direct application of caustics. Electricity aids in restoration of muscular tone. Small doses of ammonii murias and codeina will relieve the obstinate tickling and tendency to cough. TUBERCULAR LARYNGITIS. Description. — Tubercular laryngitis, or laryngeal phthisis, is secondary to general tuberculosis, and rarely primary. Most common in males and rarely found in childhood. Voice becomes weak, hoarse, and is finally lost; pain on every attempt at swallowing or speaking ; a weak cough. Late in the disease, food enters the larynx and trachea, causing violent paroxysms of coughing ; food cannot be swallowed, owing to paralysis of the pharyngeal muscles. Laryngoscope shows tuberculous infiltration around the vocal cords ; ulcers, which are limited or involve the whole cord ; small tubercles. Constitutional symptoms are usually present, such as fever ; dullness at apex of one or both lungs ; loss of flesh ; night- sweats ; tuberculous family history ; and presence of the Bacil- lus tuberculosis in the sputum. L T sually terminates fatally in six months or three years. Treatment. — It is very doubtful if any remedy has ever cured a case of true laryngeal phthisis. What Koch's lymph will do remains for future investigation. (See p. 97.) In addition to the constitutional treatment outlined under tuber- culosis (p. 96), local measures are indispensable. There are four stages of topical treatment : 1. Cleanse the laryngeal mucous membrane with a four-per- 304 A SYNOPSIS OF THE PRACTICE OF MEDICINE. cent, solution of sodii bicarbonas or biboras with an atomizer or laryngeal tube. 2. Apply a three or four grain solution of cocaiuse hydro- chloras with an atomizer to allay irritation and sensitiveness. 3. Apply, with laryngeal brush or atomizer, a solution of argentinitras, gr. ij, or zinci sulphas, gr. i-v. 4. Freely cover the larynx with an insufflation of iodoform or aristol ; or apply iodoform and ether. Feed through the rectum, or through an oesophageal tube, when they cannot swallow nourishment. LARYNGISMUS STRIDULUS. Synonyms. — Spasm of the glottis j spasmodic croup ; laryn- gospasm; "kinks." Definition. — A sudden spasmodic contraction of the laryn- geal muscles, closure of the glottis, and a temporary attack of dyspnoea or apncea. Etiology. — Neurotic in origin. Hereditary ; worms ; teeth- ing j and all debilitating diseases. A prominent cause in older children is bad temper. Most common in the first and second years. Symptoms. — Begins suddenly with a cessation of breath- ing; blueness and cyanotic condition of the skin; superficial veins enlarged and stand out ; lasts from one to several min- utes, when the spasm relaxes • a crowing, stridulous respiration ; a long breath, and the child falls back exhausted, or breaks into violent crying or screams. No after-effects. Child soon resumes its play. No cough, fever, or hoarseness precede or follow an attack. May have spasms of the muscles of the arms or legs ; convulsions. Relapses are frequent, and may have several spells in course of a, day. Diagnosis. — See table, Membranous Croup. DISEASES OF THE LARYNX. 305 Prognosis. — Children rarely die from it unless it be from convulsions. Treatment. — Preventive. — Avoid every possible source of ir- ritation. Treat all gastro-intestinal disturbances and troubles of teething. Insist on flannel next the skin ; good, fresh air • most nutritious diet ; and tonics suitable for children of that age. If a spasm is anticipated, give a mustard foot-bath and cold to the head, or a few whiffs of chloroform, ether, or nitrite of amyl. Full doses of the bromides and chloral pre- vent attacks or recurrence. Paroxysm. — This is usually over by the time the physician arrives. At once immerse the body to the neck in hot water, and apply cold to the head. A few whiffs of an anaesthetic will relax the spasm, if respiration is not absolutely checked. Follow at once with the bromides and chloral. Lac asafoet- idae, gtt. v-x, or musk, gr. J, every two hours, prevents re- currence. In older children, " kinks " come from anger, and the most effectual cures consist in the administration of such harsh measures as a sound spanking, or douching the bead with a bucket of cold water. Medication is rarely required. CATARRHAL CROUP. Synonyms. — Spasmodic croup; false croup; "child-crow- ing." Definition. — A catarrhal inflammation of the laryngeal mucous membrane, without any false membrane ; accom- panied by spasmodic contraction of the laryngeal muscles, causing threatened suffocation. Etiology. — Occurs during the first three years of life, but may come later • hereditary j exposure to cold ; enlarged ton- sils • acute laryngitis. 306 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Symptoms. — Prodromal. — Child is usually restless; un- easy ; feverish ; has a slight cough ; breathes rather heavily, with a harsh sound. All symptoms may be absent until the onset, which comes suddenly. Onset. — Child wakens from sleep with a harsh, metallic, ringing cough; great difficulty in breathing j head thrown back ; grasps at its throat j skin darkened or cyanosed ; super- ficial veins prominent; noisy, harsh breathing, or peculiar crowing inspiration. Symptoms gradually pass away, and child falls to sleep. Next day there is a slight cough. Par- oxysm will probably return next night or even during the same night. The analogy between true and false croup is so close that the latter may run into the former. Pathology. — Same as acute laryngitis, with the addition of spasmodic contraction of the laryngeal muscles. Not fully understood. Diagnosis. — See table, Membranous Croup. Prognosis. — Favorable. Death is rare. May be compli- cated by bronchitis or pneumonia. Treatment. — Prophylactic. — Exposure, the most common cause, must be avoided ; wear flannel next the skin the year round ; attend to every possible cause, and never allow any catarrhal trouble to be overlooked or remain untreated. Small doses of antimonii et potassii tart., or syr. ipecacuanhas with potassii bromidum, every two to four hours, often abort. Stimulate the emunctories. A tonic, abortive treat- ment is pursued by some, and consists in the administration of qiiininw bisulphas, gr. ij, every hour, until cough and symp- toms subside. Paroxysm. — A few inhalations of chloroform, iodide of ethyl, or amyl nitrite will relax spasmodic contraction of the laryngeal muscles. A hot bath, with cold compresses to the throat. Emetics of syr. ipecacuanha?, apomorphine, alum, DISEASES OF THE LARYNX. 307 and mustard are recommended, but must be cautiously used on account of their depressing effects. Inhalations of medi- cated steam. Follow with tonic treatment. MEMBRANOUS CROUP. Synonyms. — Croupous, membranous, or pseudo-membra- nous laryngitis ; true croup ; laryngeal diphtheria. Definition. — An acute, specific inflammation of the laryn- geal and superior tracheal mucous membranes, accompanied by a fibro-plastic exudation or false membrane ; constant fever; great dyspnoea; and usually terminating in death. Etiology. — A disease of childhood between the second and seventh years. The great similarity between true membra- nous croup and diphtheria, and the fact that the former is most common during epidemics of the latter, have led some authors to claim that it is due to a specific microbe similar to or identical with that of diphtheria. Predisposing causes are improper hygiene, exposure to cold, debility, heredity; contagion doubtful. Symptoms. — Gradual in onset. Child is cross, fretful, slightly feverish; has a hoarse cough; anorexia; disturbed sleep; and thirst. Cough becomes ringing; attacks of dysp- noea; voice husky; stridulous breathing; fever increased; tongue coated ; white spots on the tonsils or fauces. Parox- ysms of marked dyspnoea, followed by a period of calm and repose. On the second or third day, dyspnoea is marked and the least excitement causes frequent severe paroxysms ; cya- nosis. Child grasps its throat ; head is thrown back ; retrac- tion of epigastrium • pieces of membrane may be coughed or vomited ; pulse weak ; eyes sunken and staring ; cold extremi- ties ; gradual coma ; and death from asphyxia, carbonic-acid 308 A SYNOPSIS OF THE PRACTICE OF MEDICINE. poisoning, complications of pneumonia or bronchitis, on the sixth or seventh day. Favorable cases are indicated by a gradual amelioration of symptoms ; coughing up pieces of the membrane ; gradual re- turn of voice ; lessening of fever j and slow convalescence. Usually followed by bronchitis and temporary paralysis of the vocal cords. Pathology. — An irritant, possibly a germ, causes conges- tion of the laryngeal and superior tracheal mucous mem- branes j transudation of serum ; proliferation of cells ; and diapedesis of leucocytes, which gradually elongate and form fibrous cells and tissue known as false membrane. This covers and occludes the larynx and superior part of the trachea, and at times extends to the bronchi. When re- moved, small bleeding points are left. Parts are swollen and red. Lungs often present a condition of pneumonia, emphy- sema, or bronchitis, from the cupping-glass action exerted by forced efforts at inspiration. Kidney, liver, spleen, and brain are congested. Blood is thick and dark in color. Diagnosis. Laryngismus Stridu- lus. First and second years. Sudden onset at night ; no prodromes. Duration, a few min- utes. No fever. No expectoration. Croupal breathing attack. Usually no sequel. Death rare. m Catarrhal Croup. Second or third year. Sudden onset at night ; catarrhal prodromes. One to three days. Slight fever in attack. Mucous expectoration. Croupal breathing in attack. Slight bronchitis. Death rare. Membranous Croup. Second to seventh year. Onset gradual ; long pro- dromes. Duration, four to six days. Constant high fever. Expectoration of false membrane. Constantly increasing croupal breathing. Bronchitis ; pneumonia ; emphysema. Most cases die. DISEASES OF THE LARYNX. 309 Prognosis. — Few cases of true membranous croup recover. Catarrhal or false croup is too often mistaken for true croup j hence the unreliability of data at our command. Treatment. — Whether the disease be of diphtheritic origin or not, the accepted treatment for either answers, and is the same as that used in the other. Onset. — Put the child in bed between blankets ; insist on absolute quietness ; keep the room at a uniform temperature and the air constantly moist with steam. Quininae bisulphas, gr. ij, every two or three hours, with hydrargyri chloridum corrosivum, gr. ■£$ to A (some prefer the use of hydrargyri chloridum mite). Inhalations of medicated steam (oleum eucalyptol and tr. iodini comp.) every few minutes or contin- uously; constant hot or cold compresses to the throat. If paroxysms are frequent and child very restless, small doses of pulvis opii or pulvis opii et ipecacuanhas during the first stage only. Full doses of pilocarpine are said to abort, but suffi- cient statistics cannot be obtained to speak positively. Second Stage. — Continue inhalations of steam ; administer quininas and hydrargyrum. Solvents for the false membrane are of little value. Sprays of lactic acid, peroxide of hy- drogen, and sodii bicarbonas are recommended. Better still, use a spray of the free chlorine mixture ; or potassii chloras, myrrha, and acidum carbolicum (see Pharyngitis). Failing in this, tracheotomy or intubation becomes necessary. See that the tube is always kept clear, and accomplish this by a small brush or feather. Sustain strength by most nutri- tious diet and tonics. Aconite, aqua calcis, bromides, and emetics are all too depressing and of doubtful utility. Emet- ics, remedies which have been greatly abused, have their place, but why use them on every occasion ? They only sap the little patients of that much strength and vitality that will be needed to tide them over the later stages. Only when 310 A SYNOPSIS OF THE PRACTICE OF MEDICINE. there is a large mass of flapping, loose membrane is one justified in giving an emetic, and even then its utility is doubtful. Third Stage. — When recovery is imminent, the patient must be sustained and supported by tonics and best diet. Always watch the condition of the heart and let it be the guide ; re- move intubation-tube as soon as it can safely be dispensed with ; prevent exposure j treat all complications and sequelae. DISEASES OF THE BRONCHIAL TUBES AND LUNGS. BRONCHITIS. Definition. — An inflammation of the bronchial mucous membrane, accompanied by fever ; cough ; substernal tender- ness, or pain and oppression. Varieties. — Acute bronchitis ; plastic bronchitis ; chronic bronchitis. (1) ACUTE BRONCHITIS. Synonyms. — Acute catarrhal bronchitis ; cold on the chest ; acute bronchial catarrh. Definition. — An acute inflammation of the mucous mem- brane of the larger bronchial tubes, not attended with a plastic exudation. Etiology. — Exposure to cold, irritating dust, or vapors; predisposition. Most common in children. Symptomatic of measles and typhoid fever. Symptoms. — Onset is sudden, with a chill, fever, quick pulse, and general malaise ; or gradual, with nasal and pha- ryngeal catarrh, coated tongue, headache, constipation, and slight cough. At first the cough is dry, harsh, and paroxys- mal; slight expectoration of mucus, streaked with blood at times. Pain behind the sternum, increased by coughing or deep inspiration. Cough soon changes to a loose, free, muco- purulent or greenish expectoration, with no blood ; fever sub- 311 312 A SYNOPSIS OF THE PRACTICE OF MEDICINE. sides; percussion note usually normal; harsh, vesiculobron- chial breathing; sibilant or sonorous rales in first stage; moist and bubbling rales in second stage. Pathology. — Hyperasmia of mucous membrane of larger bronchial tubes, due to an irritant ; membrane is red, swollen, and dry ; vessels congested ; diapedesis and cell-proliferation. Secretion gradually increases, at first mucous, then muco-puru- lent, with desquamation of epithelial cells and, at times, rupt- ure of capillaries. Bronchial glands enlarged, especially in the symptomatic form. Prognosis. — Terminates favorably, and is not serious un- less complicated by capillary bronchitis or pneumonia. Treatment. — Abortive. — Quinina, and aconite or veratrum viride, in full doses every hour, until physiological effects are obtained. Acetanilide, phenacetin, and the other coal-tar series, are recommended by some, but are very depressing to the heart. Pulvis ipecacuanhas et opii, gr. x-xv, or ex- tractum jaborandi fluidum, gtt. xx-xl ; hot mustard foot-bath ; rest in bed and free diaphoresis. Hot drinks favor dia- phoresis. During the first stage, when the cough is dry and irritating, and some fever, the following is very good : Antimonii et potassii tart gr. j. Tr. aconiti vel tr. veratri f 3 ss. Potassii bromidi (morphinae sulph., gr. j) . . . . 3 ijss. Liquoris ammonii acetatis f I ijss. . Syr. aurantii floratis q. s. ad. f I iv. M. Signa. One teaspoonful every two or three hours. For an adult. Syr. seillae, syr. ipecacuanha?, liquor potassii citratis, are all good. It is always well to precede all medication with a free purge of hydrargyri chloridum mite. Inhalations of DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 313 moist steam ; light, nutritious diet ; and limit the amount of fluids taken. Locally. — Mustard ; hot liniments ; poultices ; blisters 3 or soft, raw cotton to the chest in severe cases. Second stage indicates stimulating expectorants, and none is better than ammonii chloridum, gr. iii-x, in mistura glycyr- rhizae comp., every three or four hours. May be necessary to use cod-liver oil and stimulants in cachectic persons. Glyce- ritum hypophosphitum comp., f 3 j, every four hours, is good. (2) PLASTIC BRONCHITIS. Synonyms. — Membranous bronchitis ; croupous bronchitis ; diphtheroid bronchitis. Description. — An acute inflammation of the bronchial mu- cous membrane, accompanied by a fibro-plastic exudation, forming a distinct membranous cast of the large and small tubes. Symptoms are identical with acute catarrhal bron- chitis, with the addition of marked dyspnoea ; violent parox- ysms of coughing j and expectoration of distinct membranous casts of the tubes, not unlike small pieces of vermicelli. Pathology. — Similar to acute catarrhal bronchitis, except that the exudation, diapedesis, and proliferation of cells are of a fibro-plastic character, and probably depend upon a distinct germ analogous to or identical with that of membranous croup and diphtheria. Prognosis. — Usually fatal in young children; healthy, strong adults recover. Treatment — Follow the same line of treatment indicated in acute catarrhal bronchitis. Administer hydrargyri chlo- ridum corros., gr. -gV, every three or four hours ; watch the heart • stimulate freely in late stages ; best nourishing, easily 314 A SYNOPSIS OF THE PRACTICE OF MEDICINE. digested food ; free inhalations of medicated steam. Emetics are nsnally of little value and too depressing. (3) CHRONIC BRONCHITIS. Synonyms. — Chronic bronchial catarrh ; " winter cough." Definition. — A chronic inflammation of the mucous mem- brane of the larger bronchial tubes, recognized b}^ the pres- ence of a slight cough, more severe in winter (sometimes ab- sent in summer) ; expectoration, slight or profuse ; slight bronchial rales ; no fever ; and presenting itself in the form of a dry catarrh ; moist catarrh ; fetid catarrh or bronchorrhoea. Etiology. — May be primary or secondary. Due to cold, exposure, great changes of temperature, all irritating vapors and dust, repeated acute attacks, extension from other parts, gout, rheumatism, tubercular and other diatheses, syphilis, alcoholism, heart-diseases. Also symptomatic and a sequela of certain fevers. Common in the aged or in children. Symptoms. — General. — Chronic bronchitis of all varieties is accompanied by a cough that manifests itself more particu- larly during the damp, cold months of the year, and in mild, early cases disappears in summer. Cough worst in the morn- ing and at night ; fever always absent ; loss of flesh, slight and scarcely perceptible at first ; acute attacks common. Percus- sion sounds clear, unless emphysema complicates. Ausculta- tion reveals all kinds of rales, depending on the variety. (See Auscultation, p. 292.) Dry catarrh (bronchitis sicca) has little or no secretion ; a harsh, violent, unsatisfactory, paroxysmal cough; small globules of tough mucus expectorated occasionally; dysp- noea; and substernal pain or soreness. Emphysema usually present. Moist Catarrh. — Paroxysmal cough ; expectoration of frothy DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 315 mucus, muco-purulent, white, yellow, or green in tinge ; most annoying at night and in the morning during winter months. Fetid Catarrh. — Expectoration very offensive ; breath bad ; and always associated with bronchial dilatation. Bronchorrhcea. — Expectoration thin, ropy, or thick; con- tains little air; often fetid; may expectorate five pints in twenty-four hours. Common in old persons with bronchial dilatation. Complications. — Emphysema ; bronchial dilatation ; heart- disease ; or phthisis. Pathology. — Same as acute bronchitis, except that the course is slower. Mucous membrane gray, thickened, and in- filtrated. Emphysema is due to over-distention and sprain of the alveoli in coughing. Bronchial dilatation (bronchiectasis) comes from a loss of tone to the bronchial muscular fibers, from continued inflammation. Fetid sputum is caused by de- composition in the dilated bronchi before it can be expelled. Diagnosis. — See table, page 95. Prognosis. — Good, when taken early in its course. Old cases promise little as to cure, but are liable to be carried off by some complication or intercurrent affection. Predisposi- tion to return, to acute attacks, and to phthisis. Treatment — Hygienic and Climatic. — Patient should live in a high, dry, uniform climate (providing heart-disease is ab- sent) of uniform temperature, and avoid all exposure both to damp and cold. Light flannel must be worn next the skin ; personal cleanliness : nutritious diet ; pure, sweet cream and nitrogenous foods ; and plenty of out-door exercise, within the limit of endurance. Living in the balmy air of pine-forests of New Jersey and the Southern States, or the high, dry climate of Colorado, New Mexico, and Arizona, is conducive to rapid recovery. Regular, systematic hours for sleep, exer- cise, and duty, combined with good hygienic measures and an 316 A SYNOPSIS OF THE PRACTICE OF MEDICINE. out-door life, will accomplish better results than medicines given on the " shot-gun principle." Medicinal Treatment. — The list of drugs recommended is legion, and we must be guided solely by symptoms and con- ditions. Pure cod-liver oil, with the phosphates or malt ex- tract, given continually for months, seems to give the best re- sults. Ammonii chloridum, administered in mistura glycyr- rhizae comp., is indicated in mucous or moist catarrh. Ext. cocillanae fluidum gives admirable results. For broncliorrJioea, calcis lactophosphatum, creosote, iodum, terebene, or one of the balsams. Never give opium for cough unless absolutely nec- essary. Codeina or pulv. ipecacuanha? et opii in small doses. Dyspnoea indicates spasmodic element — potassii iodidum, gr. iii-v, ter die, or physostigmina, gr. T ^o? ter die. Inhala- tions of steam are sometimes beneficial. Dry cupping and counter-irritation when indicated. Carbolic acid and iodum in fetid bronchitis. Watch the strength of the patient, and administer tonics as indicated. Avoid heart-depressants. Treat all complications, diatheses, and other diseased condi- tions present. CATARRHAL PNEUMONIA. Symptoms. — Suffocative catarrh ; lobular pneumonia ; bron- cho-pneumonia ; broncho-alveolar catarrh ; the so-called " cap- illary bronchitis." Definition. — An acute inflammation of the mucous lining of the smallest or capillary bronchial tubes and alveolar struct- ure, involving diffused areas in one or both lungs. Etiology. — Exposure to cold or dampness ; extension from bronchitis. Sequel and complication of influenza, diphtheria, measles, and whooping-cough. Predisposing causes are scrof- ulous and rachitic diatheses; debility; age (young children DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 317 and old persons most commonly affected) ; emphysema ; heart- disease. Symptoms. — Before the capillary bronchioles and alveoli are invaded, the symptoms are those of an acute bronchitis. Onset is heralded by a rise of temperature from 102° to 104° F. j respiration labored, increased, and difficult ; expira- tion prolonged and noisy ; inspiration short ; dyspnoea grad- ually increases and is paroxysmal ; skin dark and livid ; ve- nous congestion j cold perspiration ; stupor. Cough, during the early stages, is troublesome and rather unsatisfactory; later, when cyanosis begins, it lessens. Expectoration is scanty, muco-purulent, often in small plugs, and is sometimes streaked with blood. Depression marked, and a main feat- ure of the disease. Auscultation. — Vesiculobronchial breathing, with subcrepi- tant rales, gradually lost until resolution begins, when they assume a harsh and bubbling character as in bronchitis. Percussion. — Small areas of diffused dullness, with inter- vening clear areas. Convalescence is slow and long; weakness and depression marked. Death due to cyanosis, and is painless. Complications. — Pneumonia, tuberculosis, emphysema, ate- lectasis, chronic pneumonia, bronchiectasis. Pathology. — It is very doubtful if capillary bronchitis can exist alone clinically. Any inflammation of the capillary tubes necessarily spreads by continuity of structure to the pulmonary alveoli, giving rise to a condition of catarrhal pneumonia. The symptomatology, prognosis, sequela, and treatment of a theoretical case of capillary bronchitis or ca- tarrhal pneumonia are so closely allied that most authorities wrongly describe them under separate heads, on the principle of a theoretical difference without a clinical distinction. The bronchial and alveolar mucous membrane is hyperaemic 318 A SYNOPSIS OP THE PRACTICE OP MEDICINE. and swollen ; new cells are proliferated ; an exudation of tena- cious mncns and a purulent secretion that block the air-cells and bronchioles and act as a valve, causing imperfect aera- tion of the blood, cyanosis, functional atelectasis, emphy- sema, slight consolidation, and dullness. Resolution causes fatty degeneration, absorption and expectoration of the exu- dation, and hyperplasia. Diagnosis. — Pneumonia is self -limited • ends by crisis ; has rusty or bloody sputum ; unilateral and circumscribed. Acute Bronchitis. — Little or no fever ; no dyspnoea ; no dull- ness on percussion; large, moist, and bubbling rales; no marked prostration. Prognosis. — Occurring as it does in debilitated children and old persons, is usually fatal in fifty percent, of the cases. The mortality is much less in middle age and hardy persons. Convalescence is long and tedious. Ends oy lysis. Acute stage lasts about two weeks. The great danger lies in weakness and complications. Treatment. — Confine patient to bed in a room with a uni- form temperature. Avoid every source of cold and excite- ment. If seen in its incipient stage, administer full doses of tr. aconiti, tr. veratri, vinum autimonii, or liq. ammonii acetatis. Apply strong counter-irritation over the chest. Hot drinks and free diaphoresis. Quinina in small, tonic doses. When the disease is pronounced or fully developed, all de- pressants must be avoided, and alcoholic stimulants should be freely used. The chest should be rubbed with turpentine, camphor, or croton-oil and incased with raw cotton. Free, hot inunctions of cod-liver oil or sweet-oil, night and morn- ing. The coal-oil products, although freely used by some, are entirely too depressing in their action, and should be used only with great caution. Cough. — Never give opium, as it counteracts the very means DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 319 nature has provided for clearing away accumulations of mucus. Inhalations of medicated steam are sometimes benefi- cial, but possess the evil effects of relaxing the tissues. Small doses of any stimulating or sedative expectorant every two or three hours — ammonii carbonas ; syr. ipecacuanhas ; min- eral acids. Emetics of apomorphine and sulphate of zinc are said to relieve impending suffocation, but are extremely de- pressing, and must be used only as a last resort. Convalescence. — Best nitrogenous diet ; cod-liver oil ; change of climate to sea-shore or mountains, for several months, if possible. Live constantly in the open air and exercise mod- erately. HEMOPTYSIS. Definition. — Haemoptysis, a symptom of disease, is a term applied to hemorrhage from the broncho-pulmonary tract. Etiology. — Tubercular ulceration is a common cause ; ob- structive and valvular heart-troubles ; pulmonary hyperaemia ; excessive spraining or coughing ; inflammation ; hemorrhagic diathesis; anaemia; breaking of a pulmonary aneurysm; gan- grene ; cancer ; vicarious menstruation ; idiosyncrasy ; plethora. Symptoms. — Symptoms of causative disease. A feeling of fullness, burning, or tickling in the throat or behind the sternum, followed by a salty taste in the mouth and expecto- ration of frothy or pure alkaline blood. Sometimes patient has a salty taste in the mouth for days before hemorrhage takes place. It either follows severe coughing or may come suddenly without symptoms. Blood may be coughed up or flow without coughing. Patient becomes excited ; pulse quick and tense ; skin pale and covered with cold sweat. Hemor- rhages apt to recur at intervals of a few days or months. Bubbling rales on auscultation and localized dullness on per- cussion. Small particles or casts of dark blood are coughed 320 A SYNOPSIS OF THE PRACTICE OF MEDICINE. up for several days or weeks after hemorrhage. Pathology and prognosis depend on causative affection. Patients rarely die from hemorrhage, unless due to breaking of a pulmonary aneurysm. Diagnosis. — See page 208. Treatment. — Preventive. — Treat cause. Establish menstru- ation when it is vicarious. In plethora, relieve by regulating diet and venesection. Foresee the probability of hcemoptysis in iveak, scrofulous children, and strengthen them. Thickness of the blood tends to avert hemorrhage ; hence regulate fluidity by diet, hydragogues, and salines. In anaemia, give iron. Ten grains of calcis lactophosphatum, dissolved in a glass of water, and sipped during the day, will tone the bronchial mu- cous membrane and vessels. When there is a feeling of full- ness behind the sternum, as if a hemorrhage were imminent, twenty drops of tr. digitalis in hot water, every four hours, accompanied by a small blister, and reassurance of the pa- tient, with rest in bed, often prove effective. During the hemorrhage, apply ice to the chest ; administer a hypodermic of morphince sulphas, gr. \ ; absolute rest in bed in recumbent position. If heart is tumultuous and strong, give aconite, veratrum, or gelsemium. The condition of the heart indicates the use of stimulants or depressants. Small pieces of ice or common salt in the mouth constitute remedies used by the laity. Hypodermics of ergot are of little avail, as they do not contract the pulmonary arterioles as expected, and may do more harm than good. Hemostatics in general are of little avail, as the hemorrhage is over by the time they begin to act. Inhalations and sprays during the hemorrhage are absolute- ly worthless, as they never reach the lung structure or seat of hemorrhage. Strictly avoid all hot drinks, coughing, talk- ing, and excitement. Convalescence. — Rest in bed; flying blisters on chest; moist DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 321 air; uniform temperature; morphina or codeina to control coughing. Phenacetin or acetanilide for fever. Quinina alone favors hemorrhage. Diet of milk, rice, beef -juice, white of egg, and a little acidulated drink. Gradually harden patient, and insist on change of climate by a long sea- voyage ; mountain life, and out-doors most of the time. PULMONARY HYPEREMIA. Synonyms. — Congestion of the lungs; active or passive fluxion of the lungs. Definition. — A congestion of a portion of one or both lungs. Etiology. — Active Hypercemia. — Violent heart-action ; over- stimulation ; violent exercise ; alcoholism ; direct irritation ; excitement. Passive Hypercemia. — Valvular heart-diseases ; dilatation or hypertrophy of the heart ; obstruction of pulmonar}^ circula- tion by tumors, thrombi, emphysema, or pneumonia. Feeble heart-action. Complicates fevers and Bright's disease. Symptoms. — A sense of fullness, without pain, over the chest ; short, dry, hacking cough, with an occasional expec- toration of frothy or bloody mucus; dyspnoea of varying character ; no fever ; pulse strong and full ; lasts two to seven days. Chronic hypercemia presents similar symptoms, not so acute at first. Slight impairment of resonance on percussion ; diminished vesicular murmur, with moist and subcrepitant rales. Pulmonary (Edema. — Acute or chronic hyperemia is fre- quently followed or accompanied by an exudation of serum into the pulmonary alveoli, causing marked dyspnoea ; cyano- sis ; serus or tough mucus expectoration, tinged with blood ; 322 A SYNOPSIS OF THE PRACTICE OF MEDICINE. large, moist rales ; slight impairment of resonance on percus- sion. Pathology.— Lnngs dark red, and do not wholly collapse ; capillary vessels distended with blood. Section resembles splenic structure j hence the term splenification. When serum has exuded into alveoli (oedema), the lung pits on pressure j is heavy • does not collapse 5 serum and blood escape on section. Prognosis. — Always grave, unless active treatment is em- ployed; depends on cause. Simple acute cases terminate in two to seven days. (Edema is always attended with doubt. Treatment. — Strike directly at cause. When pulse is full or death imminent, venesection at once. Dry or wet cups. Free purgation ; diaphoresis. Stimulants as indicated. Emet- ics often relieve. Passive congestion demands regulation of cause. Avoid large quantities of hot drinks or hot foods, hot or cold air, and all excitement. Milk diet ; free use of fruits and acids. Mild cases are averted by aconite or veratrum. Tr. veratri viridis vel tr. aconiti rad gtt. j. Vini antimonii gtt. iv. Tr. opii gtt. j. Liq. ammonii acetatis f 3 ss. M. Signa. Every hour, in water, until relieved. APNEUMATOSIS. Definition. — Collapse of the air-cells in certain portions of the lungs, either acquired or congenital. A symptom, not a. disease. Varieties. — Congenital apneumatosis or atelectasis; ac- quired apneumatosis. Etiology. — Congenital. — Improper expansion of air-cells at DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 323 birth on account of weakness ; improper innervation or bronchial obstruction. Acquired. — Blocking of bronchial tubes by mucus or foreign bodies ; bronchitis ; laryngeal or tracheal obstruction ; pneu- monia ; compression by pleural effusion ; pericardial effusion ; tumors ; cancer ; aneurysm ; and spinal curvature. Symptoms. — Patient is weak; skin and nails livid from improper aeration of blood ; speaks in low voice or whispers ; respiration shallow and hurried ; pulse feeble ; absence of vesicular murmur over affected area ; slight dullness, on per- cussion, recognized at bases of lungs. Temperature often subnormal. Congenital apneumatosis shows itself, at birth, in weak chil- dren who cry very little ; abdomen retracted ; skin bluish ; in- tercostal spaces sunken ; great difficulty in nursing. Acquired apneumatosis, recognized by symptoms of cause as well as those mentioned. Pathology. — Lung dense; heavy; sinks in water ; contains no air in affected area. Most common in lower lobes of lung. Acquired cases of compression are bloodless, airless, and a gray or reddish-brown color (carnification). A bronchus be- comes blocked ; incloses air in the alveoli, which is absorbed ; alveolar walls collapse and contract. The "valvular action n theory is hardly probable. Treatment. — Congenital. — At birth, see that the child cries long and hard to completely fill the air-cells. Throw hot water in its face ; strike its chest with a cold towel to induce respiration. Artificial respiration if necessary. Stimulate freely, and avoid exposure. Acquired. — Seek cause and remove if possible ; inhalations of compressed air and oxygen ; daily pulmonary gymnastics ; supporting and stimulating diet. Stimulating expectorants if indicated. Symptomatic treatment. 324 A SYNOPSIS OF THE PRACTICE OF MEDICINE. VESICULAR EMPHYSEMA. Definition. — A condition of the king in which the air-vesi- cles are enlarged ; the tonicity or continuity of their walls de- stroyed; and an escape of air into the connective and sub- plenral tissue. Etiology. — Forced or prolonged inspiration or expiration, as in coughing or blowing wind-instruments; lack of nu- trition and degenerative changes of alveolar walls ; heredity. Follows pneumonia, chronic bronchitis, asthma, whooping- cough, and over- exertion. Compensatory emphysema in phthisis. Present in young adults and old persons. Symptoms. — Begins with shortness of breath and symp- toms of bronchitis. Least exertion causes marked dyspnoea ; cold air and asthma aggravate it ; dyspnoea increases, and is worst at night. Face is dark, livid, and veins prominent; nostrils dilated ; mouth open ; head thrown back ; and all mus- cles of respiration are used to obtain breath. Auscultation. — Prolonged expiration ; short inspiration ; vesicular murmur diminished; whistling, moist, or bubbling rales ; vocal fremitus diminished ; heart-sounds displaced. Percussion. — Marked tympany or Iryper-resonance • cardiac dullness, lessened and slightly displaced; liver dullness, de- pressed. Chest assumes a cylindrical or so-called "barrel appearance v ; more or less stooping : lower part of chest con- tracted ; intercostal spaces widened ; and whole chest moves on respiration. Paroxysms of spasmodic asthma complicate. Pathology. — Forced dilatation of the air- vesicles causes a loss of tone to their walls ; these gradually atrophy or degen- erate from lack of nutrition, and ultimately rupture, thus merging a number of air-cells into one and allowing air to escape into the connective tissue. This causes obstruction to pulmonary circulation ; extra work on the right side of the DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 325 heart, with hypertrophy, dilatation, fatty degeneration, and the train of symptoms consequent npon this condition. Left lung is most susceptible, and in upper lobes. Paroxysms of dyspnoea are due to neurotic element present. Lungs do not collapse on opening the chest- walls ; crackle on pressure ; con- tain air-spaces the size of a small cherry; do not sink in water ; very pale in color or light gray. Prognosis. — Rarely if ever causes death directly. Patients die of complications — bronchitis or heart-disease. Treatment. — Preventive.- — Prohibit forced inspiration, ex- piration, or any physical cause ; treat conditions of bronchitis ; give dry, most nutritious diet, such as meat, albumens, and con- centrated foods. Open-air exercise in moderation; slight work ; and " put off the day on which he will become an in- valid." Tonics of iron, quinine, and cod-liver oil. Change of climate. Potassii iodidum, with tonics or lobelia, relieves the spasmodic element and retards the disease. (Form, p. 327.) During a paroxysm, administer a hypodermic of morphinse sulph., gr. i, and atropinae sulph., gr. T ^ ; inhalations of com- pressed air or oxygen. Attacks are often relieved in a half- hour or less by inhalations of equal parts of nitrous oxide and pure oxygen. Nitroglycerin or eserine, gr. too, ter die, relieves dyspnoea in some cases. BRONCHIAL ASTHMA. Definition. — A functional, paroxysmal neurosis of the re- spiratory tract, recognized by attacks of great dyspnoea, which are followed by intervals of repose. Etiology. — Exciting Causes. — Change of weather; cold air ; climate ; inhalation of dust, smoke, or irritating vapors and powdered ipecac ; pollen from flowers or grain ; over- eating; sexual excesses; particular articles of diet; excite- 326 A SYNOPSIS OF THE PRACTICE OF MEDICINE. merit or fear ; Bright's disease ; any irritation to the pneu- mogastric nerve. Predisposing Causes. — Heredity ; bronchitis ; emphysema ; gouty diathesis; debility. More common in men, young adults, and high walks of life. Symptoms. — Paroxysm. — Usually appears between two and four o'clock a.m., or in the afternoon. Wake with a sense of oppression of the chest, with great effort at breathing. May be preceded by drowsiness, uneasiness, sneezing, and slight coughing. Sudden dyspnoea, rapidly increasing; gasps for breath ; head thrown back ; mouth open ; muscles of respira- tion standing out; chest full and rounded; veins full and prominent ; skin dusky • whistling, unsatisfactory cough ; no fever ; cannot lie down. Patient wants near an open window. Inspiration is short and wheezing; expiration prolonged and noisy. Hyper-resonance on percussion ; vesicular murmur ab- sent or weak ; sibilant, wheezing, and whistling rales. Slight expectoration of grayish pellets of mucus, often stained with blood. After a few hours, paroxysm subsides, but may last for days, and returns at indefinite periods. Pathology. — Undoubtedly of neurotic origin. Having a pre- disposition to asthmatic attacks, an irritant to the peripheral branches of the pneumogastric nerve causes contraction of the involuntary muscular tissue surrounding the smaller bronchi; narrowing or occluding their caliber; preventing the normal tidal respiration ; hence all the symptoms. The catarrhal theory of a temporary swelling of the bronchial mucous membrane is hardly plausible, owing to the sudden- ness of the onset and the ready response to treatment. When complicating other affections, we have in addition the pathol- ogy of the disease. Diagnosis. — Cardiac Asthma. — Not paroxysmal ; very per- sistent ; history of heart-disease ; general symptoms. DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 327 Laryngeal affections and polypi differentiated by direct ex- amination, and not readily mistaken. Prognosis. — Never directly fated. Great danger lies in complications, such as heart-disease, emphysema, and dropsy. A chronic disease, and rarely if ever cured. Treatment. — Paroxysm. — Inhalations of equal parts of ni- trous oxide and oxygen, nitrite of amyl, ether, chloroform, or bromide of ethyl. Tablets of trinitrin, gr. y^o, dissolved in mouth. Hypodermic of morphina and atropina is very effi- cient, but not always desirable. Bromides and chloral. Nauseants of lobelia, ipecacuanha, and smoking belladonna and stramonium leaves, steeped in niter and dried, are com- mon, mild measures, but rather undesirable. Ext. grindeliae fluidum. Stimulants of hot coffee, strychnina, alcoholic prep- arations, or cocoa in nervous subjects. Phenacetin or acet- anilide, in ten or fifteen grain doses, may give rapid relief in obstinate cases where other means have failed. Inhalations of condensed air, with exhalation into rarefied air. Make a strong mental impression on patient. Fright is said to have cured very obstinate paroxysms. All remedies gradually fail in time. Sangree claims excellent results from an ice-pack. Preventive. — Systematic course of arsenic, alternated with potassii iodidum, and change of air. Avoid all causes. Treat complications. Light diet ; never eat a full meal. Hunt for and treat all possible reflex causes, such as uterine diseases in women. When threatened with a paroxysm, give : Tr. lobeliae f 3 v. Ammonii iodidi 3 j. Syr. pruni virginianae f 1 ijss. Aqua? q. s. ad. f 1 iv. M. Signa. One teaspoonf ul every two or four hours as nec- essary. 328 A SYNOPSIS OF THE PRACTICE OF MEDICINE. PNEUMONIA. Synonyms. — Croupous or lobar pneumonia j pneumonitis ; u lung-fever." Definition. — An acute, localized, croupous inflammation of the alveolar structure of one or more lobes of the lung, ac- companied by an exudation into the air-cells. Etiology. — Recent research seems to point to a distinct germ {Micrococcus pneumonia?) as the cause of pneumonia. Exciting and predisposing causes are exposure to cold and dampness 5 alcoholism; rheumatism; gout; and debility of any kind. Surgical causes are foreign bodies ; injury to chest- walls by blows or penetration. Most common in winter ; not self-protective ; contagious ( ? ) ; at times epidemic ; middle lif e usually, twentieth to forty-fifth year. Recently classed as an acute, infectious or contagious fever. Symptoms. — Onset or First Stage. — Begins with an uneasy sensation in chest ; pain in the head and back ; tongue furred ; malaise ; slight cough ; chilly sensations, followed by one dis- tinct cMll 7 not repeated ; rise of temperature from 102° to 105° F. Fine subcrepitant rales on auscultation (similar to the sound produced bjr rolling the hair between the fingers) at end of inspiration, localized usually in one lobe of either lung. Sometimes the onset is insidious. Percussion note unaltered. Cough at first is dry, but changes to expectoration of sticky mucus, stained with blood. A dull or sharp pain over the region of nipple. Pulse not increased proportionately to the rapidity of breathing. Second Stage. — Respiration grows quicker and more shallow — from thirty to ninety per minute; pulse slightly increased; temperature high, 104° to 105° F. ; skin very dry and hot ; marked localized dullness on percussion over diseased lobe : DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 329 vesicular murmur lost, aud replaced by bronchial breathing ; bronchophony; lessened chest movement on affected side. Cough painful, and expectoration is of a thick, tenacious, rusty- colored, or bloody character. Slight delirium. Urine acid, high-colored, and chlorides diminished; occasional albumi- nuria. Jaundice complicates, but is rare. An eruption of herpes often occurs on lips, anus, or limbs between second and fifth day. Third Stage. — Resolution. Between the sixth and ninth day, temperature, respiration, and pulse fall oy crisis. Paralysis of the heart (heart-failure) is most common in this stage. Tongue moist; skin assumes a natural condition, and all symptoms improve. Dullness gradually diminishes; redux crepitant rales. Cough not so painful ; sputum becomes yel- low or greenish, less sticky, and loses bloody character. In place of crisis and resolution, the case may run on to caseation, with a high evening temperature ; dullness and slow cough ; marked depression ; night-sweats ; and slow recovery. In old persons, expectoration may become red and serous — "prune-juice " expectoration. Many cases assume a typhoid nat- ure and are improperly termed typhoid pneumonia. Pathology. — Onset. — An irritant, probably the Micrococcus pneumonia?, causes a congestion of the alveolar mucous mem- brane of one or more lobes of the lung — most commonly the lower right lobe. In aged persons and in children the apex is most commonly affected. An exudation of thick, tenacious serum, which causes adherence of walls of the air- vesicles ; hence the fine subcrepitant rales caused by their expansion at end of inspiration. Lobe of lung is red or reddish brown ; is in a stage of congestion ; contains frothy serum, new cells, and proliferated epithelium ; and floats in water. Second Stage. — Red hepatization, or stage of exudation. Exu- dation into air- vesicles continues ; embryonic cells are formed ; 330 A SYNOPSIS OF THE PRACTICE OF MEDICINE. epithelium is proliferated ; diapedesis ; and occlusion of air- cells. Lung is red 5 cuts like liver and looks not unlike it ; sinks in water. Third Stage. — Resolution or gray hepatization. Fatty de- generation of the exudation; absorption of part and expec- toration of remainder until air-cells resume their normal condition. Color grayish, due to leucocytes and decolorized red blood-cells. If resolution fails, there is a fourth stage, in which the lung is soft ; infiltrated with purulent material ; localized abscesses ; usually followed by death from septicaemia, pyaemia, or pul- monary gangrene. Pleuro-pneumonia is a complication of pleurisy and pneu- monia, and should never be used as a synonym for pneumonia, which is a separate affection. Diagnosis. — See Pleurisy, page 337. Prognosis. — Sthenic {active) pneumonia usually terminates favorably in ten days or two weeks b}^ crisis. Asthenic (inac- tive or lingering) cases are unfavorable. When complicating alcoholism or kidney affections, mostly fatal. Unfavorable signs are very rapid breathing, with low temperature ; marked delirium or convulsions ; involvement of both lungs ; abscess ; gangrene ; paralysis or weakness of the heart ; hyperpyrexia 5 typhoid symptoms; and jaundice. Death may occur from collateral hyperaemia or oedema in the first or second week ; in the second stage, from cerebral engorgement, paralysis or weakness of the heart ; third stage, from albuminuria or sep- tic infection. Treatment. — Absolute rest in bed. If called during onset, when heart's action is full and bounding, give tr. aconite or veratrum (with or without tr. phosphorus, gtt. i-ij, every two hours), every hour or half -hour (form, p. 322) ; vinum anti- monii or liq. ammonii acetatis ; and a full saline purge, until DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 331 symptoms are abated. A pill of aconitina, digitalin, and veratrina is very good. Many cases that threaten to become true pneumonia are entirely checked by this treatment. Full doses of acetanilide or phenacetin are so depressing that they must be guarded or entirely omitted. Blood-letting, an old method formerly practiced in most cases, has justly fallen into disrepute. It is only justifiable in intense congestion, threatened oedema, or pneumonia of alcoholism. Blood-let- ting drains away too much nutritive principle from the blood that will be needed later during crisis and convalescence. Wet cups ; tr. iodi ; or blisters over chest. Incase chest with raw cotton or poultices, kept constantly hot. Raw cotton is preferable, as poultices cannot be kept hot and are liable to chill patient during changing. Inunctions of hot oil, daily, to chest add to protection. After the stage of excitement or onset, avoid all depress- ants, and, from this time until crisis is past, watch the heart closely and stimulate with strychnina or ammonii carbonas, gr. ii-v, every two or four hours, combined with tonic doses of quininae bisulphas. Digitalis contracts the bronchial arte- rioles and is not desirable. Give richest, concentrated, albu- minous diet, so that the bulk of the blood may be kept small and rich. Watch closely for crisis, and be ready to administer a full dose of ammonii carbonas or other stimulant to avert fatal syncope. During resolution, give stimulating expectorants ; Huxom's tincture of bark ; glyceritum hypophosphiti comp. ; and good diet. Never allow patient to go out-doors until all symptoms of the disease have disappeared. The Germans reduce fever by cold baths or cold packs. The main point in treatment of all stages is to support the heart. Opium must be avoided unless absolutely indicated. 332 A SYNOPSIS OF THE PRACTICE OF MEDICINE. CHRONIC PNEUMONIA. Synonyms. — Pneumonic phthisis; caseous pneumonia; scrofulous pneumonia; non-tubercular consumption. Definition. — A chronic inflammation of the parenchyma- tous structure of the lungs, accompanied by degeneration of lung-tissue and formation of cicatricial tissue, usually termi- nating in phthisis tuberculosis. Etiology. — Predisposing Causes. — Low vital powers ; scrofu- lous and tubercular diathesis ; debilitating diseases ; heart-dis- eases ; and chronic bronchitis. Exciting causes are bad colds ; pneumonia; acute bronchitis ; irritating gases ; and dust. Symptoms. — Following pneumonia or bronchitis, patient often complains of chilliness or rigors in afternoon, followed by rise of temperature from 102° to 104° F. ; profuse and ex- hausting night-sweats ; morning temperature normal. Cough worst in morning and night. Expectoration of frothy mucus ; tenacious grayish pellets, purulent or blood-streaked. Hce~ moptysis rare. Dullness on percussion over lower lobes of lungs mostly. Cavities. Mucous rales ; bronchial breathing and bronchophony. Loss of appetite ; great prostration ; face flushed in afternoon. Intermittent fever with rigors indicates purulent infiltration. Chest- walls sunken ; marked supra- and infra-clavicular depression. Pathology. — Although classed as a non-tubercular affec- tion, its origin is questionable. When caseation is present, the case is undoubtedly tuberculous. Inflammation spreads to interstitial tissue, forming new fibrous tissue, which con- tracts, cuts off nutrition, causes atrophy, degeneration, and, in many cases, purulent infection. Tissue breaks down ; is expectorated ; and leaves cavities. Fever is hectic in type. Communication may be established between the lung and DISEASES OF THE BRONCHIAL TUBES AND LUNGS. 333 pleura, causing pneumothorax. Interference with circulation causes dilatation of right ventricle of heart and its train of symptoms. Diagnosis. — See Chronic Tuberculosis, page 95. Prognosis. — When taken early, many cases are checked, and patients live for years, often dying of other affections. Untreated cases terminate fatally in three to five years. Treatment. — Very best hygienic surroundings; constant out-door life in a dry, uniform climate ; best nutritious diet ; sweet, rich cream ; exercise in moderation. Rest in bed dur- ing the afternoon hours when fever comes on. Combat fever with pill acetanilide comp. (form, p. 27) or other antipyretics. Break night-sweats with tr. belladonna?, atrophia, zinci oxidum, or a cup of strong, hot sage-tea, a few moments before retir- ing. Expectorants are indicated in chronic bronchitis. Treat bronchorrhoea. Calcium lactophosphate, glycerol phosphates comp., and cod-liver oil. Avoid hypnotics. Symptomatic treatment. The main feature is to prevent tubercular infec- tion. FIBROID PHTHISIS. Description. — A variety of chronic pneumonia that invades the interstitial tissue of the lung, with hyperplasia, hyper- trophy, and formation of contractile tissue, which contracts and obliterates the alveoli and bronchioles. Most common in those who work in mills, factories, and dust. Called miner's phthisis ; cirrhosis of the lung; and Corrigan's disease. Slight cough, worst in cold, damp months; little expectoration at first. As disease process advances, symptoms are identical with true pneumonic phthisis, and the case is liable to become tuberculous. Marked retraction of chest- walls from pleuritic adhesions. Dullness on percussion, with isolated areas of tympanitic resonance. 334 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Prognosis. — Disease may be held in check for years. Aver- age duration is ten to fifteen years. Tuberculous infection is the usual ultimatum. Treatment. — Avoid cause by change of occupation, out- door life, and treat as in chronic pneumonia. Hydrargyri chloridum corros. ; aurii et sodii chloridum ; iodides ; and other alteratives or absorbents may prevent hyperplasia, but can never restore lost tissue. DISEASES OF THE PLEURA. ACUTE PLEURISY. Synonym. — Acute pleuritis. Definition. — Localized, or diffuse, acute inflammation of the serous membrane lining the pleural cavities, accompanied by a plastic exudation, and terminating in resolution or chronic pleurisy. Etiology. — Exposure to cold or wet ; traumatism. Second- ary to pneumonia ; Bright's disease of kidneys ; variola ; rheu- matism; phthisis; pericarditis; septic and eruptive fevers; pneumothorax ; and all septic poisons. Symptoms. — First Stage. — Dry stage, or onset. A chill or rigor, often repeated, accompanied by severe, sliarp pain in the side, near the nipple, which is increased by respiration, cough- ing, talking, and deep pressure in intercostal spaces. Some fever, ranging from 100° to 104° F. Respiration increased and shallow ; slight dyspnoea ; tongue coated ; constipation. Chest- walls do not move regularly on affected side ; pulse rapid. Dry, hacking cough, very much suppressed. Vesicu- lar murmur lessened, and replaced, over affected area, by a friction-sound heard during inspiration and expiration. Fric- tion-sound varies in degree from a very slight to a harsh, grating sound, which cau be recognized by placing the hand on chest- walls. Patient lies on affected side. Second Stage. — Effusion. By end of second or third day, friction-sounds lessen and disappear ; vocal fremitus lessened j 335 336 A SYNOPSIS OF THE PRACTICE OF MEDICINE. no vesicular murmur ; aegophony ; localized dullness on per- cussion, varying with position. When sitting, dullness is low down posteriorly. Pain decreases ; dyspnoea increases accord- ing to effusion. Loss of movement on affected side of chest ; intercostal spaces full ; very little or no cough 5 fever from 100° to 102° F. ; prostration ; quick pulse ; heart often dis- placed by effusion. When there is no perceptible effusion, the case is termed dry pleurisy. Third Stage. — Resolution. In second week fever lessens; effusion disappears rapidly or slowly ; vesicular murmur re- turns ; friction-sounds ; lung gradually expands ; chest- walls and intercostal spaces sink slightly, or, in some cases, mark- edly. If case does not progress to resolution, it becomes chronic (q. v.). Pathology. — First Stage. — Hyperemia of pleural serous membrane, usually localized to a part or the whole of one pleural cavity. Vessels engorged, dilated, and membrane of a dull red in place of a normal shining appearance. Pain is caused by friction of inflamed membrane during respiratory efforts. Second Stage. — Exudation of leucocytes ; cell-proliferation 5 and formation of a flbro-plastic, sticky exudation, which ar- ranges itself in layers on the membrane (dry pletu'isy), or may continue by an exudation of serum or a fibrinous fluid, in large amounts, nearly filling the pleural sac. Effusion presses on lung, causing temporary or permanent apneumatosis. Pain is lessened by intervention of effusion between inflamed folds of the membrane, preventing direct friction. Third Stage. — Effusion is gradually absorbed; folds of membrane come in contact and form adhesions of fibrous tissue. DISEASES OF THE PLEURA. 337 Diagnosis. Acute Pleurisy. Onset by several chills or rigors. Friction-sound during inspiration and expiration. Moderate febrile symptoms. Short, dry cough. Pain sharp and shooting. Dullness changing with position. Absence of vesicular murmur and fremitus. Chest enlarged ; intercostal spaces bulging. Frothy expectoration. Terminates by lysis. No bacillus demonstrable. Pneumonia. Onset : one distinct chill. Subcrepitant rale at end of inspira- tion. Marked febrile reaction. Cough with expectoration. Dull pains. Dullness localized ; unchanging. Fremitus increased. Absence of chest-enlargement. Bloody or " rusty " expectoration. Terminates by crisis. Micrococcus pneumoniae. Intercostal neuralgia and myalgia are distinguished by being paroxysmal ; location ; absence of physical signs ; and differ- ence in onset. Prognosis. — Most cases recover in three or four weeks by resolution. Many become chronic. Complicated by pneu- monia or empyema. Secondary pleurisy offers a bad prognosis. Treatment. — Onset. — If pain be very severe, dyspnoea great, and pulse full, administer a hypodermic injection of morphina and atrophia. Give tr. aconiti or tr. veratri every hour (form, p. 322), until heart's action lessens. In plethoric, full-blooded persons with a full, bounding pulse, venesection is justifiable and gives quick relief. Leeches, dry cups, or blisters; hot applications, provided they be kept hot constantly, relieve pain, when not too severe. If heart be weak, infusion of digitalis, administered in hot water. Full doses of phena- cetin, acetanilide, or salicylates lessen full pulse and fever, but are too depressing. A full dose of tr. jaborandi, to pro- duce free diaphoresis, is said to abort many threatened 338 A SYNOPSIS OF THE PRACTICE OF MEDICINE. cases. Strapping the affected side with adhesive straps will lessen chest-movements and relieve pain. Opium must be avoided as much as possible. (See Peritonitis.) Inhalatious of oxygen. Effusion. — Great effusion, with marked dyspnoea, requires immediate aspiration, with perfect antiseptic precautions. Infusion of digitalis with potassii acetas or nitras, every two to four hours, often lessens it, if combined with free saline laxatives and use of minimum amount of liquids. Resolution, — Diaphoresis, diuresis, and salines to favor ab- sorption of lymph. Potassii iodidum or syr. ferri iodidi aids in absorption of lymph. Most nutritious diet; iron tonics and stimulants as indicated. CHRONIC PLEURISY. Synonym. — Chronic pleuritis. Definition. — A chronic inflammation of the serous lining- membrane of the pleural cavities, recognized by a history of acute or subacute pleurisy; presence of pleuritic effusion; absence of acute symptoms ; and gradual loss of flesh. Etiology. — Most commonly follows acute or subacute pleu- risy. Complicates tuberculosis ; pneumonia ; Bright's disease ; sy philis ; rheumatism ; or alcoholic excesses. Symptoms. — Usually latent and not constant ; no marked dyspnoea ; slight or no cough ; may have marked emaciation, or no loss of flesh. At times there is hectic fever, night- sweats, and rapid pulse. Respiratory and voice sounds ab- sent or diminished; dullness on percussion, varying with position, if general ; or dullness constant, if sacculated ; chest full ; intercostal spaces bulging and wide ; diminished motion on affected side during respiration; heart and liver displaced. DISEASES OF THE PLEURA. 339 No pain. When absorption occnrs, chest- walls sink ; feeble breath and king sounds. Effusion in chronic pleurisy often becomes infected with pyogenic germs and produces empyema, with marked hectic fever, chills, and emaciation. May point as an abscess in intercostal spaces ; break ; allow pus to escape and air to euter pleural cavity, causing pneumothorax. Ab- scess may open into lungs and be expectorated; perforate diaphragm or pericardium. Pathology — Same as in acute pleurisy, but much slower and more chronic. Membrane thick ; dull-gray color ; very rough; and many bands of adhesion. When infected with pyogenic germs, the whole mass becomes purulent (empyema). Diagnosis. — Hydrothorax is bilateral; complicates kidney and cardiac diseases, with no inflammatory history. Aspirator is best diagnostic agent. Prognosis. — Chronic pleurisy may last for years without endangering life. Great danger lies in empyema or tuber- cular infection, both of which are dangerous to life — the latter always fatal in time. Treatment. — Chronic pleuritic effusion requires dry, nutri- tious diet ; saline cathartics ; minimum of liquids ; and flying blisters to chest. Aspiration often proves curative, and must be done when other means fail. Symptomatic and supporting treatment. Empyema invariably requires surgical interference. Open abscess if it points. Aspiration is not satisfactory. Supply free drainage by openings anterior and posterior, with free incisions into pleural cavity; cleanse twice daily with mild antiseptic solutions of boric acid, creolin, carbolic acid, or hydrogen peroxide. Most nutritious diet ; iron, quinine, phos- phates, cod-liver oil, and stimulants as indicated. To tins combine best hygiene and careful nursing, with thorough antiseptic measures. 340 A SYNOPSIS OF THE PRACTICE OF MEDICINE. PNEUMOTHORAX. Definition. — A condition resulting from disease or injury, in which air has entered the pleural cavity through the lungs or chest- walls. Etiology. — Tubercular ulceration • breaking of abscesses ; empyema ; perforation of chest- walls 5 or any means that may destroy the continuity of lung structure or chest-walls and permit air to enter. Symptoms. — Vary according to cause. Acute cases com- mence with a sudden, sharp pain in the side ; a feeling of something giving way ; great dyspnoea ; small pulse ; profuse sweat 5 and threatened collapse. Respiration rapid and shal- low ; intercostal spaces depressed 011 inspiration ; affected side of chest bulging and enlarged. Paroxysmal cough. Per- cussion note tympanitic or hyper-resonant. Vesicular murmur lost or diminished ; amphoric respiration ; metallic tinkling, if effusion be present. Pleurisy is developed from irritation of air. Pathology. — That of cause. Air in pleural cavity, if in- closed, may be absorbed. It acts as an irritant ; sets up inflammation, which is followed by effusion, which is gen- erally infected with pyogenic germs and causes empyema. Diagnosis. — Emphysema is always bilateral, with a differ- ent historjr of onset. Prognosis. — Very bad. Most probable termination is death, unless due to traumatism or surgical means. Treatment. — Hypodermic injection of morphiua and atro- phia to relieve pain, cough, and excitement. Follow with small doses of opium if indicated. Over-distention with air indicates aspiration or puncture of chest- walls and introduc- tion of a metallic tube with a valve that allows air to escape DISEASES OF THE PLEURA. 341 but none to enter. The inclosed air may absorb without surgical means. Treat effusion as in pleurisy and empyema. Best nutritious diet; stimulants; tonics; and constant out- door life in best atmosphere. HYDROTHORAX. Definition. — Dropsy of both pleural cavities, secondary to some other affection. Etiology. — Bright's disease ; valvular heart-diseases ; ob- struction to pleural circulation by cancer or tumors. Description. — Serous effusion into both pleural cavities is slow in onset, without acute symptoms, and accompanies general dropsy. Dyspnoea gradually increasing; symptoms of causative disorder; dullness on percussion; diminished respiratory murmur. Effusion may become purulent and is termed hydro-pyo- thorax. Prognosis. — Depends on causative trouble. Treatment. — Causative. — Aspiration is only palliative, as fluid returns. Dry diet ; salines and drastics, if patient can endure them ; limit amount of liquids taken ; treat symptoms. THE NERVOUS SYSTEM. INTRODUCTION. The nervous system is a complete whole, and for purpose of study is subdivided into the cerebro-spinal axis and the sym- pathetic system. The cerebro-spinal axis consists of the brain, spinal cord, medulla oblongata, and the nerve-trunks origi- nating from them. The sympathetic nervous system is a series of ganglia lying on each side of the spinal column, connected by commissural fibers, and extending from the ganglion of Ribes, on the anterior communicating artery at the base of the brain, to the ganglion of Impar, in front of the coccyx. Every sensation, motion, physiological and pathological action is dependent on direct and reflex nervous action. Reflex nerve-action is a stimulation and transference of an impression through an afferent nerve to a nerve-center, and its return through an efferent nerve to the parts, causing mo- tion or physiological action. It is either motor, secretory, tactile, or inhibitory. Localization of Senses and Functions. — Every sense and func- tion is dependent upon the action of a certain group of nerve- cells distinctly localized in the brain or spinal cord, which communicates with the parts by means of nerve -fibers. Any disease of or interference with these nerve-centers or their communicating nerves results in a physiological impairment of the parts governed by them, and it is by this method that nervous diseases can frequently be localized. Diagnosis of nervous diseases is dependent on symptoms only. 342 THE NERVOUS SYSTEM. 343 MOTION. Every muscle is endowed with a certain physiological mo- tion that must be studied in health to be recognized. Impair- ment of the nerves supplying that muscle, be it voluntary or involuntary, produces (1) paralysis, partial or complete ; (2) convulsions, tonic (constant) or clonic (interrupted) ; (3) inco- ordination — the inability to produce voluntary muscular move- ments in proper order, most marked when the eyes are closed. SENSATION. Sensation is the recognition of impressious made upon the peripheral sensory nerve-organs of the body, and recognizes touch, pain, heat, and cold. A loss of sensation, partial or complete, is termed ancesthesia. When there is insensibility to pain, it is termed analgesia, Polywsthesia is a pathological sensation in which the contact of one point produces the sen- sation of several. Hyperesthesia is an increased, sensibility. Hyperalgesia is increased sensibility to pain. ELECTRICAL REACTIONS. Every muscle and nerve, in a physiological state, will give a certain reaction when stimulated by electricity. In these examinations, use is made of the galvanic, faradic, and static currents. Galvanic electricity is a primary, constant current, with two distinct poles — a positive pole (anode) and a negative pole (kathode). The ayiode is sedative in its action-, the kathode is irritant. Four special reactions are noted in the use of gal- vanism : (1) When the anode is placed over the spinal center and the kathode is brought in contact with the skin over a muscle 344: A SYNOPSIS OF THE PRACTICE OF MEDICINE. or nerve, there is a reaction or contraction, called the Jcathodal closing contraction (KCC). This is due to closing the circuit. (2) When the kathode is raised from the body, there is another contraction, called the Cathodal opening contraction (KOC), caused by breaking the circuit. (3) Reverse the order by placing the kathode over the spinal center and the anode over the muscle or nerve, and when ap- plied there is a contraction — anodal dosing contraction (ACC). (4) When the anode is removed from the muscle or nerve, we have an anodal opening contraction (AOC). These reactions must be studied in health, and according to their impairment so are we able to diagnose many nervous diseases. (See appropriate works on electricity.) Faradic electricity is an interrupted, induced, or secondary current, whose poles are never constant, except in the prim- ary coil. The two poles are usually applied over the same muscle at once, and a series of clonic contractions ensues if the interruption of the current is slow, or tonic if the inter- ruption is very rapid. Static electricity is derived by friction ; stored in Leyden jars; used directly by sudden discharges of the electric spark into the different muscles ; or by the production of the static breeze. Reaction of degeneration is a diminution or loss of response to the faradic current, with no impairment or a slight increase of galvanic excitability, which may also diminish or be lost, indicating a lesion of the peripheral nerves or spinal cord. TROPHIC CHANGES. Nervous disorders always produce some nutritive disturb- ance in one or more parts of the body : wasting of the mus- cles ; falling of the hair ; impairment of nail-growth ; ulcera- tions; eruptions on the skin; and disorders of the special senses, THE NERVOUS SYSTEM. 345 REFLEXES. The reflexes of the body afford a valuable index to the diag- nosis of nervous diseases, and are classed as the superficial or cutaneous reflexes and the deep or tendon reflexes. Scapular reflex is a contraction of the scapular muscles when the skin between the shoulders is irritated. Plantar reflex is a contrac- tion of the plantar muscles when the sole of the foot is tickled. Gluteal reflex is a contraction of the gluteal muscles on stimu- lation of the skin over them. Cremasteric reflex is a retraction of the testicle on the same side when the inner and upper part of the thigh is irritated. Abdominal reflex — contraction of the abdominal muscles when irritated. Tendon Reflex. — Strictly speaking, there is no tendon reflex, as the contraction is not done by the tendon, but by the muscle to which it belongs. If the ligamentum patella or tendinous part of the rectus femoris muscle is struck a smart blow when the one leg is crossed loosely over the other and hanging in a slightly flexed state, there is a contraction of the muscle, called the patellar reflex or knee-jerk. Clonus is a reflex, irregular contraction of a muscle when suddenly stretched and held in that position. Clonus mani- fests itself best when the foot is suddenly flexed on the leg, by a series of rhythmical contractions of the gastrocnemius and soleus muscles, numbering from six to nine in each sec- ond (anMe-clonus). Other valuable symptoms must be noted. Derangement of the special senses and the power of intellection, tremors, delirium, insomnia, and vertigo afford valuable diagnostic indices, THE NEUROSES. A neurosis is a functional disturbance of the nerve-centers, whose pathology is not positively known. CHOREA. Synonym.— St. Vitus's dance. Definition. — A functional nervous affection, manifesting itself by a series of involuntary, arhythmieal, spasmodic, mus- cular movements affecting one or more groups of muscles. Etiology — It is most commonly found in children, and is caused by reflex irritations, fright, masturbation, worms, genital defects, intestinal parasites, painful dentition, and direct injury. Rheumatism produces many cases. It seems to be hereditary in some families. Female children are more frequently affected than male. It has appeared as an epi- demic among ignorant classes who were susceptible to great mental impressions, and is termed hysterical chorea. Symptoms. — Gradual onset. Child cannot remain still in one position for one minute, but is constantly fidgeting about Among many movements is a peculiar jerking of the head; distortion of expression ; spasmodic closure of eyelids ; open- ing the mouth ; protruding the tongue ; oscillation of the eye- balls (nystagmus) ; jerking of arms and legs ; spasmodic closure of hands ; and spasmodic speech. In fact, every effort is made spasmodically. Child often utters peculiar cries or certain favorite expressions, and has a very excitable temperament. Urine or faeces may be voided involuntarily in severe cases. Choreic movements continue at all times when the patient is awake ; are always aggravated by motion or excitement ; and usually absent during sleep. In mild cases these movements 346 THE NEUROSES. 347 can be controlled by an effort of the will. Mental state is lowered. Increased electrical excitability. Sensations are usually normal. Heart is irregular, tumultuous, and gives a systolic murmur at the apex in more than half of the cases. The severer forms ultimately terminate in paralysis and in- sanity. Choreic children always have a great desire for masturbation, and very excitable genital organs. Chorea may be of all grades, from the slightest muscular contraction to the most violent, in which the patient can neither stand, talk, nor accomplish voluntary motion. Hemi- chorea is an affection confined to one side of the body. Pathology. — No distinct pathological lesion has ever been differentiated. It is undoubtedly due to some irritation of the central nerve-centers, but the how, where, and when are questions for future pathological investigation. Diagnosis. — See table, Paralysis Agitans. Prognosis. — If the exciting cause can be removed, the dis- ease subsides quickly under proper attention. Neglected cases become worse and may iiltimately terminate in paral- ysis, insanity, or chronic chorea. Confirmed masturbation always leads to an increase of the trouble, and saps both physical and mental strength. In heart-lesions the prognosis is rather unfavorable. Treatment. — Cause. — Inquire carefully into the history of the case, and never neglect a thorough physical examination of every organ in the body. Remove every possible cause, and bring into activity the whole secretory and excretory system. Absolute plrysical and mental rest is imperative. Masturba- tion must be prevented, regardless of the measures necessary. Patients of this class should never be frightened, excited, or made the subject of ridicule. Nutritious diet suited to the digestive powers. Medicinal Treatment. — Administer hypnotics at night if 348 A SYNOPSIS OF THE PRACTICE OF MEDICINE. sleep cannot be obtained. Liq. potassii arsenitis, n l iii-v, after meals, gradually increased to the point of tolerance, is the most common remedy used. Zinc salts, given three times daily, are advised by some. Hyoscyamns, cimicifuga, iron, and antispasmodics. Acetanilide, phenacetin, and antipyrin are new remedies used. Strychnina or ignatia will benefit some cases. Massage, salt-water baths, and electricity. Mild cases should be controlled by the influence of the will as far as possible. Treat complications. EPILEPSY. Varieties. — 1. Epilepsy major, limit mdl or le grand mat; 2. Epilepsy minor, le petit mat, abortive epilepsy or epileptic vertigo ; 3. Jacksonian or partial epilepsy. Definitions. — Epilepsy major is a sudden, complete loss of consciousness and coordination, accompanied by tonic or clonic muscular convulsions, of short duration, and tends to recur at irregular periods of time. Epilepsy minor is a slight, temporary loss of consciousness without loss of coordination, occasionally accompanied by tonic or clonic muscular contractions. Jacksonian epilepsy is a temporary tonic or clonic spasm of one or more groups of muscles on the same side of the body, without loss of consciousness, and recurs at irregular intervals. Etiology. — Inherited. Patients with cerebral tumors, chronic meningitis, fractures of the skull, syphilis, and nerv- ous disorders are often affected with one of the varieties of epilepsy. No distinct cause has been found. Symptoms. — Epilepsy Major. — Immediately preceding the attack, and lasting from a few seconds to a few minutes, is the epileptic aura. This consists of various sensations in THE NEUROSES. 349 different persons. A hot or cold wave seems to spread grad- ually from the tips of the fingers or toes to the whole body ; sensations of tingling or numbness extend from the extrem- ities ; strange feelings about the abdomen or chest ; and the appearance of certain peculiar visions. Immediately following the aura is a sudden loss of con- sciousness, usually preceded by a characteristic cry, and the pa- tient falls very hard, if standing, and is often seriously injured. Skin is pale and cold, and muscles are in a state of tonic con- traction for a few seconds or minutes. Clonic convulsions soon follow. The thumbs are pressed firmly into the palms. Tongue is often severely bitten. Conjunctivae are absolutely free from sensation, and the pupils do not respond to light during the attack. Saliva is blown from the mouth like foam. Following the attack is a condition of drowsiness, stupor, or coma, which lasts from five minutes to several hours. Pulse rather full and slightly accelerated. Respiration is deep, full, and labored. Consciousness returns gradually; intellection is dazed for a time ; quite nervous ; skin is cold and pale, and covered with cold sweat. Headache follows an attack. Al- buminuria is not uncommon. Epilepsy Minor. — A person during conversation or at work will be seized by a sudden loss of consciousness, with rigid- ity, or, possibly, a slight twitching, of one or more groups of muscles, lasting for a few seconds only, when he resumes his work or conversation where he stopped, usually uncon- scious of the attack. Occasionally the sensation is only that of a passing dizziness. These patients rarely fall or cry out. There is no aura. Headache, weakness, or nervousness follows. JacJcsonian Epilepsy. — Some authors question the propriety of classing this phenomenon as epilepsy, but the main symp- tom consists of irregularly recurring clonic convulsions that 350 A SYNOPSIS OF THE PRACTICE OP MEDICINE. affect one or more groups of muscles, always on the same side of the body, without the epileptic aura or loss of conscious- ness. An attack lasts from one to fifteen minutes or longer. General Considerations. — Epileptic patients are usually anae- mic, nervous, inactive, and intellectually dull. They are irri- table, quick-tempered, and often demented. Occasionally one meets with an epileptic who is apparently in perfect health. The attacks come at irregular intervals, according to the ex- citing conditions. They may occur many times in one day, weekly, monthly, or yearly. Every convulsion tends to in- crease the difficulty. Pathology. — Epilepsy is classed as a nerve-storm, and is dependent upon some peripheral or central exciting cause. No definite pathological lesion has yet been found ; hence the pathology is uncertain. Diagnosis. — Malingering. — Rarely injure themselves when falling, and do not bite their tongue ; skin is natural in color ; conjunctiva is sensitive, and pupils respond to light ; can be made to sneeze by blowing snuff into the nostrils or tickling the nose with a feather ; reflexes are unimpaired, and there is sensibility to pain. Hysterical epilepsy is characterized by violent muscular ac- tion and resistance when held ; rarely bite the tongue or injure themselves in falling ; duration is longer than true epilepsy ; sensibilit} T is little impaired ; pupils react to light ; and patient is of an hysterical temperament. Prognosis. — Epilepsy, in a small percentage of cases, is curable. Hereditary epilepsy usually persists through life. Surgical operations may prove efficacious in some cases. Rarely fatal per se, but death may be caused by injury in fall- ing. The mental condition gradually grows worse in severe cases. Convulsions sometimes disappear for years and then return. THE NEUROSES. 351 Treatment. — Buying a convulsion, nothing can be done except the prevention of personal injury. Something soft — a block of wood, or cloth — should be forced between the teeth and held there to prevent biting the tongue. Lay patient flat on the floor and remove any clothing that may impede respi- ration. See to it that false teeth do not remain in the month. Cold water applied to the head often facilitates a return of voluntary functions. Inhalations of ammonia, amyl nitrite, and camphor are of little use except at the commencement of the aura. Preventive. — Remove every abnormal condition if possible. Forbid the use of tobacco in any form, masturbation, and all excesses. Give best diet, bring into activity every gland in the body, and endeavor to establish a normal physiologi- cal condition. Search for and remove all possibility of intes- tinal parasites. In anaemia, give tonics of iron, arsenic, and strychnine. ft Acidi arseniosi. Strychnines sulphatis aa. gr. -£$. Ferri redacti gr. ij. Ext. belladonnas gr. -^ . Misce. Fiat in pil. No. 1. Signa. One after each meal, continued for several weeks or months. The bromides, in doses of twenty to thirty grains, three or four times daily, are the favorite remedies to abort or pre- vent convulsions. They must be given for weeks and months to be of efficacy. Great harm may result from their pro- longed administration, and their effects must be watched closely. When the aura begins in one of the extremities, the convulsion may be avoided by tightly constricting the mem- ber near the body. Salts of zinc, copper, silver, nickel, bella- 352 A SYNOPSIS OF THE PRACTICE OF MEDICINE. donna, hyoseyamus, and many other remedies are recom- mended in varying doses. Change of climate will occasionally influence some cases favorably. Electricity. Minor and Jacksonian epilepsy are treated on the same general plan as epilepsy major. HYSTEEIA. Description. — Hysteria is a functional nervous disease eon- fined principally to women, and manifests itself by different nervous phenomena. Hysterical patients are usually of a very excitable temperament, and often inherit their predis- position. One attack predisposes to another. During the intervals the patient may be in perfect health and rational ; or there may be a constant irritability of temper and the spe- cial senses. Anger, excitement, worry, grief, fatigue, fright, in- jury, or sickness, all give rise to attacks. Ovarian and womb diseases are accountable for many cases. Hysterical attacks assume various forms. There is always a complete loss of self-control. They cry, laugh, moan, scream, or have wild delirium, but are always conscious of what is going on around them and desire sympathy. They often resort to various means of simulating certain general or skin diseases, as by applying or taking drugs. Anaes- thesia or hyperesthesia of certain portions of the body, in- tolerance of noise, light, or certain odors, are common mani- festations. Dyspnoea, aphonia, and temporary paralysis of one or more groups of muscles, without disturbance of the electrical reactions. Sometimes they assume a state of cata- lepsy or trance. Irregular tonic or clonic convulsions occur at long or short intervals. Headache is quite common. The globus hystericus is a sensation produced in the throat and oesophagus by the supposed presence of a lump or ball THE NEUROSES. 353 that " moves tip and down and is abont to strangle " them. In short, there is no known condition that hysterical subjects will not simulate. Pathology. — No definite pathological lesion has been found. Many cases are caused reflexly by ovarian and womb troubles ; others are caused by unbalanced mental equilibrium • while many are entirely inexplicable. It seems to be a nerve-storm. One writer sa} T s : "It is simply a manifestation of satanic in- fluence entirely beyond the control of the will of the subject." Diagnosis. — Most cases recover in time, with or without treatment. Marriage and the birth of children cures some cases. Death may ensue from a prolonged attack. Insan- ity, with homicidal and suicidal tendencies, terminates a small percentage of the cases. Treatment. — Examine your patient thoroughly, and re- move every trace of disease if possible. Institute the very best hygienic, moral, and psychical surroundings, and stimulate the general glandular system to activity. No definite rules can be given for treatment. Each case must be dealt with ac- cording to its indications. Sympathy and kind treatment may answer best in some cases, while others demand nothing but harsh, severe treatment. Absolute isolation and a diet of bread and water is specific with many. A sudden bath of ice-cold water often brings about a rational condition most effectually. Corporal pun- ishment is occasionally demanded with young girls. Electric- ity and massage. Valerian, asafcetida, and other antispas- modics will often prevent attacks. Do not administer morphina, but have recourse to the anaes- thetics if necessary. When food is refused, administer it forc- ibly per rectum or with the stomach-tube — one or two such treatments will suffice. It is absolutely necessary for the phy- sician and the nurse to impress the patient with the fact that 354 A SYNOPSIS OF THE PRACTICE OF MEDICINE. you mean business, and that they must be dealt with with an unswerving hand — otherwise treatment is most unsatisfactory. THOMSEN'S DISEASE. Description. — This rare disease, whose pathology is still a question of uncertainty, is characterized by a sudden rigidity of one or more groups of muscles whenever voluntary motion is first attempted after a long or short period of rest. It lasts but a few seconds and then permits voluntary motion. Every attempt to get up, run, walk, or act quickly is always preceded by this rigidity of the muscles. Excitement, cold, fright, and fear aggravate it. It is often hereditary, and affects the ex- tremities principally. No lesion of the nervous system has been discovered. The muscles are slightly hypertrophied, and respond rather slowly to the galvanic current. Muscular hypertrophy is probably caused by the excessive rigidity and muscular activity rather than the disease itself. It is rarely fatal, and may continue for years. Treatment is entirely symptomatic and empirical. It is sometimes called congenital myotonia. NEURALGIA. Definition. — Neuralgia is a functional disease characterized by pain along the course and distribution of one or more sen- sory nerves, and must be differentiated from the pain pro- duced by definite pathological conditions of the nerve sheaths, trunks, and centers. Etiology. — Most common among young adult females and in middle life. There is a peculiar nervous diathesis that is he- reditary in some families, which accounts for many obstinate THE NEUROSES. 355 cases. All forms of nervous complaints, gout, rheumatism, anaemia, debility, ocular defects, fatigue, excitement, improper exercise and food, and close confinement predispose to neu- ralgia. Among exciting causes are exposure to cold and wet, reflex irritation from carious teeth, inflammation of the uterus, metritis, malaria, syphilis, alcoholism, and metallic poisons. Symptoms. — Neuralgia is sudden in onset, and usually con- fines itself to one group of nerves and their area of distribu- tion. There is no fever, redness, nor swelling at first. Pre- ceding an attack the skin is often anaesthetic for several hours. The pain intermits and remits, at times being sharp, shooting, and lancinating, and again dull, boring, or aching. In old chronic cases or prolonged acute cases tender points are found along the course of the nerves, usually at the points of exit through bony or fibrinous foramen. The duration of an at- tack varies from a few hours to several days or a week. Dur- ing and following an attack, the skin covering the area of distribution of the affected nerve is sore and sensitive to press- ure. Trophic changes are liable to occur in severe or pro- longed cases, such as altered secretions, congested capillaries, falling of the hair and change of its color. The special symptoms of neuralgia vary according to each group of nerves involved. Trifacial neuralgia (tic-douloureux) involves one or more of the three divisions of the fifth cranial nerve, and is one of the most common forms. When the first or ophthalmic division is involved, pain is most severe in the forehead, eyelids, eye, and side of the nose. There is increased lachrymation, and discharge from the nose of a thin, watery character. Tender points are found at the supra- orbital foramen, side of the nose, and on the eyeball. The second or superior maxillary division causes pain in the cheek, nose, upper teeth, and jaw, and pre- 356 A SYNOPSIS OF THE PRACTICE OP MEDICINE. sents tender points on the malar bone, nose, and superior maxillary bone. The third or inferior maxillary division refers pain to the inferior maxillary bone, temporal and parietal regions, ear, and tongue, with tender points at the inferior dental foramen, on the zygomatic arch, and in front of the ear. Cervico-occipital neuralgia is sharp, shooting, continuous, often bilateral, and extends from the neck to the occipital re- gions, to the cheeks, and down the neck to the clavicles. This form is usually excited by carious teeth or exposure to cold. Cervico-brachial neuralgia produces paroxysms of pain in the fingers, arms, scapular region, the back and side of the neck. There is a tingling, numb feeling in the arm and hand, as if " asleep." Intercostal neuralgia occupies the distribution of the inter- costal nerves, and is usually accompanied by a vesicular erup- tion called herpes zoster. Lunibo-abdominal neuralgia manifests itself by parox3 T smal pain in the lower part of the abdomen, back, iliac regions, scrotum, and anterior aspect of the thighs. Herpes is occa- sionally present. Caused by malarial poisoning. Sciatica, usually classed as neuralgia, is considered sepa- rately as an inflammatory affection. (See p. 368.) Pathology. — The pathological process involved in neural- gia is a question of doubt. It is undoubtedly a functional disease primarily, but is soon complicated by neuritis and allied troubles. Diagnosis. — Absence of all organic lesions or obstructions j sudden, sharp, shooting, paroxysmal pain ; tender points along the course of nerve ; absence of fever and inflammation ; usu- ally confined to the distribution of one set of nerves ; trophic changes ; and, in chronic cases, a peculiar nervous diathesis. Prognosis. — If promptly treated, the majority of cases re- cover, but relapses are quite common. Chronic cases afford THE NEUROSES. 357 discouraging prospects for permanent results, although many are benefited temporarily. Treatment. — In every case seek for the cause, and, if pos- sible, remove it. Such reflex causes as carious teeth, metritis, gastritis, and allied disorders must be treated. Anaemia, syph- ilis, debility, and alcoholic excesses require appropriate treat- ment before permanent results can be obtained. The very best, most nutritious diet must be given. Cod-liver oil in the weak and anaemic, provided it can be digested. Tonics of iron, quinine, phosphorus, and strychnine are the best rem- edies for chronic cases. Resinae phosphori gr. ■£$. Strychnin ae sulphatis gr. to - * Quininae bisulphatis gr. ij. Ext. belladonnae gr. \. Acidi arseniosi gr. ifo- Misce. Fiat in pil. No. 1. Signa. One pill three times daily for two weeks, then drop the phosphorus and continue with the rest of the prescription for one week, only to resume the phosphorus again for the next two weeks, and so continue for months. During the paroxysm, order your patient to lie down quietly in a dark room, and administer a pill of acetanilide, quinine, and cocaine every fifteen or thirty minutes until relieved. (See formula, p. 27.) Phenacetin may be given in doses of one to ten grains. Antipyrin, given in five-grain doses, although it will some- times relieve a paroxysm, should be used with great caution. Trinitrin (one-percent, sol.), gtt. j, every hour, will often relieve obstinate cases. Aconite and belladonna, given in combination, are useful. MorpJiina must be given only after all 358 A SYNOPSIS OF THE PRACTICE OF MEDICINE. other remedies fail. Counter-irritation with mustard, blisters, liniments, heat, or cold, over the painful points, will produce great relief. A mild current of galvanic electricity, properly applied, is one of the most certain curative measures at our command. Place the positive pole over the painful spot and the negative pole over some neutral point, and pass from two to five mil- liamperes for five or twenty minutes. Repeat as often as nec- essary. Surgical measures have been resorted to, such as neurotomy, neurectomy, and nerve-stretching, with varying degrees of success. MIGRAINE. Synonyms. — Megrim j sick-headache. Description. — Migraine is dependent upon many causes. It is frequently hereditary in nervous and gouty families j most common in young adult females who lead sedentary lives and are surrounded by improper hygiene. Indigestion, constipa- tion, eye-strain, anxiety, grief, fright, fatigue, and defects of vision predispose and excite paroxysms. Onset is usually preceded by one or more sensory symp- toms, viz., dimness of vision ; floating, bright spots before the eyes j tingling sensations in the arms, hands, feet, face, and tongue ; aphasia in severe cases ; temporary, partial paralysis ; and a sense of general uneasiness and restlessness — frequently fear of impending death. Accompanying or following these sensory impressions is headache, which varies from a dull, heavy feeling in the head to a very sharp, throbbing pain, mostly on one side of the head (hemicrania). Occasionally the pain centers in the eye, temple, ear, or forehead, and is increased by motion, noise, and excitement. Face is pale ; skin cold and clammy ; pulse THE NEUROSES. 359 feeble and slow: but the contrary conditions may exist in certain cases. Lachrymal and salivary secretions are often greatly increased. Migraine is periodical in its course, and may appear daily, weekly, monthly, or at any uncertain period. It is rarely dangerous, and may in time be replaced by attacks of epilepsy, asthma, or some other nervous affection. Vomiting is characteristic; consists of bilious material; is most common during the height of the paroxysm; and fol- lowed by temporary or permanent relief. During the intervals, patient is in perfect health, or may suffer from slight headache and nervousness. Treatment. — During a paroxysm, lie in a dark and quiet room, with cold compresses to the head. Vomiting will pre- vent analgesic drugs from acting, and it is well to administer as much warm water as can be taken, to cleanse the stomach of bile and food. After this, admirable results are obtained by giving : Cupri arsenitis gr. tot • Tr. nucis vomicae f 3 ss. Aquae f 1 iv. M. Signa. One teaspoonful every ten minutes until re- lieved. Pill acetanilide comp. (form, p. 27), every half -hour ; full doses of phenacetin, acetanilide, sodium salicylate, or bro- mides, if retained, afford prompt relief. Trinitrin, in certain cases, is very good. Avoid opium and its preparations. . During the interval, break up sedentary habits ; correct con- stipation and indigestion ; carefully regulate diet according to individual requirements ; correct all defects of vision ; insist 360 A SYNOPSIS OF THE PRACTICE OF MEDICINE. on daily exercise in the open air ; attend carefully to hygiene. Administer tonics of iron, arsenic, strychnine, cod-liver oil, and others, as indicated in neuralgia ; attacks can frequently be averted by rest in bed and full doses of phenacetin, acet- anilide, quinine, bromides, or the prescription given above. PARALYSIS AGITANS. Synonyms. — Shaking palsy ; Parkinson's disease. Definition. — A disease of old persons, recognized by con- stant rhythmical contractions of the muscles of the extremi- ties, head, and neck, partially under the control of the will, absent during sleep, and increased by excitement or physical exertion, together with weakness and rigidity of the muscles. Etiology. — Begins after the fortieth year, and is more frequent among men than women. No distinct cause can be determined, although it often dates from a severe fright, nerv- ous shock, injury, exposure, or some acute disease. Symptoms. — Onset is slow and begins in one or more groups of muscles, causing alternate flexion and extension of the fin- gers, wrist, arm, leg, or parts affected. These contractions average from five to eight in a second ; gradually spread to the corresponding parts on the other side of the body, and may finally involve most of the voluntary muscles. At first they can be controlled temporarily by an effort of the will, but otherwise continue during the hours of waking, and are absent during sleep. Speech is not affected ; writing is ir- regular and characteristic j nystagmus is absent. Muscular weakness and rigidity precedes, accompanies, or follows the trembling ; grasp of the hand is weak • and every slight effort causes excessive fatigue and profuse sweating. Muscular movements become slow and difficult ; the muscles assume a rigid form, without hypertrophy, and when patient THE NEUROSES. 361 begins to walk he either stumbles until he falls or is unable to stop or turn without assistance 5 equilibrium is easily lost. Complete paralysis is the ultimate result in two to twenty years. Complications are bed-sores, headache, vertigo, dis- eases of the lungs, and exhaustion. No pathological process or lesion is demonstrable. Recovery is the exception. Diagnosis. Paralysis Agitans. A disease of old age. Rhythmical move- ments. Speech unaffected. No nystagmus. Movements slightly in- creased by motion. Can take food and drink without aid. Constant movements during waking hours. Chorea. Disease of childhood. Arhythmical, spasmod- ic movements. Natural or spasmodic. No nystagmus. Movements increased by motion. Can take food and drink without aid. Movements not con- stant ; irregular. Mult. Spinal Sclerosis. Adults or children. Irregular movements. Scanning speech. Nystagmus. Great increase of move- ments by motion. Unable to drink from a cup without spilling. No movements except during voluntary ex- ertion. Treatment. — Entirely symptomatic, for no known remedy will cure. Barium, arsenic, iron, and strychnine have been used, but the improvement noted in a few cases may have been a coincidence, as the disease often ceases spontaneously without treatment. Galvanism and faradism may be benefi- cial. If movements become very painful, administer sedatives. Institute best diet and hygiene. Treat all complications. M. Charcot has devised a mechanical chair and helmet which, by a series of rapid vibrations, is used in treating these cases. Great relief is afforded; the trembling disappears or is re- duced temporarily j the muscular stiffness ceases. 362 A SYNOPSIS OF THE PRACTICE OF MEDICINE. NEURASTHENIA. Description. — Neurasthenia is a deficiency or exhaustion of nerve-force, together with debility of the nervous centers, manifesting itself in both sexes. It is caused by prolonged excitement, worry, study, family and business troubles, pro- longed sickness, fright, traumatism, indigestion, inheritance, excessive venery, alcoholism, and the use of narcotics. Such persons find their power of endurance and concentra- tion of thought impaired 5 trifling things worry and irritate them; they become fretful, dissatisfied, irritable, cross, or tyrannical ; hysterical or hypochondriacal ; have headache and insomnia 5 start up from sleep ; general nervousness j loss of appetite, and suffer from indigestion; emaciation slight or marked ; constipation ; general anaemic and sallow complex- ion ; and a peculiar, piercing, sharp eye. Tender points are often found along the spine, with sharp or dull tingling pains along the course of one or more nerves. Temporary or permanent paralysis may result. Neurasthenia is functional in character, and entirely beyond the control of the will. There is a tendency on a neurasthenic's part to conceal the trouble until the very last moment. Recovery is the rule. Treatment. — Absolute rest and freedom from business and family cares, with an endeavor to take the patient's mind off himself and keep it occupied with some light and amusing thoughts. Never allow him to converse or dwell upon his ailments or trials. Diet must be light, nutritious, and suited to his power of digestion. Let him feel that you are doing something and are interested in his case, for a good mental impression is nearly as good as drugs. Absolutely avoid opium and use a minimum amount of seda- THE NEUROSES. 363 tires, for they are temporary in their action and followed by "bad results and habits. A season at some. chalybeate or other mineral spring, nnder the care of a physician, is often cnrative. Galvanism, faradism, and massage all play important parts as curative agents. Exercise judgment in the administration of tonics, as each case will require special study and medicinal treatment suited to it. WRITERS' CRAMP. Synonyms. — Writers' palsy ; graphospasm ; mogigraphia. Definition. — A temporary or permanent, partial or com- plete paralysis of the muscles of the fingers, hands, and wrist, with incoordination, occurring in those who use these muscles for a prolonged period of time. Etiology. — More common in men from eighteen to fifty, from the fact that they are more frequently employed at the work that predisposes to it, and especially so if there is a his- tory of hereditary nervousness. May be caused by a local in- jury to the muscles or nerve-trunk, but usually comes from prolonged use and over-exertion of a group of muscles by writing, telegraphing, type- writing, piano-playing, or fine work. Symptoms. — Onset is slow, manifesting itself first by a tired feeling in the muscles of the fingers, wrist, and arm ; this is replaced by stiffness and a slight aching, until finally the muscles contract painfully, cause irregular writing, and may produce a tonic or clonic spasm of the muscles which will last several minutes. Rest for a short time affords tem- porary relief, but it soon returns if work is resumed. Elec- trical reaction is not usually affected. Pain may be neuralgic in type. Certain cases manifest themselves only by tremor during efforts to use those particular muscles. 364 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Treatment. — Preventive. — If compelled to do much writing, use finger, wrist, and arm movements at alternate intervals, to avoid prolonged use of one group of muscles. If possible, use a type- writer for a time. Always avoid a tight grasp on a pen or any other instrument. Active Treatment — Absolute rest of the affected muscles is the only certain process of cure. All proposed methods of hold- ing and using the pen are but temporary expedients and of little avail in the end. Active massage of each muscle, gal- vanism, and inunctions of hot olive-oil are most beneficial. If neuritis is present, treat as indicated. Build up the general system with tonics and proper food. Always warn your patients that relapses are quite common if their old habits are resumed. First of all learn the proper method of caring for your own muscles, then instruct your patients. DISEASES OF THE NERVES. NEURITIS. Definition. — Neuritis is an inflammation of a nerve-trunk, recognized by pain, loss of power, redness and tenderness along its conrse. Perineuritis is an inflammation of the nerve sheaths and coverings, with manifestations similar to those of nenritis. Etiology. — Traumatism; exposure to damp and cold; ex- tension from other parts j chemical causes ; secondary to acute diseases, such as rheumatism, variola, diphtheria, syphilis, and lead-poisoning. Symptoms. — Onset is slow or sudden. Begins with a numbness and tingling sensation in the area of distribution of the nerve. This is soon followed by occasional neuralgic pains and a dull, boring, tingling pain, increased by motion and pressure. Slight fever may develop in a few days, and continue for an indefinite period. Painful, spasmodic con- tractions of the muscles supplied by the affected nerves may occur; muscular power is diminished, and, in prolonged or chronic cases, may be entirely lost (paresis). In the super- ficial nerves there is a glossy redness along their course ; the nerve is prominent and swollen like a hard cord, and small vesicles form over its course and area of distribution . As a late symptom, atrophy of the muscles results. Electrical Reactions. — Faradic irritability is rapidly dimin- 365 36G A SYNOPSIS OF THE PRACTICE OP MEDICINE. ished and lost in abont two weeks. Galvanic irritability is first diminished, then greatly increased, and remains so for a long time before it is finally lost (reaction of degeneration). Pathology. — Inflammation of the trne nerve structure is rarely well marked, for the nerves are not very vascular. It most commonly involves the sheaths of the nerves and inter- cellular structures ; causes proliferation of cells and exudation of leucocytes; gives rise to new inflammatory tissue which presses on the nerve structure, and causes its atrophy and destruction. By this pressure and destruction of nerve sub- stance, nervous impressions are improperly conveyed and de- layed by broken axis-cylinders and atrophied nerve-cells — hence a diminution and loss of sensory and motor impulses. As in other inflammatory affections, it extends along the nerve toward the central structures, and ultimately involves them (neuritis ascendens) ; or extends to the peripheral fila- ments (neuritis descendens). In chronic cases, nothing may remain of the original nerve but a fibrous cord, with here and there a few degenerated and atrophied nerve-cells. Neuritis varies in character according to the nerves in- volved, each separate nerve presenting its own characteristic symptoms. In the encephalic nerves there may be a loss of sight, smell, taste, and motion, or permanent loss of physio- logical action of the parts involved. Prognosis. — Traumatic and acute cases generally termi- nate favorably in one to eight weeks. Permanent paralysis may result. Prognosis should always be guarded. Treatment. — Bemove cause if possible. Put the parts at absolute rest, with bandages and splints if necessary. Hot applications along the affected nerve are most desirable ; cold may be more efficient and soothing in certain traumatic cases. If pain is very severe, give hypodermic of morphina. Establish free action of the emunctories by cathartics and diaphoretics j DISEASES OF THE NERVES. 367 give light, nutritious diet. Local blood-letting may be very efficient. When cases do not respond to this method ; apply isolated blisters, sinapisms, or liniments at different points along the nerve-trunk over the seat of pain. Avoid electricity during the acute stages. Chronic neuritis requires alteratives and absorbents — full doses of iodides and mercury; counter-irritation and galva- nism. Strong currents must not be used except in prolonged chronic cases. Place the anode over the tender spot and move the kathode along the nerve for ten or twenty minutes. MULTIPLE NEURITIS. Synonyms. — Polyneuritis; disseminated neuritis; periph- eral neuritis. Definition. — A disease in which a number of nerves be- come inflamed at the same time, recognized by high fever, general aggravation of all symptoms of simple neuritis in the extremities, and is usually symmetrical. Etiology. — Most common in middle life from alcoholism lead-poisoning and toxic poisons ; syphilis ; specific diseases eruptive diseases ; tuberculosis ; rheumatism ; gout ; leprosy and septic infection. It may occur without any perceptible cause. Often follows or complicates epidemic meningitis. Symptoms — Begins with a numbness, slight tingling and pricking sensations in the extremities, increased by pressure and motion. Numbness soon becomes prouounced in the fingers and toes ; muscular action is weak. Severe paroxys- mal muscular cramps occur at intervals. Walking is very painful, unsteady, and, in some bad cases, impossible. The floor feels soft and yielding. Pulse is quick and excited; temperature may run to 105° F. in the early stages of acute 368 A SYNOPSIS OF THE PRACTICE OF MEDICINE. eases. Paralysis extends from the periphery toward the cen- ter ; extensor muscles are more affected than the flexors ; lar- yngeal paralysis ; loss of reflexes ; muscular atrophy ; reaction of degeneration. There is tenderness, redness, and swelling along the course of the nerves, and often a vesicular eruption. Trophic changes are marked; bed-sores common; arthritis and fixation of the joints ; gradual affection of the mind, de- lirium, and general incoordination may complicate. Prognosis. — It is a very slow, tedious disease, prone to frequent relapses, and often terminates fatally during its early stages, from involvement of the diaphragm, heart, and respir- atory muscles. Alcoholic cases are unfavorable. Partial or complete recovery may occur in two to twelve months. Treatment. — Treat on the same general principle as in simple neuritis, directing remedies toward the cause. Alco- hol must be avoided. Narcotics may be necessary to control severe pain. During convalescence, give most nutritious, albuminous diet, and tonics suitable to each individual case. SCIATICA. Definition. — An inflammatory affection of the great sciatic nerve-trunk or its surrounding structures, recognized by ex- treme neuralgic pain along its course and distribution, and accompanied by slight constitutional symptoms. Etiology. — Exposure to cold and damp ; acute rheumatism ; direct injury ; extension from other parts ; pressure on the sciatic nerve by tumors, cicatrices, and adhesions; predispo- sition by heredity. More common in men. Symptoms. — Begins with a stiff, tired feeling in the back, hip, and leg on one side (both sides may be affected), followed by a numb, pricking, tingling pain along the sciatic nerve. DISEASES OF THE NERVES. 369 Pain increases, is dull, boring, and aching, and every effort to move causes sharp, neuralgic pains, most marked in the hip, back of the thigh, and knee. Leg is flexed on the abdomen — this is the most comfortable position to them. Tenderness exists along the sciatic nerve, most marked at the back of the trochanter, popliteal space, side of the leg, and foot. There may be slight fever ; irritability ; constipation ; and anorexia. Electrical excitability is not materially changed. In long-continued cases there are atrophy of the muscles, pa- ralysis, reaction of degeneration, and trophic changes. Pathology. — Sciatica is not neuralgic in origin, but has the pathological lesions of neuritis or perineuritis. Adhesions form between the nerve trunk and sheath in very acute and chronic cases, producing pain and interference in the motion of the parts. Atrophy of the nerve- tissue occurs in prolonged cases. Diagnosis. — Neuralgia has tender points only ; sharp, shoot- ing pains ; very slight anaesthesia j no paralysis ; no atrophy of the muscles ; more paroxysmal in character ; electrical re- actions not diminished ; no fever. Myalgia or muscular rheumatism has no tender points ; is confined to a group of muscles; has no lancinating pains; is not greatly increased by motion; is relieved some by pressure. Prognosis. — Very favorable in acute cases. Chronic cases are obstinate, easily aggravated, and prone to relapses. Treatment. — Acute Sciatica. — Rest in bed in recumbent position, with the leg slightly flexed and supported by pil- lows. If pain is severe, administer a hypodermic of morphina and atropina, but do not repeat it. Chloroform, injected deeply over the sciatic nerve, is very efficient for pain. Hot applications, sinapisms, and blisters over the sacro-sciatic 370 A SYNOPSIS OF THE PRACTICE OP MEDICINE. region. Begin treatment with a free saline cathartic, and follow with : ft Ext. cascarae sagradae flnidi f 3 v. Sodii salicylatis f 1 j. Aquae aurantii flor q. s. ad. f 3 iv. M. Signa. One teaspoonfnl every fonr or six hours. Full doses of acetanilide, phenacetin, and salicylates give temporary relief. When acute symptoms subside, and it tends to become chronic, administer colchieum, iodides, or mercury for a long period. Nerve-stretching, by forced flexion of the leg on the abdomen, will often break adhesions. Galvanism. Acu- puncture of the nerve at the sacro-sciatic foramen is practiced by some. FACIAL PARALYSIS. Synonym. — Bell's palsy. Definition. — A partial or complete loss of power of motion in the voluntary muscles of one side of the face which are supplied by the facial nerve (seventh cranial or portio dura nerve). Etiology. — Pressure of tumors on the nerve-trunk at the base of the brain j extension of inflammation from meningitis, causing neuritis or perineuritis j injury to the petrous part of the temporal bone, through which the nerve passes ; exposure to cold and wet. Secondary to certain acute diseases — rheu- matism, diphtheria, and syphilis. Symptoms. — Onset is sudden or slow, with a feeling of numbness, tingling, or pricking on the affected side ; facial muscles feel weak and drawn, and cannot be used freely. Complete loss of muscular power on the affected side soon DISEASES OF THE NERVES. 371 follows, and the face assumes a typical appearance, with an entire lack of expression on the one side. Mouth cannot be properly closed, and the corner droops. Eyelids are relaxed, half closed; epiphora; and dryness of the cornea. The whole face appears drawn toward the un- affected side ; tongue is protruded to one side ; deglutition is often impaired j tinnitus aurium ; reflexes abolished. Electri- cal reactions: faradic excitability is soon lost; galvanic ex- citability is first increased, then diminished, and finally lost (reaction of degeneration). Prognosis. — Uncomplicated acute attacks recover in a few days or several weeks. Chronic cases depend upon central or structural lesions, and are unfavorable as to cure. Treatment. — Acute cases require rest in bed; free diapho- resis ; blisters, leeches, or hot applications over the mastoid process of the temporal bone and in front of the ear. Aconite and belladonna to relieve over-active circulation. Treat rheu- matic troubles as indicated. Chronic cases do best under the use of alteratives, hydrar- gyrum, and iodides. Galvanism is indicated when all acute symptoms have subsided. Massage may prove beneficial. Good, nutritious diet. DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. SPINAL MENINGITIS. Varieties. — (1) Acute spinal meningitis or acute lepto- meningitis spinalis ; (2) chronic spinal meningitis or chronic leptomeningitis spinalis ; (3) pachymeningitis externa and in- terna. (1) ACUTE SPINAL MENINGITIS. Definition. — Acute spinal or leptomeningitis is an acute in- flammation of the pia mater and arachnoid, recognized by pains in the back, motor and sensory disturbances of the nerves involved. Etiology. — Exposure to cold and dampness; traumatism; rheumatism ; acute diseases ; extension from other parts. It is associated with acute, epidemic cerebro-spinal meningitis. Symptoms. — Onset may be sudden, with a chill or rigor, or may begin slowly with rise of temperature ; localized or gen- eral severe pain along the spinal column, which is increased by motion, deep pressure, and percussion. Sharp, shooting, tingling pains are reflected along the nerves arising from the affected area, and that portion of the skin which is supplied by them is hyperaesthetic. Violent muscular spasms may oc- cur, causing opisthotonos, emprosthotonos, pleurosthotonos, or orthotonus. 372 DISEASES OF THE SPEn t AL CORD AND ITS MEMBRANES. 373 Reflexes are increased. Constipation ; occasional retention of urine ; a girdle sensation aronnd the body. On the second to fourth day symptoms of pain lessen, and are replaced by anaesthesia, paralysis, and diminished or abolished reflexes. Galvanic and faradic reactions, although increased at first, are soon diminished or lost. Symptoms will vary according to the parts affected. Pathology. — At first the pia mater and arachnoid are con- gested and red, bnt soon become inflamed, swollen, and cov- ered with an opaqne exudation which may become purulent. Adhesions form between the membranes, cord, and nerve- trunks. Swelling and inflammatory tissue cause pressure on the spinal cord and nerve-trunks, producing pain and all sensory and motor symptoms. The cord and nerves soon be- come inflamed, and the inflammation may spread to 'the cere- bral meninges and nerve-sheaths. Diagnosis. Myelitis. Onset usually very slow. Fever is slight, not typical. Pains and muscular spasms not de- fined. Sudden, complete paralysis and anaesthesia. Pains little influenced by pressure and motion. Cutaneous and muscular hyperes- thesia absent. Convalescence is very slow. Complications and sequelae marked. Obstinate bed-sores ; alkaline urine and cystic troubles. Acute Meningitis. Onset usually rapid. Fever is high and. persistent. Pains and muscular spasms well denned. Paralysis and anaesthesia are early symptoms, but not complete un- til late. Pains increased by pressure and motion. Cutaneous and muscular hyperaes- thesia well marked. Convalescence more rapid. No marked complications and se- quelae. No obstinate bed-sores ; cystic com- plications not marked. Prognosis. — Must always be guarded. Greatest danger lies in extension of inflammation to the centers of respiration 374 A SYNOPSIS OF THE PRACTICE OF MEDICINE. and the heart. Recovery is usually accompanied by paraly- sis, partial or complete. Convalescence is slow. Treatment. — Absolute rest in bed, lying on the side or stomach. Wet or dry cups over the affected area of the spine ; applications of cracked ice. Administer a free saline cathar- tic and endeavor to establish diaphoresis and diuresis. Diet of beef -extracts, milk, farinaceous foods, toasted stale bread, and crackers. Avoid alcoholic stimulants and stimulating diet. If pains are very severe, administer morphina hypo- dermically, or give the bromides, acetanilide, or phenacetin. When the acute stage has subsided, administer mercury and iodides, with counter-irritation, galvanism, and massage. Stimulate as necessary. (2) CHRONIC SPINAL MENINGITIS. Etiology. — Acute inflammation may become chronic ; it may pursue a chronic course from the first, from syphilis, ex- posure, traumatism, chronic myelitis, and acute or chronic diseases. Symptoms. — No fever ; muscular spasms and rigidity come on slowly, and are not as well marked as in the acute ; local- ized and usually not general ; paralysis comes rather early. Other symptoms are similar to the acute form. Pathology — Pia mater and arachnoid are thickened and filled with new fibrous tissue and inflammatory products. Adhesions between the membrane and cord are numerous and well defined. Pressure upon the nerve-trunks and spinal cord produces atrophy and inflammation of their structures, fre- quently causing myelitis or neuritis. Prognosis. — Complete recovery is rare. It is obstinate to treat, and results are obtained slowly. Relapses are common. Localized permanent paralyses. DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 375 Treatment. — Causal if possible. Counter-irritation over the spine, in the form of blisters and sinapisms. Cups and leeches frequently applied. Full doses of the iodides and mercury. Attend closely to all physiological functions — pre- vent retention of urine and obstinate constipation. Galva- nism and massage. Symptomatic treatment. (3) PACHYMENINGITIS SPINALIS. Description. — Pachymeningitis or inflammation of the dura mater is acute or chronic, external or internal. It is caused by an extension of inflammation from spinal caries, cancers, ulcers, and wounds j alcoholism and traumatism. The symp- toms are similar to those of acute and chronic leptomeningitis. In external pachymeningitis the external surface of the dura mater is thickened, infiltrated, and may be covered with a layer of creamy pus. Internal pachymeningitis affects principally the cervical re- gion and involves the brachial plexus of nerves. The internal surface of the dura mater is thickened, infiltrated, red, and may be covered with a diffuse hemorrhage. The nerve-roots are compressed. Acute cases are moderately favorable, and the chronic will depend on the cause. Treatment. — Treat as acute and chronic leptomeningitis. Remove every possible cause, such as carious bone, ulcers, and tumors. Evacuate pockets of pus promptly. Sustaining, nu- tritious diet and rest. ACUTE MYELITIS. Synonym. — Acute inflammation of the spinal cord. Etiology. — Exposure to cold ; shock ; traumatism ; general diseases j syphilis j compression; extension from other parts; 376 A SYNOPSIS OF THE PRACTICE OF MEDICINE. and great functional activity. More common in men and during young adult life. Symptoms. — Onset may be sudden, with a chill, followed by a temperature of 102° to 104° F., and rapid pulse ; or it may begin slowly with sharp, shooting, darting pains in one or more parts of the body, varying with the nerve-roots affected, together with a numb, tingling, jagging feeling. Parts soon become anaesthetic; girdle sensations about the chest or abdomen. Paraplegia develops suddenly or slowly in a few hours or several days ; control of bladder and rectum soon lost j reflexes abolished ; reaction of degeneration at first, but all electrical reaction is soon lost; dyspnoea; gastrointes- tinal irritability ; priapism • urine alkaline ; occasional muscu- lar cramps ; trophic changes ; and obstinate bed-sores. Symp- toms vary with the part of the cord affected. Pathology. — Inflammation of the structure of the spinal cord is diffuse or focal. Diffuse myelitis involves large areas of the cord, and is very rare. Focal myelitis is confined to small areas, and is the most common form. The affected part of the cord is enlarged and softened. On section, the small capillary vessels are congested and prominent ; gray matter is quite dark. Microscopically, the nerve-fibers are broken up ; axis cylinders are enlarged ; nerve-cells are degenerated and destroyed ; new fibrous tissue is formed, and a large amount of granular matter is present. The spinal mem- branes are usually congested and involved. When cases be- come chronic, a distinct condition of sclerosis exists. Diagnosis. — See Meningitis, page 373. Prognosis. — Very grave. Death is caused slowly or sud- denly by paralysis of the muscles of respiration or of the heart ; general exhaustion ; cystitis and suppression of urine ; pyae- mia ; and intercurrent diseases. Complete recovery is rare, as some complications and sequelae almost invariably remain, DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 377 Treatment. — Rest on a soft, downy mattress or water-bed to prevent bed-sores. Dry or wet cups, blisters, sinapisms, poultices, or cracked ice, as indicated by eacli case. When dne to cold, give free saline purge, diuretics, and diaphoretics during first stage only. Aconite, veratrum, acetanilide, phe- nacetin, or quinine may be beneficial if used early. Watch, the bladder closely to prevent retention of urine. Full doses of iodides and mercury may be beneficial when the most marked acute symptoms subside. Treat all complications and follow general rules given for meningitis. POLIOMYELITIS ANTERIOR ACUTA. Synonyms. — Anterior cornual myelitis ; acute spinal pa- ralysis ; atrophic spinal paralysis ; essential paralysis of chil- "dren. Etiology. — Exposure to cold; dentition; spiual injuries; acute diseases ; rheumatism ; and exanthemata. Most com- mon among children before the tenth year, but may occur in adults, when it is known as acute spinal paralysis of adults. Symptoms. — Onset is sudden, with a chill, rigor, or convul- sion, followed by moderate fever, which persists about one week. Occasional sensations of tingling and formication in the members supplied by the affected nerves. In a few days the power in one or more members is diminished and finally lost. Paralysis may involve both arms and legs. One pecul- iar characteristic of the disease is that one muscle or group of muscles may be paralyzed while the others are not affected. Those involved degenerate, atrophy, and show the reaction of degeneration ; reflexes are also lost. The heart, muscles of respiration, bladder, and rectum are affected. Paralysis manifests itself in one group and rarely spreads to others. 378 A SYNOPSIS OF THE PRACTICE OF MEDICINE. The affected member is cold ; circulation is poor ; and growth retarded. Sensation remains unchanged. Pathology. — The pathological lesion is an acute inflamma- tion of the anterior cornu of the gray matter of the spinal cord. At first there is congestion, followed by true inflam- mation, formation of new connective tissue, transmigration of leucocytes, destruction and atrophy of motor nerve-cells and axis cylinders leading from them. Inflammation and degen- eration extend along the motor-roots of the nerves leading from the affected area. An entire absence of motor nerve- cells is found in prolonged cases. Affected muscles are in a state of fatty and granular degeneration and atrophied. Prognosis. — Rarely fatal per se, unless the lesion exists in the medulla. Death usually follows complications. Complete recovery is very rare. Treatment. — Complete rest in bed until acute symptoms subside. Give aconite, liq. ammonii acetatis, or potassii cit- ras for fever. Compresses of ice to the spine. Potassium iodide or syr. acidi hydriodici, every three or four hours, with infusion of digitalis. Institute best hygiene and feed regu- larly at intervals of four hours. When acute symptoms subside, use weak galvanism, mas- sage to the affected muscles, and administer strychnina in full doses. Use any mechanical devices to support and preserve the impaired members. PARALYSIS ASCENDENS ACUTA. Synonym. — Landry's palsy. Description. — A disease described by Landry in 1859, in which paralysis begins in the lower extremities, rapidly ex- tends upward, produces death, and is not characterized by any distinct pathological lesion. It is more common among DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 379 men, and follows exposure to cold, acute diseases, and syphilis. It is heralded by formication, numbness, pricking pains in the legs, and a bilateral loss of power in those members. Paraly- sis soon becomes comj^lete. In one or two days the muscles of the thighs, hips, back, and abdomen are paralyzed ; power of rectum and bladder are unimpaired. The paralysis ex- tends upward, finally involves the diaphragm and respira- tory muscles, and causes death by asphyxia. Occasionally the cranial nerves are involved before death. Sensation is not lost ; muscles do not atrophy ; little or no fever ; electri- cal reactions not affected; reflexes are diminished or lost. Recovery is rare ; death may ensue in twenty-four hours to a month. No satisfactory method of treatment is known, but it is wise to follow the general rules given for acute myelitis. SPINAL SCLEROSIS. Definition. — An overgrowth of the interstitial connective tissue of the spinal cord, accompanied by degeneration and atrophy of the nerve-cells ; dependent upon inflammation and manifesting itself in many different symptomatic forms, viz. : (1) antero-lateral spinal sclerosis ; (2) posterior spinal sclerosis ; (3) multiple spinal sclerosis ; (4) hereditary ataxia. Etiology. — Follows acute myelitis or spinal meningitis ; direct injury ; acute diseases ; syphilis ; mineral poisons ; ex- posure ; alcoholism ; venereal excesses. A disease most com- mon among men from thirty to fifty years of age. Is fre- quently hereditary. (1) ANTERO-LATERAL SPINAL SCLEROSIS. Synonyms. — Duchenne's disease ; chronic anterior polio- myelitis; chronic diffused atrophic paralysis (Fagge). 380 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Symptoms. — Lower extremities become weak • patient walks on tiptoe with a waddling gait and a tendency to fall forward. Complete paralysis soon develops, and may spread to the mus- cles of the back and arms. Muscles are flabby ; waste rapidly ; give reaction of degeneration ; sensation is not lost ; bladder and rectum not affected; absence of bed-sores; joints become stiff. Pains in the back and limbs of a tingling or dull char- acter ; headache ; slight fever ; muscular stiffness and occa- sional cramps, which precede the actual paralysis. It either pursues a chronic course, gradually becoming worse, involving the upper extremities, or gradually improves until partial or complete return of power ensues. Prognosis is uncertain; may last four or five years before fatal termination. Pathology. — In the anterior cornu, the multipolar gray nerve-cells and axis-cylinders are degenerated, atrophied, and destroyed ; considerable granular matter is present ; prolifer- ated cells and general sclerotic condition of the anterior and lateral columns of the cord. Motor nerve-roots are atrophied. This condition spreads from below upward. (2) POSTERIOR SPINAL SCLEROSIS. Synonyms. — Locomotor ataxia ; tabes dorsalis ; locomotor ataxy. Symptoms. — Onset is very slow, and among the first symp- toms noted are sharp, shooting, neuralgic pains, which occur in the lower extremities at irregular periods. Pain may con- tinue for a few seconds or intermit and remit with more or less severity for several hours Reflexes are diminished and finally abolished. Sensation is soon impaired ; cannot distin- guish when the feet are set firmly on any object ; sensation is that of walking on velvet or some very elastic substance ; a feeling very similar to that produced when the " foot is asleep." DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 381 Sensory impressions are delayed several seconds or minutes after the impression has been made. Ocular symptoms appear in the form of strabismus, diplopia, ptosis, squinting, and the Argyll-Robertson pupil — a myotic pupil which responds to accommodative effort, but not to light. Powers of coordination are diminished; gait is un- certain, with a tendency to fall when eyes are closed or feet closely approximated ; cannot walk in a straight line ; cannot turn around without help and are unable to stop themselves voluntarily. As disease advances, the legs are thrown wildly about when walking and the heels come down on the floor very hard. Electrical reactions are normal ; muscles do not atrophy, except from disuse ; muscular power is retained and sometimes increased. Girdle pains ; sensory changes — anaesthesia, analgesia, prick- ing sensations ; and increased susceptibility to heat and cold. Bladder is irritable and power soon lost ; sexual organs greatly excited at first, but impotence results. Gastric crises are sharp pains in the stomach and back, and obstinate vomiting. Crises may occur in any of the viscera. Trophic Changes. — Brittleness of the bones; changes in joints ; falling of the hair and nails ; blisters ; localized sweat- ing. Among complications and sequelae are optic neuritis and loss of sight ; deafness ; paralysis ; severe headaches ; apo- plexy ; epilepsy ; most obstinate bed-sores ; cystitis ; pyaemia ; and general paralysis of the insane. Absolute recovery is rare ; may persist for many years and terminate in death from one of the crises or complications. Pathology. — Posterior columns of the spinal cord are scle- rosed, most marked in the lumbar region. Posterior cornu of gray matter is more or less involved, showing degeneration and atrophy of the nerve-cells and axis-cylinders ; meninges over affected part of cord are frequently involved; sensory 382 A SYNOPSIS OF THE PRACTICE OF MEDICINE. nerve-roots are atrophied. In the bones there is an increase of mineral salts, rendering them brittle. Pains are due to in- volvement of sensory nerve-roots. Impression made on the extremities is carried by the sensory nerves until the diseased parts are reached, when it is either stopped or reaches the nerve-centers through circuitous routes, thus producing de- layed sensation. Incoordination is dependent upon impaired sensory action. (3) MULTIPLE SPINAL SCLEROSIS. Synonyms. — Disseminated sclerosis ; insular sclerosis ; cere- brospinal sclerosis ; Charcot's disease. Symptoms. — Onset is usually slow, but may be sudden, with weakness and trembling in the arms or legs, and loss of mus- cular control. Tremor is very characteristic ; is absent dur- ing rest and sleep, and present only during voluntary efforts. When the arm is moved, it vibrates with a quick, jerking motion from side to side, increasing with the effort. This vibratory movement or tremor is so pronounced that it is im- possible for the patient to lift a glass of water without spilling it. Not ouly are the arms affected, but the head nods to and fro, the body sways from side to side, and the legs are very unsteady. The eyeballs oscillate (nystagmus) from side to side whenever an effort is made to concentrate them upon any object. Speech is spasmodic, scanning, staccato in character, and slow, with distinct articulation of every syllable. Sensa- tion is altered ; there is numbness, formication, tingling, and, occasionally, complete anaesthesia. Muscles atrophy; electri- cal reactions are diminished late ; headache ; diminution of vision ; delusions and general paralysis of the insane. Pathology. — Small isolated and disseminated spots of chronic inflammation and sclerosis are found in the brain, DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 383 medulla, and spinal cord. These spots are darker than the surrounding structure, and harder. Sclerosis may extend to the nerve-roots and produce neuritis. Nerve-cells and axis cylinders are degenerated and destroyed in the sclerosed areas ; vessel-walls are thickened and in a state of fatty de- generation. Diagnosis. — See table, page 361. Prognosis. — Disease may run for twenty years. Death may ensue from sudden apoplectic attacks. Complete paraly- sis and inability to help themselves may last for years. These patients are very susceptible to acute diseases, which usually prove fatal. (4) HEREDITARY ATAXIA. Synonym. — Friedreich's disease. Description. — A disease transmitted by heredity to one or more members of one family. It is a sclerosis of the lateral and posterior columns of the spinal cord ; begins in early life, about puberty. There is a lack of coordination in the legs ; movements are uncertain and jerky ; patellar and plantar re- flexes are diminished early ; sensation is not often impaired at first 5 anaesthesia may develop later ; absence of sharp pains ; speech is uncertain, hesitating, and interrupted ; nystagmus produced by lateral motion of the eyes, but checked when they are fixed on any object. Arms, head, and neck are soon involved. Absence of complete paralysis, optic neuritis, crises, trophic disorders, and mental changes. Disease may continue many years, and death ensue from complications. Recovery is rare ; usually get worse. Treatment. — The treatment of all forms of spinal sclerosis is similar and rather unsatisfactory. Diet, hygiene, and exer- cise must be regulated according to the needs of each case. Iodides, mercury, double chloride of gold and sodium, zinc 384 A SYNOPSIS OF THE PRACTICE OP MEDICINE. salts, phosphorus, silver salts, arsenic, strychnine, belladonna, ergot, iron, and numerous other remedies are recommended and given in doses which vary with the therapeutical and physiological indications. Counter-irritation over the spine ; galvanism and faradism — the former producing best results. For the pains of locomotor ataxia, morphina hypodermically. Cannabis Indica, gr. |-, every three or four hours ; phenacetin or acetanilide, gr. x-xv, every three hours. Always watch for retention of urine. Charcot's method of suspension of the body by the head and shoulders is supposed to relieve spinal tension and some unfavorable symptoms of locomotor ataxia. It is a dangerous method ; must be very cautiously used ; must not be practiced longer than twenty seconds to three minutes, varying with each case, and must be followed by absolute rest in the recumbent position. In fact, all forms of i treatment resolve themselves into treatment of symptoms and complications. DISEASES OF THE BRAIN AND MEMBRANES. ACUTE CEREBRAL MENINGITIS. Etiology. — Traumatism • exposure to cold ; extension from other parts, as from the ear; exposure to the sun; alcohol- ism ; syphilis. Most common in young adults. Symptoms. — Prodromal. — For an uncertain period of time there is uneasiness, headache, nausea or vomiting, feverish - ness, tinnitus aurium, and giddiness. First Stage. — Onset generally begins with a chill, which is soon followed by high fever, 104° F. Headache, tinnitus aurium, and vertigo increased; conjunctivae are congested; face is red and hot ; persistent nausea and vomiting ; pulse is tense and rapid; photophobia; pupils often contracted; con- stipation. Delirium and convulsions follow. Hyperesthesia ; muscular twitchings and spasms, often amounting to opistho- tonos. Second Stage. — In one to four days delirium and muscular spasms subside and patient becomes comatose ; extremities are cold ; pupils dilated ; pulse feeble and slow ; urine and f a?ces passed involuntarily ; fever is diminished ; paralysis of one or more groups of muscles ; death from deep coma or collapse. If recovery ensues, there is severe headache, which persists for many months or years. Pathology. — An acute inflammation of the cerebral pia mater and arachnoid membranes. A serous effusion, often becoming purulent, is found in the subarachnoid space and 385 386 A SYNOPSIS OF THE PRACTICE OP MEDICINE. ventricles of the brain. Meningitis may be general; may affect the convexity of the brain or its base (basilar meningitis). Owing to pressure of the exudation and inflammatory products, the brain substance is impinged upon, flattened, and, not in- frequently, atrophied, destroyed, ecchymotic, or filled with small abscesses. Prognosis. — Most cases are fatal. Headaches, defects of vision, blindness, deafness, epilepsy, or muscular paralysis may follow cases of recovery. Treatment. — Put patient in a dark, cool room, and keep as quiet as possible. Cold water, coils, compresses of cracked ice should be applied constantly, and the head slightly elevated above the level of the body. Administer a free drastic or saline cathartic at the onset. Venesection may be necessary to relieve severe congestive symptoms. Aconite or veratrum to reduce active circulation. Large doses of bromides, acet- anilide, or phenacetin will give partial relief to headache, but are liable to depress the heart. Ergot is of doubtful utility. Give a diet of milk and farinaceous foods. When acute stage subsides, give stimulating diet and stimu- lants as indicated. Small doses of calomel or mercury pro- tiodide. Occasional blisters to the base of the skull may be beneficial. Surgical operations have recently been advocated for removal of large intracranial effusions. TUBERCULAR MENINGITIS. Synonyms. — Acute hydrocephalus; basilar meningitis. Etiology. — A disease found most frequently in youug male children who inherit or show a predisposition to the tubercular diathesis. It may occur in adults and is brought into activity by acute diseases, hip-joint disease, or diseases of the middle ear. DISEASES OP THE BRAIN AND MEMBRANES. 387 Symptoms. — Child may be drooping, indifferent, uneasy, fretful, constipated, and generally debilitated for weeks or months before the onset. Onset begins with slight headache, which soon assumes a severe, constant type, and causes the child to cry out and scream with the pain ; nausea and vomit- ing, followed by convulsions. Slight fever develops ; pulse is quick ; great sensitiveness to light and sound. Patient lies in bed all the time and does not wish to be disturbed. There is squinting and diplopia. In a few days vomiting ceases, but headache persists or in- creases ; delirium and drowsiness ; head, neck, and back are drawn into a condition of opisthotonos ; pulse is slow and ir- regular ; high temperature ; face flushed ; vaso-motor disturb- ance, shown by a persistent redness of the skin after slight pressure on it; bowels constipated; loss of appetite; optic neuritis. Drowsiness and all symptoms increase ; Cheyne- Stokes breath- ing ; hyperpyrexia; local paralysis; unequal pupils; convul- sions; profound coma and death. The duration of the dis- ease, from time of onset to its termination, varies from two days to three weeks. Pathology. — Pia mater is the membrane involved, and is covered by an effusion of lymph of a clear, opaque or yellow color over its basilar portion, its prolongation into the fissures, and along the cerebral arteries. The upper portion of the pia mater over the hemispheres is almost entirely free from the exudation. All over the affected area are found miliary tubercles of a grayish color, some of which have caseated. The ventricles of the brain are filled with fluid — hence the term acute hydrocephalus. Tubercles are sometimes found in the spinal membranes, lungs, and other organs. Prognosis. — Most cases terminate fatally in two to four weeks. Death may occur in a very few days. 388 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Treatment. — Entirely symptomatic. Treat as acute cere- bral meningitis (p. 386). CEREBRAL PACHYMENINGITIS. Description. — Inflammation of the dura mater covering the brain maybe external (pachymeningitis externa), from trauma- tism, extension from diseased bone, or disease of the middle ear ; or internal (pachymeningitis interna). Inflammation of the dura mater may be accompanied by hemorrhage — hence the name hcematoma of the dura mater, or meningitis interna licemor- rhagia. The latter condition may occur in old people from apoplexy, alcoholism, gout, and syphilis. The dura mater is soft and friable, but in chronic cases it is tough and fibrous. Symptoms. — Not constant. Headache ; photophobia • gid- diness; drowsiness, gradually assuming a type of coma; twitchings and convulsions of various muscles ; slow, irregu- lar pulse ; slight fever. Intellect, memory, and intelligence may be impaired. Diagnosis is never certain, and prognosis is unfavorable. Treatment. — Symptomatic and causal. HYDROCEPHALUS. Definition. — The presence of large quantities of fluid in the ventricles of the brain, the pia mater, arachnoid spaces. brain substance, or all. Most common in children, and mani- fests itself by varying nervous phenomena. Congenital or chronic hydrocephalus occurs as an external hydrocephalus when the effusion is in the pia mater, internal hydrocephalus when in the ventricles of the brain, and mixed hydrocephalus when in both. Acute or acquired hydrocephalus is dependent upon tubercu- lar meningitis, already described (p. 380). DISEASES OF THE BRAIN AND MEMBRANES. 389 Etiology. — A disease of young children of tubercular and syphilitic extraction, in whom there is an arrest of cerebral development or intracranial irritation. Symptoms. — Congenital Hydrocephalus. — Gradual enlarge- ment of the head, and emaciation. Appetite is good ; general drowsiness and listlessness ; dullness of intellect and lack of the general brilliancy of most children. The head soon as- sumes a size entirely out of proportion to the child's body 5 face is small and wrinkled ; head becomes too heavy and tends to sag. Voice is shrill and pitched in a high key. If case progresses, convulsions soon occur ; muscular power becomes deficient ; vision and other senses are often impaired or lost ; vomiting may complicate, and death ensue from convulsions, coma, or intercurrent diseases. In rare cases the fluid has been known to escape by rupture of the integument. Cases may be arrested in their course, but the general duration of life varies from one to ten years — one case running twenty- one years. Pathology. — The effusion, which is similar to the cerebro- spinal fluid, varies in amount from a few ounces to a quart ; is found in the ventricles of the brain, in the arachnoid spaces, in the substance of the pia mater, and, occasionally, in the brain substance itself. As the effusion accumulates, it presses against the brain and flattens it against the skull ; the bones of the skull are forced outward in the lines of least resistance, and in time become as thin as tissue-paper. The veins are prominent all over the head. Inflammatory changes may be present or absent. When the fluid is in the arachnoid spaces and not in the ventricles, pressure on the brain reduces it to a small, compact mass. Diagnosis. — Rachitis presents a skull which is compressed laterally and is quite long ; has a high, square forehead ; gen- eral symptoms of rickets. A hydrocephalic skull is rounded 390 A SYNOPSIS OF THE PRACTICE OF MEDICINE. in ail directions ; prominent, overhanging forehead; promi- nent and divergent eyeballs. Treatment. — Surgical measures meet with most favor. As- piration of small amounts of the fluid from time to time, fol- lowed by adhesive strips or bandages to exert slight pressure. Mercury and the iodides. Nutritious diet of milk, animal- broths, whites of egg, beef preparations, and scraped beef. Observe general rules for treating persons with a tubercular or specific diathesis. CEREBRAL HYPEREMIA. Synonyms. — Congestion of the brain ; cerebral congestion. Definition. — An abnormal increase of the arterial or venous supply of blood to the brain, recognized by headache, giddiness, flushed face, and general nervous manifestations. Etiology. — Active or arterial hypercemia is caused by excess- ive action of the heart, as in violent exercise, or by hypertrophy of the left ventricle; injury to the head; apoplexy; plethora; insolation; alcoholism; mental over-activity or excitement; excesses ; anger ; obstruction to the circulation ; prolonged stooping or hanging with the head downward. Passive or venous hypercemia is caused by some obstruction to the return venous circulation. Symptoms. — Begins suddenly or gradually with a feeling of fullness and throbbing in the head, accompanied by dizzi- ness ; ringing in the ears ; " bleary vision " ; flashes of light in the eyes ; grea/t mental excitement ; inability to concentrate thoughts ; irritability ; slight delirium ; dyspnoea ; and a throb- bing or neuralgic headache. Carotids pulsate freely ; face is red and flushed ; conjunctivae are congested. In old persons these phenomena are often replaced by apoplectic symptoms. DISEASES OF THE BRAIN AND MEMBRANES. 391 Attacks may be transitory in character ; may last one minute to several days, and often recur. Diagnosis. — Apoplexy. — Consciousness is lost entirely; paralysis is unilateral; symptoms prolonged; motion and sensation involved at the same time in same part. Embolism. — Sudden onset ; prolonged or permanent paraly- sis ; history of heart or arterial diseases. Treatment, — If due to an over-loaded stomach, administer an emetic. Give full doses of aconite or veratrum to control over-active circulation. Place patient in recumbent position, with head elevated ; apply cold to head, and put feet in hot mustard-water. Venesection may be indicated in plethoric persons and those predisposed to atheroma. A hypodermic injection of morphina and atrophia allays excitability. Give saline cathartics and calomel. Limit amount of liquids taken, and do not administer them hot. Let diet be a light, farina- ceous one. Treat symptoms and complications as they arise. Passive hyperemia is treated on the same general principles, taking care to give remedies for heart-troubles and to relieve local obstructions. CONCUSSION OF THE BRAIN. Description. — Concussion or violent shaking of the brain is caused by a direct blow upon the head ; or, indirectly, by a shock produced by falling from a height, but alighting on the feet. Symptoms will depend upon the shock produced. It may amount to a mere stunning or blunting of intellect for a few moments, together with slight nausea, yawning, and un- easiness. In severe cases, sensibility is lost ; pupils are con- tracted ; face is pale and cold ; pulse rapid, thready, and com- pressible ; nausea ; shallow respiration ; diarrhoea ; retention or involuntary passage of urine ; can be roused from the stupor 392 A SYNOPSIS OF THE PRACTICE OF MEDICINE. only with difficulty. This stage may last for several hours, when they either die or show signs of reaction and restoration of functions. Inflammation of the meninges or brain may follow. Diagnosis. — Compression of the brain has complete insen- sibility ; pallor • stertorous respiration ; dilated pupils and fixed eyes ; pulse is full and slow ; bowels inactive j local paralysis. Treatment. — Remove all tight clothing- rub the body and extremities freely to restore circulation. Administer diffusible stimulants by the mouth, if they can swallow ; but if not, give strychnina or ammonia hypodermically. Small inhalations of ammonia often encourage restoration ; apply warmth to the feet and body. Cold should be applied to the head. When reaction is established, opium and sedatives may be indicated to avert inflammation. Patient should be cautioned to re- main in bed for several days or longer, until convalescence is fully established, as inflammatory symptoms are prone to fol- low for some time after reaction. CEREBRITIS. Description. — Inflammation of the structure of the brain may be acute or chronic, local or general. Acute cerebritis is caused by direct injury, embohsm, septi- caemia, pyaemia, or extension from other parts. That portion of the brain involved is soft and friable ; quite red in color from increased vascularity and hemorrhage, and is called red softening of the brain. The nerve-cells are degenerated. It begins with headache, vomiting, and slight fever. Convul- sions and delirium soon follow. It may begin suddenly like an apoplectic attack. Paralysis is limited and involves cer- tain groups of muscles. Aphasia may occur. Mind is never perfectly sound, and death follows. DISEASES OF THE BRAIN AND MEMBRANES. 393 Chronic cerebritis is dependent on syphilis, embolism, cere- bral hemorrhage, prolonged mental work, insanity, and exten- sion from other parts. The affected area of the brain is soft, and creamy white or yellow in color, termed yellow softening of the brain. It manifests itself by a gradual failure of intel- lect ; dizziness ; hypergesthesia or ansesthesia ; general debility ; headache ; local paralysis ; senses may be diminished or lost. In one to three years, patient dies of debility or intercurrent affections. Treatment. — Little can be done in acute or chronic cere- britis except to treat symptoms, and upon the general plan of tonics and alteratives. Endeavor to nourish patients as much as possible. Stimulate as necessary. CEREBRAL HEMORRHAGE. Etiology. — Cerebral hemorrhage is most common in men who have passed forty. Secondary to atheroma, miliary cere- bral aneurysms, syphilis, gout, plethora, tuberculosis, various diatheses, Bright's disease of the kidneys. In many cases it is hereditary. Exciting causes are over-exertion, mental and physical ; in- temperance in diet and drink ; sudden or prolonged stooping ; may occur during rest or sleep, without any apparent exciting cause. Symptoms. — Apoplectic. — Apoplexy may begin suddenly or be preceded for a few hours or days by slight headache, un- easiness, giddiness, and numbness of the extremities. Onset is sudden, with rapid loss of consciousness ; patient falls sud- denly after some exertion or during rest. It may begin with very severe headache, faintness, impaired speech, paralysis, convulsions, followed by a gradual loss of consciousness until they become comatose and cannot be roused, 394 A SYNOPSIS OF THE PRACTICE OF MEDICINE. Face is red and congested ; breathing is stertorous ; absence of superficial reflexes; pupils may be contracted, dilated, or uneven ; subnormal temperature ; rapid pulse ; profuse sweat- ing in some cases ; gradual cyanosis and death. On the other hand, they may remain comatose for several hours or days, and gradually regain consciousness. Hemiplegic. — When consciousness returns, temperature rises to 102° or 104° F., and one or more groups of muscles on the same side of the body are paralyzed, usually the muscles of an arm, leg, or both. Tongue is often protruded to one side, or corner of the mouth is drawn. These paralyses may re- cover entirely in a few weeks or months ; may recover par- tially ; or may be permanent. Muscles sometimes become rigid and cause permanent flexion of the fingers ; are slightly atro- phied, but retain their normal electrical reactions. Aphasic. — Aphasia is a complete or partial loss of power of speaking or understanding spoken or written language, caused by some central nerve-lesion. Aphasic symptoms vary in character. The mind may be as blank as that of a baby; they may be able to utter sounds, but not intelligent and ar- ticulate speech (aphemia)-, absolute loss of memory (amnesic aphasia). Some use wrong words to express their ideas. They may be able to speak intelligently, but cannot write (agraphia) or read. Pathology. — Arteries of the brain are found in a state of atheromatous degeneration, or their peripheral branches are filled with miliary aneurysms. Hemorrhage varies in amount, from a very slight effusion of blood, which presses on one part of the brain substance, to very profuse ones, which break down the brain and fill the ventricles, sulci, and fissures. Re- cent cases show a dark-red clot, old cases a dark-yellow clot, of disintegrated blood. When blood first escapes, it forms a DISEASES OF THE BRAIN AND MEMBRANES. 395 clot which in time contracts, undergoes degeneration, and is partially or entirely absorbed. Hemiplegic, aphasic, and other symptoms will vary accord- ing to the nerve-centers involved, and the seat of hemorrhage can be determined during life by a knowledge of cerebral lo- calization of the functions. Hemorrhages are most common in the branches of the middle cerebral artery, in the optic thalamus and corpus striatum. Brain substance is degener- ated in the region of the clot. Hemiplegia is always on that side of the body opposite to the part of the brain affected — hemorrhage on the right side of the brain means paralysis on the left side of the body. Diagnosis. — Epilepsy. — Previous history ; sudden onset with epileptic cry ; frothing at the mouth ; grinding the teeth and biting the tongue; no hemiplegia; can be roused from stupor ; is a disease of young people ; no subnormal tempera- ture ; no characteristic breathing. Alcoholism. — Insensibility not complete ; no stertorous breathing ; pupils react to light ; pulse is rapid ; can be roused by stimulants ; absence of hemiplegia ; detection of alcohol in urine. Opium Narcosis. — Gradual onset ; pupils contracted to pin- points ; can be temporarily roused ; no hemiplegic symptoms ; slow pulse and respiration ; history of case ; uncertainty of age. Urcemic Coma. — History ; preceded or accompanied by con- vulsions ; albuminuria ; can often be roused temporarily ; no paralysis ; no congestive symptoms of face ; normal reflexes ; no secondary fever. Prognosis. — Favorable if consciousness and rise of tem- perature begin within twenty-four hours. Unfavorable as to life in irregular respiration, convulsions, vomiting, and pro- longed low temperature. One attack is commonly a forerun- 396 A SYNOPSIS OF THE PRACTICE OF MEDICINE. ner of others which will ultimately result fatally. Recovery is prolonged, tedious, and always followed by one or more sequelae or complications. Treatment. — Whenever premonitory symptoms manifest themselves, patient should be put to bed at once ; cold applied to the head and heat to the extremities. Free saline or dras- tic cathartics should be administered until free action is ob- tained. Avoid hot, stimulating drinks. Aconite or vera- truni for over-active circulation. Venesection in full-blooded, plethoric persons. During the attack, cold should be applied to the head ; head must be elevated ; warmth to the body and extremities. When pulse is full and bounding, venesection may be advisable, or hypodermic administration of veratrum or aconite. If pulse is weak, unsteady, and compressible, give digitalis, ammonia, or- strychnina hypodermically. Attend carefully to bladder and prevent retention of urine. When consciousness begins to return and patient can swallow, establish free purgation, if patient is plethoric and not depressed. If weak and anaemic, give tonic medication and avoid purgatives. Do not allow the circulation to become very active nor fever to remain high for any long period. When all acute symptoms subside, alteratives and absorb- ents should be administered for weeks or months. Massage and electricity to the affected limbs. Great care must be ex- ercised in habits of physical and mental activity, hygiene, and diet, to prevent recurrence. CEREBRAL EMBOLISM AND THROMBOSIS. Definitions. — Cerebral embolism is the lodgment of an em- bolus (a blood-clot carried from some point in the circulation) in one of the cerebral vessels. DISEASES OF THE BRAIN AND MEMBRANES. 397 Cerebral thrombosis is the gradual formation of a clot or thrombus in one of the cerebral vessels. Etiology. — Embolism is due to the formation of clots in valvular heart-diseases, thrombosis, and endocarditis, which become detached and are carried into the cerebral vessels by the circulation. Cerebral thrombosis is due to the formation of a clot on the roughened wall of a degenerated or atheromatous cerebral vessel. Symptoms. — Cerebral Embolism. — Onset is sudden, with vertigo and severe headache ; nausea and vomiting ; impair- ment of speech and hemiplegia. Symptoms often simulate those of cerebral hemorrhage, and begin suddenly with com- plete loss of consciousness. Death not infrequently occurs, but recovery soon ensues if collateral circulation is established. Cerebral thrombosis is preceded by headache, slight dizziness, and nausea j formication, numbness, and impaired motility in one half of the body j absent-minded j impairment of speech ; general anxiety, lasting from a few hours to several days, when patient is seized with symptoms similar to cerebral hemor- rhage. Recovery may ensue, or death from exhaustion, paral- ysis, septicaemia, or pyaemia — the latter if the thrombus is of septic origin. Pathology. — When an embolus or thrombus occludes a cerebral vessel there is anaemia and malnutrition of that part of the brain supplied by it, which results in softening of the brain. This means a destruction of a number of centers, with corresponding motor and sensory symptoms in the parts which they control. If collateral circulation is established early, complete recovery may be expected. Treatment. — Sustain with nourishing diet and stimulants. Avoid depressants and venesection. Treat diseases of heart as indicated. Ammonium carbonate, with iodides and mer- 398 A SYNOPSIS OF THE PRACTICE OP MEDICINE. cury, seems to hasten absorption of clots. Treat as in the second and third stages of cerebral hemorrhage. CEREBRAL ABSCESS. Description. — Abscess of the brain is rarely primary, bnt is secondary to snppnration of the middle ear, scarlatina, necro- sis, diseases of the nose and frontal sinuses, syphilis, and pyae- mia. Abscesses may be single or multiple, and will vary in position according to cause ; are small, or one or two inches in diameter ; contain a greenish and, at times, a very offensive pus. Symptoms. — Vary according to size and location. Pain in the head is dull, throbbing, sharp, or neuralgic, and ex- acerbates at irregular intervals. Pyaemic symptoms of chills, rigors, fever, and profuse sweating. Vomiting and convul- sions ; optic neuritis ; alterations in mental faculties ; loss of flesh j motor and sensory paralyses, varying with the centers affected ; aphasia may be expected. Cerebral abscess may run a rapid course in a few weeks or may last for many months. Death is caused by debility, inanition, and paralysis of the various vital centers. Recovery may ensue, but the prognosis is always unfavorable. Treatment. — Symptomatic, palliative, and surgical. Ab- scess should be opened freely by trephining as soon as diag- nosed, for delays are unusually fatal. CEREBRAL TUMORS. Varieties. — Glioma is a tumor of neuroglia-cells, occur- ring in the substance of the brain and spinal cord, belonging to the variety of round-cell sarcoma; is the most common DISEASES OP THE BRAIN AND MEMBRANES. 399 tumor found in the brain j is never encapsuled, and is very prone to hemorrhage. Sarcoma grows from the membranes or the bones of the cranium ; is either primary or secondary, single or multiple. Tubercle is either single, as a large tumor in the brain sub- stance or on the meninges ; or multiple, as in miliary cerebral tuberculosis. Gumma form on the membranes, inner surface of the cranial bones, and are caused by syphilis. Cysts may form from parasites and disintegrating tumors. Aneurysm may be single or multiple ; very small or large. Etiology. — Syphilis; tuberculosis; parasites; injury; athe- roma of the vessels ; cancer ; heredity. Cerebral tumors are most common in males. Symptoms. — They vary according to the location, char- acter, and duration of the tumor. Among symptoms common to all cerebral tumors is headache, which is constant, and at times very severe ; localized, but may be general. Nausea and vomiting frequently begin early, are constant symptoms, and often prevent retention of nourishment. Optic neuritis, single or double, complicates most cases. Vertigo, impaired hearing, convulsions, drowsiness, loss of memory, slow pulse, and constipation. Local conditions of anaesthesia, pricking, numbness, hemi- plegia, tonic or clonic muscular spasms, and ataxic symptoms. Diagnosis. — A positive diagnosis cannot be made directly, but by exclusion. Prognosis. — Unfavorable, except in syphilitic cases, where moderately favorable results may be expected. Treatment. — In syphilitics, treat with alteratives and ab- sorbents, as indicated in the tertiary stage of syphilis (see p. 101). Surgical operations promise much in a select line of cases. Treat symptomatically as indicated by each case. 400 A SYNOPSIS OF THE PRACTICE OP MEDICINE. INSOLATION. Varieties. — (1) Sun-stroke; (2) heat-stroke. Description. — (1) Sun-stroke is caused by prolonged ex- posure to the direct rays of the sun or high temperature. It begins suddenly with a dull feeling in the head; headache; dimness of vision ; nausea ; giddiness ; and loss of conscious- ness. Temperature is abnormally high, and varies from 106° to 112° F., or higher ; skin is dry and hot ; urine high-colored and scanty ; muscles relaxed but not paralyzed ; pupils do not respond to light ; stertorous respiration ; flushed face, and vessels prominent; heart is over-active and strong;. muscular tremors or convulsions ; occasional remissions of wild delirium. Death may ensue from hyperpyrexia, convulsions, or coma. Recovery is slow, and followed by unpleasant sequela?, such as headaches, vertigo, impairment of intellect, insomnia, general debility, and a general tendency to return on slightest ex- posure. (2) Heat-stroke is similar to sun-stroke, but never so severe or serious. It begins by dizziness, slight nausea, weakness, paleness of the skin, weak pulse, and rapid respiration. It may become so pronounced that consciousness is lost. Tem- perature rarely rises above 105° F. In a few hours or days patient is as well as ever. Pathology — That of acute cerebral congestion. Lungs, kidneys, liver, and spleen often enlarged. Serous effusions into the ventricles of the brain. Blood is thick, dark, and has altered corpuscles. Treatment. — Sim-stroke. — Never delay one moment, but strip patient at once and bathe him all over with cold water. Put ice to the head, and pour cold water over the body until hyperpyrexia is diminished. Antipyretic drugs are too slow DISEASES OF THE BRAIN AND MEMBRANES. 401 to be of any service. When hyperpyrexia is reduced, put patient in warm blankets, still continuing cold applications to the head, and administer sufficient morphina to keep quiet and to relieve pain. Let food be light, such as milk, beef- extracts, soups, and boiled rice. Meet all symptoms as they arise. Tonics when necessary. During convalescence, which should be in bed, administer iodides and alteratives. Estab- lish free action of bowels with salines. Heat-stroke. — Cold to the head; cold sponge-baths, if tem- perature is above 102° F. Stimulate freely with diffusible stimulants (ammonia, alcohol, or camphor), followed by strych- nina in small doses. Meet symptoms ; prohibit early return to active mental or physical work. PSYCHOSES. INTRODUCTION. The psychoses are a class of diseases affecting the mind, and are considered under the general term insanity. Mind is that immaterial power behind matter which con- stitutes the true man and his actions ; which embodies the understanding, reasoning faculties, and perceptions, and mani- fests itself directly through the cells of the central nervous system, and indirectly through the various anatomical mechan- isms of the body. Insanity (in, not; sans, sound), lunacy, is a loss of power to control one's own free will, with a lack of responsibility for their actions — a pathological condition of the mental faculties dependent upon some perversion of the mind by external or psychological causes. The differentiation between sanity and insanity, between a crank and a lunatic, is so uncertain that it is impossible to define where the one begins or the other ends. An illusion is a modification of perception whereby an ob- ject or impression is presented by one of the senses in a false light. A man is mistaken for a demon. Thunder is mistaken for a voice from heaven. An hallucination is a false perception of one of the senses, founded upon imagination only, and not dependent on ex- ternal impressions. They hear noises and voices ; see ghosts, angels, and devils ; smell sweet and foul odors — all of which are not recognized by others. 402 PSYCHOSES. 403 A delusion is a peculiar form of mental exaltation in which .he patient imagines himself immensely wealthy ; a descendant from royalty ; about to reform the world ; thinks his friends are his enemies, and that they are conspiring to kill or poison him — all of which tends to violence in the end. It is to be ob- served that illusions and hallucinations depend upon sensory action, while delusions are entirely mental or imaginary. GENERAL ETIOLOGY. Mind manifests itself physiologically through a perfect or- ganism, and, being immaterial, is never diseased. Let this organism undergo changes, and the manifestations of mind will vary, even though the same mind exists back of the mech- anism. This is aptly illustrated by a fine musician who plays excellently on a perfect pipe-organ. Each combination thrown on simply intensifies the melody, but a faulty one is accident- ally set and produces an ignominious failure. The instrument is a,t fault and not the musician. Mind acts physiologically through certain groups of central nerve-cells, but renders itself absurd or violent when attempting to use others. The gradation of intelligence is dependent upon the high or low development and arrangement of central nerve-cells in various individuals, whereas the same power of mind is behind each. The etiology of insanity is shrouded in mystery in many cases, but a combination of circumstances exists which favors its development. Predisposing Causes. — Heredity is the great predisposing cause, and is most frequently transmitted from the mother to her daughters. Children of extremely nervous parents often develop insanity. Educated and well- trained persons are least susceptible. The changes of puberty and old age may excite it. Extreme work, required of a weak mind to 404 A SYNOPSIS OF THE PRACTICE OP MEDICINE. keep pace with the demands of the day, is often pernicious. Dark, gloomy, damp, and foggy days predispose to mental dis- orders, while bright, fresh, and invigorating sunshine always cheers. Exciting Causes. — Direct injury to the head ; acute or chronic diseases ; epilepsy ; influenza ; sexual disorders and masturba- tion 5 intemperance ; indigestion ; constipation ; womb-dis- eases ; child-birth ; prolonged irritation of the mind or temper by study, jealousy, hatred, love, reverses, or great successes. CLASSIFICATION. Maudsley classifies insanity into affective and ideational in- sanity. Affective, emotional, or pathetic insanity is manifested by ab- normal actions. Ideational or intellectual insanity is shown by the improper use of words, sentences, rhetorical absurdities, irrational con- versation and reasoning. Insanity may be affective, ideational, or both. Ideational 'nsanity is usually preceded by the affective form, the latter being the last to disappear during convalescence. We judge a person's sanity from his conversation or acts. Affective in- sanity is much more dangerous than the ideational, for in the former the first indication shown may be a violent act, while in the latter there is incoherent, absurd, or threatening talk, which soon leads to direct treatment or control. The diagno- sis of affective or em.otional insanity is often difficult. Pro- fessor J. K. Bauduy says: "Emotional insanity is therefore known to exist by the history of the case, the existence of hereditary predisposition, the presence of some well-known conditions of causation, the change of character, the cessation of social harmony with surroundings, the corroborative cir- PSYCHOSES. 405 cumstances, the impaired judgment of relations, the measur- ing of the perversion according to an individual standard or to one accepted by the common sense or the general consent of mankind, the motiveless assaults upon relatives and inti- mate friends, the existence, of some of the physical symptoms of insanity ; in other words, our diagnosis is to be based upon all the above-mentioned states, the etiological conditions, the sequence of symptoms, and the general course of the affection." Affective insanity manifests itself in a moral form, in which the whole character of the patient changes from religious to profane moods ; from miserly to liberal actions. It also as sumes an impulsive form, where there is a constant menacing or irresistible desire to commit atrocious crimes or acts, independ- ent of any mental perversion and beyond control of the will. The legal responsibility of an insane person rests entirely upon the proof of the presence or absence of will-power. To inflict corporal punishment or the death penalty for a truly insane act is not legal, but such patients must be confined strictly in an asylum for life, if the offense be capital. MANIA. Definition. — Mania is a psycho-neurosis, recognized by a varying degree of mental excitement, irrational conversation, a pathological association of ideas, unnatural, excitable, wild movements and actions. It is divided into (1) acute delirious mania ; (2) acute mania ; (3) chronic mania. (1) ACUTE DELIRIOUS MANIA. Synonyms. — Delirium grave ; typhomania. Etiology. — Most common in women from twenty to thirty years of age. Often follows great mental shock from a death, disappointment in love, financial failures, parturition, insola- 406 A SYNOPSIS OF THE PRACTICE OP MEDICINE. tion, or alcoholic excesses. It may develop in cases of tuber- culosis or any of the acute diseases. It sometimes occurs periodically. Epileptics are liable to develop it. Symptoms. — Onset is usually very sudden and violent, when patient may sing, cry, laugh, scream from fear, or attack those around her. Her delusions are not constant, and are thus characteristic. Insomnia is an early symptom ; sexual desire is increased, and the appetite voracious. Temperature varies from one to six degrees above normal, and the condi- tion may lapse into a typhoid condition called typhomania. Rapid pulse ; tongue dry and coated ; profuse fetid perspira- tion; great asthenia and prostration. Vaso-motor changes are common. It rapidly progresses to a fatal termination by coma, collapse, or exhaustion in a few days or weeks, or gradu- ally subsides, leaving impairment of some of the mental facul- ties or chronic mania. Pathology. — Brain and membranes are greatly congested and ©edematous. The ganglia are opaque and granular, and the spaces filled with blood-elements. The vessels of the pia mater are often surrounded by leucocytes. Diagnosis. — Acute meningitis is preceded by headache, drowsiness, tingling and numbness of the extremities, and followed by rapid pulse, high temperature, and optical illu- sions ; pupils often contracted, and stomach irritable. Delirium tremens manifests itself by anxious expression, alarm, good-nature, restlessness, moist skin, soft pulse, moist tongue, and history. A few days will serve to differentiate. Prognosis. — Typhoid symptoms, depression of feeling, and rapid pulse are unfavorable. Death may be very sudden. Mortality is high. Cheerful and gay delirium and sleep are favorable signs. Treatment. — Removal to an asylum is not absolute^ neces- sary, nor is it desirable if proper attention can be given at home. The patient should be placed in a dark room where PSYCHOSES. 407 everything has been removed which might be used in self -in- jury, and should be under the constant care of a good, strong, attentive, commanding nurse. Relatives and visitors must be excluded except in special cases. The patient's condition must not be discussed nor mentioned in his hearing. The most nutritious, albuminous food must be given at regular inter- vals of three or four hours. They require considerable water, and it must not be withheld. Stimulants should not be given as a routine practice, but only when indicated. Insomnia must be met with chloral, one-half to one dram at a dose. Sulphonal, gr. x-xx, in hot tea is also recommended, but should never be continued, as it is too depressing, and the habit of using it may be acquired. Sleep is usually fol- lowed by an absence of delirium, but the delusions still re- main. Opium is followed by aggravation of symptoms. Delirium and high temperature are best reduced by a cold bath under the usual precautions. Warm baths are some- times followed by sleep. Meet all untoward symptoms and complications as they arise. (2) ACUTE MANIA. Synonyms. — Raving madness ; raving insanity. Etiology. — May follow simple mania or melancholia. It is not a disease of young adults, but often present after the fortieth year in nervous temperaments. Hereditary. Symptoms.— Premonitory, when present, are delusions of a mild type ; change of character, disposition, and habits ; head- ache, restlessness, and mind not perfectly clear ; a f eeling of impending calamity ; a great desire to do something wrong or violent ; insomnia or disturbed sleep j and a peculiar piercing luster to the eye. It may begin suddenly, without premoni- tory signs, with great mental excitement, violent raving, shout- ing, singing, laughing or crying, which continues for hours or days without intermission. Personal injury, self-abuse, 408 A SYNOPSIS OF THE PRACTICE OF MEDICINE. entire change of manner, or violence to surroundings. Con- versation is rambling and disconnected. Delusions are not fixed. Actions are more or less spasmodic and violent. Great self -exaltation and esteem. Insomnia ; constipation. Tem- perature is rarely above 99° to 100° F. Delirium is entirely absent. Thought is almost immediately followed by action. The disease may rapidly progress to dementia, chronic insan- ity, or melancholia. Pathology. — General irritation of the brain from hyperae- mia. Cerebral anaemia may be present in some cases. The pathological conditions of the various brain-centers cannot be accurately demonstrated, but they are undoubtedly involved, thus producing the great stimulation of thought and action, accompanied by a lack of inhibition. Prognosis. — The presence of fixed delusions or previous debilitating disease is bad. Recovery may be very sudden, in a few days, weeks, or months. It may progress to dementia or chronic insanity. Relapses are very common. Treatment. — Send to an asylum at once where moral treat- ment is strictly enforced and a system of rewards and punish- ments adhered to according to merit. When there is cerebral congestion, the bromides should be administered in full doses ; in anaemic conditions they should be avoided. Applica- tions of cold to the head and spine as indicated. Insomnia must be combated with chloral, gr. x-xl, sulphonal, gr. x-xx, or hyoscyaminae sulph., gr. T io> hypodermically. Conium is suggested when there is great motor excitement. The most nutritious food must be administered regularly, even though the stomach-tube is necessary. (3) CHRONIC MANIA. Description. — The exact stage at which acute mania be- comes chronic is not definitely determined, but writers claim PSYCHOSES. 409 that when it is from three to twelve months' duration it may be called chronic. It manifests itself ver} r mnch like the acute form, with these differences : the raving is not so constant, but intermits, with periods of comparative or complete quiescence. The delusions assume a less rambling form and tend to be- come fixed. There may be a period of complete rationality, or the loss of will and volition is fixed. Monomania is a form of chronic insanity characterized by delusions upon one or more constant points, with aD appar- ently rational mind upon all other subjects. Such is not the case, for a partial insanity is an impossibility, even though the patient may seem sound on other points. There is an unusual degree of self-esteem and personal exaltation which greatly excites the patient if he is antagonized in this respect. He imagines himself wealthy, very strong, a saint, an apostle, or he may think that certain persons are conspiring against his life by poisoning his food or lying in wait for him. Illu- sions sometimes exist. Hallucinations may develop, when they see a certain spirit, hear imaginary voices, or converse with departed spirits. Monomania is usually the result of acute insanity. Pctrancea is a primary monomania, produced without definite cause, in which the power and strength of the mind are not lost at. first, but which tends to assume the distinct form of monomania. It is usually hereditary. Such patients are termed cranks. Parancea receives the name of protopatMc insanity, insane diathesis, or unsoundness of mind. Chronic insanity may exist for years without affecting the duration of life. Recovery is usually hopeless. Monomaniacs in their earliest stages may be cured, but if the delusions are fixed for six or eight months it is doubtful. Paranoea may recover, but tends to fixed delusions and dementia. Treatment. — Asylum treatment is indicated, and a strict 410 A SYNOPSIS OF THE PRACTICE OF MEDICINE. moral influence exerted. Violence must be avoided. Control insomnia and complications as indicated. ACUTE DEMENTIA. Description. — Acute dementia is a sudden or gradual loss of reason or mind, occurring almost exclusively in persons under forty years of age. Among prominent causes are great mental excitement, shocks from fright, grief, or accident; mental exhaustion from prolonged work ; exposure to intense cold or heat ; sexual excesses ; recovery from asphyxiation ; neurotic predisposition ; syphilis ; and acute diseases — typhoid fever. Patient suddenly or gradually assumes a blank, idiotic, or ignorant expression. Voice is low and muttering, and every bodily movement is slow and indolent. Pulse is very weak ; respiration shallow and slow ; movements automatic ; ana?s- thesia of the skin ; mouth is open and saliva dribbles j skin is cold ; pupils sluggish or inactive 5 and personal uncleanliness. The characteristic symptom is the complete loss of knowledge. Professional men know no more than a baby, and cannot do the simplest sums nor answer intelligently. Little attention is given to personal address, and the ideas cannot be collected. Cataleptic states may develop. Recovery is rare in extreme cases, or when complicating phthisis or pneumonia. The general tendency is to gradual recovery, complete or partial, with the affected period of life a perfect blank. Treatment. — These patients are best treated at home if proper care can be given. They require as much attention as a young child. Albuminous food must be administered at intervals of four to six hours, even though the stomach-tube is necessary. Quinine, strychnine, iron, arsenic, and manga- PSYCHOSES. 411 nese are of service as indicated. Systematic exercise and massage. Galvanism of the head has been nsed to advantage. Apply warmth as necessary, and always wear wool or flannel next the skin. CHRONIC DEMENTIA. Description. — Chronic, terminal, or secondary dementia is a loss of mental power as a result of acnte insanity or melan- cholia — the ultimate result to which all forms of mental affec- tions tend. Chronic imbecility. Very old people may lapse into a similar condition from age alone. The general appear- ance is characteristic. There is a vacant stare and blank ex- pression on the face ; looks much older than he really is ; gait is uncertain, and bodily strength rather feeble. He may have a mania for walking, running, standing still, crouching in a corner, dancing, or hopping. The finer emotions are not capa- ble of impression. Disposition is usually happy, but may be gloomy, morose, depressed, mischievous, or revengeful. Delu- sions, hallucinations, and illusions are fixed. They will nurse a bottle, stick, or any object for a baby, and engage in all such similar practices. Personal habits are often filthy, and morals depraved. The impairment of mind varies. It may be a perfect blank concerning the past and present events ; the past may be clear and the present impaired. The nearest friends and relatives may not be known, and after conversing with any one the fact is forgotten at once. He may live over past years and imagine himself young again. General health is good, but they are subject to phthisis and intercurrent diseases. Constant care is necessary to prevent personal neglect. The prognosis is very unfavorable, and re- covery is the exception. Confinement in an asylum is not 412 A SYNOPSIS OF THE PRACTICE OF MEDICINE. necessary, unless there be a tendency to violence or revenge. Make them exercise daily ; give frequent baths ; do not allow them to lie long in bed, as obstinate bed-sores will form. MELANCHOLIA. Description. — Melancholia is a form of affective insanity, manifested by extreme depression of spirits, despondency, great feeling of dejection and sorrow, which is beyond control of the will, and often referred to some imaginary cause. Some patients will sit or stand for hours in the same position, ap- parently oblivious of their surroundings, with an agonized expression on their face. Others are very restless and pass a great part of the time in crying, moaning, walking to and fro in their room, wringing their hands, and constantly censuring themselves for some imaginary wrong or sin. At first there may be lucid intervals, but the patient is liable to lapse into permanent delusions. They have committed the unpardon- able sin or murder, or have some bad disease, pains, parasites, and animals in the intestinal tract. Insomnia and an anaes- thetic condition of the skin. Most common after the fortieth year, but may occur at any age. Melancholia accompanied by delusions is termed lypemania. When there is extreme fear and terror without referable cause, it is termed pantophobia. The general condition of melancholia seems to depend upon anaemia of the brain. Hypochondriacal melancholia is manifested by a constant study, investigation, and brooding over supposed bodily de- fects or diseases, which in time leads to more or less disease, fixed delusions, and uncontrollable actions. Maudsley relates a case where a patient penetrated his intestines with a piece of glass, " to let out the gas." These patients constantly talk, PSYCHOSES. 413 study, and consult about their supposed ailments. If you can divert their mind for a time, all imaginary disease disappears temporarily. Furor mdancJiolicus, or melancholy with excitement, is sometimes mistaken for mania. There are delusions, great depression, deep mental anxiety, and tendency to suicide or homicide. Such patients, when asked their reason for homi- cide, will say that it was not for spite, but on account of an irresistible desire to kill a certain person. They conceal knives, pins, needles, or glass for accomplishing their mur- derous desires. The paroxysms are often periodical, and the patient requires a constant watch. Melancholia attonita, or melancholia with stupor, is char- acterized by what might be termed "vegetable life." They refuse all food for fear it is poisoned; will remain for hoars or days in the same position, with little or no movement ; the face is without expression ; they are unconscious to surround- ings. One delusion or idea is liable to concentrate the mind for days. Periods of comparative repose and rational exist- ence may occur. It is analogous to catalepsy. Circular insanity (folie circulaire) is a condition of alteration between the manifestations of mania and melancholia. The patient may be melancholic for a season, become maniacal for a short time, and thus alternate indefinitely. This form is very grave and often terminates in dementia. Treatment. — Asylum treatment, based upon moral prin- ciples, is best, for a more speedy recovery is possible. They may be kept under the strictest eye and placed in such posi- tions that they can do themselves or others no physical harm. When depressed they should be encouraged 5 when excited, calm and soothe them, even though physical force is necessary. Deal with them as you would with children, and give proper rewards and punishments. Milk, beef -juice, and nitrogenous 414 A SYNOPSIS OF THE PRACTICE OF MEDICINE. foods must be given regularly, by the stomach-tube if neces- sary. Attend to constipated conditions at once, and keep the bowels regular with cascara, aloin, strychnina, and belladonna. Headache is relieved by acetanilide or phenacetin combined with strychnine or caffeine. Insomnia must be controlled with chloral, sulphonal, or paraldehyde. Alcoholics are some- times beneficial. MORAL INSANITY. Description. — Baucluy says: "It is never moral depravity, and moral depravity is not always moral insanity."' If a steady, conscientious, religious, moral man were to suddenly change into a life of lust, lasciviousness, murder, association with bad company, profanity, and open self -pollution without cause, and such a man had come from a highly neurotic or insane family, he would be called morally insane. A close in- vestigation into the previous history will usually show certain inexplicable peculiarities or change of character. Fagge says : " When once we have given up the arbitrary notion that the presence or absence of delusions determines whether the in- tellectual faculties are or are not impaired, there seems to me to be no basis whatever for the doctrine that ' moral insanity ' is to be regarded as a separate form of mental disorder." IDIOCY. Definition. — Idiocy is a congenital form of insanity due to an arrest of cerebral development during gestation or soon after birth, and is to be distinguished from imbecility, which may occur at any time after birth as a result of some patho- logical condition, injury, or disease. PSYCHOSES. 415 Symptoms. — They vary in degree with each case. The worst cases are absolutely helpless; cannot talk or utter a sound ; take no interest in surroundings ; are oblivious of time ; and will never manifest a desire for food. Some can utter slight sounds or monosyllables, and move the face or extremities. When we pass to a higher form where there is recognition, action, and motion, the case is probably one of imbecility. That these patients are really impressed with points about which they seem to be oblivious is shown by the supervention of acute diseases which may cause them to speak about these very subjects. The senses, with the exception of sight, are greatly blunted or dormant. Sexual function and development are poor, and often entirely suppressed. There is liability to dwarfing and imperfect body development. Pathology. — Inflammation, and the excessive use of lime salts in young children, may be classed as causes. It develops mostly in children of the nervous or insane temperament. The head is microcephalic, imperfectly developed, and the sutures close early. The brain is small and may weigh from fourteen to twenty ounces. Its surface presents comparatively few convolutions and shallow sulci. The hemispheres are poorly developed, and one may be larger than the other. The ventricles are sometimes filled with fluid, and the brain sub- stance is very thin. Sclerosis of the brain is present in some cases. Prognosis. — Very grave. Most cases are hopelessly idiotic. A change may be produced by great care and nursing. Treatment. — When proper care cannot be given at home, they should be placed in an asylum. Linear craniectomy has been done by home operators, with a view of increasing the intracranial cavity and giving the brain room to expand and develop. These cases -have been reported as improved, but time must elapse before the method can be proved and adopted. 416 A SYNOPSIS OF THE PRACTICE OF MEDICINE. CRETINISM. Description. — Endemic cretinism is a peculiar form of idiocy, characterized by marked deformity of the cranium, face, and body. The mind is the same as found in idiocy. Cretins are rarely more than four or five, and may be only three feet tall. Fagge says : " They have large heads, especially in the direc- tion from ear to ear. The features are broad and thick ; the eyes are wide apart; the nose is very flat at the root, and spreads out enormously toward the alee ; the mouth is very large, widely open, with thick lips, and allows the saliva to escape. The forehead, and cheeks are wrinkled, and the skin is coarse and rough, so that they have always the appearance of old age. A cretin thirty years old is exactly like a cretin of forty. The hair comes low on the forehead and is coarse and bristly. Cretins have narrow chests, large bellies, crooked limbs. Their hands are broad but short, with short fingers." Goiter is almost always present in districts where cretinism is present, and may exist in many cases. Some of the typi- cal cases show no goiter. Virchow believes that the result- ing deformity in the head is due to an early osseous union of the occipital and sphenoid bones at the base of the skull, thus preventing enlargement of the base antero-pos- teriorly. Sporadic cretinism? occurs in any part of a country, and is also closely related to goiter. In most cases the thyroid gland is very small or absent, but in its place are found two swell- ings or soft lumps outside the sterno-mastoid muscle and above the clavicle, which are made up of fatty tissue and are pink in hue. They vary from the size of a hazel-nut to a good-sized duck-egg. The same mental condition exists as in the other forms, but they are usually quiet and easily controlled. PSYCHOSES. 417 Cretinoid Condition. — Sir William Gull cited a case similar to cretinism occurring in an adult woman. The eyes became wide apart ; nose flat, broad, sunken, and thick ; lips thick ; adi- pose tissue under the chin and eyes increased ; large tongue ; unwieldy hands ; and marked change of disposition. Treatment. — Entirely symptomatic, and cures have not been reported. DEMENTIA PARALYTICA. Synonyms. — General paralysis of the insane ; progressive paralysis of the insane ; and, improperly, " general paralysis." Definition. — A disease of middle life, characterized by a great mental change, dementia, general tremor, unequal, slug- gish, pin-point pupils, and progressive paralysis, which tends to fatality. Etiology. — Most common in blonde men between the ages of thirty-five and fifty years. More common in towns and cities. General insanity. Sexual excesses ; great nervous shock from business failures • or injury to the head. Syphilis is said to cause a large number of cases. May be hereditary. Symptoms. — The earliest symptoms noticed are referable to character. He is absent-minded ; forgets readily ; becomes careless in habits and dress 5 spends his money with great freedom; has spells of dullness and moodiness; forgets his meals and appointments; has insomnia and poor appetite. The pupils may be unequal or greatly contracted, and do not respond to light readily. In a few days or weeks chronic delusions develop, and he imagines himself a king, banker, reformer, a millionaire, or he may think that his friends are conspiring against his life. Accompanying this condition is a peculiarity of articulation. He mixes long words ; does not enunciate distinctly ; hesitates, 418 A SYNOPSIS OF THE PRACTICE OF MEDICINE. stops, or substitutes the wrong word in a sentence. The tongue and lips tremble when he is told to hold them still. There is a slight tremor of the hand. The gait is unsteady and stiff, and he falls readily. Sometimes the walk is like an ataxic. High reflexes ; the pupils remain unequal or con- tracted. Transitory paralysis is common and lasts for a few hours or days. Attacks of raving and violent insanity. Improvement may follow and the patient seem cured, but relapse is the rule. Some progress rapidly to complete paral- ysis and dementia, with a fatal termination in one to five years from the onset. Death is the result of personal violence, bron- chitis, or pneumonia. Complete recovery never occurs. Pathology. — There does not seem to be any definite patho- logical process demonstrable. Autopsy has shown a thicken- ing of the pia mater, with adhesions to the convolutions of the brain in some cases, and in others the pia mater is sepa- rated from the brain by fluid. The arachnoid is often thick- ened ; pachymeningitis and hematoma of the dura mater have been demonstrated. Weight of brain is diminished. Authors differ as to whether the condition is one of " a diffused inter- stitial cortical encephalitis " or " a diffused parenchymatous cortical encephalitis." The spinal cord presents changes not unlike the different forms of sclerosis. The nerves undergo changes, and the axis-cylinders are exposed, atrophied, or ob- literated. General atheroma. Diagnosis. — Impaired speech, motionless, contracted pu- pils, increased reflexes, mental impairment, tremors, and paral- ysis will serve to diagnose it in the early stages. Prognosis. — Temporary improvement is frequent, but a permanent cure is impossible. Every true case is necessarily fatal in three to five years. Treatment. — Very unsatisfactory, and must be symptom- atic. Chloral and bromides for insomnia and convulsions. PSYCHOSES. 419 Keep bowels active. Confine in an asylum if violent dementia appears. Tonics as indicated. Shaw and Tuke each opened the cranium to diminish intracranial tension and thus bring about a reaction, but with temporary success. In syphilitic cases use iodides and mercury in full doses. INDEX. Abdomen, tumors of, 230. Abdominal reflex, 345. Abscess, cerebral, 398. hepatic, 248. metastatic, 156. of floor of mouth, 187. of stomach, 198. perinephritic, 277. retro-pharyngeal, 186. Acetanilide, pill, comp., 27. Acid, hydrochloric, test for, 204. lactic, in rheumatism, 111. test for, 204. nitric, for albumin, 264. picric, 264. salicylic, in rheumatism, 112. uric, in gout, 105. test for, 265. Acme, 18. Aconite in fever, 24. Adhesions, pericardial, 140. pleural, 336. iEgophony, 294. Agraphia, 394. Ague, 47. cake, 51. double quotidian, 48. tertian, 48. dumb, 48. quartan, 48. quotidian, 48. i tertian, 48. Albumin, tests for, 263. Albuminuria, scarlatinal, 62. Alcoholism, 395. Allopathic treatment, 10. Amygdalitis, 181. Anaemia, 146. essential, 150. idiopathic, 151. malignant, 151. primary, 150. Anaemia, prog, pernicious, 151. secondary, 146. symptomatic, 146. Anaesthesia, 343. Analgesia, 343. Anatomy, topographical, 289. Anchylostomum duodenale, 235. Aneurysm, 142. thoracic, 143. Angina Ludovici, 187. membranous, 77. pectoris, 136. Anode, 343. Anthrax, 89. Antipyretic measures, 22. Antiseptics, intestinal, 221. Aortic diseases, 131. insufficiency, 131. murmurs, 121. stenosis, 132. Apex-beat, 119. Aphasia, 394. Aphemia, 394. Aphthae, 166. confluent, 166. discrete, 166. Apneumatosis, 322. acquired, 323. congenital, 323. Apoplexy, cerebral, 393. Appendicitis, 215. Arcus senilis, 126. Argyll-Robertson pupil, 381. Arthritis, gonorrhoea^ 113. rheumatic, 109. Ascaris lumbracoides, 236. Ascites, 241. Asphyxia, 307. Asthma, bronchial, 325. cardiac, 326. hay, 298. spasmodic, 325. 421 422 INDEX. Ataxia, hereditary, 383. locomotor, 380. Ataxy, locomotor, 380. Atelectasis, 322. Atrophy, acute yellow, of liver, 255. Aura, epileptic, 348. Auscultation, 292. Axis, cerebro-spinal, 342. Bacillus anthracis, 89. comma, 75. lacticus, 194. malarias, 51. tetanus, 87. tuberculosis, 91. typhosus, 40. Baths, cold, 23. Beriberi, 101. Bile-ducts, catarrh of, 257. Bilharzia heematobia, 282. Bilious attack, 195. Biliousness, 247. Bladder, anaesthesia of, 286. catarrh of, 283. diseases of, 283. hyperesthesia of, 285. hypertrophy of, 284. paralysis of, 287. Blood, diseases of, 145. poisoning, 154. vomiting of, 208. Blood-vessels, diseases of, 142. Bones, rickety, 108. Bothriocephalus latus, 235. Brain, abscess of, 398. compression of, 392. concussion of, 391. congestion of, 390. diseases of, 385. inflammation of, 392. softening of, 392, 393. tumors of, 398. Break-bone fever, 68. Bright's disease, acute, 268. amyloid, 273. chronic, 269. cirrhotic, 271. Bromides, the, 351. Bromoform, 83. Bronchial tubes, diseases of, 311. Bronchiectasis, 315. Bronchitis, 31 1 . acute, 311. Bronchitis, capillary, 316. chronic, 314. croupous, 313. diphtheroid, 313. membranous, 313. plastic, 313. sicca, 314. Bronchophony, 294. Broncho-pneumonia, 316. Bronchorrhcea, 315. Bruit, 143. de diable, 147. Buboes, 36. Cachexia, malarial, 51. tubercular, 94. Caecum, inflammation of, 215. Calculi, biliary, 258. hepatic, 258. oxalic, 279. phosphatic, 279. renal, 279. uric acid, 279. Camp fever, 32. Cancer, hepatic, 253. in mouth, 174. pancreas, 244. stomach, 203. intestinal, 229. renal, 278. Cancrum oris, 167. Carbuncle, 89. Cardiac dilatation, 124. hypertrophy, 122. murmurs, 121. Cardialgia, 209. Carnification, 323. Catabolism, 148. Catalepsy, 352. Catarrh, bronchial, acute, 311. chronic, 314. dry, 314. duodenal, 214. epidemic, 24. fetid, 315. gastric, acute, 193. chronic, 196. drunkard's, 196. intestinal, 213. nasal, acute, 295. chronic, 296. of bile-duct*. 257. caecum, 215. INDEX. Catarrh, of rectum, 217. pharyngeal, 177. suffocative, 316. summer, 299. Cephalalgia, 104. Cephalodynia, 104. Cerebritis, 392. Cerebro-spinal axis, 342. fever, 30. meningitis, 30. typhus, 30. Ceylon disease, 101. Chancre, hard, 99. Hunterian, 99. Changes, trophic, 344. Charbon, 89. Chest, cold on the, 311. Cheyne-Stokes breathing, 293. Chicken-pox, 54. Child-crowing, 305. Chills and fever, 47. Chlorides, tests for, in urine, 265. Chlorosis, 150. Cholera, 73. Asiatic, 73. bilious, 219. English, 219. epidemic, 73. infantile, 222. infantum, 222. morbus, 219. nostras, 219. sporadic, 73. Cholerine, 75. Chorea, 346. hysterical, 346. Chyluria, 282. Circulatory system, diseases of, 119. Cirrhosis of kidney, 271. liver, 250. lung, 333. stomach, 207. Clonus, 345. ankle, 345. Cold, local application of, 22. Colic, hepatic, 258. intestinal, 232. lead, 232. renal, 279. stomachic, 209. Colitis, 226. ulcerative, 226. Coma, diabetic, 115. Coma, urasmic, 266, 395. Comma bacillus, 75. Complications, 9. Confluent varicella, 54. variola, 56. Congo paper, 204. Constipation, 233. Consumption, 94. galloping, 92. non-tubercular, 332. pulmonary, 332. tubercular, 94. Contagious fevers, spread of, 20. Contents, 13. Convalescence, 18. Convulsions, infantile, 225. uraemic, 266. Corpuscles, red blood, 145. white blood, 146. Coryza, acute, 295. chronic, 296. Costiveness, 234. Cough, stomach, 197. winter, 314. Cowpox, 58. Cramp colic, 232. writers', 363. Cranks, 409. Cremasteric reflex, 345. Cretinism, endemic, 416. sporadic, 416. Cretinoid condition, 417. Crises, gastric, 381. Crisis, 9, 18. Croup, catarrhal, 305. false, 305. membranous, 307. pharyngeal, 181. spasmodic, 304. true, 307. Cutaneous reflexes, 345. Cutis anserina, 47. Cynanche, 181. Cystitis, acute, 283. chronic, 283. Cysts, hydatid, of kidney, 282. liver, 254. ovarian, 242. Dance, St. Vitus's, 346. Dandy fever, 68. Defervescence, 18. Definition, 8. 424 INDEX. Degeneration, reaction of, 344. Delirium, grave, 405. tremens, 406. Delusion, 403. Dementia, acute, 410. chronic, 411. paralytica, 417. secondary, 411. terminal, 411. Dengue, 68. Desquamation of measles, 65. scarlatina, 61. Diabetes, 114. insipidus, 113. mellitus, 114. Diagnosis, 9. differential, 289. physical, 289. Diarrhoea, 213. choleraic, 74. elimination in, 221. inflammatory, 224. summer, 224. Diastole, 120. Diathesis, 8. hemorrhagic, 160. insane, 409. tubercular, 91. Diet in fever, 22. Digitalis in scarlatina, 63. Dilatation, cardiac, 124. of oesophagus, 191. stomach, 206. Diphtheria, 77. bronchial, 313. laryngeal, 307. nasal, 78. of the mouth, 167. paralysis of, 79. Diplococci, 30. Disease, 7. Addison's, 162. bad, 98. Basedow's, 137. bleeders', 160. Ceylon, 101. Charcot's, 382. contagious, 7. Corrigan's, 333. Duchenne's, 379. endemic, 8. epidemic, 8. Friedreich's, 383. Disease, functional, 7. Graves's, 137. Hodgkin's, 152. infectious, 7. organic, 7. Parkinson's, 360. prophylaxis of contagious, 21. sporadic, 8. Thomsen's, 354. valvular, 130. Disinfection, 21. Dropsy, abdominal, 241. asthmatic, 101. of pelvis of kidney, 275. pericardial, 141. peritoneal, 241. pleural, 341. Duodenitis, 214. Duodenum, catarrh of, 214. Dysentery, acute, 226. catarrhal, 227. chronic, 228. diphtheritic, 227. epidemic, 226. gangrenous, 227. mild, 217. Dyspepsia, 210. atonic, 210. nervous, 210. Dysphagia, 189. Echinococcus hominis, 282. Eclampsia, 266. Effusion, pericardial, 141. pleural, 342. Electrical reactions, 343. Electricity, faradic, 344. galvanic, 343. static, 344. Elimination, 10. Embolism, cerebral, 396. Embolus, 396. Emphysema, compensatory, 324. vesicular, 324. Empyema, 339. Endocarditis, acute, 128. chronic, 130. diphtheritic, 128. septic, 129. ulcerative. 128. Enteralgia. 232. Enteric fever, 37. INDEX. 425 Enteritis, 213. catarrhal, 224. Enteroclysis, 76. Enuresis, 286. Ephemeral fever, 23. Epidemic catarrh, 24. cerebrospinal meningitis, 30. cholera, 73. Epilepsy, 348. abortive, 348. cardiac, 137. hysterical, 350. Jacksonian, 349. major, 348. minor, 349. partial, 348. Erysipelas, 69. phlegmonous, 70. puerperal, 71. Etiology, 8. Exophthalmic goiter, 137. Exophthalmos, 137. Fainting, 211. Famine fever, 28. Faradic electricity, 344. Fastigium, 18. Fatty degeneration of heart, 126. liver, 253. Febricula, 23. Febris recurrens, 28. Fehling's solution, 264. Fermentation test for sugar, 116. Fever, 17. bilious, 193. malignant, 44. relapsing, 28. remittent, 48. break-bone, 68. camp, 32. cerebro-spinal, 30. chills and, 47. congestive, 49. contagious, 19. dandy, 68. diet in, 22. endemic, 19. enteric, 37. entero-mesenteric, 37. ephemeral, 23. epidemic, 19. eruptive, 19, 54. Fever, famine, 28. gastric, 193. hay, 298. idiopathic, 19. infectious, 19. intermittent, 19, 47. irritative, 23. jail, 32. lung, 328. malarial, 46. malignant bilious, 44. intermittent, 49. malarial, 49. marsh, 48. Mediterranean, 44. mild malarial, 47. neurotic, 19. paludal, 47. pernicious, 49. malarial, 49. putrid, 32. relapsing, 28. remittent, 19, 48. rheumatic, 109. rose, 299. sailor's, 44. scarlet, 60. ship, 32. simple continued, 18, 23. essential, 23. specific, 19. splenic, 89. sporadic. 19. spotted, 30. spread of contagious, 20. stupid, 32. symptomatic, 19. typhoid, 37. typhomalarial, 49. typhus, 32. yellow, 44. Fevers, congestive, 49. continued, 23. eruptive, 54. malarial, 46. periodical, 44. spread of contagious, 20. Filaria sanguinis hominis, 281. Fistula, rectal, 219. Flux, bloody, 226. Fluxion, splenic, 261. Folie circulaire, 413. Fracture, green-stick, 108. 426 INDEX. Fremitus, 291. Functions, localization of, 342. Furor melancholicus, 413. Gall-stones, 258. Galvanic electricity, 343. Gastralgia, 209. Gastritis, 193. acute suppurative, 198. chronic, 196. phlegmonous, 198. toxic, 199. Gastrodynia, 209. Gastrorrhagia, 208. Genickkrampf, 30. Giddiness, 211. Gingivitis ulcerosa, 167. Glioma, 398. Globus hystericus, 352. Glossitis, 171. Glottis, oedema of, 301. spasm of, 304. Glucose, Fehling's volumetric test, 116. fermentation test, 116. qualitative tests for, 264. quantitative tests for, 116. Glucosuria, 114. functional, 117. Gluteal reflex, 345. Goiter, exophthalmic, 137. Gout, 105. acute, 105. chronic, 106. Graphospasm, 363. Gravel, 279. Green-sickness, 150. Grippe, the, 24. Haematemesis, 208. Haematuria, 287. Haemophilia, 160. Haemoptysis, 319. Hallucination, 402. Haut mal, 348. Hav asthma, 298. " fever, 298. Head, cold in the, 295. hydrocephalic, 389. rachitic, 108. Headache, sick, 358. Heart, the, 119. dilatation of, 124. Heart, the, diseases of, 119. fatty degeneration of, 126. fatty infiltration of, 127. hypertrophy of, 122. inflammation of, 127. neuralgia of, 136. palpitation of, 135. rupture of, 127. valvular diseases of , 130 Heart-burn, 210. Heart-failure, 329. Heat-stroke, 400. Hemichorea, 347. Hemicrania, 358. Hemiplegia, 394. Hemorrhage, bronchial, 319. cerebral, 393. from mouth, 174. gastric, 208. intestinal, 231. pulmonary, 319. Hepatic cancer, 253. colic, 258. Hepatitis, acute, 248. interstitial, 250. suppurative, 248. Hepatization of lung, 329. Herpes zoster, 356. Homoeopathic treatment, 10. Hooping-cough, 81. Hydatids of kidney, 282. liver, 254. Hydrocephalus, 388. acquired, 388. acute, 386. chronic, 388. congenital, 389. Hydronephrosis, 275. Hydropericardium, 141. Hydrophobia, 87. Hydrothorax, 341. Hygiene, 22. Hyperaemia, cerebral, 390. hepatic, 247. pulmonary, 321. renal, 267. spinal, 373. splenic, 261. Hyperaesthesia, 343. Hyperalgesia, 343. Hyperpyrexia, 17. Hypertrophy, cardiac, 122. INDEX. 427 Hypertrophy, compensatory, 123. gastric, 207. of "bladder, 284. stomach, 207. splenic, 262. Hypodermoclysis, 77. Hysteria, 352. Hystero-epilepsy, 350. Ice-bags, 23. Ice in hyperpyrexia, 23. Ichthyol ointment, 81. Icterus, 246. neonatorum, 247. Idiocy, 414. Ileo-colitis, 224. Illusion, 402. Imbecility, 414. Incoordination, 303. Incubation, period of, 8, 20. Indigestion, acute, 193. stomachic, 210. Induration, fibroid, 207. gastric, 207. Infantile paralysis, 377. Infection, mixed microbic, 40. Infectious diseases, 73. Influenza, 24. Russian, 24. Inoculation for hydrophobia, 89. variola, 58. Insane, general paralysis of, 417. Insanity, 402. affective, 404. circular, 413. emotional, 404. ideational, 404. impulsive, 405. intellectual, 404. moral, 414. pathetic, 404. protopathic, 409. raving, 407. Insolation, 400. Insomnia, 407. Inspection, 290. Insufficiency, aortic, 131. mitral, 130. pulmonic, 133. tricuspid, 132. valvular, 130. Intermittent fever, 47. Intestines, diseases of, 213. Introduction, 7. Intussusception, 230. Invagination of intestines, 230. Invasion, period of, 20. Isolation, 21. Jail fever, 32. Jaundice, 246. catarrhal, 257. hematogenous, 246. hemorrhagic, 255. hepatogenous, 246. malignant, 255. Kakke, 101. Kathode, 343. Kidney, albuminoid, 273. amyloid, 273. cancer of, 278. colic, 280. congestion of, 267. contracted, 271. diseases of, 266. dropsy of pelvis of, 275. floating, 277. gouty, 271. hydatids of, 282. inflammation' of pelvis of, 274. lardaceous, 273. large white, 270. movable, 277. stones, 279. tuberculosis of, 278. waxy degeneration of, 273. Kinks, 304. Koch, bacillus tuberculosis of, 91. comma bacillus of, 75. Koch's lymph, 97. La grippe, 24. Landry's palsy, 378. Laryngismus stridulus, 304. Laryngitis, acute catarrhal, 300. chronic, 302. croupous, 307. diphtheritic, 307. membranous, 307. oedematous, 301. pseudo - membranous, 307. tubercular, 303. Laryngospasm, 304. 428 INDEX. Larynx, diseases of, 300. Leptomeningitis, acute spinal, 372. chronic spinal, 374. Leucaemia, 151. lymphatica, 152. myelogenica, 152. splenic, 152. Leucocythsemia, 151. Leucocytosis, 152. Lightheadedness, 211. Line, gingival, 95. Liver, abscess of, 248. acute parenchymatous degen- eration of, 255. yellow atrophy of, 255. albuminoid, 252. amyloid, 252. cancer of, 253. cirrhosis of, 250. congestion of, 247. diseases of, 245. fatty degeneration of, 253. gin-drinkers', 250. hob-nailed, 250. hydatids of, 254. lardaceous, 252. nutmeg, 248. scrofulous, 252. stones, 258. syphilitic, 251. waxy, 252. Lockjaw, 86. Locomotor ataxia, 380. Lumbago, 103. Lumbodynia, 103. Lunacy, 402. Lungs, atelectasis of, 322. cirrhosis of, 333. congestion of, 321. diseases of, 311. oedema of, 321. tuberculosis of, 94. Lymph, Koch's, 97. Lympho-sarcoma, 152. Lypemania, 412. Lysis, 9, 18. Madness, raving, 407. Mai, haut, 348. le grand, 348. le petit, 348. Malaria, 46. Malaria, acute, 47. chronic, 50. masked, 48. pernicious, 49. treatment of, 52. Malarial fevers, 46. Malasma suprarenale, 162. Malignant intermittent fever, 49. jaundice, 255. pustule, 89. remittent fever, 49. sore throat, 77. Malingering, 350. Mania, 405. acute, 407. delirious, 405. chronic, 408. Marsh fever, 48. Measles, 64. black, 65. false, 67. French, 67. German, 67. hemorrhagic, 65. malignant, 65. Medication, internal, in fevers, 22. Medicine, practice of, 8. science of, 7. Mediterranean fever, 44. Megrim, 358. Melaena, 208. Melansemia, 51. Melancholia, 412. attonita, 413. hypochondriacal, 412. Melituria, 114. Membrane, false, 78. Meningitis, acute cerebral, 385. spinal, 372. basilar, 386. chronic spinal, 374. epidemic cerebro-spinal, 30. hysterical, 31. tubercular, 386. Mensuration, 290. Mercurialism, 175. Metastasis, 84. Micrococcus erysipelatis, 71. intracellularis menin- gitidis, 32. pneumoniee, 328. Migraine, 358. INDEX. 429 Milk, preparation of, 223. Mind, 402. Mogigraphia, 363. Monomania, 409. Morbilli, 64. Motion, 343. Month, abscess of floor of, 187. cancer in, 174. catarrh of, 164. diphtheria of, 167. diseases of, 164. gangrene of, 172. hemorrhage from, 174. inflammation of, 164. nlcers of, 168. white, 169. Mucus, test for, 265. Muguet, 169. Mumps, 84. Murmurs, cardiac, 121. diastolic, 121. functional, 121. organic, 121. presystolic, 131. systolic, 121. hsemic, 130. table of cardiac, 121. vesicular, 292. Myalgia, 103. Myelitis, acute, 375. anterior cornual, 377. chronic, 379. diffuse, 376. focal, 376. Myocarditis, 127. Myotonia, congenital, 354. Nackenstarre, 30. Nephritis, acute desquamative, 268. tubal, 268. chronic desquamative, 269. chronic interstitial, 271. tubal, 269. parenchymatous, 268, 269. peri-, 276. pyelo-, 274. Nephro-lithiasis, 279. Nerve-action, reflex, 342. Nerves, diseases of, 365. Nervous system, the, 342. Neuralgia, 354. Neuralgia, cervico-brachial, 356. occipital, 356. intercostal, 356. lumbo-abdominal, 356. of heart, 136. intestines, 232. stomach, 209. trifacial, 355. Neurasthenia, 362. Neuritis, 365. ascendens, 366. chronic, 367. descendens, 366. disseminated, 367. multiple, 367. optic, 399. peripheral, 367. Neuroses, the, 346. Neurosis, 346. Night-sweats, 94. Noma, 172. Non-infectious diseases, 103. Nose, acute catarrh of, 295. chronic catarrh of, 296. diseases of, 295. Nystagmus, 346, 382. Obstruction, aortic, 132. intestinal, 230. mitral, 131. pulmonic, 133. pyloric, 206. tricuspid, 133. (Edema of glottis, 301. lungs, 321. Oesophagitis, 190. (Esophagus, dilatation of, 191. diseases of, 189. stricture of, 190. Oidium albicans, 170. lactis, 170. Oposthotonos, 31. Oreillous, 84. Orthotonos, 31. Oxyuris vermicularis, 237. Ozena, 297. Pachymeningitis, cerebral, 388. spinalis, 375. Palpation, 291. Palpitation, cardiac, 135. Palsy, BelPs, 370. Landry's 378. 430 INDEX. Palsy, shaking, 360. writers', 363. Pancreas, cancer of, 244. diseases of, 244. Pancreatitis, 244. Pantophobia, 412. Papoicl, 197. Paralysis, acute spinal, 377. of adults, 377. agitans, 360. ascendens, acuta, 378. atrophic spinal, 377. chronic dif- fused, 379. diphtheritic, 79. essential, of children, 377. facial, 370. general, of insane, 417. Landry's, 378. of bladder, 287. Paranoea, 409. Paraplegia, 376. Parasites, intestinal, 235. renal, 281. Paresis, 365. Parkinson's disease, 260. Parotitis, 84. idiopathic, 84. symptomatic, 84. Pasteur's virus, 89. Pathology, 9. Pectoriloquy, 294. Percussion, 291. respiratory, 292. Pericarditis, acute, 139. chronic, 140. dry, 140. Pericardium, diseases of, 139. Perinephritis, 276. Perineuritis, 365. Periproctitis, 219. Peritoneum, diseases of, 239. Peritonitis, 239. Perityphlitis, 216. Pertussis, 81. Petit mal, 348. Pharyngitis, acute, 177. chronic, 179. follicular, 179. herpetic, 180. phlegmonous, 181. sicca, 181. Pharyngitis, tubercular, 180. Pharynx, catarrh of, 177. diseases of, 177. herpes of, 180. syphilis of, 185. Phlebitis, 144. Phosphates, tests for, 265. Phthisis, acute, 92. chronic, 94. fibroid, 333. laryngeal, 303. miner's, 333. pneumonic, 332. tubercular, 94. Pill acetanilide comp., 27. Plague, bubonic, 35. Levantine, 35. Oriental, 35. the, 35. Plantar reflex, 345. Pleura, diseases of, 335. Pleurisy, acute, 335. chronic, 338. dry, 336. Pleuritis, acute, 335. chronic, 338. Pleurodynia, 103. Pleuro-pneumonia, 330. Pneumonia, 328. caseous, 332. catarrhal, 316. chronic, 332. croupous, 328. lobar, 328. lobular, 316. scrofulous, 332. typhoid, 329. Pneumonitis, 328. Pneumothorax, 340. Poliomyelitis anterior acuta, 377. chronic, 379. Polya?sthesia, 343. Polyneuritis, 367. Polyuria, 113. Pox, 98. Predisposition, 8. Prevention of contagion, 21. Proctitis, 217. chronic, 218. Prognosis, 10. Prophylaxis of contagious diseases, 21. Pseudo-leucaemia, 152, INDEX. 431 Psychoses, 402. Psychrophobia, 89. Ptomaine, 20. Ptyalism, 175. Pulmonic insufficiency, 133. stenosis, 133. Pulse, Corrigan's, 131. dichrotic, 331. water-hammer, 131. Pupil, Argyll-Robertson, 381. Purpura, 158. hsemorrhagiea, 158. rheumatica, 158. simplex, 158. urticans, 158. Pustule, malignant, 89. Putrid fever, 32. Pyaemia, 156. Pyelitis, 274. Pyelonephritis, 274. Pylephlebitis, adhesive, 256. suppurative, 256. Pyonephrosis, 275. Pyrexia, 17. Pyrosis, 210. Quinsy, 181. acute, 181. blind, 182. chronic, 182. Rabies, 87. Rachitis, 107. Rales, 293. Reaction of degeneration, 344. Reactions, electrical, 343. Rectitis, 217. Rectum, catarrh of, 217. Reflex, abdominal, 345. cremasteric, 345. gluteal, 345. plantar, 345. scapular, 345. Reflexes, 345. cutaneous, 345. tendon, 345. Regurgitation, aortic, 131. mitral, 130. piilmonic, 133. tricuspid, 132. Resonance, vocal, 294. Respiration, 293. Cheyne-Stokes, 293. Respiration, puerile, 292. Rheumatism, acute, 109. gonorrhceal, 113. inflammatory, 109. muscular, 103. Rhinitis, acute, 295. chronic, 296. dry, 297. moist, 297. Ribs, beaded, 108. Rickets, 107. Risus sardonicus, 86. Rosary, rickety, 108. Rose, the, 69. Rose-cold, 299. fever, 299. Roseola, 67. Rotheln, 67. Rubella, 67. Rubeola, 67. Salivation, 175. Saprasmia, 153. Scapular reflex, 345. Scarlatina, 60. anginosa, 62. maligna, 62. simplex, 61. Scarlet fever, 60. Sciatica, 368. Sclerosis, antero-lateral spinal, 379. cerebro-spinal, 382. disseminated, 382. insular, 382. multiple spinal, 382. posterior spinal, 380. spinal, 379. Scorbutus, 159. Scurvy, infantile, 159. land, 158. sea, 159. Sensation, 343. Senses, localization of, 342. Septicaemia, 154. Shaking palsy, 360. Ship fever, 32. Sickness, green, 150. Side, stitch in the, 103. Signs, physical, 289. Smallpox, 55. black, 55. confluent, 57. discrete, 56. 432 INDEX. Softening of the brain, 392, 393. Sore throat, clergymen's, 179. syphilitic, 99. Spinal cord, diseases of, 372. inflammation of, 375. meningitis, 372. Spirillum cholerae, 73. Spirochete Obermeieri, 29. Spirometer, 290. Spleen, amyloid, 262. congestion of, 261. diseases of, 261. hypersemia of, 261. hypertrophy of, 262. Splenification, 322. Splenitis, 261. Sponging, cold, 22. Spotted fever, 30. Sprew, 169. St. Anthony's fire, 69. St. Vitus's dance, 346. Static electricity, 344. Stenosis, aortic, 132. mitral, 131. pulmonic, 133. pyloric, 206. tricuspid, 133. valvular, 130. Stomach, cancer of, 203. catarrh of, 193. cirrhosis of, 207. dilatation of, 206. diseases of, 193. hemorrhage from, 208. hypertrophy of, 207. neuralgia of, 209. Stomach, ulcer of, 200. Stomatitis, 164. aphthous, 166. chronic, 164. croupous, 166. erythematous, 164. follicular, 166. parasitic, 169. simple, 164. ulcerative, 167. vesicular, 166. Stools, rice-water, 74. Streptococcus pyogenes, 156. Strychnine in tuberculosis, 96. Stupid fever, 32. Succussion, 294. Sugar, qualitative tests for, 264. Sugar, quantitative tests for, 116. Summer complaint, 222. diarrhoea, 224. Sun-stroke, 400. Suprarenal capsule diseases, 162. Symptoms, 9. objective, 9. pathognomonic, 9. prodromal, 9. subjective, 9. Synache maligna, 77. Syncope, 211. Synochus, 23. Synonyms, 8. Syphilis, 98. cerebral, 100. hepatic, 251. pharyngeal, 185. System, the nervous, 242. sympathetic, 242. Systole, 120. Tabes dorsalis, 380. Taenia echinococcus, 254. medioeanellata, 235. saginata, 235. solium, 236. Tape-worm, 236. Temperature, 17. rectal, 18. Tendon reflex, 345. Tests for albumin, 263. bile, 265. chlorides, 265. hydrochloric acid, 204. lactic acid, 204. mucus, 265. phosphates, 265. sugar, 264. uric acid, 265. Tetanus, 86. idiopathic, 86. neonatorum, 86. traumatic, S6. Throat, acute sore, 177. clergymen's sore, 179. follicular sore, 179. malignant sore, 77. putrid sore, 77. Thrombosis, cerebral, 396. Thrush, 169. Tic-doulouroux, 355. Tongue, inflammation of, 171. INDEX. 433 Tongue, psoriasis of, 171. Tonsilitis, acute, 181. chronic, 182. Tonsils, herpes of, 186. hypertrophy of, 182. inflammation of, 181. Tophi, 106. Tormina, 232. Treatment, 10. alkaline, 112. Trichocephalus dispar, 235. Tricuspid insufficiency, 132. stenosis, 133. Trismus, 86. Tropseolin paper, 204. Trophic changes, 344. Tuberculin, 97. Tuberculosis, 91. acute, 92. chronic, 94. external, 91. internal, 91. laryngeal, 303. medical, 91. miliary, 92. pulmonary, 94. renal, 278. staining of bacillus, 92. surgical, 91. Tumors, cerebral, 398. Typhlitis, 215. Typhoid fever, 37. walking, 40. Typhomalaria, 49. Typhomania, 405. Typhus, 32. abdominal, 37. apoplectic cerebral, 30. cerebrospinal, 30. icterodes, 44. Ulcers, duodenal, 214. gastric, 200. of intestine, 229. mouth, 168. rectum, 218. Ulcers, phagedenic, 173. syphilitic, 99, 169. Uraemia, 266. Urine, 263. composition of, 263. incontinence of, 286. retention of, 288. Uvula, elongated, 179. Vaccination, 58. Valvular diseases, 130. Varicella, 54. Variola, 55. confluent, 57. discrete, 56„ hemorrhagic, 57. malignant, 57. mitigated, 57. Varioloid, 57. Vermiform appendix, inflammation of, 215. Vertigo, epileptic, 348. stomachic, 211. Voice, the, 294. Vomit, coffee-ground, 204. faecal, 230. Wet-pack, 23. Whooping-cough, 81. Winter cough, 314. Worms, intestinal, 235. round, 236. seat, 237. tape, 236. thread, 237. Writers' cramp, 363. palsy, 363. Wry-neck, spasmodic, 104. Wunderlich, ambiguous period of, 39. Yellow fever, 44. Jack, 44. Ziegenpeter, 84. Ziehl's solution, 92. ,"- H 246 83 ; i - **U A* *■ o • * ;• * v ^ -A 6* n3 i? *>, , * A V <* • # t • ^ v ** v ••^B?/ *v *- *°+ .0° ** V * •> • * 4^ .• ^ 4y* ** • L**f tf<^ aV^. ,^^