¿ 1 ! B 477827 DUPL I Leta ARTES LIBRARY 1837 VERITAS 'Spropeles UNIVERSITY OF MICHIGAN E PLURIBUS UNUM SCIENTIA TUE BUR OF THE SI-QUAERIS PENINSULAM AMOE NAMU CIRCUMSPICE PARLARZAIJA VASARADARANYA PAZ AJAUN ASPADA JASHARA AVANZAROM HOMOEOPATHIC LIBRARY и что is no f Bought mor, Y. V #616.08 *24 1882 1 3 } SPECIAL PATHOLOGY AND DIAGNOSTICS WITH THERAPEUTIC HINTS NEW YORK: 145 GRAND STREET. BY C. G. RAUE, M.D. SECOND EDITION REWRITTEN AND ENLARGED. AUDE BOERICKE & TAFEL: PHILADELPHIA: 1011 ARCH STREET. LONDON: TRÜBNER & Co., LUDGATE HILL. LONDON: HOMEOPATHIC PUBLISHING CO., No. 2 FINSBURY Circus. 1882. F I : 1 · Copyright, C. G. Raue, 1881. PRESS AME PHILADELP 1 • 12 X R میں 34 Sha TO MY STUDENTS, NEAR AND FAR, IN WHOSE BEHALF THE FIRST EDITION WAS ELABORATED, AND TO THE MEMORY OF OUR MUTUAL FRIEND AND TEACHER, CONSTANTINE HERING, THIS SECOND EDITION IS DEDICATED. ? PREFACE TO SECOND EDITION. THE first edition had become old; it needed renovation. The pathological views had changed so grievously since its appearance, that a re-statement of the same through- out the work became a necessity. Not so, however, the therapeutic hints. They are as true to-day as they were when written years ago, and, I am happy to say, have been reliable guides at the bed- side to many physicians, and also a fruitful source, ac- knowledged or not, to many writers in journals and of books. What I had to do with these hints was this: to express their meaning still more accurately, to enlarge their spheres, and to add such new facts as the experi- ence of others and my own would admit. This has aug- mented to a considerable extent even the therapeutic part of the work, and thus I may state in truth, that this second edition is re-written for the most part, that it is greatly enlarged and, I hope, also greatly improved. Although I have given credit in the text to the several authors from whom I have drawn, it may be well to mention the principal sources for the pathological part: von Ziemssen's Cyclopædia, Frerich's Diseases of the Liver, Walton's work on the Eye and von Troelsch's work on the Ear. Compare also the introductory remarks to the first edition. The therapeutic hints I have selected from the entire homœopathic literature, using all such indications as I deemed reliable and characteristic. 230175 (5) vi PREFACE. The chapter on the eye has been kindly and carefully overhauled in the manuscript by Dr. G. S. Norton, and that on the ear by Drs. G. S. Norton and Henry C. Houghton; their valuable notes will be found credited to them in the text. The arrangement is the same as that of the first edition. Although great pains have been taken to avoid clerical errors, nevertheless some have crept in, for instance, saly- cilic for salicylic and others. Wherever you find them, please correct them. C. G. RAUE. Philadelphia, 121 North Tenth St., in the month of September, 1881. 1 INTRODUCTORY REMARKS TO FIRST EDITION. WHEN I was called upon to lecture on Special Pathol- ogy and Diagnostics, about four years ago, I looked around for a work which would furnish the essential points of these branches of medical education, together with Homœopathic Therapeutics, in a concise manner and up to the latest researches; but I looked in vain. I was obliged to prepare my own materials. The result of these labors seemed, in the estimation of my pupils and indulgent friends, worthy of a more permanent form and a wider diffusion than oral teaching affords. In its preparation I have consulted the best recent as well as older works on the different subjects contained herein: Virchow, Rokitansky, Vogel, Griesinger, Hasse, Wintrich, Bamberger, Simon, Niemeyer, Bock, Bednar, Hübner, Küttner, Wagner, Skoda, Hebra, Wilson, Da Costa, Hughes, Barclay, Bryan, Hammond; Hahnemann, Hering, v. Boenninghausen, Rückert, Oehme, Hartmann, Jahr, v. Grauvogl, Müller, Meyer, Baehr, Kafka, Ludlam, Hale, Wells, Dunham, and others; New York Homœo- pathic Transactions and various journals. I have made free use of all of them as far as they suited my purpose, but have not followed any one exclusively. The ar- rangement, selection and elaboration of the whole are my own. The composition, however, would have un- avoidably contained many Germanisms had they not been expurgated. I am indebted to Dr. G. R. Starkey, formerly Professor of Surgery in the Homœopathic Col- lege of Pennsylvania, for his kind offices in correcting J - (7) viii INTRODUCTORY REMARKS. the manuscript so as to render it more agreeable to the English ear. This book does not pretend to be a special Therapia, because, as v. Grauvogl already remarks: "It is impossible to prepare a complete, special Therapia for any so-called dis- ease; just as impossible as to describe all human beings of all times, because the conditions of getting sick change constantly in the course of time." What the genius epidemicus re- quires, for example, in an epidemic of whooping-cough at this season may not answer at all for a like epidemic of next year. Hence, my intention has been to give only therapeutic HINTS. These hints I have carefully selected out of the rich treasury of our Homœopathic literature, and I have added the results of my own experience. But all this does not make it perfect. Many a colleague, on opening the book and glancing over this or that chapter, will miss one or another remedy which he has been ap- plying successfully in a certain form of disease. It lies in the nature of such a work that this must be so. On being informed, however, of such remedies and their characteristic indications, the author would be happy to receive and apply them. This book does not give any prescriptions in regard to the dose, because that is still an open question, and must be left entirely to the free judgment of the practitioner. My hints are collected from all sorts of observations, with low, middle, high and highest potencies. I, myself, pre- fer the higher potencies; and it is possible that the more accurately we individualize the more we may become in- clined to choose the highest. Others may think differ- ently. So much is certain, that there are undoubted facts which seem to favor both sides of the question. Cases are recorded in which low potencies were given in vain, and a higher one of the same remedy at once effected a cure, and vice versa. Judge then for thyself. THE AUTHOR. CONTENTS. HEAD. DISEASES OF THE BRAIN AND ITS MEMBRANES. Anæmia, Hyperæmia, Vertigo, Sleep, Stupor, Insomnia, Meningitis tuberculosa, Hydrocephalus acutus, Leptomeningitis infantum, Hydrocephalus acutus sine tuberculosis; simple Meningitis, Simple meningitis of the base, Meningitis of the convexity, Metastic meningitis, Traumatic meningitis, Hydrocephalus chronicus, Hydrocephalus congenitus, Hydrocephalus senilis, . Meningitis cerebro-spinalis epidemica, spotted fever, Pachymeningitis, inflammation of the dnra mater, Encephalitis, abscess of the brain, red and white softening of the brain, Insulatio, sunstroke, thermic fever, Apoplexia sanguinea, Occlusion of the cerebral arteries, embolism and thrombosis, softening of the brain, Atrophy of the brain, Dementia paralytica, Senile dementia, Aphasia, Thrombosis of the cerebral sinuses, Hypertrophy of the brain, Delirium tremens, Chronic alcoholism, dipsomania, Opium and morphine poisoning, Tumors of the brain and its membranes, D } 33 36 41 52 58 IINN*** 60 62 62 63 68 68 70 70 75 76 78 81 ****** 89 93 94 96 98 103 106 110 111 (ix) X CONTENTS. a. Abnormal largeness of the head. Dropsy of the scalp, Hypertrophy of the skull, The bruised head of a child after birth, b. Abnormal smallness. DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. c. Affections of the skull without enlargement. Atrophy of the skull, d. Diseases of the integuments. Erysipelas of the scalp and face, Eczema capitis, humid tetter or scald, Impetigo, Dandruff, Seborrhoea capillitii, The hair. Favus, honey-comb ringworm, tinea favosa or maligna, porrigo favosa or lupinosa, Tinea, herpes tonsurans, or ringworm of the scalp, The wen, Teleangiectasia, or vascular nævus, mother's mark Alopecia, Baldness, Change in color, Plica palonica, matted hair, General observations, Lids and Lachrymal Apparatus. Inflammation of the eyelids, Hordeolum, Tumors of lids, Dacryocystitis, Blennorrhoea of lachrymal sac, Conjunctiva. Catarrhal ophthalmia, Purulent ophthalmia, Gonorrhoeal ophthalmia, Ophthalmia neonatorum, Granular ophthalmia, Phlyctenular ophthalmia, Diphtheritic conjunctivitis, Croupous conjunctivitis, Pterygium, EYES. 114 115 115 117 118 122 123 125 126 126 128 128 128 129 129 130 130 131 131 136 137 138 139 140 142 143 143 145 147 150 150 151 CONTENTS. xi Cornea. Corneitis, Keratitis, Abscess of cornea, Onyx, Iris. Hypopion, Staphyloma, Sclerotica. Scleritis, Sclerotitis, Iritis, Choroidea. Choroiditis, Glaucoma, Optic Nerve and Retina. Neuro-retinitis, Hemiopia, Hemeralopia, night-blindness, Hyperesthesia retina, Lens. Cataract, Sight. Refraction and accommodation, Presbyopia or old sight, Hypermetropia, Myopia or short-sightedness, Astigmatism, . Asthenopia, Muscles and Nerves. Mydriasis, Myosis, Ptosis, falling of upper lid, Strabismus, squint, Nystagmus, trembling of eyeballs, Luscitas, or fixed state of eyeball, Morbid winking, Twitching of lids or quivering, Blepharospasm, Neuralgia of eye, Orbit. • • Orbital cellulitis, Basedow's or Grave's disease; exophthalmic goitre, • 152 153 153 153 154 157 158 161 163 166 168 169 169 170 172 174 175 175 176 177 179 179 180 180 181 182 182 182 182 183 184 184 xii CONTENTS. Analogy between ear and eye, General observations on ear, Auricle. Eczema, • The Middle Ear. Auditory canal and drumhead or membrana tympani. Examination of these parts, Earwax diminished or increased, Furuncles of external canal, Otitis externa, or diffuse inflammation of the auditory canal, • Examination of the middle ear, Otitis media, Chronic forms of otitis media, Polypi, Nervous deafness, Menière's disease, Tinnitus aurium, Otalgia nervosa, • • • General observations, Erysipelas of face,. Crusta lactea, milk crust, Its external parts, EARS. General observations, Examination of the cavity of the nose, Catarrh, coryza, cold in head, Chronic catarrh, ozæna, Comedo, acne punctata et rosacea, Lupus, Ulcus rodens and epithelioma, • Influenza, grippe, . Yearly cold, rose cold, hay fever, hay asthma, Epistaxis, nosebleed, Polypi in nose, Inflammation of the nose, NOSE. FACE. • MOUTH. 188 189 190 191 193 195 196 197 202 207 212 213 214 215 216 217 219 220 . 225 229 231 232 234 234 235 239 239 241 242 242 244 CONTENTS. xiii The Gums. Parulis, gumboil, inflammatory swelling of the gums, Epulis, a kind of fungoid growth on the gums, Fistula of the teeth, The Teeth. Odontalgia, toothache, Swelled face from toothache, The Tongue. * Its color, Its humectation, Its temperature, Its covering and coating, Its form and size, Cracks and fissures, Paralysis, Glossitis, inflammation of tongue, Cancer of tongue, • The Salivary Glands and their Ducts. Saliva, Parotitis, Ranula, frog, The Tonsils. Inflammation of tonsils, amygdalitis, tonsillitis, angina tonsillaris, The Uvula, Soft Palate and Fauces. Angina faucium, angina catarrhalis, sore throat, Chronic sore throat, angina granulosa or follicularis, Ulcers in the fauces, ulcerated sore throat, Retro-pharyngeal abscess, Deep inflammation of the connective tissue of the throat; angina Lud‹ - vici, · General observations, Bronchocele, stroma or goitre, The Mucous Membrane of the Mouth in General. Parasitic sore mouth of infants, thrush, Stomatitis ulcerosa, ulcers in the mouth, Diphtheria, diphtheritis, Noma, gangrene of the cheeks, • · NECK. • 245 245 246 248 265 266 266 267 267 268 269 269 270 272 273 274 277 278 281. 283 286 287 288 289 291 294 306 307 308 xiv CONTENTS. Esophagus. Esophagitis, dysphagia inflammatoria, . Stenosis œsophagi, narrowing of the oesophagus, Dilatation of the œsophagus, Larynx and Trachea. Auscultation, Laryngoscopy, • Acute catarrhal laryngitis, catarrh of larynx, Laryngitis catarrhalis chronica, Croup, Edema glottidis, oedema laryngis, Perichondritis laryngea, Phthisis laryngis, tubercular ulceration, Syphilis laryngis, . Neoplasms of larynx, Neuroses of the larynx, Hyperesthesia and neuralgia, Paralysis, Spasm of the glottis, Inspection, Palpation, Percussion, Auscultation, • · Pleura. • THORAX. Affections of the Bronchial Tubes. Bronchitis, bronchial catarrh, Tussis convulsiva, pertussis, whooping cough, Bronchial asthma, asthma bronchiale nervosum seu convulsinum, Affections of the Pulmonary Parenchyma. Pneumonia, Pulmonary consumption, phthisis, Acute miliary tuberculosis, Emphysema pulmonum, Hyperæmia and oedema of the lungs, Gangræna pulmonum, Hæmorrhage of lungs, hæmoptoë, hæmoptysis, Pleuritis, pleurisy, inflammation of the pleura, Pneumothorax, Hydrothorax, dropsy of the chest, Hæmatothorax, • 309 311 312 314 315 317 320 322 327 329 330 332 332 333 334 334 336 339 342 346 351 365 376 380 385 394 403 405 409 411 412 415 424 426 429 CONTENTS. XV Auscultation, Diseases of the Pericardium. Pericarditis, inflammation of the pericardium, Hydropericardium, dropsy of the pericardium, Diseases of the Endocardium. Endocarditis, Insufficiency of the mitral valves, Constriction or stenosis of left auriculo-ventricular opening, Insufficiency of the aortic valves, Constriction or stenosis of the aortic opening, Insufficiency of the tricuspid valves, Stenosis of the right auriculo-ventricular opening, Insufficiency of the pulmonary valves, Stenosis of the pulmonary opening, Heart clots, Nervous Affections of the Heart. Diseases of the Heart-Muscle. Myocarditis, carditis, inflammation of the heart-muscle, Hypertrophy and dilatation of the heart, Fatty heart and fatty degeneration of the heart, Diseases of the Aorta. Nervous palpitation of the heart, Angina pectoris, stenocardia, THE HEART. Diaphragm. Aneurism of the thoracic aorta, General observations, Stomach. Diaphragmitis or inflammation of the diaphragm, Singultus, hiccough, Neuralgia, Rupture and Perforation, Dyspepsia, indigestion, Vomiting, Acute catarrh, gastritis, Chronic catarrh, Gastritis toxica seu caustica, • ABDOMEN. 430 438 443 444 447 448 449 450 450 451 451 451 453 454 454 456 458 461 464 466 467 468 468 469 472 474 475 479 481 xvi CONTENTS. Gastralgia, cardialgia nervosa, cramp of stomach, Ulcus ventriculi perforans or rotundum, chronicum, the round perforat- ing ulcer of the stomach, Carcinoma or scirrhus ventriculi, cancer of stomach, Hæmorrhage from the stomach, hæmatemesis, Gastromalacia, softening of the stomach, Intestinal Canal. Catarrhus intestinalis, enteritis catarrhalis, intestinal catarrh, Chronic intestinal catarrh, Typhlitis, perityphlitis and inflammation of the vermiform process, Proctitis, catarrhal inflammation of the rectum, Periproctitis, Dysentery, Cholera, Cholera morbus or nostras or Europea, Cholera infantum, Summer complaint, Constipation, Hernia, internal and external strangulation, Tersion or twisting of the bowels, Intussusception, invagination, Ileus, miserere, Hæmorrhagia intestinalis, intestinal hemorrhage, malæna, Hæmorrhoids, piles, Flatulency, bloatedness, meteorism of the abdomen, Colica, enteralgia, Tuberculosis intestinalis, consumption of bowels, Cancer of the intestines, Polypus of rectum, Fissura ani, Fistula recti, Prolapsus recti, Proctalgia, Intestinal worms, entozoës, helminthes, Trichina spiralis, Trichinosis, Peritoneum, Peritonitis, Oxyuris vermicularis, thread, seat or pin-worm, Ascaris lumbricoides, round worm, Tape worms, Tricocephalus dipar, Anchylostomum duodenale, dochmius s. strongylus duodenalis, > Liver. Ascites, dropsy of the peritoneum, Tympanites abdominalis, • • • Physical examination, Pigment liver, melanæmic liver resulting from malarial fever, Hyperæmia, congestion of the liver, 482 486 490 495 498 500 503 506 510 512 513 519 527 529 529 535 540 543 544 545 546 547 554 555 563 564 565 565 566 568 569 569 569 570 572 576 576 577 579 584 584 588 592 592 593 594 CONTENTS. xvii Peri-hepatitis, inflammation of the capsule of the liver and of Glisson's capsule, Hepatitis vera circumscripta s. suppurativa, Cirrhosis, hob-nail liver, interstitial inflammation, gin-drinkers' liver, . Syphilitic inflammation of the liver, Acute yellow atrophy, Hepar adiposum, fatty liver,. Colloid, lardaceous, warty liver, amyloid degeneration, Carcinoma hepatis, cancer of the liver, Hydatids of the liver, Echinococcus cysts, Catarrhal inflammation of the biliary passages, Cholelithiasis, gall-stones, Thrombosis and occlusion of the portal vein; pylethrombosis; pyle- phlebitis adhæsiva chronica, Diseases of the Spleen. Phlebitis suppurativa, purulent inflammation of the portal vein, Icterus, cholæmia, jaundice, Diseases of the Pancreas. Physical examination, Anatomical peculiarities of the spleen, Hæmorrhagic infarction, splenitis, lienitis or inflammation of the spleen, Acute tumor, or hyperæmia of the spleen, Chronic tumor, or hypertrophy of the spleen, Cancer of the spleen, Echinococcus cysts, Rupture of the spleen, Diseases of the Kidneys. Pancreatitis, inflammation of the pancreas, Fatty disease of the pancreas, Cancer of the pancreas, • • · Examination of urine, Diabetes, mellituria, glycosuria, Diabetes insipidus, • • · • Hæmaturia, passing blood with the urine, Albuminuria, > • Uræmia, . Acute parenchymatous nephritis, Chronic parenchymatous nephritis, Interstitial inflammation or induration of the connective tissue of the kidneys, Amyloid degeneration of the kidneys, lardaceous or waxy kidneys, Suppurative nephritis, renal abscess, Nephrolithiasis, renal gravel or calculi, nephralgia, colica renalis, Pyelitis, inflammation of the renal pelvis, Perinephritis, paranephritis, inflammation of the renal capsule, Morbus Addisonii, . 596 597 600 602 603 605 606 607 609 611 612 616 617 618 625 627 627 629 630 631 631 631 633 633 633 634 642 651 652 656 657 658 663 667 671 673 673 676 677 678 2 xviii CONTENTS. Diseases of the Bladder. Cystitis, inflammation of the bladder,. Calculi vesicæ, stones in the bladder, Hyperæsthesia or irritability of the bladder; spasm of the bladder, Atony, paresis, paralysis of the bladder, Enuresis nocturna, . Venereal Diseases. Gonorrhoea, Complications and sequelæ, Epididymitis; orchitis, ORGANS OF GENERATION. • MALE GENITALS. Prostatis gonorrhoica, inflammation of the prostata, Gonorrhoea vesicæ, Buboes, Ophthalmia gonorrhoica, Gonorrhoea of the rectum, Strictures of the urethra, Gonorrhoeal rheumatism, • General contamination of the system, Balanitis, gonorrhoea spuria or præputialis, Chancre, Constitutional syphilis, Condylomata, sycosis, fig-warts, Inguinal bubo, Syphilitic skin diseases or syphilides, Macular syphilide, Papular syphilide, Squamous syphilide, Lichen syphiliticus, Pustular syphilide, Tubercular syphilides, Alopecia, Alterations of nails, Syphilitic affections of the mucous membranes, Syphilitic affections of the periosteum, of the bones and cartilages, Syphilitic contractions of muscles and tendons, Gummata in the subcutaneous and submucous cellular tissue, Syphilitic affections of inner organs, Syphilis congenita seu hereditaria, • Diseases of the Testes. Hydrocele, Orchitis, inflammation of the testicles, Sarcocele, Hydrosarcocele, Carcinoma testes, Varicocele, Spermatocele, . 680 686 688 689 691 693 699 699 699 700 700 700 700 700 701 701 702 702 705 712 713 715 715 715 716 716 717 718 718 718 719 719 720 720 721 721 722 724 725 725 725 726 CONTENTS. xix Diseases of the Prostata. Prostatitis, inflammation of the prostate gland, Enlargement and tumors of the prostata, Diseases of the Vesicula Seminales. Pollutiones nocturnæ et diurnæ; spermatorrhoea, Impotence; sterility in the male, Aspermatism, Azoöspermatism,. Examination of the parts, Ovaries. Uterus. Oophoritis, Ovaritis, Hydrops ovarii, ovarian dropsy; formation of cysts in the ovaries, FEMALE GENITAL ORGANS. Endometritis; catarrh of the uterus; leucorrhoea, . Parenchymatous metritis, Hydrometra, Hæmometra, partial or total closure of the womb, Displacements of the.womb, Anteversion and anteflexion, Retroversion and retroflexion, Prolapsus and procidentia, Inversion, Morbid growths within the womb, Cancer of the womb, Hysteralgia,. Metrorrhagia, hæmorrhage from the womb, Vagina. Menstrual Anomalies. 1. Menorrhagia, 2. Amenorrhoea, 3. Dysmenorrhoea, menstruatio difficilis, Mamma. Catarrh of the vagina, vaginitis, Pruritus vulvæ, Anæmia, Hyperæmia, Mastitis, inflammation of the breast, Scirrhus seu carcinoma mammæ, scirrhus or cancer of the breast, SPINE. 726 727 730 734 735 735 736 737 740 744 751 755 756 757 757 758 759 765 767 771 771 776 778 782 786 787 788 790 793 794 XX CONTENTS. Apoplexy, or extravasation of blood, Spinal irritation, Neurasthenia spinalis, spinal nervous weakness, Hydrorrhachis congenita, spina bifida, Leptomeningitis spinalis, Myelitis, inflammation of the spinal marrow, Myelomalacia, non-inflammatory softening of the spinal marrow, Multiple sclerosis, Tabes dorsalis, sclerosis of the posterior columns, gray degeneration of the posterior columns, progressive locomotor ataxy, leukomyelitis posterior chronica, Spasmodic spinal paralysis, . Polyomyelitis anterior acuta, acute inflammation of the gray anterior columns (anterior horns), Polyomyelitis anterior subacuta et chronica, subacute and chronic in- flammation of the gray anterior horns, chronic atrophic spinal paralysis, Paralysis ascendens acuta, acute ascending paralysis, Coccyodynia, Motory Apparatus. Rheumatismus, 1. Rheumatismus articulorum acutus, acute rheumatism of the joints; polyarthritis rheumatica acuta, 2. Rheumatismus articulorum chronicus, chronic rheumatism of the joints, 3. Rheumatismus muscularis, muscular rheumatism; Myopathia, my- algia rheumatica, 4. Gout, podagra, arthritis, 5. Arthritis deformans, Rachitis, rickets, Malacosteon; mollities ossium; osteomalacia, softening of the bones, Progressive muscular atrophy, Osteitis, caries, necrosis, exostosis, Tuberculosis of the joints, white swelling, Anatomical Diseases of the Nerves. • Coxarthrocace, coxalgia, hip-disease, Gonorthrocace, tumor albus genu, white swelling of the knee, Bursitis, . Podarthrocace, abscess of the ankle-joint, Malum Pottii, kyphosis, angular curvature of spine, spondylarthrocace, Bunion, Ingrowing toe-nails, NERVES. 1. Neuritis, inflammation of the nerves, 2. Atrophy of the nerves, 3. Hypertrophy and neoplastic formations in the nerves. 794 796 799 800 801 803 806 806 809 813 815 816 816 817 820 820 822 823 831 834 835 837 838 840 842 843 847 849 849 850 851 850 852 852 852 CONTENTS. xxi Functional Diseases of the Nerves. 1. Hyperæsthesia, anesthesia, 2. Neuralgia,. Cephalalgia, hemicrania or migræna, nervous sick-headache, Neuralgia of the trigeminus or fifth nerve, prosopalgia, neuralgia facialis, dolor faciei Fothergillii, tic douleureux, Cervico-occipital neuralgia, Cervico-brachial neuralgia, Intercostal neuralgia, Lumbo-abdominal neuralgia, . Mastodynia, neuralgia of the mammæ, Neuralgia ischiadica, sciatica, ischias postica, malum cotunnii, Crural neuralgia, ischias antica, Anæsthesia, Anesthesia of the trigeminus, Spasm, convulsion, cramp, hyperkinesis, Spasmus facialis, mimic spasm of the face, Hysteria, Trismus and tetanus, Mogographia, graphospasmus, writer's cramp, pianist's cramp, etc., Chorea, St. Vitus' dance, Catalepsy, Epilepsy, Eclampsia acuta, Eclampsia gravidarum et parturientium, puerperal convulsions, Eclampsia infantum, convulsions of children, Tremor, trembling, . Paralysis agitans, shaking palsy, Paralysis, akinesis, Peripheral paralyses, Spinal paralyses, Cerebral paralyses, - Myopathic paralyses, Infantile wasting palsy, essential infantile palsy, Hydrophobia, lyssa, rabies, Leukæmia, Hydræmia, Cyanosis, Dissolution of the red blood-corpuscles, Plethora, Anæmia, oligamia, • • THE BLOOD. Progressive pernicious anæmia, Chlorosis, Hæmophilia, hæmorrhophilia, Scrofulosis, Scurvy, scorbutus, Purpura hæmorrhagica, morbus maculosus Werlhofii 853 854 855 862 866 867 867 868 868 869 873 873 874 875 877 878 878 883 887 891 892 900 901 902 905 906 908 909 909 910 910 915 916 923 924 925 926 927 927 928 930 935 938 939 940 xxii CONTENTS. Clinical thermometry, Crisis and critical days, Intermittent fever, fever and ague, Pernicious intermittent; remittent and continuous malarial fevers; con- gestive fevers, Typhus ambulatorius, Typhus tumulturius, Yellow fever, Dengue or break-bone fever, Typhus, Typhus exanthematicus, petechial typhus, Typhoid fever, typhus abdominalis, ilec-typhus, Abortive typhoid fever, Exanthemata. Measles, morbilli Scarlatina, Scarlatina maligna, typhosa, Pneumo-typhus, broncho-typhus, Relapsing fever, typhus recurrens, The plague, I. Hypertrophy of Skin. Ichthyosis or fish-skin, Angina maligna, Rubeola, Rœtheln, Variola, small-pox, variolois, varioloid, Varioloid, Purpura variolosa, . Varicella, chicken-pox, • • · FEVER. facials, præputialis, Zoster, or Zona, shingles, II. Atrophy of the Skin. III. Hyperæmia and Anaemia of the Skin. IV. Dermatitis, Inflammation of the Skin. 1. Erythema, 2. Herpes, 3. Urticaria, nettle-rash, 4. Eczema, vesicular eruption, 5. Impetigo, pustular eruption, contagiosa, SKIN. 943 945 947 959 961 971 972 972 975 981 981 981 981 996 999 1001 1007 1010 1010 1020 1021 1025 1025 1020 1031 1033 1034 1034 1035 1035 1036 1038 1041 1041 CONTENTS. xxiii 6. Ecthyma, isolated, large pustules, 7. Pemphigus, pompholyx, isolated large bullæ, 8. Rupia or rhypia, isolated blisters which form crusts, 9. Furuncles, boils, 10. Carbuncles, 11. Pustula maligna, malignant pustules, 12. Epithelioma, epithelial cancer, 13. Panaritium, paronychia, whitlow, run-around, felon, 14. Psoriasis, 15. Lichen, 16. Prurigo, pruritus, 17. Scabies, itch, 18. Prairie itch, prurigo contagiosa, V. Anomalies in the secretions of the skin. Sudamina, miliary rash,. Prickly heat, Partial hyperidrosis, Comedones, Milium, Atheromata, Molluscum, 1042 1043 1044 1044 1045 1047 1048 1048 1051 1052 1053 1054 1057 1058 1058 1058 1059 1059 1059 1059 S ! · 1 ་ HEAD. DISEASES OF THE BRAIN AND ITS MEMBRANES. Anæmia, A DEFICIENCY in the proper quantity of blood in the brain in general, or of arterial blood in particular. Inspection shows the grayish substance to be paler, or nearly white; and the white substance still whiter than normal on account of the absence of the usual blood-points. The blood-vessels are not entirely empty, though they contain comparatively less blood than usual, while in most cases an increased quantity of serum has been found between the subarachnoid spaces. AS CAUSES, may be mentioned: 1. All influences which bring on general anæmia: blood-letting, hæmorrhages, loss of vital fluids by too long-continued lactation or exhausting diarrhoeas, especially summer-complaint; long-con- tinued fevers, hepatization of the lungs in weakly persons from the constant wasting away of blood and muscles; and starvation, which cuts off all recuperation of the lost vital fluid. 2. Congestion or fluxion of blood to other organs. So may Junod's cupping-boot, an instrument which has been invented in imita- tion of the cupping-glass, to be applied to a whole limb, in order to cause an artificial afflux of blood into it, when used incau- tiously, produce anæmia in the brain, and for the same reason do we find persons of weakened activity of the heart faint more easily in a standing than in a lying position, because then the propelling force is not sufficient to overcome the natural gravity of the blood. We may add the effects of "shock," where, accord- ing to H. Fischer's theory, a reflex paralysis of the vasomotor nerves, especially the splanchnic, causes a collection of blood in 3 34 BRAIN. large quantity in the distended vessels of the abdominal cavity; the fainting away sometimes after the sudden expulsion of the foetus, where the hitherto compressed abdominal vessels fill quickly after the compressing cause is removed; the fainting in consequence of too rapid withdrawal of ascitic fluid for the same reason. 3. Compression or obstruction of the carotid or vertebral arteries— by artificial ligation, tumors or emboli, which prevent the normal afflux of blood to the brain. 4. Spasmodic contractions of these vessels, as is evident in emotions of the mind, from which not only paleness of the face, but also swooning and unconsciousness may result; nervous apoplexy of some writers? 5. Exudations, extravasations, tumors, depressions of the skull, whereby the internal capacity of the skull becoming diminished, the necessary supply of blood to the brain is impossible. Anæmia, when it consists in a deficiency of arterial blood in the brain, is caused by 6. All those states of the system which prevent the normal oxygeniza- tion of the blood, such as different heart and lung diseases. It has been shown by Kussmaul and Tenner that by sudden suppres- sion of respiration, whereby the blood ceases to receive oxygen, the same symptoms are produced which a depletion will bring on. In accordance with these causes the SYMPTOMS vary. In case of sudden depletion we have: sudden paleness of face with cold perspiration on forehead; gaping; slow breathing; ringing in the ears; dimness and flickering before the eyes; nausea, even vomiting; fainting away, which may be attended or followed by epileptiform convulsions. In the gradual development of anæmia the symptoms differ in individual cases more widely; all, however, are characterized by a great paleness of the face. The cerebral disturbances take either the form of depression (mental torpor, drowsiness, somno- lence, coma), or excitation (restlessness, sleeplessness, delirium, a condition mostly observed in cases caused by starvation, and in persons whose general state of anæmia is excessively aggravated by exhausting diseases or loss of blood). Vertigo is frequently present and headache occasionally. Specks and dimness before the eyes is common, and commoner still the ringing and buzzing in the ears; total amaurosis is rare. As regards the motor appa- ratus, we have either great weakness of all the muscles amount- ANEMIA. 35 ing to temporary paralysis, or epileptiform convulsions. The latter rarely happen in the gradual form, while the first, at least as general weakness, is present in almost all cases. The anæmia consequent upon summer-complaint was first and well described by Marshall Hall, who appropriately named it hydrocephaloid, on account of the great similarity of its symptoms to those of hydrocephalus acutus, and by him was divided into two stages—the irritable and torpid. In the first the children are restless; throwing themselves about in bed; starting frequently in sleep, and giving piercing shrieks; they grate their teeth; their face looks red; the pulse is frequent, and the skin hot; and spasms even may occur; thus making the whole resemble very much an acute attack of hydrocephalus. In the second stage, however, the children collapse, become apathetic; do not look at objects held before their eyes; their eyelids are half closed; pupils do not react against the light; their respiration becomes irregular; pulse very frequent and small; they gradually grow cold all over, first in the face; and, in fatal cases, they die with symptoms of coma. THERAPEUTIC HINTS.-In the first place, where the patient suffers with general anæmia, we ought to provide for him a diet which will best supply the lost vital fluids. Especially in sum- mer-complaint, wine and mutton-chops often do more good than medicine. Beef-tea, which principally consists of Potassa combi- nations, produces, according to Pflüger's experiments in small doses, an increase in the frequency and force of cardiac contrac- tions; in large doses it acts as a poison, causing death by appa- rent paralysis of the heart. It ought to be used, therefore, with great caution. In the second place, where the heart's impulse has become weakened, we ought to take care that the patient should lie quiet in a horizontal position, not to allow him to leave the bed too soon, or even to rise for the purpose of using the chamber. The special treatment must be dictated by the conditions of each case; success is possible only when we take each case as a "unicum," and search for its corresponding remedy in the Materia Medica. The symptoms indicating the remedy may lie entirely outside of the group of those symptoms which constitute the diagnosis. In general, however, the following remedies may be mentioned 36 BRAIN. as the most important in anæmic states after loss of vital fluids: Calc. carb., Carb. veg., China, Kali carb., Mercur., Nux vom., Phosphor., Phos. ac., Pulsat., Sepia, Silic., Staphis., Sulphur. Dizziness, vertigo, better in a horizontal position, after eating; worse in the morning, and in the open air; complaint of old people: Ambra, Baryta c., Graphit., Lycop., Phosphor., Silic. Delirium in consequence of great loss of blood: Arnic., Arsen., Ignat., Laches., Lycop., Phosphor., Phosph. ac., Scilla, Sepia, Sul- phur, Verat. Convulsions in consequence of loss of blood: Arsen., Bellad., Calc. carb., Cina, Conium, Ignat., Lycop., Nux vom., Pulsat., Sulphur, Verat. Summer-complaint will find particular mentioning under the head of abdominal disorders. Hyperæmia Of the brain is that state in which it is overcharged with blood, either by active congestion, rush of blood, or fluxion to the brain, or by stagnation of blood in the brain, passive hyperæmia, or hyperæmia by stasis. Post-mortem examination frequently reveals a large quantity of blood in the vessels and sinuses, especially of the dependent parts of the cranial cavity. This may be a mere post-mortem result, since in other cases nothing of the kind is to be seen. The gray substance appears swollen and darker than usual; the white substance presents, in exceptional cases only, a reddish hue. The subarachnoidal mashes contain no fluid. In chronic cases the blood-vessels are almost always dilated; the substance of the brain is atrophied, and the subarachnoid spaces are filled with a large quantity of fluid, especially in the bodies of drunkards. In some cases, however, post-mortem examination does not reveal any such objective signs. On the contrary, the brain appears entirely empty of blood, although during life every symptom pointed to hyperæmia. This fact has not yet been fully explained, and shows that appearances in the dead body do not always clearly reveal what has been going on in the living. Here the question may be asked: Is hyperæmia possible at all? As the brain is encased in an unyielding capsule, how can more blood enter than there is flowing off? To answer this question HYPERÆMIA. 37 we have to point to the cerebro-spinal fluid as a means of regu- lating the intra-cranial circulation. This fluid easily recedes when the cerebral vessels become distended and enters again whenever the pressure subsides, and thus we find it always absent when there is a greater afflux of blood, and present in considera- ble quantity within the meshes of the textus cellulosus sub- arachnoidealis, where there is an anæmic state of the brain. Only when the brain is atrophied, there is also an increase of this fluid besides hyperæmia; and it is wanting again even if there be anæmia present, when the room of the skull is filled by tumors or effusion in the ventricles. As still other means for the regu- lation of the intra-cranial circulation recent researches consider: the perivascular lymph-spaces, the thyroid gland, the peculiar arrangement of the cerebral sinuses and the mechanism of the circle of Willis. - Congestion takes place― 1. In consequence of an undue activity of the serous membranes which, enveloping the brain, act like a suction-pump within the skull. This seems to be the condition of those persons who are subject to "rush of blood to the head." 2. In consequence of obstructions to the flow of blood to other and different portions of the body, whereby it is diverted with increased force towards the brain. We see examples of this condition in compression of the aorta abdominalis by tumors, effusions, or enlarged abdominal viscera; in the contraction of the capillaries of the skin during the chilly stage of intermittent fever; and in the suppression of menstrual and hæmorrhoidal discharges. 3. In consequence of dilatation of the capillaries within the brain; generally the result of the abuse of opium and alcoholic drinks and other narcotic substances; of the exposure to the rays of the sun; of long-continued irritation of the brain by mental over- exertion. 4. In consequence of paralysis of vasomotoric nerves. For example: after cutting through the cervical portion of the sympathicus we find that the blood-vessels of the corresponding side dilate. So have also certain emotions similar effects; by them the normal innervation of the walls of the vessels is altered, they dilate and thus convey a larger mass of blood. This may be the key for the explanation of some sudden deaths which ensue in conse- quence of violent mental emotions, fright or joy. Stagnation or hyperæmia by stasis may be caused— 38 BRAIN. 1. By compression of the jugular veins from strangulation; by goitre, glandular tumors in the neck, or by aneurism of the aorta pressing upon the vena cava descendens. 2. By violent expiratory movements, as take place during violent fits of coughing, straining, and the blowing of instruments; to which also belongs Dr. Bonwill's method of producing a transient state of anæsthesia for the purpose of drawing teeth and perform- ing minor surgical operations, by causing the patient to make rapid and deep inspirations. 3. By diseases of the heart; such as tricuspid insufficiency, stenosis of the venous orifice, and insufficiency of its valves. 4. By some lung diseases, as emphysema, extensive pneumonia, cirrhosis, and large pleuritic exudations; also diseases of the larynx, such as croup, oedema of the glottis and presence of foreign bodies. The SYMPTOMS of hyperæmia are best arranged under two heads, in accordance with its two stages: that of excitability and depression. To the first belong headache, sensitiveness to the light, noise and touch; flickering before the eyes; singing and ringing in the ears; pain and formication in the flesh; restlessness; jerking and automatic motions of the limbs; grating of the teeth; con- vulsions; dizziness; hallucination; sleeplessness and vivid dreams. To the second, the stage of depression, belong insensibility to light, noise or pressure. In this stage also the limbs go to sleep, lose their mobility, and feel heavy as lead; the pupils become dilated; the pulse frequent, and the respiration quite slow, irreg- ular, or snoring; and there is frequent vomiting. These are the general symptoms which vary, however, greatly in individual cases. In some, signs of irritation predominate, such as headache, great sensitiveness of the senses, flickering before the eyes and ringing in the ears; restless, dreamful sleep; redness of face, injected conjunctiva, quick and full pulse. In some persons a cup of coffee or glass of wine brings on such a condition. In place of these external signs of hyperæmia there may be paleness of the face. In other cases, especially those of children during dentition, convulsive motions predominate, from the mere jerking, twitching of single muscles to general convul- sions with loss of consciousness, vomiting, constipation, contrac- tion of pupils, etc. Other cases are characterized by headache, sleeplessness, restlessness, a feeling as if they should go crazy, HYPERÆMIA. 39 delirium, symptoms, mostly brought on by overexertion of the brain. In still other cases we find this mental irritation increased to mania and rage after exposure of the head to the rays of the sun and the abuse of alcoholic drinks, especially in such indi- viduals as use them periodically and then to excess. Still other cases are characterized by depression and paralytic symptoms, which it is often difficult and sometimes impossible to distinguish from apoplectic fits. THERAPEUTIC HINTS.-Rush of blood to the head indicates: Acon., dry and hot skin; the patient is very restless and beside himself; cries and complains much; is impatient and full of anxiety. Amyl. nitr., heat, throbbing and feeling of intense fulness in the head; protruding, staring eyes, throbbing in the ears; flush- ing of the face, choking feeling in throat, along the carotids; tumultuous action of the heart. C Apis, jerking, crying out in sleep; frightful visions with fear and trembling; drowsiness; apathy; if Bellad. did not help. Arnica, head hot, remaining body cool; after a blow or fall. Aurum, heat and roaring noise in the head, fiery sparks before the eyes, worse after mental exertion; fearful and longing for death. Bellad., hot and red face, sparkling eyes, and dilated pupils; throbbing of the carotids; drowsiness with inability to sleep, or drowsy sleep with starting; fearful mood; symptoms are aggra- vated by motion, leaning the head forward, or lying down; by light or sounds. Bryonia, the patient feels as though his brain would burst through the forehead; nosebleed; puffed, red face; great irrita- bility and fits of anger. Calc. carb., the patient is worse in the morning, with puffiness of the face; palpitation of the heart after eating; swelling of the pit of the stomach; after mental overexertion. Chamom., flickering before the eyes, often followed by headache; stopped-up feeling in the ears with humming noise, often when awaking in the morning; exceedingly irritable, fits of anger; diz- ziness. Stagnation in the portal system with disposition to piles; disagreeable feeling in the small of the back. China, the slightest touch of the scalp is unbearable; earthy color of the face. Headache worse from moving the eyes or shutting them; better when sitting still in an upright position. 40 BRAIN. Ferrum, the face is hot and red, with swollen blood-vessels, accompanied by beating and humming in the head, and great sensitiveness of the scalp to touch. Gelsem., when, during dentition, children become drowsy, com- atose and convulsive; or when from the effects of heat there is dizziness, enlarged pupils, dimness of sight and a dull, confused headache spreading from the occiput over the whole head. Sleeplessness in delirium tremens. Glonoin., throbbing headache, great restlessness; inclination to run away; violent pulsations of the carotids; after exposure to excessive heat or cold. Hyosc., the patient is unconscious and delirious, with red, spar- kling eyes, and bluish-red face; or drowsy, jerks in sleep, cries out in sleep, grates his teeth; subsultus tendinum. After Bellad. Kali hydr., weakly constitution; disposition to tuberculosis; hammering pain in forehead; anxiety, restlessness, sleeplessness; sensation as though the head were larger; even if there is delirium and high fever. Nux vom., the patient is worse in the morning, in the open air, after the use of coffee, liquors, or opium; with constipated bowels and suppression of hæmorrhoidal discharges. Opium, stupefaction; snoring and rattling; slow breathing; slow pulse; sighing and moaning; bluish-red and bloated face; throb- bing of temporal arteries; cold perspiration in face; falling of lower jaw. Phosphor., heat on the top of the head, dizziness, buzzing and throbbing in the head; swelling under the eyes; and palpitation of the heart from mental emotions; emphysema. Pulsat., the face looks yellowish, and yet feels hot, with constant chilliness; worse in a warm room; better in the open air; no thirst; scanty or suppressed menses. Rhus tox., humming, formication and throbbing in the head; glistening redness of the face, and restlessness, which keeps the patient moving about. Spigel., palpitation of the heart; violent headache; dizziness and stupefaction; frightfulness; oppression of the chest. Spongia, pressing, beating in the forehead; redness of face, with anxious features; better in a horizontal position; goitre; heart disease. Stramon., unconscious and senseless; loss of sight and hearing; face turgescent; convulsive motions of the head; wild or stupid HYPERÆMIA-VERTIGO. 41 expression; great thirst with hydrophobia; or furibund delirium; greatest restlessness, wants to run away; sleeplessness. Sulphur, flying heat in the face; diminished hearing; burning, throbbing and buzzing in the head; better in the room, worse in the open air; in hæmorrhoidal complaints; and after the sup- pression of cutaneous eruptions. Ver. vir., sense of fulness, weight, distention in the head; giddi- ness, intense headache, throbbing arteries, stupefaction; double, partial, luminous visions; nausea, vomiting; tingling, numbness in limbs; mental confusion, loss of memory, convulsions or pa- ralysis; during dentition; congestion from alcoholic stimulants. In summing up as to the various causes, the following scheme may be of some use, although it must not be considered as ex- hausting the subject. From mental emotions: Acon., Amyl. nitr., Coffea, Ignat., Opium, Ver. vir. From mental overexertions: Aurum, Calc. carb., Nux vom.; Phosphor., Sulphur. From teething: Acon., Bellad., Calc. carb., Gelsem., Ver. vir. From suppression of hæmorrhoidal discharges: Acon., Chamom., Calc. carb., Carb. veg., Nux vom., Pulsat., Sulphur. From suppressed or scanty menses: Acon., Apis, Bellad., Bryon., Calc. carb., Carb. an., Chamom., Conium, Dulcam., Ferrum, Graphit., Laches., Lycop., Merc. sol., Phosphor., Pulsat., Sepia, Silic., Sulphur, Veratr. From hypertrophy of the left heart: Acon., Aurum, Cact. grand., Glonoin, Jodium, Kalmia, Spigel, Spongia. From insufficiency of the tricuspidalis: Bellad., Hyosc., Kali carb., Pulsat. During a chill: Acon., Arnica, Arsen., Bellad., Bryon., Calc. carb., Chamom., Digit., Ferrum, Hyosc., Ipec., Lycop., Mercur., Nitrum, Rhus tox., Sabad., Stramon., Sulphur, Veratr. From alcoholic drinks: Acon., Arsen., Calc. carb., Gelsem., Laches., Nux vom., Pulsat., Opium, Ver. vir. From straining: Acon., Arnic., Bryon., Rhus tox. In chronic cases: Aurum, Calc. carb., Ferrum, Phosphor., Spongia, Sulphur. Vertigo. This symptom so conspicuous in anæmia, as well as in hyper- æmia of the brain and in many other quite different affections of 42 BRAIN. (( the body, has been defined by F. Niemeyer as a hallucination, consisting of the vivid conception of a motion of the body or of the surrounding objects, which the patient imagines to see and to feel, although he himself and his surroundings are in perfect rest." This definition is undoubtedly defective. For if vertigo is a hallucination, colic and all other subjective symptoms would be. Kafka calls it "a sensation of seeming motion which, by full consciousness, is perceived to take place in oneself or in the surrounding objects, with a feeling of loss of balance of the body and an uncertainty in standing, walking, sitting or lying." He considers it as a peculiar affection of motor-nerves, caused either by the brain itself, or the cranial nerves or by some more remote ganglia or organs." This definition, too, wants correction. Let us consider a simple instance in which vertigo is produced in even quite healthy persons-the swift swinging around of the entire body in a circle. If we observe closely, we find that ver- tigo in such a case is experienced not exactly during but at the sudden cessation of this motion. Why? Because so long as the whole body moves in a certain direction, all its parts move with it, fluids and solids, just as you may, by means of a sling, swing water in an open vessel in a circle without losing a single drop; but stop its motion suddenly and vessel and water will fly to the ground. So when the rotatory motion of the body is suddenly stopped, the fluid parts of the body and especially the large col- lection of blood in the cranial sinuses must necessarily recoil and assume a motion in disharmony with the whole body. It is this commotion of the blood in the brain which is immediately felt and designated by the name of vertigo. Vertigo, then, we should say, is the sensation of an actual commotion of the blood within the cranial cavity. This separate, disharmonial motion affects the sensient nerves and is perceived by the sensorium, from which again, by reflex action, motor nerves are excited, hence the tottering, reeling or grasping for something, or the falling down, when the undue excitement should bring on momentary unconsciousness, or the seeming motion of the surrounding ob- jects, etc. Thus we experience vertigo by all such motions of the body which are capable of producing a disharmonial motion of the blood within the cranial cavity, for instance, concussions of the body, dancing, bending forward or backward and rising, looking up or turning around quickly, swinging, sailing in ves- sels, etc. In regard to this latter it is a known fact, that one VERTIGO. 43 gets seasick more readily on the lakes than on the ocean, because here the waves are shorter and more irregular than there, caus- ing a much more abrupt shaking of the passenger. When the body of a passenger is thus suddenly concussed, the blood in the sinuses cannot follow the sudden motions of the solid parts of the body in equal tempo; it is caused to vibrate in a tempo of its own, and this perturbation or commotion of the blood within the sinuses we feel as vertigo, or seasickness. Seasickness, therefore, does not abate until a person exposed to being constantly tossed about, becomes so thoroughly accustomed to the motions of the ship, that he unconsciously anticipates all the pranks which the unruly waves may play and harmonizes his motions with those of the vessel, preventing in this way any further perturbation of the blood within the cerebral sinuses. We have still to consider, however, other cases in which the unwonted motion of the blood within the cranial cavity is not so apparent a cause of vertigo as in the above mentioned instances. We also see vertigo produced under circumstances where such external concussions do not exist, as for instance by exudations within the brain, by tumors, tubercles, cancer or atheromatous degeneration of the cerebral blood-vessels, by great heat, me- phitic exhalations, aromatic odors and above all by almost every one of the drugs proved, with but few exceptions, for instance, Fluor. ac. Does our view hold good even in these cases? In the first place we should say that concussions of the body, swinging, sailing, etc., do not produce vertigo in all persons. There must be, then, something deeper still to be considered be- fore we shall be able to fully understand the phenomenon of ver- tigo. And here I must draw attention to the arachnoid mem- brane which envelopes the brain and, like other serous mem- branes, is a shut sac. The functional action of this and all other like membranes may, according to C. Hering, be likened to that of a suction-pump. When excited it draws a greater amount of blood into the cranial cavity than when in a state of relaxation. It is thus one of the principal means by which the circulation within the brain is regulated. But its influence extends not only over the amount of blood in the brain, it at the same time controls more or less also the movement of the blood within the sinuses. The more healthful its action, the more readily it will regulate this flow and check any undue commotion, while during a relaxed state the slightest functional or mechanical cause may 44 BRAIN. bring on perturbation, and this explains why some persons do not feel dizzy from turning, dancing, sailing, etc., when others do. And if we further take into consideration that exudation, tumors, tubercles, etc., in short various kinds of morbid processes within the brain, and also numerous drugs when taken during a state of health, must necessarily affect the arachnoid, either excite or relax its action, we have sufficient reason to assume that in either case the regular flow and circulation of the blood through the sinuses must also be more or less disturbed, which would account for the feeling of vertigo in all such cases. We come thus to the conclusion that vertigo, even in those instances where its course is not so apparent as in cases of external concussion, etc., is never- theless the feeling of an undue commotion of the blood within the sinuses, which is produced, or which, at least, is not checked by the arachnoid in consequence of its own excitation or relaxa- tion. Authors have spoken of hyperæmic or congestive, of anæmic, nervous toxic, epileptic, stomachic and psychic vertigo. All these different designations have reference to morbid affections with which vertigo is frequently associated, or which are the cause of disturbance in the circulation of the blood within the brain. Vertigo may appear under the most varied conditions: in rest or motion; on stooping or rising, or turning the head; during lying, even in sleep; from dazzling or streaked light; from the quick motion of objects before the eyes, in passing a railing or riding in the cars; by the sight of an unpleasant object—a bleed- ing wound, a surgical operation, etc.; by looking down from a height or looking up to a height, and in many more other ways. It is rarely observed in children, more frequently in adults and oftenest in old age. Its PROGNOSIS depends entirely on the nature of those morbid processes with which it is connected. THERAPEUTIC HINTS.-Acon., congestive; heat and pain in head; red face; nosebleed; pulsation of carotids. When trying to sit up in bed, the patient tumbles over; he is afraid to rise lest he might fall again; must take hold of something. Stoppage of menstrual flow from cold, fright, fear or vexation; after habitual blood-letting. Agar, heaving and whirling of objects around; tendency to fall forward; partial amaurotic blindness, with floating musca and VERTIGO. 45 vibrating spectra; partial numbness of left side of tongue. Hy- peræsthesia of smell; unusual sensitiveness to cold air; hysteria and nervousness brought on by exciting debate or by protracted mental application; by overexertion of the eyes; by strong light of the sun. Anac., great forgetfulness; dim sight; on stooping and rising from stooping, he feels as if he were turning to the left. Apis, headache; heat in head; red face; nosebleed; pulsation of carotids. Worse when sitting than when walking; extreme when lying down and closing the eyes. Arg. nitr., chronic, as if every thing were turning around; dyspnoea; palpitation of the heart; paralysis of diaphragm; left half of body very weak; left arm or hand heavy and numb; trembling weakness brought on by walking with shut eyes; by walking in streets with high houses, which seem to fall upon him. Arnica, as if every thing were turning around or falling upon him; ears feel stopped up when speaking, swallowing or blowing the nose; better in lying, disappearing on stooping; after bodily overexertions or injuries. Ast. rub., single case by Petroz. Man has fits of vertigo, as if the head were suddenly concussed; head always hot, face red, pulse hard, contracted and frequent; obstinate constipation by good appetite; constant contractions of the muscles of the lower limbs; gait uncertain, because the muscles do not obey the will; restless and sleepless. Arsen., hyperesthesia of hearing; burning in stomach and vomiting; malarial with loss of appetite, vomiting and head- ache; dilatation of right ventricle, emphysema, bronchial ca- tarrh; sleeplessness. During pregnancy, with pale, bluish, puffed face, blue lips and nails and undulation of jugular veins. Aur. mur., hypertrophy of left ventricle, with great congestion towards head and face. Bellad., acute and chronic; revolving; staggering, reeling, must take hold of something; transient unconsciousness; anxi- ety; shuns people, is bashful; head appears double; sees frightful things on shutting the eyes. Headache pressing, throbbing; gnawing pain in the bones of the skull, face and teeth; rush of blood to head and face; sometimes sensation as of icy-cold water streaming down from head to face; flickering and dimness be- fore eyes; hyperesthesia of eyes; enlarged pupils; buzzing in ears, with dulness of hearing; nosebleed; pulsation of carotids; 46 BRAIN. loss of appetite and vomiting; stitching pain in chest; slow pulse, weakness and trembling of limbs when walking; drowsy in daytime, sleepless at night; hysteria and general nervousnèss; epileptic vertigo. Worse on rising from lying, sitting or stoop- ing; in standing; after eating. After typhoid fever; taking cold; violent fright; overexertion of the eyes, with muscæ vol- antes; from the smell of flowers, gas, etheric oils, turpentine, etc., with stupefaction. Some prefer Atrop. in some cases. Borax, a feeling as if pushed from right to left and somewhat forward; on descending or being moved downward. Bovist., in the morning with loss of consciousness and pressing pain in head. Bryon., like whirling on sitting up, standing and walking; burning in stomach and vomiting; distention, passage of offen- sive flatus, and constipation; bronchial catarrh; emphysema ; dilatation of right ventricle. After suppressed hæmorrhoids; bodily overexertion. Calc. carb., stupefying; epileptic; hyperæsthesia of eyes; dim- ness of sight; abdominal congestion, distention, flatus, constipa- tion; amenorrhoea, which has gradually developed; climaxis, with flushes of heat and sweat; hypertrophy of left ventricle, with congestion towards head and face; hypochondria, hysteria and nervousness; sleeplessness; tuberculous disposition; rha- chitis; scirrhous tumors. Worse in morning, in walking out-doors, especially on suddenly turning the head, on stooping and ascend- ing. Brought on by mental overexertion; by reading, fine sew- ing, etc.; by sedentary life, high living, excess in venere. Calc. jod., glandular swellings on neck, goitre. Carb. veg., venous stagnation in abdomen, flatus, constipation; from sedentary life; mental exertion; high living; spirituous drinks, tea, coffee, tobacco, opium. Caustic., attacks at 11 o'clock A.M., with stitches in top of head, pain in back and small of back when rising from a seat; on looking upwards, inclination to fall towards left side; on stoop- ing, to fall backward. Chamom., fits of anger; congestion in portal system; distention from wind. China, anæmic from loss of blood or vital fluids; hysteria and nervousness. Coccul., intoxication, stupefaction; nausea, pressing and throb- bing in temples; alternate going to sleep of either feet or hands; VERTIGO. 47 ! difficult speech; distention of abdomen from wind; constipation; chlorosis. Worse on rising and after eating. Coffea, hysteria and nervousness; sleeplessness. Conium, frequent drowsiness; on bending, the head forward, heaviness in occiput; dimsightedness; nosebleed in spring; venous abdominal hyperæmia and amenorrhoea; acrid fluor albus; torpid urine with mucus; climaxis, with flushes of heat and sweat; rhachitis and swelling of lymphatic glands. Cyclam., dyspepsia; hyperesthesia of the cutaneous nerves of the extremities; hysteria and nervousness. Ferrum, anæmic from loss of blood. Gelsem., intoxication, confusion, headache; dimness of sight; dilatation of pupils; general depression of system from heat. Glonoin., congestive; forerunner of apoplexy; intoxication and heaviness of head, with bending the head forward; reeling, trembling, falling; headache; heat in head; redness of face; photophobia; injection of conjunctiva; flickering before the eyes; buzzing in the ears; pulsation of carotids. Worse on sit- ting up. Graphit., hyperæsthesia of eyes; venous stagnation; constipa- tion; incarceration of flatus. From overexertion of the eyes by reading, sewing, etc. Hepar, hyperæsthesia of smell; decreased peristaltic motion; hard feces. Hyosc., stupefaction; depressing mental influences; hypochon- driacal; from the smell of flowers, gas, etheric oils, etc. Ignat., epileptic; gastric symptoms; gaping; abdominal conges- tion; flatus; tingling as of ants; jerkings; heaviness of right arm; spinal affection; anæmia; sleeplessness; hystery and nervous- ness. Worse from slightest motion of head, especially stooping. Brought on by depressing mental influences; fear, anxiety, fright. Ipec., malarial headache; loss of appetite and vomiting. In pregnancy, with pale, bluish, puffed face, blue lips and nails; undulation of jugular veins. Iodum, goitre; hypertrophy of left ventricle, with great conges- tion towards head and face; hysteria and nervousness. Kali carb., nausea and vomiting; after eating, with heat in head and red face; darkness before the eyes; sometimes one cheek hot, the other cold. Must lie down or he falls down. Before falling stitching pain in forehead, root of nose and eyes; fatty degenera- tion of heart. 48 BRAIN. Kali brom., goitre. Kali hydr., glandular swelling on neck; rhachitis. Laches., epileptic; can't bear anything coming near him; venous stagnation; constipation; flatulency; burning in stomach, vom- iting and diarrhoea. Lycop., head heavy; scathing, roaring and noises in head; fears to lose senses; ebulitions from stomach to chest and head; he gets hot, face reddens, eyes water and become dim; constant pain in back and small of back; venous stagnation in abdomen; disten- tion; constipation; incarcerated flatus. Worse on stooping; when drinking. Mercur., headache, nausea, loss of appetite; in bed and out of bed; can't rise and sit up for fear of falling; must lie down; feels like swinging, lying in bed. Receded cutaneous eruption. Merc. corr., syphilitic tumors in the brain. Merc. jod., syphilitic tumors in the brain. Mezer., syphilitic affections of brain. Natr. mur., with feeling of fainting; periostitis of scull; dyspep- sia; abdominal congestion; flatulency; constipation; suppressed hæmorrhoidal discharge. From sedentary life; depressing mental influences; mental exertion; reading, sewing, etc.; high living; spirituous drinks, tea, coffee, tobacco, opium. Nitr. ac., climaxis; syphilitic taint. Nux vom., epileptic; malarial; revolving; sudden, like an elec- tric shock; before vertigo, drawing headache with heat in fore- head, yawning. Headache; loss of appetite and vomiting; burn- ing in stomach after eating; dyspepsia; abdominal congestion ; flatulency; constipation; hæmorrhoids; hysteria and nervous- ness; hypochondriacs. Worse after dinner or eating; when stooping and rising; sometimes at nights, waking out of sleep. Brought on by mental exertion or sedentary habits; high living; alcoholic drinks; smoking, coffee, opium; from the smell of flow- ers, gas, etheric oils, etc., attended with nausea; suppressed flow of hæmorrhoids. Opium, stupefaction as after intoxication; drowsiness; red, glossy eyes; enlarged pupils; dimness of sight; pale face; de- creased peristaltic motion, difficult defecation. Worse on sitting up in bed. After fright. Phosphor., revolving, as if he would fall; malarial; headache; weight and throbbing in forehead on waking; rush of blood to the head; hyperæsthesia of smell; loss of appetite; nausea, vom- VERTIGO. 49 iting; burning in stomach; abdominal congestion with flatu- lency; during pregnancy pale, bluish, puffed face, blue lips and nails, undulation of jugular veins; hypertrophy of left ventricle with congestion to head and face; dilatation of right ventricle; fatty degeneration of heart; emphysema; bronchial catarrh; sleeplessness; atrophy of brain in old age; scirrhous tumors; periostitis of skull. Worse morning and evening; after eating; during sitting. Brought on overexertion of the eyes, attended with muscæ volantes; by the smell of flowers, gas, etherial oils, turpentine, attended with fainting; by loss of vital fluids. Phosph. ac., hypochondriacs after excess in venere; climaxis with flushes of heat and sweat. Platin., overestimation of self. Pulsat., hot head; flickering before eyes; stitch pain in ears and tearing in head; pale face; painful crawling in stomach; tearing in limbs; shifting rheumatic pains; scanty, retarded or suppressed menses; sleeplessness; chlorosis. Worse when sitting and lying; on getting up from a seat. Brought on after anxiety, fear and fright. Rhus tox., tipsy feeling; in aged persons; dilatation of right ventricle; emphysema; bronchial catarrh; worse in morning after rising, with uncertainty in walking, wants to be supported by a cane or another person; better from continued motion; worse on getting up from lying, on turning, stooping. Brought on by bodily overexertion. Ruta, overexertion of the eyes with muscæ volantes; bodily overexertion. Sambuc., fatty degeneration of heart. Sanguin., vertigo during sleep. Sec. corn., hyperæsthesia of cutaneous nerves, especially of the spine. Sepia, dyspepsia; venous hyperæmia in abdomen; constipation; flatulency; gradual developing amenorrhoea; hypochondriacs; climaxis with flushes of heat and sweat; sleeplessness. Worse when drinking. Brought on by mental overexertion; excess in venere. Silic., stupefying; preceded by rush of blood to the head; op- pression of chest and pit of stomach. Headache; menses too early, too protracted, too copious; after menses, fluor albus; venous stagnation in abdomen; constipation; incarcerated flatus; hypochondriacal; sleeplessness; tuberculous disposition; rhachi- 4 50 BRAIN. tis; periostitis; scirrhous tumors. Vertigo during sleep. Brought on by overexertion of the eyes from reading, sewing, etc.; by excess in venere. Spigel., stumbling and falling as if intoxicated; pressing pain in top of head, worse from stooping, walking and talking; better when lying; hypertrophy of heart; feeling of fainting. Spongia, goitre; hypertrophy of heart. Staphis., hypochondriacal; depressing mental influences. Stramon., twitching in face; spasm in chest; spasmodic laugh- ing; worse at night on lying upon the side. Sulphur, constant feeling of wavering in head and body, as if swinging and as if the bed were not wide enough to hold him; feeling of tightness in head, as if bound; dimness of sight; venous stagnation, and feeling of fulness in abdomen, constipation, flatu- lency; suppressed hæmorrhoids; receded or suppressed cutaneous eruption; occasional itching after itch; periostitis. Tart. em., venous stagnation of abdomen with flatulency; during pregnancy pale, bluish, puffed face; blue lips and nails, undula- tions of jugular veins. Therid., nausea with vertigo on closing the eyes, worse from noise and motion. Thuja, epileptic; hair dry and finger nails ribbed. Ver. alb., malarial with headache and loss of appetite; over- estimation of self; hyperesthesia of hearing; burning in stomach; vomiting and diarrhoea; venous stagnation in abdomen with flatulency; during pregnancy pale, bluish, puffed face, blue lips and nails, undulation of jugular veins; dilatation of right ven- tricle; emphysema; bronchial catarrh. Brought on by spirituous drinks, tea, coffee, tobacco, opium. Zincum, in the occiput, with falling to the left when walking. Zingib., with heavy limbs. The following scheme was prepared by Kafka relating to ner- vous vertigo: Vertigo in the morning: Calc. carb., Nux vom., Phosphor., Rhus tox., Natr. mur. in the evening: Bellad., Pulsat., Cyclam., Sepia, Zincum, Laches. when lying down: Pulsat., Cyclam., Arsen., Aurum. when rising: Nux vom., Rhus tox., Coccul., Laches., Conium. when walking: Pulsat., Lycop., Conium, Capsic., Phosphor. when stooping: Calc. carb., Bryon., Sepia, Spigel. VERTIGO. 51 Vertigo with an empty stomach: Phosphor., Iodum., Calc. carb., China. after eating: Calc. carb., Nux vom., Natr. mur., Phosphor., Lycop., Sepia. after sleeping: Phosphor., Sepia, Nux vom. in the fresh air: Nux vom., Silic., Coccul. in the room: Silic., Agar., Arsen., Pulsat. before the menses: Calc. carb., Pulsat., Sepia, Ver. alb. during the menses: Phosphor, Hyosc., Graphit., Lycop. after the menses: Nux vom., Phosphor., Graphit. Amelioration by motion: Rhus tox., Pulsat., Capsic., Cyclam., Lycop. by rest: Nux vom., Natr. mur., Bellad., Colchic. Revolving vertigo: Phosphor., Nux vom., Bryon., Arnica. Stupefying vertigo: Calc. carb., Silic., Bellad., Hyosc. Staggering vertigo: Acon., Rhus tox., Nux vom., Platina. Vertigo with trembling and uneasiness: Phosphor., Calc. carb., Ignat., Arsen. with fainting: Phosphor., Nux vom., Natr. mur., Arsen., China. with vomiting: Nux vom., Ipec., Ver. alb., Arsen., Pulsat. Vertigo with inclination of falling forward: Phosph. ac., Graphit., Cicut. vir., Spigel. with inclination of falling backward: Rhus tox., Nux vom., Bryon., China. with inclination of falling sideways: Silic., Sulphur, Ipec. Sea-sickness. Even here we have to study the peculiarities of the single case. Apomorphia, nausea without any apparent signs of gastricism. Dr. Skinner gave it with success. Borax, perhaps never given, should be tried on account of its symptoms of aggravation on downward motion. Calc. carb. may be indicated by its aggravation on upward mo- tion. Coccul. is perhaps the oldest remedy recommended in sea-sick- ness. Nausea with tendency to faint. Colchic., excessive sensitiveness of smell against cooking. Nux vom., headache; gastric symptoms; constipation. Opium, great sleepiness; constipation. vouryo w TM 52 BRAIN. Sepia, headache; desire for sour and refreshing things. Petrol. has proved beneficial very often. Pulsat., drowsy, thirstless; dizzy, especially on getting up from a seat; feels better on deck. Some persons are greatly benefited by applying a piece of blotting paper, soaked in rum or brandy, upon the pit of the stomach. In all cases it will be well to exert the will-power in order to gain command over the body against the motions of the vessel and to harmonize its motions with that of the ship. Sleep, Stupor, Insomnia. The fluids and tissues of the body are constantly undergoing change by the ceaseless activity of its various parts as an organ- ized entity. Every voluntary or involuntary motion of the mus- cles, the action of the different glands, the working of the entire nervous system is attended with a continuous retrograde meta- morphosis of constituent elements. All this must, at certain periods, inevitably result in exhaustion. The consequent neces- sity for reparation of the lost elements manifests itself in active assimilation of new material from what has been prepared by di- gestion; in other words the conscious activity of the cerebro-spinal system gives way to the unconscious activity of the sympathetic system-we fall asleep. Sleep, therefore, in its real nature con- sists in the predominant activity of the sympathetic system over that of the cerebro-spinal. For this reason, we find during sleep, as Durham in his "Physiology of Sleep" observes, “a notable in- crease of blood in the stomach and other abdominal viscera,' which is drawn there by the increased action of the assimilating system; for wherever there is greater activity there is a greater afflux of blood. But this heightened action of the assimilating system has also another effect; it subdues all other activities. Mentally we become unconscious, partly from actual want of ex- citing elements which have been consumed during waking life, and partly from the withdrawal of exciting elements by the in- creased action of the assimilating organs; we find, therefore, physiologically corresponding, less blood in the brain, as has been demonstrated by Durham, Hammond and others. Bodily our voluntary muscles subside into inactivity and the amount of work done by the excretory organs is equally lessened; we find, "" SLEEP, STUPOR, INSOMNIA. 53 physiologically corresponding, respiration as well as circulation decidedly slower than during waking life. All this is the necessary consequence of the increased action of the assimilating system. For it is impossible that all our activi- ties could be excited at the same time in an equal degree. We see this clearly portrayed in the action of our mental life. Even during our waking periods conscious excitement belongs only to a very small portion of what we mentally possess; the bulk of our possessions lies dormant. Consciousness shifts from one mental modification to another, sometimes swiftly even tumultuously; or only slowly or evenly, but always involving only parts and portions of our entire mental acquisitions. The same holds good when we consider man mentally and physically as one whole. During the predominant activity of his cerebro-spinal system, the sympathetic system is in comparative rest, while the latter subdues the former, when the primary forces have been consumed and a new supply has to be prepared by its action. How great the force is with which the assimilating process assumes its ruling, we all have repeatedly experienced; the eye- lids droop, the sounds grow indistinct and irresistably we fall asleep. The restitution of vital forces must be done and during that process all other activities must partially or totally cease. It is erroneous, therefore, to say that "the state of comparative re- pose which attends upon this condition (sleep) allows the balance to be restored” (Hammond), since in fact this restitution or more definitely expressed, the assimilating process does not allow the accustomed action of the mind, brain and other organs. Uncon- sciousness, partial or total, is a necessary concomitant of sleep, not its essential nature, just as the comparative repose of the volun- tary muscle and excretory organs is the natural consequence of the heightened activity of the assimilating system. As long as either reigns, the other must be silent. And as an increased activity always causes an increased circulation and vice versa, it is erroneous to say that the loss of consciousness, total or partial, during sleep be due to the lessened circulation of blood within the brain, since in fact the comparative inability of the mind (unconsciousness) and the consequent inactivity of the brain as its condition, is the cause of this lessened circulation. Being not needed in the brain and all other organs which are under the control of the cerebro-spinal system, the circulation slackens here and increases where a heightened activity calls for it, i. e., in the assimilating system. 54 BRAIN. Playfair thinks that sleep is due to "a diminished supply of oxygen to the brain" (Northern Journal of Medicine, No. 1, 1844, p. 34; see Hammond on sleep, p. 30); and Preyor holds the opinion "that the oxygen during sleep is used up in a different. manner than in the waking state. During exercise of the brain, as well as of the muscles, a kind of peculiar material, so-called "material from weariness" forms, which accumulates in quanti- ties corresponding to the intensity of the activity, is very oxid- able, and which lays hold of the oxygen during sleep, and thus becomes oxidized" (Wiener Freie Presse, Sept., 1876; North. Am. Journal, Febr., '77, p. 349). These views are just as valuable and correct as the idea of a diminished circulation of blood in the brain during sleep. For oxygen is certainly a necessary con- stituent to healthy blood and of the consequent activity of any kind. But when, according to Pettenkofer's experiments, the system accumulates during sleep much more oxygen than dur- ing its waking state, one cannot clearly see why an increasing acquisition of oxygen should just induce sleep, which is supposed to be due to a diminished supply of oxygen. Here as elsewhere again a condition is taken for the cause. The cause lies in the hightened action of the assimilating system, which again re- plenishes what during the activity of the cerebro-spinal is needed and consumed. It will not do, to oppose this truth by reminding of the fact that an artificial interruption or suppression of the circulation within the cranium by compressing the carotids will cause un- consciousness; for we have never stated that healthful circula- tion of the blood be not required for the functional activity of the brain, nor that a healthy brain be not a necessary condition for the legitimate exercise of the mind. A certain amount of healthy blood within the brain is a necessary condition for its successful operation, but is a condition the cause? Still, if it might be allowed to say that a certain amount of opium, chloral, carbonic oxide, etc., causes stupor (unconsciousness), why should we not likewise consider the lessened circulation of blood during sleep as the cause of its attending unconsciousness? Because thereby we would not at all explain the lessened afflux of blood to the brain, and the question would still remain: What lessens the circulation in the brain during sleep? And we have stated the cause: it is the reduced activity of the brain in consequence of the hightened activity of the assimilating system. Wave-like SLEEP, STUPOR, INSOMNIA. 55 do these activities interchange, like ebb and flood, and where the one is in the ascendency, the other has to go down. The neces- sity of each regulates their periodicity. In the new-born child the vegetative sphere is yet so predominant, that in the first six weeks, if well, the child sleeps all the time with but short inter- ruptions. Gradually, however, as its mentality widens, sleep be- comes shorter, until it is reduced to a certain space of time neces- sary for the assimilation of new forces required for action of the cerebro-spinal system. Worriment of mind, great passions, etc., may banish sleep for a considerable length of time, that is, may subdue by its strength the activity of the vegetative system, but not without an adaquate cost to the whole organism, and yet finally even the strongest passion will have to yield to the still greater power of recuperating necessity. Stupor, Coma, or whatever a state of unconsciousness, resembling deep sleep, may be called, is no sleep. It is caused by a violent interference with the conditions necessary for a normal action of the brain. Such CAUSES are various remedial agents, like opium, chloral, carbonic oxide, alcohol and others, which vitiate the blood; or different blood-poisoning diseases, like typhus, scarlatina, uremia and others; or hæmorrhage within the brain (apoplexy), which compresses the organ so as to make it unfit for a successful operation of the mind. Sleep and stupor differ, therefore, in this that the first is the natural consequence of the predominating activity of the assimilating system, while the latter is induced by a direct violence to the brain; there health, here disease is represented. The approach of sleep is favored by everything which either depresses mental life (cuts off the supply of exciting elements, especially fatiguing mental toil, and also listless reverie, want of external excitement), or which gives in- creased impetus to the bodily act of assimilation, such as super- abundance of food, hot drinks, great bodily exhaustion, loss of blood, etc. Excessive cold does not produce sleep, but stupor, like excessive heat. In both cases the effect is congestion towards the brain, which renders this organ unfit for the successful exercise of mental action. If on the contrary by excessive mental strain, as we find it not unfrequently with business men, too eager students, or after great trials, sorrow, anxiety, night-watching, etc.—the assimilating pro- cess has been unduly restricted for a greater length of time- Sleeplessness (Insomnia) is the natural result. Mental and conse- 56 BRAIN. quently cerebral activity so overbalances the process of appropria- tion, that the assimilating system at last becomes weakened, and losing its connative force, leaves the work undone which it is de- stined to do. This necessarily must prove destructive to the entire organism, and cause bodily an overwrought condition of the brain (relaxed and enlarged blood-vessels), while the mental activities gradually confine themselves to fixed ideas or uncon- trollable combinations, until at last but an insane wreck of a formerly well-balanced constitution is left. But there are also a number of BODILY CAUSES which induce sleeplessness; they all may be summed up under the one head: Whatever interferes with the process of assimilation. The number of such disorders is large, and their pathological specification will appear in the course of this work. In general most fevers have this effect, and among the daily used beverages, coffee and tea are the most prominent, as they retard according to physiological experiments, the process of waste and repair in the tissues. THERAPEUTIC HINTS.-It is one of the most favorable signs when soon after the administration of a remedy, a natural sleep ensues. By no means ought such sleep to be interrupted. While it lasts, nature replenishes and rebuilds what has been spent and wasted. It does more good than a repetition of medicine, by which indeed the first beneficial effect might be destroyed; the remedy which induces it will quietly work on for the benefit of the patient; it is the remedy. This rule applies only to natural sleep. In case of Drowsiness, Stupor, etc., medicine must be re- peated just because of this state, and it may be one of the leading symptoms for the selection of the remedy. Apis, sopor with piercing shrieks; meningitis. Bellad, heavy sleep with frequent starting, or snoring, scream- ing or singing; with eyes half open; always attended with fever; skin may be dry, but is mostly perspiring; face may be flushed, but is often pale. Many febrile diseases. Bryon., drowsy sleep with starting and crying; with chewing and swallowing. Head hot; children cry when taken up or being moved. Meningeal irritation. Chamom., starting, moaning, screaming, talking, weeping dur- ing sleep; mouth open; face occasionally distorted by convulsive motions; head perspires a great deal. Dentition. Laches., great drowsiness attending many complaints; feels bad MENINGITIS-INSOMNIA. 57 or worse after sleep; starts when at the point of falling asleep and moans during sleep. Lycop., very sleepy during day with unsuccessful yawning; starting and jerking of the limbs during sleep; sudden loud screams during sleep; waking with a peevish mood, scolding, screaming, ugly demeanor, nervous irritation. Fevers. Nux mosch., unconquerable drowsiness; falls asleep whenever sitting down to rest. Long spells of somnolence. Tongue often dry without any thirst. In company with many complaints. Opium, stupor; snoring; eyes half closed; mouth open. Phosph. ac., being roused, answers correctly but goes to sleep again at once; typhoid. Pulsat., very sleepy with various symptoms of head, stomach and bowels. Rhus tox., drowsy sleep with murmuring and talking; typhoid. Insomnia. Acon., fever-heat, dry skin; tossing about; lamenting; great pain with inflammatory processes in teeth, chest, bowels, during menstrual period; after fright, fever. Bellad., drowsy and yet unable to sleep; anguish; visions; large pupils; congestion towards the head; after morphium. China, ideas crowd upon the mind; after loss of blood and weakening diseases. Coffea, nervous excitement; wide awake; not the slightest in- clination to sleep; after great mental strain, joy, night-watching, acute diseases; dental irritation. Hyosc., drowsy or sleepless; wild expression; delirious; after chloroform. Ignat., after grief and depressing emotions; after overstraining the mind by racking business. Moschus, hysterical sleeplessness; after chloral. Nux vom., after mental strain till late at night; abuse of coffee, wine, liquor, opium, tobacco. Opium, excessive wakefulness, or drowsiness with inability to go to sleep. Pulsat., indigestion; after quinine, ferrum and strychnine, tea, chloral. Sulphur, very important with many and different symptoms; sleepy in daytime; sleepless at night. 58 BRAIN. These are the main remedies, of which one or the other may be indicated when drowsiness or sleeplessness is one of the lead- ing symptoms of the case. However, there are a number of cases where these symptoms, although prominent and distressing, may entirely lose their rank as guiding symptoms, and none of them indeed would prove satisfactory. Then we have to choose our remedy irrespectively of these symptoms, which will disappear as soon as the main string is touched. For such cases, of course, special therapeutic hints cannot be given a priori. Meningitis tuberculosa, Hydrocephalus acutus, Is in its nature an inflammatory affection of the pia mater, de- pendent upon the development of miliary tubercles. In this it differs from all other meningeal affections. The miliary granulations are always found in the immediate neighborhood of vessels, sometimes especially of those at the con- vexity, sometimes of those at the base; frequently at the arteries. given off from the circle of Willis; they may be spread over large surfaces, or they may be confined to only particular portions of the pia. Their number likewise varies as their distribution, and so do their stages of development; they grow in crops. The pia shows frequently, especially at the base, yellowish cloudy patches along the vessels and swelling of its tissues; the ventricles are dilated and contain hydrocephalic effusion. The quantity of this effusion however varies greatly, and in many cases is entirely absent. The brain in some cases shows white softening, either of only a portion of the fornix and the corpus callosum, or of larger portions of its tissue lying upwards and contiguous to these parts. In other cases this softening is entirely wanting. The cortex and neighboring white substance is in many cases anæmic and of a dry condition, most probably a result from the pressure of the hydrocephalic effusion within the ventricles. Miliary tubercles are found almost in all other organs of the body. It seems then, that scrofulosis as the main spring of tuberculosis, is also the main cause of this disease. May it be latent or apparently it always has a tendency to bring inflamma- tory exudations to a cheesy degeneration, and when present, irri- tation of almost any kind: whooping-cough, pneumonia, measles, and other eruptive diseases, or bronchial or intestinal catarrhs, dentition, colds, traumatic lesions of the bones, or periosteum of MENINGITIS. 59 the joints, suppressed eruptions of the head, may lead to that same end. The sex attacked most frequently is that of the males; the age that between one and six years; from seven to ten years we find it less often, still less from ten to sixteen, and rarely afterwards. The SYMPTOMS may develop slowly or rapidly. It seems that a crop of tubercles may be endured without causing marked dis- turbances; it is only when by some exciting cause an irritation is set up that the disease develops. The commencement may manifest itself in a mere indisposition, a change of mood, with frequent short naps full of dreams and starting; loss of appetite; irregularities of the bowels; febrile conditions towards evening, headache and giddiness. This undefined state may last a week and longer. Where there is already a developed pulmonary tuberculosis, the superadded meningitis may not be suspected until suddenly facial paralysis, loss of consciousness and vomit- ing set in. As the inflammation progresses, we find headache; vertigo; great sensitiveness to light and noise; vomiting of anything taken, or especially when being moved; coming at intervals and disappearing after some time; constipation usually, but diarrhoea sometimes to the end. If partial or general convulsions set in, we have: tremor of the eyeballs; squinting; distortions of the face; stiffness of the muscles of the nape of the neck and back; retraction of the abdominal muscles, so that the belly looks like a tray or boat. There may also be paralysis of the face; paralysis of the eyelids; one pupil may be larger than the other. The fever rises with evening exacerbations up to 102.2° or 103° F. The skin is in some cases easily reddened by slight pressure or scratching. And as the internal pressure in conse- quence of exudation increases, the mind becomes clouded; the patient is drowsy, even comatose. We occasionally hear a pecu- liar piercing shriek which, if heard once, is scarcely ever for- gotten. Convulsive movements become more frequent, such as distortions of the face; squinting; chewing; winking the lids; grinding of the teeth. Paralysis of the one or the other ex- tremity also sets in, while the other may still keep up convul- sive motions; there may be paraplegia; there may be paralysis of the tongue and deglutory muscles. The pulse at this stage falls down to sixty and lower, but is easily excited to a hundred and over by any exertion; the temperature remains the same or 60 BRAIN. sinks to about 100° F., although the pulse may have risen from any exertion to 120 or 140. Now the fontanel in children com- mences to bulge; the coma increases; convulsions and paralysis continues; the pulse rises again to 120 or 140; the respiration is irregular; sometimes the breathing seems to cease altogether, followed by a deep, long, sighing respiration. The face fre- quently changes color, now pale, and again red, and sometimes one side is pale and the other red. Or red spots appear on the face, coming and going. The blood-vessels of the eyes become injected, especially those of the inner canthi. This condition of things may last several days. When, however, the skin gets dripping with perspiration; when the abdomen becomes bloated; when stool and urine pass off involuntarily; when the anterior fontanelle suddenly sinks in, and we hear the ominous rattling in the chest, then the scene will be closed within a few hours. The PROGNOSIS is bad. Is the disease always fatal? Because there are no infallible means to distinguish during life between it and simple meningitis, those cases which have recovered and were claimed to be tubercular meningitis are simply set down as errors in the diagnosis; the real proof-post-mortem—is wanting, and therefore, as all cases which came under the hands of these physicians, the post-mortem proved their diagnosis correct, they concluded that all the other cases must likewise be fatal. Against this conclusion I allow myself modestly to protest. Might not a different treatment prevent post-mortem examinations? And are all tubercular affections necessarily fatal? I have lost cases of tubercular meningitis, to be sure, but I do believe that I also as well as others have cured some of them. The prognosis is bad, that is true. I shall defer therapeutic hints until I have spoken of other forms of meningitis. Leptomeningitis Infantum; Hydrocephalus Acutus sine Tuberculis; Simple Meningitis. Like tubercular meningitis this affection is considered an in- flammatory process of the pia, although on post-mortem no in- flammatory signs, not even traces of arterial hyperemia are found. The pia is unchanged; it contains a moderate quantity of blood or is anæmic. The cortex and white substance are- compressed, dry and firm; the ventricles are usually dilated symmetrically from hydrocephalic effusion; the softening of the MENINGITIS. 61 surrounding brain-tissue is less extensive than in tubercular meningitis. Only the plexus chorioidei shows signs of greater hyperæmia than the superficial portions of the pia. No exuda- tion at the base. The question then, as to its inflammatory or hyperæmic nature, cannot be answered by anatomical evidence post-mortem. C As exciting causes the following are mentioned: dentition; eruptive fevers; acute pulmonary affections; concussions of the brain. The disease belongs decidedly to the age of childhood, from one to five years. Its SYMPTOMS correspond so closely to those of tubercular meningitis, that there is none to enable us to distinguish posi- tively between the two, unless we take the general outspoken tendency to scrofula, if it is outspoken, or the hereditary disposi- tion in that direction as a basis for our judgment. In many cases, of course, the symptoms vary, but the general type remains the same. Usually there are less premonitory warnings; some- times the inability to swallow sets in at an early stage; the skin of the body is dry, while the head often perspires profusely; facial paralysis and paralysis of the extremities are less frequent than in tubercular meningitis, yet they do occur. For further particulars compare the foregoing. The PROGNOSIS is less fatal than that of tubercular meningitis. Simple Meningitis of the Base. Without tuberculous infiltration this inflammatory process causes in some cases the formation of dense, hard stripes of con- nective tissue, or in other more acute. cases, a fibro-purulent infiltration in the tissue of the pia at the base of the brain; where hydrocephalus is present it is generally very severe. There is nothing known of predisposing causes; the victims are strong persons, between sixteen and thirty years of age; its duration is from seventeen to sixty-four days. SYMPTOMS.-Usually commencing with a chill or chilliness, which is followed by heat, sweat, thirst, entire loss of appetite and total unfitness for work, its main and most distressing symptom is a persistent headache, all over the head; at times more especially in the occiput. The fever-heat is paroxysmal, the temperature rising in an irregular manner to 104° F. and above, to fall down again in the morning or forenoon with a sudden leap to the normal point. · 62 BRAIN. In other cases the fever continues throughout the disease, while in others still, the temperature shows periods of remark- able low even subnormal grades. There is a similar irregularity in the march of all other symptoms. Periods of entire conscious- ness alternate with mild or wild delirious attacks; one paralysis may disappear or give way to another; contractions and spasms may disappear for hours and then reappear again; altogether the motor symptoms make their appearance only at a very ad- vanced period; and in some cases they are entirely absent. Death follows during coma. These peculiarities distinguish simple basal meningitis almost from any other disease. Its sudden beginning in healthy indi- viduals in the prime of life without any tuberculous antecedents; its long duration without any marked changes except those stated above; the late occurrence of paralyses; the rareness of spasmodic symptoms; the persistent headache-all taken together make a peculiar type. Typhoid has a different record of tem- perature and almost always enlargement of the spleen; cerebro- spinal meningitis is an epidemic disease and besides has no such long-continued clearness of the sensorium; abscess of the brain grows only upon abnormal conditions of the body (purulent and ichorous processes, affections of the bones, purulent affections of the lungs), and has no such characteristic march throughout. Tubercular meningitis may sometimes have a similar protracted course; but here the tubercular diathesis decides. The PROGNOSIS is not favorable, but cured cases are recorded. There are still other forms of meningitis, which I shall briefly mention. Meningitis of the Convexity May come on spontaneously, that is without any known cause, or may be due to inflammatory processes in neighboring tissues, such as inflammation of the skull bones, caries of the inner ear, puriform softening of a thrombus in the sinus, panophthalmitis, erysipelas capitis, carbuncles of face and neck, old intra-cerebral affections. Metastic Meningitis Must be considered as a terminal complication of some acute dis- ease, of some suppurative processes at a distance. Such are MENINGITIS. 63 croupous pneumonia with fungoid vegetations; cheesy deposits in the lungs; ulcerative endocarditis; pyæmia; acute rheuma- tism; dysentery; diphtheritis; measles; scarlatina; typhoid fever; Bright's disease. Traumatic Meningitis Is due either to concussion of the brain or an injury of only the soft parts of the skull, or a perforating injury, or a necrosis of the skull bones after such injury, or the breaking of an abscess of the brain. THERAPEUTIC HINTS.-As a general rule the pregnant woman ought to be under the watchful eye of her physician during that whole period. She may be relieved just during that time of many chronic troubles, better than at any other time and her offspring saved of as many serious afflictions. But where a mother has lost already one or more children from hydro- cephalus, Grauvogl's advice to administer to such a mother dur- ing another pregnancy Sulphur and Cale. phosph. at suitable inter- vals, ought never to be forgotten. Even after the birth of a child with suspicious hereditary proclivities, we may be able to ward off an acute outbreak of meningeal inflammation by one or the other of the following remedies: Baryta carb., children who do not grow, but pine away, with swelling of glandular structures. Calc. carb., fat babies with large heads, wide open fontanels, which are often covered with dirty or scurfy skin; fair com- plexion; they are lively, precocious; their head sweats profusely during sleep, especially on the occiput; stomach and bowels are large, sensitive to pressure; bowels inclined to be loose; feet damp and cool; dentition slow and troublesome. Calc. phosph., flabby, shrunken, emaciated children; skull thin and soft, with fontanels wide open; will not stand any more; do not learn to walk; want to nurse all the time; great desire for salt meats and potatoes; after eating and drinking, bellyache; retarded dentition with cold tumors, emaciation and loose, green and at times slimy stools. Lycop., children sleep apparently soundly, but scream out sud- denly in sleep, stare about and cannot easily be pacified. Silic., rickety children; sweat much about the head,. especially 64 BRAIN. forehead and face; claw their mouth during dentition; are prone to abscesses, glandular swellings and a fetid sweat of the feet. Sulphur, children who do not like to be washed; have pimples, boils and other eruptions on head, face and everywhere; pick at nose; have red lips; crave sour things; feel faint in the forenoon; may have diarrhoea early in the morning; sleep restless; start when falling asleep; cry out during sleep; or murmur, moan and whine, or snore; their feet are cold in the morning and hot in the evening; they run about, but do not like to stand; sit hunched and walk stooping. Thuja, children of sycotic and syphilitic taint; they are rather thin than fat, are prone to eruptions which, on healing, leave purple spots; their teeth soon turn black and decay at the gums; the salivary glands swell; there is sometimes thrush or ranula; offensive discharge from the ears; soreness of penis or vulva and about the buttocks; frequently recurring morning diarrhoea; pain in the left iliac region; fetid foot-sweats; often the uncov- ered parts sweat, while the covered parts are dry and hot. Their parents, one or both, have a greasy skin, and warts and moles, and crave salt, and the little one will by and by show these he- reditary symptoms.-(T. P. Scales.) When the real meningeal inflammation has set in, we shall have to choose between the following remedies: Acon., in the first state of irritation and in the traumatic form, especially where there is fever-heat, dryness of the skin, restless- ness and impatience. The pulse is full and bounding or thready; the breath is short. Apis, convulsions; eyes, ears and skin lose their sensitiveness; when water is put into the mouth, there is no effort at swallow- ing; sopor, interrupted by piercing shrieks; bending back and rolling of the head; muscles of neck tense; profuse, sticky sweat on the head, of a musk-like odor; inability to hold up the head; eyes sunken, half shut; on opening eyelids no reaction; squint- ing; dilated pupils; hearing gone; occasional red streaks or crim- son spots on the face or different parts of the body; face pale, of a milky blue; grating of teeth; scanty, but frequent emissions of a dark and sometimes of a milky urine, or suppression of urine; no stool, or thin, scanty stool, passed but seldom and uncon- sciously; trembling of the limbs; twitching or moving of the limbs of one side and paralysis of the other; irregular, slow pulse, or very quick and weak. • MENINGITIS. 65 Apoc. cann., sutures opened; forehead projecting; sight of one eye totally lost, the other slightly sensible; stupor; constant in- voluntary motion of one leg and arm; urine suppressed. Arg. nitr., according to Grauvogl in the last stage. He gives it in the 6th dilution every two hours, and at the same time Calc. phosph., 2d trit., night and morning. Arnica, after a fall causing either concussion, a bruise or a per- forating wound; also where there is suppuration in consequence. There are cases where the meningeal irritation does not show until several weeks after the injury. For such cases Arnica is specific. Art. vulg., convulsions of right and paralysis of left side; body cold all over; sopor, and yet drinking and swallowing water eagerly; face pale and oldish looking; involuntary stools, green- ish and thin. Bellad., vertigo on sitting up, with nausea or vomiting; redness and heat of the face, or alternate redness and paleness; sparkling, shining eyes, with dilated pupils; rolling and squinting of the eyes; blindness; throbbing of the carotid arteries; drowsiness, yet inability to sleep; or drowsy, restless sleep, with frequent startings; trembling hastiness in taking hold of things and sit- ting up; spasms affecting eyes and face, or spasms of one side and paralysis of the other; involuntary discharge of urine. Dur- ing dentition; after taking cold by exposure to a cold north wind. Bryon., leaning head against something; putting hand to the head; uncertain, tottering gait; tired; sudden change of disposi- tion; dizziness; fall often and strike against things; sudden change of color in the face; loss of appetite; restless sleep-as premonitory signs. Later: head bent backwards; very dark red face, “crimson red;" dry lips; dry, brownish tongue; hasty, im- petuous drinking and swallowing; constipation; suppressed or painful urination with much straining; dry heat all over and especially of the head; drowsy sleep; chewing and swallowing during sleep; cries when being taken up or moved. Canthar. may be a rival to Apis. Is important in inflamma- tions of serous membranes, why not in meningitis? There are a number of symptoms which hint to it. Compare Condensed Materia Medica. Cina, either real or simulating meningitis with so-called worm symptoms. Cicuta, rolling of the head from side to side, or boring of the 5 66 BRAIN. occiput into the cushions; head hot; eyes closed; on lifting the lids, eyes stare upwards; great agitation; child grasps at one's clothing in a frightened manner; jerking of limbs; convulsions with screaming afterwards. Cuprum, hot head; deep sopor with twitching and jerking of the limbs; coldness of the hands, and a bluish appearance of the fingers. "During scarlet fever without eruption; afraid of and shrinking away from every one who approaches him; afraid of falling; clinging tightly to the nurse; won't stay in bed but in the lap; conscious, knows people." Tongue darting forth and back with great rapidity, like a snake's. After catarrhal or ex- anthematic fevers; during difficult dentition. Digit., sopor; unconsciousness; pupils dilated, insensible to light; blindness; one-half of face convulsed; pulse very slow, often hard, with a corresponding powerful stroke of the heart, sometimes intermittent and small; breathing heavy, slow and deep; sleep with frequent startings, and dreams of falling; gen- eral convulsions. Gelsem., the child wants to be let alone, wants to lie still; head hot, hands and feet cool; face red; eyes dull; tongue coated yellowish white; no thirst; breath hot, sometimes offensive; sleepy and drowsy, sometimes comatose; during sleep, convulsive motions; creeps and flushes run up the back; more or less moist- ure of the skin, especially on palms of hands and in the axillæ; pulse depressed at first, later frequent and soft. During summer or warm weather with southerly or southeasterly wind. Glonoin., headache; every pulse is felt, as if the head should burst; stupefaction; sunken eyes; under the eyes a bluish pallor ; red eyes with photophobia; optical illusions; lightening; black spots before the eyes; blindness; in the ears pain, fulness, pulsation, ringing, deafness; face is pale in spite of high fever, or red and hot; temporal arteries pulsate violently; heart beats strong and laborious; pulse mostly accelerated, often changing suddenly to slow and back again; nausea, vomiting with the headache; sudden spasms. Gratiola, has been given as extract with good result in a case where there was low respiration; occasional sighing; gnashing of teeth; eyes shut; pupils enlarged; slow pulse; unconscious discharge of fæces and urine. Helleb., great irritability, getting angry easily; vertigo as if drunk; eyes staring or rolled up, lids half closed; squinting; MENINGITIS. 67 forehead drawn in folds and covered with cold perspiration; face pale and puffy; frequent rubbing of the nose; nostrils dry and dirty; chewing motions with the mouth; greedily swallows cold water; wants food occasionally but rejects it when offered; rolls the tongue from side to side; lower jaw sinks; vomits green mucus; passes dark urine with a sediment like coffee-grounds. Breathing sometimes quick, sometimes slow and deep; sighing; boring back of the head; soporous sleep with screaming and starting; automatic motions of one arm and one leg; convulsive movements of muscles and jerking; exudation. Kali hydr., is the remedy of Kafka, for, scrofulous and tubercu- lous subjects. The disease develops gradually, and this remedy ought to be given at an early stage, although even later with symptoms of exudation it has been found to act favorably. Laches., is often indicated after Lycop., especially when there is difficulty of swallowing; gagging with throwing up of wind; hot abdomen. Lycop., is one of the most important remedies in tubercular meningitis. Generally speaking it corresponds to scrofulosis and tuberculosis, cheesy degeneration and dropsical effusion. Special indications: drowsiness, loud screams during sleep; sleep with half open eyes, throwing the head from side to side with moan- ing; bad humor after sleep; comatose state; great emaciation; pale face; flushes of heat in the face; spasmodic twitching of the face; stiffness of the neck; constipation. Also in complications with eruptive fevers and pneumonia. Merc. sol., drowsy, sleepiness with restless throwing about and occasional waking with a shrill cry which is followed again by dozing off. The sensitiveness of the eyes to light is diminished; squinting. Mercury is considered as being capable of exciting the process of absorption. Opium, soporous condition with half open eyes; snoring; iris insensible to light; congested face; suppressed urine. · Spongia, according to Hering, of great importance on account of its relationship to scrofulosis and tuberculosis. Guiding symp- toms: congestion of blood to the head with pressing, knocking and pulsating in the forehead; redness of face with anxious mien; better when lying in a horizontal position; heat in the head; bending the head backwards with tension in the neck. Eyes staring, lids wide open; double sight; face pale and cold with the heat; alternately red and pale. Twitching of the muscles 68 BRAIN. with the fever; frequent waking with a start; tossing about; stupid slumber. Stramon., head is thrust forward instead of back; conjunctiva injected; pupils contracted; desire for light, or bright light and glistening things cause spasms; calls for his parents who are present but does not know them; violent delirium; stammering; great dryness of the mouth; dysphagia; urine suppressed ; trembling and convulsive movements of the limbs; striking with hands and feet; frequent torsions of the trunk; screaming; sup- pressed miliary eruptions. Sulphur, heaviness of the head; it sinks backwards; sweat on head of musk-like smell; frequent change of color in the face; pale, distorted features; sour smell from the mouth; turbid urine with red sediment; suppressed eruption on head, behind the ears or elsewhere. Often indicated after Bryon. or Helleb. See above. Zincum, cross and crabby in the afternoon and morning; pain in forehead, better when lying; sensitive to light; dry nose; pale, waxy face; relaxed features; gagging and vomiting and yet a voracious appetite; stool retarded, omitting for days; scanty, turbid urine, as if mixed with clay; cannot keep the feet still. Heat and fever morning, evening and part of night; restless sleep before midnight, after midnight more quiet, and in the morning awakes brightly. Complication with scarlatina. Hydrocephalus Chronicus Develops itself, in grown persons, of acute attacks of different forms of meningitis, which may have been brought on by ir- ritations of the brain from exposure to heat or cold; external injuries; the abuse of intoxicating drinks, or too great mental exertion. In children, even if it originates after birth, it is never- theless identical with the affection called Hydrocephalus Congenitus, that form which children are born with. It is probably the con- sequence of an inflammatory process of the lining of the ventri- cles during foetal life; perhaps it is a deficiency in the proper as- similation of calcareous substances which form the bones. Why it is, we do not know in either case. Some women have given birth to hydrocephalitic children several times in succession, without any apparent cause. HYDROCEPHALUS CHRONICUS AND CONGENITUS. 69 As the water collects in the ventricles while the sutures of the bones have not yet united, its constantly increasing bulk drives the bones asunder and enlarges the head to an enormous size. Or, if we take the other view, which is perhaps the more plausi- ble of the two, we might explain it in this manner: The insuffi- ciently-developed bones are not capable of restricting the grow- ing brain within its proper limits; they give way here and there, and the brain gains entirely too much space within the skull. As, however, a vacuum can never exist, it is at once filled up with the general equalizing medium, water or serum. In this way the inner pressure becomes still stronger, and the still deficient bony structure becomes still less capable of restraining the in- creased internal pressure; it gives way again and again; and for the same reason the effusion of water must increase still more, until at length the whole cranium-attains to an enormous size. The disease can be recognized at once, although it may not have come to its full development. There is a disproportion between the size of the skull and that of the face; the fontanels are much wider than usual, and the frontal opening may be traced down into the frontal bone; and laterally, down between the parietal and frontal bones. The bones themselves feel thin under pressure of the fingers; and externally the veins appear greatly enlarged, shining through the skin. All these external changes appear only when the collection of water is very considerable. There have been found from six to ten pounds of serum within the ventricles, which then appear enormously distended and thickened, while the substance of the brain in the neighborhood is wasting away. A small amount of serum does of course not change the external form of the cra- nium; neither is it changed should the effusion take place at a later period, when the sutures of the skull bones have closed; to this there are a very few recorded exceptions. Children born with hydrocephalus fully developed, die fre- quently during birth or soon afterwards. Others show no signs of this malady in the first weeks; even during the whole of the first year it may be overlooked, until the inability of the child to hold up its head calls attention to it. But even then there may be no enlargement of the head visible, yet the child is slow in all its mental developments; it does not make any attempt to talk or walk; it remains uncleanly, and its actions look strangely; when in joy or fear it makes antics and straggles 70 BRAIN. with its extremities. Its eyes do not look knowingly at any ob- ject; it shows no interest for things; it appears imbecile and fool- ish. Saliva is constantly oozing out of the half opened mouth; it eats greedily, and often is seized with spasms. The progress of the disease is either a steady one, going on from bad to worse, until at last general paralysis ends the scene; or it is interrupted by stationary periods, or it remains for years seemingly unaltered. It is rare, however, for such patients to live beyond the age of puberty; a few only have been observed to live to the age of twenty. THERAPEUTIC HINTS.-The most important remedies for this affection are: Arsen., Calc. carb. and phosph., Helleb. and Sulphur. The old school confesses that by diuretica, drastica, iodine- preparations and calomel nothing has been achieved; neither has the compression of the skull by adhesive strips, nor a re- peated punction or tapping, been of use. Hydrocephalus Senilis Is that form of hydrocephalus which is found in old age, the second childhood of man. It seems to be developed from the following condition of things: The brain in old age is apt to shrink, which necessarily would cause an empty space within the skull. As no vacuum can exist, the would-be empty space is at once filled up with serum. The same takes place when, from some cause or other, only a portion of the brain becomes atrophied. The space which hereby is vacated is at once taken up by an exudation of fluid. Hence this sort of hydrocephalus is termed Hydrocephalus ex vacuo. It sometimes happens that the exudation of serum takes place so suddenly and so profusely as to cause all the symptoms of an apoplectic stroke, when it is called Apoplexia serosa. In most cases it is impossible to make a differential diagnosis between it and Apoplexia sanguinea; neither have we any distinct signs by which to diagnose Hydrocephalus senilis. Meningitis Cerebro-Spinalis Epidemica.-Spotted Fever. This is an acute, diffusive inflammation of the pia of the brain and spinal cord, resulting in an exudation of purulent matter. MENINGITIS CEREBRO-SPINALIS EPIDEMICA. 71 "It is deposited both on the convexity and at the base, especially along the course of great vessels, in the folds and depressions of the surface of the brain, in the fissure of sylvius, along the sulci, between the pons variolii and chiasma, and on the pons and cere- bellum. In rare cases the whole surface of the brain is uniformly covered." In the spinal cord the exudation is found "chiefly in the lumbar, less in the cervical region, and almost exclusively on the posterior surface of the cord," owing to the tendency of any fluid to flow to the dependent parts. "The brain substance is sometimes congested with punctiform hæmorrhage and secondary development of small spots of softening; at other times, when the disease has been hyperacute or very long-continued, it is juicy or oedematous, with a smooth, level surface, and of a watery appear- ance on section. More rarely the substance is of a tough con- sistance." (Von Ziemssen.) Although this disease may have prevailed at times in previous centuries, the first epidemic ascertained with certainty, is that in Geneva, from February to April, 1805. Since then many epi- demics have been observed and in all parts of the globe, with the exception of the tropical regions proper. It is an infectious dis- ease, but what its disease-germ consists of, is entirely unknown. It generally occurs during winter and spring, and especially when there is great moisture of the air and great variations of temperature. It selects not malarial regions, but rather sandy, dry plateaus, though malarial neighborhoods are not exempt. Childhood is most severely attacked, yet no age is spared. The disease-germ seems best to thrive where it finds a soil prepared by insufficient nourishment, damp, overcrowded, badly ventilated houses with unclean ground floors. SYMPTOMS.-It most always sets in suddenly, commencing with a chill, followed by fever; violent headache; vomiting; extra- ordinary prostration of strength and great restlessness. The headache is unusually severe, sometimes in the front, sometimes in the back part of the head; its cessation is a very favorable sign. Vomiting is especially excited by rising and rarely absent. The fever-temperature is very irregular, varying in the mean from 100.4° F. to 104° F., with very irregular variations above and below these points, often interrupted by long-continued normal temperatures, while the other symptoms continue un- abated. The pulse is likewise irregular; its frequency does not always correspond to the height of the temperature, and varies C 72 BRAIN. sometimes thirty to forty beats in a few hours. A slow pulse is less frequently found than in meningitis tuberculosa, and a con- tinued rapidity is unfavorable. In severe cases there occur at the start loss of consciousness, coma or delirium, or at least som- nolence, out of which the patient may be roused by being spoken to, answering correctly, but soon relapsing into the same state again. Some cases commence with convulsions, and that char- acteristic stiffness of the neck, which in a few hours may develop into a tonic contraction of all the extensors of the spinal column; orthotonos is frequent; opisthotonus is rarer; rarest is pleurotho- tonos or the unilateral contraction of the spinal erector muscles. In rare instances, however, the stiffness of the neck is entirely absent. There is great aching in all the limbs, and especially in the spine, a universal oversensitiveness of the skin; every touch and motion causes great pain. Now appear also cutaneous erup- tions, herpes on the face, or on the extremities; then erythema, roseola, urticaria and petechiæ. The name of the spotted fever was suggested by those irregular, purplish ecchimosed spots from the size of a pin's head to larger patches, which appear generally on the second day of the disease upon various parts of the body, usually first on the upper eyelids, gradually extending to other parts; they do not get white under pressure. In some cases they are absent. From the third to the fifth day the tongue becomes dry and cracked, in comatose cases; in other cases it remains moist but heavily coated. There is sometimes diarrhoea, at other times constipation. In other cases the symptoms of irritation are followed by symptoms of depression; no reaction ensuing; unconsciousness is complete, stools and urine pass off involun- tarily, pulse and temperature rise, convulsive movements, half- sided paresis, general convulsions, profound coma follow each other and death closes the scene. In favorable cases these symp- toms of depression do not set in at all, or are not so marked nor lasting. The headache, the pains in the limbs and spine con- tinue, but gradually grow milder and convalescence begins in from one to two weeks, though sometimes later. There are cases especial during the commencement of an epidemic, which ter- minate fatally in from twelve to thirty hours; and on the other hand, there are cases even during the height of an epidemic, which are so light, as to allow the patient to continue work. AS SEQUELE have been observed: "Deafness, derangements of vision, chronic hydrocephalus and chronic meningitis, with the MENINGITIS CEREBRO-SPINALIS EPIDEMICA. 73 consequent impairment of intelligence, and lesions of motility in the form of paralysis and paresis.' "" The DIAGNOSIS is difficult in isolated cases and when the dis- ease occurs in complication with other acute diseases, especially croupous pneumonia. It differs, however, from Tuberculous men- ingitis by the suddeness of its attack, the irregularity of pulse and temperature, and its peculiar eruptions; from Typhoid by the same pecularities. In the first days a distinction between the two may not be possible, but a few days of observation of the temperature will decide. When in complication with pneu- monia, its diagnosis may remain doubtful for some time; how- ever, the stiffness of the neck and the painfulness of the spine will lead us to suspect such complication. Its PROGNOSIS is grave, especially in infancy and old age and in all cases where the symptoms are very violent and the state of depression continues without any apparent reaction. Each single case has to be weighed by its own peculiarities and even these doubtful cases may take a favorable turn, while others prove fatal even under careful treatment. THERAPEUTIC HINTS.-Acon., chill; fever; restlessness; dry skin; great thirst. Still I have not seen, nor found mentioned great achievements from this remedy. Act. rac., intense pain in the head, as though a bolt were driven from the neck to the vertex with every throb of the heart; pain at the base of the brain and up and down the whole length of the spine; stiffness of neck and back; intense pain in the eye- balls; tongue swollen, or raw and red; redness of fauces and palate; soreness and bruised feeling of the muscles generally, or sometimes confined to a circumscribed spot, and often changing location, and with a feeling as if an abscess were forming; great sensitiveness of the skin. Creeping chills in the back; profuse, sometimes cold perspiration all over; tonic and clonic spasms; delirium, like delirium tremens; sees cats and dogs, etc. Apis, often indicated. Compare Meningitis. Arg. nitr., recommended by Grauvogl, is undoubtedly of great importance. It has tremendous headache of all kinds; vertigo; photophobia; clouds before the eyes; double vision; eyeballs floating in mucus; deafness; pale and emaciated face; lips and nails blue; white coated tongue, or dry and hard tongue, like bark and black; black coated teeth; cannot talk; wants to drink 74 BRAIN. sweet things, sugar water, the juice of boiled, sweet prunes; stools and urine unconsciously; oppressed breathing; wants to be covered all the time and yet wants fresh air, the windows open ; cannot move himself. Soporous sleep, with constant murmur- ing; it is difficult to rouse him, and when half roused, the eyes, scarcely opened, fall shut again. The whole left side is weak. Emaciation; constant trembling of hands; jerking of single muscles. Arnica, sopor; cringes when touched anywhere, even during unconsciousness; great soreness all over; diuresis; during stage of great weakness. Arsen., great restlessness and prostration; arsenic thirst; inter- mittent type. Bellad., often indicated by the violent headache, drowsy state, and delirium; dilated pupils; double sight. Bryon., bursting headache; stiffness of neck; great pain in joints and limbs, all worse from motion. Camphora, cold, deadly pale or blue, almost pulseless from first shock of chill without reaction. Cann. ind., vertigo on rising with stunning pain in the back part of the head; fixed gaze; dilated pupils; sensitive to sounds; cold face, with drowsy and stupid look; anguish in the chest with great oppression; pain across shoulders and spine; paralysis of lower extremities and the right arm; convulsions; emprostho- tonus, with loss of consciousness; collapse; stupor; pale, clammy and insensible skin; feeble, irregular pulse. (Hale.) Chin. sulph., violent throbbing headache; vertigo; heat in face; involuntary closing of the eyelids from sheer prostration; inter- mittent type. Cicuta, insensibility; double sight; dilated pupils; staring look; jerking of eyeballs, muscles of face, arms and hands; perfect deaf- ness; dumb for several days; ashy paleness of face; head re- tracted; rigid spine; dysphagia; first diarrhoea then constipa- tion; rapid pulse; insensibility to touch and pinching; paralysis all over. Crotal., horrid headache; delirium with open eyes; pain in all the limbs; ecchymosed spots everywhere; convulsions and pa- paralysis. Gelsem., feeling as of a tape around the head; great drowsiness; itching of head, face and neck; loss of vision and speech; nausea; pulse feeble; respiration labored and feeble; trembling and com- plete loss of muscular power; sweating relieves. PACHYMENINGITIS. 75 Glonoin., violent throbbing headache with sense of expansion; blindness with faintness and nausea; pale face; pain through the whole length of spine. Hyosc., delirium, muttering or wild; double sight; convulsions. Lycop., sopor; sinking of lower jaw; fan-like motion of nos- trils; feeling of tension in chest and abdomen as of a hoop; don't want to be alone; jerkings of limbs and body. Compare under Meningitis. Opium, stupor; spasms; drawing the body backwards and roll- ing from side to side; deep, slow breathing; very quick, or very slow pulse. After violent emotions, fear, grief, fright, which acted like a blow, stunning the whole nervous system. Rhus tox., stupefaction and vertigo; various eruptions, eczema on face; nosebleed; dry cough, perhaps bloody sputa; great ach- ing pains all over with restlessness. Ver. vir., during first stage with coldness of surface; loss of con- sciousness, labored, slow and irregular pulse. Later: trembling as if frightened and on the verge of spasms; convulsions; retrac- tion of head; rolling of head; rolling up of eyes; opisthotonos; very frequent and feeble pulse. - Protracted recovery hints to: Calc. carb., Carb. veg., Psorin., Silic., Sulphur, Zincum. Pachymeningitis, Inflammation of the Dura Mater. The dura consisting of a periosteal (external) and an inner lamella, pathology recognizes: 1. Pachymeningitis externa, which may be caused by external injuries; separating the membrane from the inner surface of the skull, or bruising and tearing it; or by transmission of inflam- mation from neighboring tissues. It always is confined to cir- cumscribed spots, and seldom recognizable as a separate affection, because of the ease with which the inflammatory process may spread to the inner lamella and pia. Pachymeningitis of old age is frequently detected post-mortem, without any marked symptoms during life. 2. Pachymeningitis interna may be a mere continuation of in- flammatous and suppurative processes of the outer layer. As such it is as little recognizable during life as the former. 3. Pachymeningitis interna Hæmorrhagica or Hæmatoma durae matris is in fact not an inflammation, but an extravasation of 76 BRAIN. blood, which undergoes the usual changes of a coagulum, and developing from itself a new formation. It is found either on the surface of both hemispheres or only on one, and principally at- tacks persons after 30 years of age and upwards, although cases under that age are likewise recorded. The SYMPTOMS must naturally vary according to the quantity of extravasation, its location on one or both hemispheres or its spreading from one to the other, and its repetition. A sudden and increasing compression is indicated by headache, drowsiness, loss of consciousness, fever, slow, sometimes irregular and towards the end mostly very frequent pulse. The contraction of the pupils, the absence of strabismus and ptosis indicate that the convexity is the seat of the lesion; the simple rigidity, paresis or actual paralysis of the muscles, the disturbances of sensation, numbness, formication, when present on one side only or on both, or progressing from one side to the other, indicate its location on the opposite hemisphere or over both, or its spreading from one to the other. Coma, disturbances of respiration, slowness of pulse, inability to swallow, cessation of reflex movements of the pupils, indicate a compression of the whole brain, while convulsions of one side and then on the other, afterwards paresis of one side with paresis of the facial or hypoglossus of the same side, then paresis of the other side show irritation of the motor centres of the sur- face of the brain. The intervals between different attacks of ex- travasation are characterized by headache, diminution of intelli- gence, loss of memory, drowsiness, partial paralysis, disturbance of speech, sudden mental excitement without cause and fre- quently mixed symptoms of dementia paralytica. Its predisposing influences are old age, atrophy of the brain from alcoholism, atheroma, affections of the lungs, heart and kidneys, chronic psychoses, anæmia perniciosa, hæmophilia, scorbutus. Its duration may extend from one day to one year and longer. For therapeutic hints see under meningitis and apoplexy. Encephalitis; Abscess of the Brain; Red and Yellow Softening of the Brain. It is a true inflammatory lesion of the cerebral substance, a red softening and consequent abscess of the brain. The yellow soften- ing is the consequence of a hæmorrhagic infarction, through the ENCEPHALITIS. 77 plugging up of a cerebral vessel, which may lead, however, by irritation, to a true encephalitis, and so may, vice versa, after its inflammatory stage has passed away, the true encephalitis assume the appearance of yellow softening and even be accom- panied on the surrounding cerebral tissue by a partial necrosis, so that indeed we may find spots of softening in the brain, of which we cannot ascertain the nature of the preceding process. True encephalitis is found always only in small spots (foci). These foci are red from extravasated blood and swollen; its boundaries imperfectly defined. By and by, if they are not ab- sorbed almost completely, which small ones of a traumatic nature certainly do in many cases, they undergo the well-known destruc- tive and reabsorbing changes; we see before us a focus of yellow softening, which gradually becomes more colorless, is transformed into a cavity with a thin emulsive fluid, and may, at last, lead to the formation of firm sclerotic cicatrices; or the transformation results in a collection of pus-an abscess. Recent abscesses have usually no enveloping capsule, while old ones have. As they grow they increase the intercranial pressure and retard the cir- culation in the brain, or compress the neighboring vessels in such a degree as to cause yellow softening of the surrounding brain- tissue to a large extent. The abscess may perforate the surface of the brain into the ventricles, or open upon the base and give rise to diffuse acute meningitis of the base. It causes widespread acute oedema and also anæmia of the brain, and when located in the cerebellum in such a position that it lessens the cavity of the fourth ventricle, or of the aquæ- ductus Sylvii, hydrocephalus internus chronicus. It may discharge through the skull into the subcutaneous tis- sue, or into the frontal sinuses and nasal fossæ, or through the temporal bone in the neighborhood of the processus zygomaticus, under the temporal muscle, or into the cavity of the tympanum. Abscess of the brain is either single or multiple and varies in size. The most frequent CAUSE of acute inflammation and recent ab- scess is traumatic injury; but there are also mentioned: Affections of the skull-bones, tumors in the brain, acute diseases, such as typhoid, scarlatina, affections of the heart, suppurating and sloughing processes in different portions of the body. These same causes apply to the capsulated and chronic abscess. Its SYMPTOMS are not at all well defined. An acute encephalitis, 78 BRAIN. 1 say from a non-perforating injury of the head, may run its course without our having a suspicion of its existence. Still symptoms, like the following, should not be unheeded: Dizziness; head- ache; vomiting; loss of consciousness; sopor; pupils wide and fixed; pulse slow; rolling of the eyeballs; transitory divergence; paralysis of the face or even hemiparesis or hemiplegia; twitch- ing of both hands and feet; convulsions of the extremities. Its extent cannot be determined. If not cured, it may result in cal- cification of ganglion-cells, situated under the injured part; in chronic irritable melancholy; in chronic headache, dizziness, anxiety and hallucinations; in inability to think, with intercur- rent periods of excitement and illusions of the senses; in com- plete imbecility, in a state resembling dementia paralytica; in epilepsy and tumors. The DIAGNOSIS must principally be based on the knowledge of its etiology. THERAPEUTIC HINTS may be looked after under the preceding chapters on the different forms of meningitis. Insulatio, Sunstroke, Thermic Fever. Whether it be, according to von Grauvogl, a want of water in the blood; or according to H. C. Wood, a paralysis of the vaso- motor nerves or some controlling centre in the brain, which in- fluences the production of heat in the body; or according to Hill in Braithwaite's Retrospect, 1867, an imperfect decarbonization of the blood; or according to Huguen, a hyperæmia of the pia and brain; or according to Arndt, a diffuse encephalitis; or accord- ing to Nothnagel, a venous hyperæmia, dependent upon a dimin- ished power of activity of the heart; or according to R. Gregg, a development of gas or steam in the brain-we shall leave un- decided; all physicians, however, agree that it is caused by the influence of excessive heat, and not merely by an exposure to the direct rays of the sun. The results of post-mortems are meagre; the most important may be gleaned from Dr. H. C. Wood's, Jr., Thermic Fever, 1872, in which he states: "Right heart and pulmonary arteries, with their branches, gorged with dark fluid blood; venous congestion of the lungs and entire body. The heart, especially left ventricle, rigidly contracted in every case, caused by a coagulation of the myosin, is pathognomic INSULATIO. 79 of sunstroke. In most cases, however, it is a post-mortem rather than an ante-mortem phenomenon. The muscles after death from heatstroke soon become rigid, sometimes instantaneously so." As PREDISPOSING CAUSES are enumerated: "Want of accli- matization, lengthened exertions, deprivation of water, the free and habitual use of vile drinks, debility, a febrile state, fatigue, bad ventilation, improper head covering and clothing, depressing influences." SYMPTOMS. The final "stroke" does not at all set in without warnings. At first the wonted work becomes a burden; the muscles lose their elasticity; there is great debility, loss of ap- petite, but great thirst. The head grows dizzy, achy; the chest feels oppressed, with frequent and short breathing and sighing; the throat gets dry, and swallowing painful; the voice becomes weak and hoarse; there is a general anxiety and irritableness of the mind; numb feeling in the extremities; restless sleep, or great drowsiness; increased vertigo, perhaps nosebleed, redness of the conjunctiva, pale face, tottering gait, or giving way of the knees. Many complain of a dreadful goneness at the pit of the stomach, nausea, vomiting; pain in the bowels, perhaps sudden diarrhoea, with profuse cold perspiration. Oftener the bowels re- main constipated. The mind becomes clouded, he answers con- fusedly. If for such and similar indications nothing is done in the vain hope that it be a mere transient indisposition, the "stroke” will surely and speadily follow, unless a change in the tempera- ture should heed it off by a still more rapid turn. This last link of a whole chain of more or less pronounced symptoms is very appropriately called "stroke." As if felled down by a blow, the patient sinks suddenly to the ground, with entire loss of con- sciousness, and complete insensibility of longer or shorter dura- tion; subsultus tendinum; partial spasms, or violent general convulsions; or paralysis of the spinal cord, so that he cannot move a limb. The face at first is very pale, gradually growing flushed, suffused, often deeply cyanosed, and finally assuming a leaden hue. The breathing is slow and sighing, or rapid; or deep and labored, often stertorous, with rattling in the trachea. The pulse grows feeble and exceedingly rapid; later irregular, intermittent and thready. Such a "stroke" might be mistaken for apoplexy, if it were not for the heat of the season and the premonitory symptoms. Apo- plexy may occur at any season and is often preceded by apparent good health. 80 BRAIN. } Sunstroke is not necessarily fatal and least under homœopathic treatment; however, it occasionally leaves very unpleasant after- effects, which "consist principally in symptoms of deranged inner- vation, inability to endure heat and sunshine, insomnia, vertigo and weakness, headache which returns after exposing oneself to the rays of the sun, or comes at regular times and in various parts of the head; chronic encephalitis; insanity; constipation; dyspepsia and derangement of the liver." THERAPEUTIC HINTS.-Man will never be satisfied. Cold water he improves by ice. Now-a-days it would be very old- fashioned not to keep ice-water summer and winter, and to gulp it down during, after and between meals. So dictates fashion, and it is good for the doctors and ice-companies. So in the treatment of sunstroke. Plain water, as well or river provide it, is entirely out of date. Being a "stroke," it must be dealt with "strikingly." Ice-water and ice-bags are the order of the day. Do we cure a frozen limb by boiling it? Will you cure a man, nearly boiling, by freezing him? Where is the sense? But fashion has none. When you are called to treat a man struck down by the sweltering heat, take water as river or well present it, and bathe his face, head, chest and spine, arms and limbs well with it. If you can have it lukewarm, it is better, because it is nearer to his temperature and by evaporation will withdraw sufficient heat, to cool the body down to a natural temperature in a very short time, without shock or malice. This alone may restore conciousness in a short time. But we have also remedial agents which may prevent the stroke, or shorten its attacks and prevent bad consequences. Among the remedies of prevention Gelsem. is the most important. It covers all the symptoms of a man who feels "play'd out," as Lilienthal so characteristically designates it. It is especially indicated in hot, damp, stifling weather, the exact meteorological condition of sunstroke and it has, at least in my practice, proved itself adequate to the occasion. Acon. and Arsen., are characterized by great thirst, hot and dry skin. - Ant. crud., by a white tongue, loss of appetite. Bryon., by great thirst, gastric derangements and aversion to motion. Carb. veg., vertigo; heaviness of head; pulsative pain above eyes; general debility; obtuseness of sensibility. INSULATIO-APOPLEXIA SANGUINEA. 81 Laches., by great dryness of throat, hoarseness; tightness and oppression of chest, and drowsiness. Ver. vir., by prostration, febrile motion and accelerated pulse. Among the remedies during the attack Glonoin is the most important. Violent headache; vertigo; does. not know the street nor his own house; losing senses and sink- ing down unconcious. Conjunctiva reddened; mist, black spots or visions of light before the eyes; pale and agitated countenance. White tongue as if painted. Thirst, pain and throbbing in the pit of stomach with a sense of sinking. Oppressed breathing, sighing, constriction and anxiety. Laborious and violent action of the heart. Numbness of limbs; muscular tremor; great pros- tration; sopor; convulsions. Amyl nitr., anxiety; longing for fresh air; dull confusion of head; giddy, intoxicated feeling; head feels full to bursting; eyes protruded, staring; conjunctiva bloodshot; intense surging of blood to the face; crampy, epigastric pain; burning and press- ure in stomach; dyspnoea and constriction of chest and heart; tumultuous beating of heart; tremulousness of hands and tired feeling in legs; tottering gait; weak, relaxed feeling. Bellad., similar to Glonoin. Drowsiness; dulness of mind; congestions towards head; loss of consciousness; headache; ver- tigo; anguish; flashes before the eyes; whizzing in ears; con- striction of chest; worse in summer heat. Camphora, sinking of the forces; oppression of breathing; em- barrassed action of the heart; coldness of body; tremors and cramps. Opium, unconsciousness; deep coma; eyes glassy and half closed. SEQUELE may be met with by Agar., vertigo from sunlight. Anac., loss of memory. Baryta carb., Laches., Natr. carb., Stramon., headache from being exposed to the sun. Apoplexia Sanguinea. It consists of an intra-cerebral hemorrhage, forming clots of various dimensions, usually from the size of a hazel-nut to that of a small apple, but they may be much larger or much smaller; their shape is either round or they are spread out in layers to a greater or less extent; they may occur singly, which is the rule, 6 82 BRAIN. or in numbers of two, four or more. Their favorite seats are the corpus striatum and the nucleus lenticularis, with the neighbor- ing parts of the hemisphere, and the thalami optici; in other parts they occur only exceptionally, and in the cornu Ammonis, the corpus callosum or the fornix scarcely ever. Unless fatal after a few hours, these clots and the surrounding tissue soon undergo structural changes. By absorption of the fluid- parts the whole mass thickens, turns at first dark red and later yellowish, and the surrounding tissue becomes soft partly from the inbibition of serum and partly from fatty degeneration, or inflames to a greater or less extent. If the patient survives the attack for some time, the clot forms into a cyst which may persist without change, or is converted into so-called apoplectic cicatri- cial tissue. Capillary hæmorrhages, showing blood-points of the size of a pin's head and smaller, are met with in places of softening, or in the cortex cerebri in consequence of thrombosis of the venous sinuses; they are secondary processes and should not be consid- ered under this head. The CAUSE of these intra-cerebral hemorrhages is now in gen- eral attributed to a diseased condition of the cerebral vessels, espe- cially the arteries, which consists according to Charcot and Bou- chard in the formation of numerous miliary aneurisms, in conse- quence of chronic periarteritis. They may burst spontaneously under an ordinary amount of blood-pressure within the cranium, as in cases where the apoplectic attack occurs during sleep or in perfect rest, or they may be ruptured by an increased amount of blood-pressure during spells of hard coughing, vomiting, laugh- ing, straining at stool, or during parturition; in consequence of mental excitement, or bodily exertions; after a full meal and the use of alcohol and coffee and other cardiac stimulants. The most frequent occurrence of apoplectic attacks is after forty years of age, although childhood is not exempt. SYMPTOMS.-In some cases, not in all, the first attack is pre- ceded by premonitions for weeks, months, even years. These are: frequently recurring dizziness, headache, ringing in the ears, muscæ volitantes, alterations in the disposition, sudden but transient loss of power to speak without paralysis of the tongue; sudden transient paresis in one arm, or leg, or both; or a sense of stiffness, a feeling of "pins and needles," numb feelings, or sensation of heat and cold, or of pain of an indescribable character APOPLEXIA SANGUINEA. 83 in the extremities; disturbances of vision, diplopia and even amorosis; sometimes nosebleed. The attack itself is ushered in by a sudden loss of conscious- ness, in many but not in all cases. It may develop itself gradually with symptoms above described, and unconsciousness following only after a lapse of several hours or days, especially after vene- section; or it may commence with paralyis of one side; or with chronic or tonic spasms of certain muscles which later become paralyzed, when hours afterwards sopor follows; or consciousness may not be lost for a moment, although the symptoms which precede the attack and those which usually follow and remain permanently after the return of consciousness in the usual cases, leave no doubt of an actual intra-cranial hæmorrhage. In case of complete sopor and relaxation of all the muscles in a de- gree that hemiplegia cannot be recognized in order to distinguish the attack from opium poison, asphyxia, etc., we shall find the eyeballs turned toward the non-paralyzed side of the body; this symptom usually lasts a few days. The color of the face is not uniformly the same in all cases; sometimes it is deep red, even cyanotic; sometimes natural, or again quite pale; the pupils may be dilated, of normal size or contracted; one pupil larger than the other points to a unilateral affection of the brain; the pulse varies likewise in different cases; in most cases it is slow and sometimes irregular; in others very rapid and regular; the respiration may be quiet and regular as in healthy sleep; it may be labored, stertorous; it may, during deep sopor, be a kind of blowing, drawing the cheeks in during inspiration and puffing them out during expiration-the so-called tobacco-smoker's re- spiration; towards the end respiration becomes intermittent and irregular. The temperature is at first usually lowered to 96.3° F., and remains so in the fulminating form until death. If life endures for from ten to twenty-four hours, the temperature rises rapidly. If life is prolonged to a still longer period, the temper- ature rises only to 99.8° or 100.4° F. where it remains; another sudden rise is a very unfavorable symptom, as it usually precedes death. Urine and fæces pass off involuntarily during sopor. Fulminating cases terminate in from five minutes (rare cases) to three or four days. Recovery rarely takes place after the coma has lasted forty-eight hours. But even if the coma ceases, health is by far not restored; now inflammatory reaction sets in; the tem- perature rises from a few tenths of a degree to two degrees; there 84 BRAIN. is occasional cloudiness of mind, even delirium; loss of appetite; convulsive movements, even tonic contractions with pain in these parts. This may last for several days, and then subside for a time, when the same symptoms, although in a milder form, reappear again at intervals of two, four or eight days. But there remain permanent symptoms for a long time often through life which depend on the extent and seat of the destruction caused by the hæmorrhage. These are, with a few exceptions, hemiplegia of that side of the body which is opposite to that in which the lesion of the brain occurred; paraplegia if the hæmorrhage oc- curred simultaneously in both hemispheres; partial paralysis, for example, of the facial nerve, in connection with extravasation in the optic thalamus, and in the corpus striatum; contracture (in the later stages) of the paralyzed limbs; anæsthesia of the affected parts, which may or may not diminish or completely disappear; hyperalgesia, by which a light touch is felt as pain, and which may alternate with anesthesia or even exist side by side with it for years; spontaneous attacks of pain in the partially or totally paralyzed limbs. There are also disturbances of the trophic and vasomotor nerves. The affected limbs are often hotter and redder for some time than those of the unaffected side; they are swollen, oedematous; they sweat profusely; after some time, however, they become cold; or the skin is tending to be dry and scaly from the first; the pulse is diminished in its amplitude; bedsores appear; the nails be- come yellowish, ridgy, brittle and curved in both directions; the hair grows thicker and longer, and the skin becomes hyper- trophied-all on the paralyzed side. Of the special senses taste is limited to the forepart of the tongue on one side in consequence of an affection of the chorda tympani; this symptom usually disappears soon, but may last for a long time. Hearing is sometimes slightly affected, and sight in the form of hemiopia frequently. Among the mental disturbances deficiency of memory is the most prominent, especially in regard to recent impressions, while old ones can be recalled with unimpaired distinctness. The power of judging may gradually weaken until the patient is re- duced to childishness or dementia; the disposition often changes to peevishness and irritableness. The PROGNOSIS is grave; even if recovery from the shock takes place, the consequences of the reactive inflammation are always APOPLEXIA SANGUINEA. 85 to be dreaded, and there is no safety for a renewed attack at any time thereafter. THERAPEUTIC HINTS.-Remedies to prevent the attack ought to be studied under hyperæmia, to which may be added: Sepia, after previous attacks; in men who have been addicted to drinking and sexual excesses, with a disposition to gout and hæmorrhoids. Forerunners: dizziness in walking, with stagger- ing; things fall out of their hand; forgetfulness; use wrong words when writing; cold feet; intermitting pulse. Remedies during the attack and its inflammatory stage: Acon., head hot; carotids throbbing; skin hot; pulse full and hard, but not intermittent; after fright or vexation, or suppressed habitual bleedings. Arnica, head hot and rest of body cool; paralysis of left side; pulse intermittent or irregular. Bellad., red face; dilated pupils; loss of sight, smell and speech; pulsation of carotids; spasms in the face; thick tongue, protrud- ing; difficult deglutition; involuntary emission of urine; reach- ing with the hands to the genitals; moaning; paralysis of limbs right or left; coma, sopor. Coccul., face red and hot; eyes closed, with the balls constantly rolling about; pupils dilated; breathing without noise; stupor; left or right extremities paralyzed; after night-watching and exhaustion. Gelsem. and Glonoin., see under Hyperæmia. Hyosc., sudden falling down with a shriek; soporous condition; face red; inability to swallow; involuntary discharge of feces; blood-vessels swollen; pulse quick and full; numbness of hands after consciousness returns. - Laches., left side mostly affected; blowing expiration; cannot bear anything to touch his neck; when conscious, talks and jumps abruptly from one idea to another; after the use of liquors or mental emotions. Lauroc., vertigo; bloated face; jerking of the facial muscles; speechless by full consciousness; palpitation of the heart; scarcely perceptible pulse; cold, moist skin. Nux vom., snoring; paralysis of lower jaw and (mostly) of the lower extremities, which are cold and without sensation; after a hearty dinner, or abuse of liquor or coffee. Opium, open eyes; dilated pupils; red face; jerking of the mus- 86 BRAIN. cles of the face; sinking of the lower jaw; foam before the mouth; slow, irregular or stertorous breathing; convulsive mo- tions of the extremities, or tetanic stiffness of the whole body; cold paralyzed limbs; hot sweat on the head. After conscious- ness is restored, the patient cannot retain what he reads and for- gets the connection of consecutive thoughts. Old drunkards; is followed well by Nux vom. Remedies for subsequent chronic changes: Anac., loss of memory; general paralysis. Caustic., inability to select proper words; paralysis of face or ex- tremities, which latter is complicated with muscular contractions. Cuprum, paralysis of tongue, stuttering, deficient speech; the paralyzed limbs grow thinner, but preserve sensation; frequently complicated with unyielding contractions or chorea-like par- oxysms. Plumbum, consciousness blunted; memory deficient; speech im- peded, single syllables are omitted or the syllables cannot be combined into words; mimic spasms of face when speaking; trembling of tongue when it is put out; semi-paralysis of the buccinator muscles and of the velum palatinum, which manifests itself by violent snoring; sleeplessness, fear of death; the organs of the senses are torpid and insensible, the eyes are principally affected; the eyelids droop as if paralyzed; the pupils most con- stantly dilated; all objects seem smaller and farther removed from the focus of vision; they may be seen as through a gauze; diplopia; pulse always slow, 50 to 60 in the minute; sometimes hard and tense like a wire; all the muscles may be paralyzed, especially of left side; the paralysis affects equally the motor and the sentient nerves, is often attended with violent pains in the paralyzed parts, and considerable contractions, especially of the extensor muscles, which feel as hard as wood; in other cases the spasms are tonic, which, if they reach their full development, run into complete epileptic convulsions; the muscles of the affected parts become atrophied. If the paralysis is not complete, the patient's gait is unsteady, with particular tendency to fall for- ward. The paralyzed respiratory muscles often occasion a high degree of dyspnoea. The sphincters are scarcely ever paralyzed. (Baehr). Zincum, senses remain disturbed after the attack. Besides, compare what has been said under Meningitis. OCCLUSION OF THE CEREBRAL ARTERIES. 87 Occlusion of the Cerebral Arteries; Embolism and Throm- bosis; Softening of the Brain. An occlusion of the cerebral arteries takes place either by em- bolism, when the occluding mass is carried by the stream of blood from some other parts of the vascular system to a place where, on account of the smallness of the vessel, it cannot go any farther; or by thrombosis, when the occluding mass is produced on the very spot of the occlusion. The emboli consist either of blood clots, masses of fiberine, con- nective-tissue growths, or chalky concretions, the principal source of which is endocarditis; and next aneurism of the aorta; seldom thrombotic masses from within the lungs. Thrombosis takes its origin through structural changes in the vascular walls, such as fatty degeneration, or inflammation of the coates of the arteries, leading to sclerosis, ossification, or cal- cification, by which a gradual slackening in the speed of the blood-current takes place, until an entire stoppage ensues. The emboli are carried much oftener into the left carotid than into the right, and they only exceptionally become lodged below the circle of Willis, but are swept into the arteria fossæ Silvii, which is the chief direct prolongation of the carotid. Sometimes several arteries become the seat of occlusion at the same time. If the seat of occlusion is below or on the cardiac side of the circle of Willis, or if the embolus is swept onward into the arte- rial system of the cortex, no anatomical changes follow in the cerebral substance, because the circulatory disturbances are readily compensated for by collateral circulation. When, how- ever, the embolus is lodged in a terminal artery of the basal sys- tem, or is carried beyond the circle of Willis, it causes first “red softening" of the neighboring brain-tissue, that is, the brain sub- stance appears swollen and discolored in different shades of red and is dispersed with numerous dots of blood ("capillary apo- plexies"). By and by the red color fades into yellow, partly from the absorption of the coloring matter of the blood, and partly from the ensuing fatty degeneration of the nerve elements; this state of things is called "yellow softening." After a lapse of several months, if the patient lives that long, the affected tissue is converted into a semi-fluid milky substance, which is termed "white softening." At length even this may partially be absorbed, leaving a sort of cyst filled with quite thin fluid. 88 BRAIN. The PREDISPOSING CAUSE of embolism is preeminently acute rheumatism, and it is therefore found oftener in relatively youth- ful persons, while thrombosis has its predisposing cause in a mor- bid change of the vascular system, and is therefore oftenest met with in advanced years. SYMPTOMS.-Embolism always sets in suddenly and very often with a condition, which resembles precisely that of an apoplectic stroke, without any premonitory symptoms. In some cases, how- ever, there is no loss of consciousness or coma; there may be delirium, aphasia, vomiting, paralysis—all disappearing in a few hours. Thrombosis comes on slowly with headache, dizziness and a sense of general confusion, loss of memory, numbness, coldness and creepings either in only one extremity, or throughout the distribution of one nerve, or in one entire half of the body; paretic and paralytic symptoms, perhaps with preceding slight convulsive movements, likewise confined to certain regions of the body and determined by the size and importance of the oc- cluded vessel. Finally the total occlusion may manifest itself with all the symptoms of an apoplectic fit, or may occur without any loss of consciousness. In the further course of development embolism or thrombosis may be described conjointly. Either of them may terminate in death or in complete recovery, or be followed by a repetition, or by a chronic development of symptoms as consequences of the structural changes within the brain above described. Only these latter symptoms concern us here. The temperature begins to rise on the second or third day and may quickly reach 104° F., when after two or three days it rapidly sinks again and finally becomes stationary. Indeed the complex of symptoms now developing may be regarded as identical with that of cerebral hæmorrhage, and need not, therefore, be repeated. Aphasia is of very frequent occurrence in this affection, because the left Sylvian artery is the most common seat for embolic occlusions, inducing functional disturbances in that district of the cortex cerebri with which disorders of speech are regularly associated. The DIAGNOSIS between embolism and hæmorrhage is very diffi- cult, unless we can take the predisposing causes (valvular diseases of heart and affections of the lungs) as a starting point. A dis- tinction between thrombosis and hæmorrhage is not possible, only that the first occurs much less frequently than the latter. - APHASIA. 83 THERAPEUTIC HINTS.-Compare Apoplexy and the various forms of meningeal affections spoken of before, to which I add the following remarks of Dr. H. R. Stiles: "When the disease shows evidence of inflammatory action, or is recent, Bellad., Nux vom., Mercur.; where it is evidently due to atheromatous condi- tions of arteries, Phosphor., Phosph. ac., Anac., Zincum; for hemi- plegia, Nux vom., Coccul., Baryta carb., Arnica; for vertigo, Iodine (congestive); Sulphur, Digit, (cardiac); for sleeplessness, Coffea, Hyosc., or Nux vom., and Chamom., if the patient has been addicted to the use of coffee; China, if he has been a great tea drinker; for paralysis (general), Phosphor., Conium, Coccul., (local) Caustic., Acon., Ignat., Bellad.; for convulsions (simulating epilepsy), Bellad., Calc. carb., Cuprum, Strychnine; for emotional disturbances, Ignat.; headache (active), Acon., Bellad., Bryon., Nux vom., Glonoin., (pas- sive) Gelsem., Opium; for imbecility, Arnica, Ambra, Selen., Sepia; or sensation of formication, Secale." Aphasia. Under this term clinical observers have arranged a variety of deficiencies of speech. When there is an incapacity for the motor co-ordination, so that the patient, although he understands all that is said to him and is able to express his wishes by writing, is yet unable to express them by words, although his organs of speech-tongue, etc.,— are in perfect order, it is called ataxia aphasia. Here the connec- tion between the idea and the organs of speech is interrupted. In some of these cases this does not amount to entire speechlessness; some words of one syllable may possibly be in his reach, and he uses them as best he can, making up by writing and gestures what he cannot convey by words; others utter only a few senseless syllables and words; but none can repeat words even if dictated to them. At times ataxic aphasia is complicated with agraphia, an inability to write either a single letter or a combination of letters into intelligible words and sentences, although otherwise the hands are fit to perform all sorts of other mechanical uses. The speech of gestures is seldom implicated in this affection. When there is an incapacity for the recollection of words, although the idea is present and the articulation is at the service of the word, it is called amnesic aphasia. Here the association between the idea and the word (its verbal expression) is interrupted. This occurs 90 BRAIN. even during health. Sometimes, with our best endeavors, we can not recollect a name; in the diseased state especially nouns, which cannot be roused into consciousness; therefore the pa- tient tries to describe what he means by other words, for in- stance calling a pair of scissors "that which cuts." Or it is only the initial letters which are wanting, and he omits them in speak- ing and writing; or in more profound derangements, although the patient may be able, by paying strict attention, to repeat what another speaks aloud before him several times, of his own accord he cannot utter it at all, or only badly articulated, mutilated and distorted. So also the letter-signs are either totally forgotten, or applied in unintelligible connections, while on the other hand the reading of written or printed matter may not meet any obstacles. When there is an inability to understand the words which they hear, or to read the words which they see, although sight or hearing and the ability to express their thoughts by speech and writing are unimpaired, it is called word-deafness and word-blindness (Kuss- maul). Here the association between the word (spoken or written) and the idea is impeded, or in other words the external stimulus does not reach the idea, while in the amnesic form of aphasia the idea is not capable of exciting its corresponding verbal expression. This affection, however, is generally combined with amnesic aphasia or agraphia, and patients of this kind have been taken for deaf and demented, because their answers did not correspond to the sense of the questions, and they used distorted or wrong words. When there is an inability to connect the ideas with their appro- priate word-expressions, so that instead of the appropriate term, another word of a different meaning or altogether strange and unintelligible expressions are used, it is called paraphasia. Here the connection between the ideas and their proper expressions is loosened, in a way that other words or names of ideas similar perhaps in meaning or sound interpose themselves and repress the proper ones. This disorder occurs at times without any pronounced morbid condition of the brain, when for instance from want of proper attention we use a word which belongs perhaps to another train of thoughts, but which at that time preoccupies the mind; or in the hurry of excitement, displace the consonants of certain words and form strange, irregular com- binations, say, for instance, “mood gorning" instead of "good APHASIA. 91 morning," or instead of "Liebig and Mitscherlich," as an absent- minded professor did, "Mitschich und Liederlich." But in marked states of the brain this paraphasic confusion may amount to such total perversion and corruption of words and sentences that it is completely impossible for the hearer to understand what the patient means. And the same is true of paragraphia. "Royal naval medical office, etc.," one wrote in the following manner: "Roydudendd navendendd oforendendd, etc." By numerous post-mortems it is proved that lesions of the left frontal lobe, and especially its third frontal convolution are the most frequent CAUSES of aphasia; the island with the neighboring frontal, parietal and temporal districts comes next in frequency. Aphasias, from lesions in other regions are exceptions to the rule, as for instance the lesions of the right frontal lobe. These latter cause aphasia only in left-handed people, for the reason that such persons have exercised for speech and action the right frontal lobe; a lesion of the left frontal lobe does not affect their speech, since that of the right, which alone has been exercised, remains intact. Left-handed people, therefore, become aphasic only when the lesions include the right hemisphere; while lesions of the left lobe always cause aphasia in right-handed persons. These lesions for the most part consist of necrotic softenings from embolism and thrombosis of the artery of the fissure of Syl- vius; then follow in frequency in the order named hæmorrhages, abscesses and tumors of this region. Aphasia is, therefore, merely a symptom of pathological conditions, most of which we have already described separately. Its PROGNOSIS depends entirely on the severity of these conditions, and they ought to be studied thoroughly in any case of aphasia. THERAPEUTIC HINTS.-Here we must naturally refer to those already given under the corresponding chapters. Cases reported have been cured by: Bellad., compare symptoms under apoplexy. Conium, parenchymatous nephritis after scarlet fever. Glonoin., loss of memory for words and of the power to articulate. Kali brom., 3d trit., without symptoms mentioned. Lycop., confusion of thoughts; forgetful; mixed up letters and syllables of words in writing, or left out part of them. Stramon., in several cases used empirically with success. 92 BRAIN. For additional hints compare the following collection of symp- toms: Senseless after waking from a sleep at noon: Conium. Forgetful and absent-minded, with headache: Amm. carb. Cannot remember things which he wants to remember: Hyos. nig. Forgets names: Anac., Olean., Sulphur. Remembers having seen a person, but cannot remember her name: Crocus. All things appear new to him, after waking, even his friends: Stramon. Makes mistakes about time and objects, although they are quite clear and visible: Crocus. Unable to express himself properly while talking: Conium. Cannot talk connectedly: Canthar. nor express himself properly, with rush of blood to the head: Arg. nitr. Distracted, does not know what to say: Natr. mur. Slow remembrance, talks slow, hunts for the words when talk- ing: Thuja. Absentminded and forgetful: Alum., Bellad., Bovista., Coccul., Phosph. ac., Platin. with awkwardness in talking: Amm. carb., Natr. mur., Sepia, Sulph. ac. and awkwardness in writing: Bovista. Inability to find the right words: Anac., Arg. nitr., Mercur., - Pulsat. with stammering: Chamom., Opium. with making mistakes in writing: Chamom., China, Graphit., Hepar, Ignat., Nux vom. With headache uses wrong words: Caustic., Nux mosch., or has difficulty in talking: Thuja. Absent-minded, says what she does not intend: Natr. mur., and makes mistakes in writing: Natr. mur. Leaves words out when writing: Rhodod. When he wants to write something down, he loses the ideas: Crocus. Forgetful, so that he cannot recall what he was about to write: Natr. mur. He can express himself on abstract subjects very well; when talking about common things, he gets confused: Lycop. He cannot read what he wrote himself: Lycop. Difficulty in understanding what he is reading: Conium. THROMBOSIS OF THE CEREBRAL SINUSES. 93 Thrombosis of the Cerebral Sinuses. The sinuses being of a rigid nature and incapable of collapsing, they being also traversed by bands of connective tissue, and hav- ing no muscular walls to promote the flow of blood, it is easily comprehensible, that in them a coagulation of blood may readily occur, if either the propelling power of the heart, the vis a tergo, should become weakened, or there should form obstacles to the flow of blood in the sinuses themselves by inflammation of their walls (phlebitis). The first usually occurs under conditions as are known by the name of marasmus, particularly common among children during their first year of life, when they are prone to sudden collapse induced by severe diarrhoeas; also in adults through the influence of various conditions which induce enfee- blement of the propelling force of the heart, such as profuse suppuration, cancer, marasmus senilis, etc. This form of throm- bosis is especially found in the longitudinal sinus and in the transverse sinuses, and is called marantic thrombosis. : The second or phlebitic form originates most commonly from disease of the cranial bones, especially of the petrous portion of the temporal bones which accompanies otitis media; then its seat is in the neighboring sinuses-the sinus transversus and petrosus; if phlebitis arises from caries of other cranial bones, or large furuncles in the face, especially on the upper lip, or erysipelas of the head and face, its seat is determined by the location of these lesions. The SYMPTOMS of marantic thrombosis when accompanying con- ditions of marasmus in children, resemble greatly those of hydren- cephaloid, both giving rise to cerebral anæmia; collapse, followed by somnolence and coma is common to both. As a general rule of distinction between the two, the following may be laid down: If diarrhoeas, occurring in children a few months old, are followed by cerebral disorders of the active motor kind, such as rigidity of the muscles of the neck and sometimes of the back, and even of the limbs, sometimes nystagmus, the probability speaks for thrombosis of the superior longitudinal sinus; whereas the clinical history of hydrencephaloid usually closes with col- lapse, somnolence and coma, terminating either in death or re- covery; convulsions or paralysis are only exceptionally met with. Marantic thrombosis in adults is in its manifestations still more indefinite. It may show nothing but a slight degree of apathy and general depression, a varying complex of symptoms of dif- 94 BRAIN. 1 fused, undefined cerebral diseases, such as headache, delirium, loss of consciousness, disturbance of the motor functions either of the spasmodic or paralytic kind. In some cases, however, symptoms occur in children as well as in adults, which are diagnostic, namely: swelling of those veins outside of the skull, which communicate with the affected sinuses; epistaxis; tensely filled vessels, running from the anterior fontanel to the neighborhood of the temples and ears on both sides; cyanosis of the face, all this in case of thrombosis of the superior longitudinal sinus. When the transverse sinuses are affected, there may be œdema limited to the parts behind the ears; or the internal jugular vein may be found less filled on the side of the lesion, than on the other side, but this symptom is not often so prominent that it could be turned to account. When the sinus cavernosus is the seat of the disease, there usually exists hyperæmia of the fundus oculi, œdema of the eyelids and conjunctiva, and prominence of the eyeball; sometimes on ac- count of the pressure upon the first division of the trigeminus, the trochlearis, the abducens, and the oculo-motorius, paralysis of the motor nerves, or neuralgia or trophic disturbance of the eye may arise. Sometimes particles from the thrombi are carried off by the blood-current and become lodged in the lungs. If such pul- monary embolism are found under conditions above described, it would be another sign in favor of the conclusion, that thrombosis of the cerebral sinuses actually exists. The PROGNOSIS of this affection is decidedly unfavorably, and in regard to therapeutic hints, I must refer to hydrencephaloid, anæmia, summer-complaint, inflammation of the inner ear and other affections which are more or less related to this affection. Hypertrophy of the Brain Means an overgrowth of the brain. However, we ought to know, that it is not the cerebral substance itself, which develops more largely, than naturally, but that it consists of an undue growth of the interstitial tissue which binds the nervous elements to- gether. It is confined mostly to the cerebrum; yet there are a few cases in which the cerebellum has also been said to be af fected. Partial hypertrophy is still more rare, and, in part, of very doubtful nature. HYPERTROPHY AND ATROPHY OF THE BRAIN. 95 On post-mortem examination the brain is observed to swell out from under the removed bone above the skull bones. The adjustment of the removed bones to their original position is quite difficult. The membranes are thin and bloodless and be- tween the arachnoidal spaces there is no cerebro-spinal fluid. The convolutions on the surface of the cerebral hemispheres are flattened and compressed, and the sulci between them scarcely noticeable. The ventricles are narrow and the substance of the brain itself is anæmic, but its consistence and elasticity is greater than in a normal brain. This abnormal growth is either congenital (and then is fre- quently combined with an imperfect growth of the body), or it develops itself after birth, mostly during early childhood, rarely afterwards. In the latter case, we find it frequently associated with rhachitis and enlarged lymphatic glands. Its CAUSES are unknown. Its external SYMPTOMS are: a considerable enlarge- ment of the head, if it takes place before the sutures of the skull are perfectly closed; a condition entirely similar to that in the enlargement of the head in consequence of hydrocephalus. When it takes place after the closure of the sutures, such extension is impossible, but the skull bones grow thinner and their inner layer becomes roughened by absorption. In the first place it can be distinguished from hydrocephalus by this fact: that children having this affection are rather forward in their mental develop- ment, while in hydrocephalus the reverse always obtains. A hypertrophy after the closure of the sutures is never recognizable with certainty. One of its most important symptoms, however, are frequent attacks of fits, which resemble epilepsy. THERAPEUTIC HINTS cannot be given a priori. Each individ- ual case must be studied by itself. Compare Hyperæmia. Atrophy of the Brain Is the opposite of hypertrophy, a shrinking, wasting away of the brain. Deficiencies of growth have been found congenital, being con- fined either—1, to both hemispheres of the cerebrum; or, 2, to both hemispheres of the cerebellum; or, 3, to certain parts of the brain which are not developed at all. In such cases the children are idiots. In some other cases the deficiency has been found confined—4, to one-half of the cerebrum and to the opposite half 96 BRAIN. of the cerebellum, (the usual condition), or to the corresponding half of the cerebellum; then the children are not idiots, but mostly affected with hemiplegia of the opposite side and in a great many cases with epileptic fits. This deficiency, in the proper development of the brain, the causes of which we do not know, is called agenesia. Real atrophy is a shrinking-wasting away—of the cerebral substance. It occurs, occasionly, in old age, in consequence of marasmus senilis, where a want of general nutrition causes a waste of the brain; the lost substance being at once replaced by an exudation of serum, constituting hydrocephalus senilis. It also occurs as a result of exhausting diseases and chronic alco- holism; almost always leading to general paralysis and imbecility of mind. But it may develop itself in portions of the brain only—partial atrophy-when in consequence of apoplexy, inflammation or ex- udation, as we have already seen, by destruction or pressure upon the capillaries or arteries, such portions become deprived of the necessary nutrition. Its consequences are, in almost all cases, aberrations of the intellect, imbecility of mind, and paralytic affections. THERAPEUTIC HINTS.-A deficient development of a portion of the brain can not be remedied; congenital deficiencies are there- fore clearly out of the reach of any medicine. Where we suspect an atrophy in consequence of exhausting disease, we must select our remedies according to these circumstances. Destroyed por- tions will ever remain destroyed in spite of medicine. Dementia Paralytica Is understood as "a diffused disease of the brain and often also of the spinal cord, which is characterized by a peculiar combination of physical changes with motor disturbances in the muscles of different parts of the body, which has a chronic course and ends in death." (Hitzig). In the protracted cases post-mortem always shows atrophy of the brain, which can be recognized by inspection and frequently by weight. The dura lies in folds over the frontal lobes; the pia is either locally or universally oedematous; the ventricles are en- larged; the dura often adheres so firmly to the skull that it can- DEMENTIA PARALYTICA. 97 not be removed without injuring the brain; it may present all varieties of dulness, thickening and deposits upon its surface, also innumerable larger or smaller flattened extravasations, which have all shades of color between yellow, red and black; even large hæmatomas have been found; yet there are numerous other cases in which the dura appeared intact. The brain-tissue by microscopical examination reveals a chronic or sometimes a sub-acute interstitial (peri) encephalitis, which in course of time leads to destruction of the ganglion cells and to atrophy of the brain. The spinal cord presents gray degeneration of the poste- rior columns or granular cell myelitis; the membranes of the spinal cord undergo, though more rarely, changes similar to those of the brain. As predisposing CAUSES heredity has been mentioned. Probably the combination of excessive labor with excesses in Baccho and Venere is the most common cause, although injuries of the head, constitutional syphilis and the influence of acute febrile diseases may also give rise to the development of this disease. It scarcely occurs under the age of twenty; is most frequent between thirty and forty-five or, according to some authors, between fifty and sixty years of age. Its PRODROMAL SYMPTOMS, which sometimes for years precede the final outbreak, are the most important for the physician, be- cause then and there lies his only chance of preventing greater mischief. Spells of dizziness, which pass over quickly; of headache, more or less severe and worse in the morning; of rheumatic pains, especially in the lower extremities, changing location and com- ing and going suddenly, worse at night. With these chance symptoms appear an unusual irritability of character entirely foreign to the patient's former behavior, and a weakness of memory, especially for recent events, while past ones are well remembered; he often forgets his hat, his cane, or pocket handkerchief, etc.; the muscles around his mouth occasionally are seen to tremble either spontaneously or when other facial muscles are in action. The patient is unconscious of it, and recognizes the fact only when he sees it in the mirror; his speech becomes nasal, or diffi- cult and imperfect, especially in regard to the labials and sibi- lants; a kind of lisping as if slightly intoxicated; the tongue trembles, and the voice changes. Apoplectic attacks are often the commencement of the disease. 7 98 BRAIN. >> In its further progress the patient shows peculiar exaggerated ideas of his own importance or greatness, he possesses a thousand or a million horses, a thousand million dollars, etc., and although now it may be proved to him, that he is wrong, he immediately for- gets all about it, and gradually falls into an idiotic silliness from the weakness of memory, which was one of the very first symp- toms of the disease. He also gradually loses his affection for his family and before his friends may have become aware of his unaccountableness, he may have squandered away the very subsistence of his family. Sometimes there are outbursts of anger amounting to blind rage, making him dangerous to those around him, and in other cases we meet with depressing, hypochondria- cal, melancholic states of mind, which again may interchange with conditions of excitation. So also is kleptomania of frequent occurrence; the patients pocket things without in fact knowing it, or carry them away openly, because they believe they are mak- ing use of their own property. The MOTOR CHANGES consist either of disturbances of co-ordina- tion-staggering when the eyes are shut; jerking, uncertain gait, difficulty of turning round, peculiar trembling, jerky handwrit- ing—when there is gray degeneration of the posterior columns- or shuffling, awkward, helpless gait, unsteadiness on attempting to turn quickly, but no increased swaying of the body when the eyes are shut-when there is granular-cell myelitis. More or less complete, persistent, unilateral facial paralysis is often noticed, and if apoplectic attacks repeat, they leave behind hemiplegia which may disappear again, while the intelligence degenerates so much more quickly; or the attack is often combined with unilateral or general epileptiform spasms, ending occasionally in death. Anesthesia, persistent and extreme, is found in all cases, when far enough advanced. Senile Dementia. "To be perfectly candid, we must confess that there is not a single symptom which is so pathognomonic of general paralysis that it may not be found also in senile dementia, and excepting the peculiar weakness of memory, in alcoholism also; and even the grouping of the symptoms as a whole may in the two latter diseases be such as to afford an entire analogy with undoubted cases of general paralysis. In senile dementia the course of the SENILE DEMENTIA DEMENTIA PARALYTICA. (6 - ! 99 affection itself often enough furnishes no definite conclusion, while alcoholism certainly affords a much more favorable prognosis." Only those cases can with certainty be considered as senile dementia in which advanced age, want of motor disturbances, or the presence of very marked hemiplegia, and, finally, absence of the extravagant delirium of grandeur, are all found associated. The delirium of old age is, as a rule, almost invariably of a more childish nature, while it is concerned with the most diverse sub- jects. Besides, epileptiform attacks almost never occur in the de- mentia of age and the apoplectic attacks of these old people are accompanied with serious permanent paralysis, if they do not end in death. Finally, the course of senile dementia is regular, less broken by remissions and intermissions. Nevertheless, that is an uncertain criterion and the same may be said to a still higher degree of all the other diagnostic points mentioned above." (Hitzig.) THERAPEUTIC HINTS.-The following are taken from Dr. S. Lilienthal's treatise on dementia paralytica in the November number of the Hahnemannian Monthly, 1876. For the remedies which hold out some hope, let us study that classical work, Hering's Analytical Therapeutics, where we read (1. c., pp. 114 and 115) for headache with ill-humor, and especially in the forenoon: Amm. carb., Platina, Kreos., Petrol., Stannum (gradual increase and gradual decrease), Phosphor., Calc. phosph.; for headache with diminished intellectual power, Phosphor., Nux mosch., Sarsap.; for forgetfulness, Amm. carb., Capsic., Caustic:, Mezer., Moschus, Viol. od.; sensation in forehead as if the skin were too tight, with anxiousness, Phosphor.; sensitive to light, fretful, dis- contented, complaining, Arsen.; oversensitiveness of hearing, Carb. veg.; noise unbearable, with anxiety, Aurum, Capsic., Caustic., Petrol., Pulsat.; fear, with noise in the street, Caustic.; cannot move the tongue right, with anxiety, Caustic.; difficult speech, Caustic.; ab- sent, loses the train of ideas, Amm. carb. (p. 247); convulsions with or without consciousness, Kali carb., Lycop., Nux vom., Platina, Plumbum; irritable, discontented, Nux vom.; idiotic condition before the attacks, Caustic.; bodily and mental infirmity, Natr. carb.; lassitude in the limbs, with indisposition to work, Amm. carb.; men- tal and physical prostration in the morning, Laches., Phosphor.; las- situde with irritability, Ambra, Calc. carb., Carb. veg., Caustic.; 100 BRAIN. bodily weakness, with its increase memory declines, Nitr. ac.; mental dulness with prostration, Alum., Anac., Aurum, Digit.; nervous af- fection with mental listlessness, Nux mosch.; no ambition, tires soon, Nux vom.; indisposed to work or walk, Zincum; heaviness of mind and body, Phosphor., Phosph. ac.; sleep disturbed by restless dreams, Arsen.; sleeplessness before midnight, Arsen., Kali carb., Pulsat., Veratr.; weak memory, Carb. veg.; periodical mania, Arg. nitr. Symptoms of mania de grandeur we find under Cuprum, Platina, Lycop., Laches., Stramon., Veratr. Symptoms of extravagance under Ammon., Bellad., Caustic., Chinin., Iodine, Petrol., Phosph. ac., Platina, Stramon., Sulphur, Veratr. Obtuseness of intellect with obscuration of eyes, Carb. veg. Weak memory, for correct writing, Laches.; for what has hap- pened, Graphit., Natr. mur., Sulphur; for words, Baryta, Lycop.; on awaking, Stannum; with debility, Nitr. ac.; with headache, Kalmia, Moschus. Sensitiveness of the ears to noise, with anxiety, Capsic.; with ill- humor, Bellad., Phosphor. Distortion of the mouth, Bellad., Graphit., Laches., Lycop., Nux vom., Opium, Phosph. ac, Secale, Stramon. Dilatation of pupils, Bellad., Calcar., Crocus, Hyosc., Nux vom., Opium. Difficult speech, Bellad., Caustic., Laches., Nux vom., Opium, Sulphur, Stramon., Veratr. Kleptomania, Sulphur, Pulsat., Arsen., Bryon., Kali, Lycop., Nux vom., Sepia. Doxomania, conceited mania, Platina, Cuprum, Hyosc., Laches., Lycop., Stramon., Veratr. (2.) Alum., Arnica, China, Conium, Ferrum, Ipec., Paris, Phosphor., Secale. Epileptic fits as a complication, Arsen., Bellad., Calcar., Cuprum, Hyosc., Ignat., Laches., Mercur., Opium, Nux vom., Plumbum, Pulsat., Sulphur. Caustic. In the disease, as well as in the remedy, we find from the start great melancholy, looking on the dark side of every- thing, facial neuralgia and facial paralysis, weakness of voice, and other paralytic affections. Hahnemann (Chronic Diseases, iii, 78) gives us the hypochondriac depression of spirits, peevishness, dull, gloomy, pressure on the brain making the head feel obtuse, vertigo, incipient amaurosis, roaring and buzzing in the ears, rheumatic and arthritic affections of all kinds, tremulous weak- Mal DEMENTIA PARALYTICA. 101 ness, epileptic convulsions, prosopalgia, paralytic affections, espe- cially of one side. Allen (Encyclopedia, iii) gives us the whole complex of symptoms; the tearing, lancinating pains of the ex- tremities, muscular twitchings, and excessive weariness in both limbs, especially in the morning in bed; attacks of spasms, in the morning in bed, sometimes with consciousness, at other times with unconsciousness; peevish, irritable mood, fretfulness, indo- lence, slow succession of thoughts, absence of mind with loss of ideas, weakness of memory (but no insane delusions are found under Caustic.); vertigo forward and sideways, at night in bed; vertigo, almost like a loss of consciousness, while sitting he nearly fell; constrictive pressure in the forehead; tensive headache arising from the nape of the neck; indistinct vision, it seems as though a thick cloud hovered before the eyes; spasmodic sensa- tion in the lips, etc., etc. Amm. carb., gloomy and uneasy mood, aggravated by cloudy weather; low spirits, with considerable excitement; very forget- ful, and headache when reflecting; absence of mind, with anxi- ety; speaks and writes incorrectly; weight and confusion of the head; vertigo, as from intoxication; great lassitude, and disin- clination to all work; most severe muscular contractions, spasms; violent rheumatic drawing pains through all the limbs, hands, feet, nape of the neck, head, etc. Laches. for persons with a melancholic or choleric tempera- ment, with a phlegmatic spongy constitution; with dark eyes and disposition to lowness of spirits and indolence; for acute and chronic rheumatism, recurring every year; for emaciation and exhaustion; for hemiplegia; for convulsions and epilepsy. Among its symptoms we read: Indolent, taciturn, brooding and melancholic; he considers himself too feeble to do anything, with aggravation of the symptoms every other day; great absence of mind; great weakness of memory, he forgets entirely what he had been hearing a moment before; frequent mistakes in writing; vertigo, with staggering to the left side, early in the morning after rising; deep stinging through the whole head; deep-seated headache; sensitiveness of the eyes to light; dim and weak eyes; very sensitive to noise; prosopalgia; distortion of mouth and lips; difficulty of speech, as if the tongue were too heavy; rheu- matic pains extending from the back to the limbs; difficulty of falling asleep for weeks; no sleep in spite of great lassitude; con- stant exhausting sleeplessness; aggravation of all complaints 102 BRAIN. after sleeping; painful wandering of the pains from one part to another; awkward, stumbling gait; hemiplegia; typical recur- rence of the aggravations. Nux vom. exactly suits such cases which owe their origin to sexual excesses and immoderate intellectual exertion, and also to persons of middle age, especially when they have changed their former busy life for a quiet one. The old school also claims to have derived many a benefit from hypodermic injections of mini- mal doses of Strychnine in this disease; and wherever the pro- dromal and even the first stage last a good while, Nux may be the simile to the existing stage of the disease. Among its symp- toms we find: Periodical affections of the nervous system; tear- ing, drawing-tensive rheumatic pains, with weakness and feeling of numbness in the affected parts; hyperæsthesia of the nerves of the senses; tonic spasms and convulsions; emotional epilepsy; central softening of the spinal cord (here also the gray matter); paralysis of the upper and lower extremities; periodical head- ache, gradually increasing, and after reaching its acme, gradually decreasing; dulness of mental powers; obscuration of sight; pa- ralysis of the tongue, with difficult and indistinct speech, in con- sequence of cerebral apoplexy. The irritable temper of Nux is well-known, and even for the second stage of the disease we find corresponding symptoms, as awkwardness, he easily stumbles against something; makes mistakes in speaking and writing (cer- tainly cerebral functions); compression of the head as from nightly revelling; chronic vertigo, with obscuration of sight and buzzing in the ears; twitching of the facial muscles; distortion of the mouth to one side, etc. Phosphor. is the grand remedy for a weak, exhausted brain. Here we have to deal with a disease whose whole tendency is to degeneration of the nerve-mass, to atrophy of the brain, and we might with certainty expect some benefit from a remedy which causes fatty degeneration throughout the body. Among its symptoms we find: Great lowness of spirits; great irritability; forgetful and dizzy; vertigo; dull, stupefying headache; con- strictive headache every other day; frequent attacks of sudden blindness in the daytime, and sensation as if a gray cover were hanging over the eyes; constant buzzing in the ears; pale, sickly complexion; great weariness in the extremities; sleeplessness and restlessness; heaviness of mind and body; exaggerated ideas of his own importance; monomania le grandeur et de la richesse; DEMENTIA PARALYTICA-DELIRIUM TREMENS. 103 forgets names and what has happened recently; unconnectedness of ideas when writing or talking; lastly silliness; idiocy. Aurum. The suicidal melancholy of Aurum seems to mark a contraindication for this remedy in any stage of this disease, certainly during the expansive delusions. During the conse- quent stage of apathy and palsy it can hardly be indicated; still it was prescribed by close observers on account of the venous hyperæmia in the brain. We here find hypochondriasis, but not melancholia so much; the epilepsy rests upon a very material basis; the exhaustion is a natural consequence of premature senility, hence the disgust of life, and we mention it only as hav- ing many symptoms in common with the prodromal stage, but the causes being so often different, it will be only in rare cases of real benefit. It may alleviate, but will not stay the ravages of this disease. Cuprum.-What Zincum is for later stages, Cuprum might be for the prodroma. According to Schmid, of Vienna, all the cere- bral disorders cured by Cuprum are of the reflex order, which would limit the applicability of Cuprum in dementia paralytica to very rare cases; still, Rademacher's indication, when there is premature exhaustion of strength in illness, may point towards its use in patients of neurotic temperament, especially where heredity can be shown. Silicea.-Carroll Dunham, in his usual masterly manner (N. A. J. of H., xx, 361), thus describes the action of Silicea on the ner- vous system: "With evidence of exhaustion, furnished by sensa- tion of weakness, paralysis, etc., there is an exalted condition of susceptibility to nervous stimuli; the special senses are morbidly keen, the brain cannot bear even moderate concussion, and the whole surface is unnaturally tender and sensitive; cold aggra- vates and warmth relieves. There is an erethism, conjoined with exhaustion, which is not evanescent, but endures for some time." Certainly such a remedy promises much in the prodromal stage of our disease, and carefully studied and applied in the right case may fulfil this promise and lead to a cure. In addition I may recommend to compare corresponding chap- ters, previously treated of, and also chronic alcoholism. Delirium Tremens. Delirium tremens is an acute form of chronic alcoholism, which breaks out either during and in consequence of excessive use of 104 BRAIN. alcoholic drinks, or follows the sudden deprivation of stimulants in the case of habitual soakers. Without any marked prodromal symptoms, it commences with hallucinations of vision (the seeing of beetles, rats, birds, serpents and the like, or other horrid images such as great black beasts, the devil, or a persecuting officer, etc.,) hallucinations always characterized by their unsteadiness and horrid nature. If the sense of hearing is affected, its hallucinations are likewise of a horrid nature, although in some cases music, songs and other pleasant things are heard. Sometimes the patients feel as if they were enclosed in a fine net of spun glass or of some textile fabric, or as if little insects were crawling under their skin. They move their hands and fingers objectlessly about, or act as if they were removing small objects from their body or bed. Their eyes look unsteady and wild and sometimes they even have nystagmus. Consciousness they lose seldom or only for a very short time, and therefore answer questions for the most part correctly. They are very restless, are very much troubled by their hallucinations and sleep never touches their eyes. In some cases they become violent, destructive, maniacal. Tremor, more or less extensive and violent is present in some and absent in other cases, as also tetanic and eclamptiform convulsions have been observed in some cases. Individual cases, however, vary greatly. All symp- toms are worse during the night, and the attack lasts from a few days to a fortnight. Post-mortems have shown pigmented and thickened mucous membranes of the stomach, fatty degener- ation of the liver and kidneys, pachymeningitis, and dryness and anæmia of the brain. THERAPEUTIC HINTS.-If the attack sets in during debauch, it may be well to apply the stomach-pump, in order to rid the stomach of its alcoholic contents. It is also benefical to urge the patient to drink cold water and skimmed milk as much and as often as possible, in order to thin the alcoholic poison. One or the other of the following remedies will then act so much the more favorably. Act. rac., restlessness and fear of death. Hale: "nausea, retch- ing, dilated pupils, tremor of the limbs, incessant talking and changing from one subject to the other; sleeplessness; imagines strange objects, as rats, sheep, etc.; quick, full pulse, and peculiar wild look out of the eyes." DELIRIUM TREMENS. 105 Agar., no clinical cases as yet but its symptoms call loudly for its mention in this place. Arsen., great restlessness anxiety and oppression with cold per- spiration; hallucination, especially at night; pale or yellowish color of face; eyelids red on edges; no appetite, great thirst; vomiting every morning; region of liver painful and swollen; stool retarded and as if burnt, or violent diarrhoea. For sots who have had attacks before. Bellad.; young persons with congestion to the head and excita- bility of the sensorium; want of memory; sparks like lightning before the eyes; anxious and unsteady, walks about as if busy and cannot be persuaded to desist of doing different things; imagines he sees water running over the table, or panes of glass, cats, etc.; wants to extract a tooth, and reaches for that purpose in his mouth: stammering, indistinct speech with a constantly smiling face; dry feeling in the throat, with difficult deglutition and violent thirst. Jerking of limbs; cramps in the calf of the legs; trembling of hands. Calc. carb., hallucinations of fire, murder, rats, mice, etc.; red face, dilated pupils; hallooing, screaming, restless; pulse soft, full and frequent; skin moist; tongue coated whitish; consti- pation. Cann. ind., when the illusions both of sight and hearing are characterized by taking the form of tremendous magnitude, so that a step appears to him as an enormous distance, or a small noise as a tremendous sound. Coffea, thinks he is not at home; walks restlessly about; no sign of feeling sleepy; quick pulse and trembling hands. Crotal., constant drowsiness, with inability to sleep, after Hyosc. had failed. Digit., in cases which come on slowly with gradually increas- ing pain in pit of stomach, continuous nausea, thirst, palpitation of the heart, gastric headache, vertigo and paleness of face. Gelsem., produced sleep, after morphia had failed. Gratiola, successful in cases where the delirium assumes the character of anger rather than of anxiety, in subjects not yet greatly exhausted. Hyosc., epileptiform fit precedes the attack; continuous talking at night; wants to run away for fear of being persecuted by the police; tremor of limbs. Ignat., chorea-like and epileptiform convulsions; paresis; an- 106 BRAIN. æsthesia combined often with hyperesthesia of the legs; sub- sultus tendinum; jerking of the limbs; trembling of the tongue. Kali brom., in first stage with horrid illusions, flushed face, red eyes and hard and quick pulse. (Crude doses). Nux vom., most frequently applied. Indescribable anxiety; finds no rest in any place; sees different images; congestion to the head; face pale and bloated; tongue coated white or brown, dry and thirsty; nausea and bitter vomiting; vomiting in the morning; pressing pain in stomach and region of liver; trem- bling, cannot bring the glass to his lips without spilling its con- tents; aversion to coffee; constipation or diarrhœa. Opium, preceded by epileptiform fits; imagine they see frightful objects, and are in great fear; believe themselves to be murderers or criminals who shall be executed; want to run away. Staring look; twitching of the muscles of the face and mouth; lockjaw; tremor. Reduced subjects. Stramon., frightful visions of animals which appear to jump up at his side; imagines one half of his body being cut off; hallu- cination of hearing, as if on the right side of the occiput a loud voice were abusing and insulting him; wants to run away; uses wrong words when talking; glistening, staring eyes, with en- larged pupils; tremor of all the limbs. Tart. em., after excessive drinking of young persons; gnawing pain in the stomach. Zincum, great fear, as if persecuted by men or the devil, on ac- count of crimes which he has never done; is afraid of becoming imprisoned, or poisoned, or shot, or buried alive, with great ex- citation, pappy taste, whitish coated tongue, eructations, loss of appetite, retarded stool, vertigo and heat in head and face. Chronic Alcoholism; Dipsomania. It is without exception the consequence of long-continued and continuous abuse of spirits, and although persons of this category are seldom seen in a state of actual drunkenness, still their whole system is shattered and shaken to its very foundation. They lose their character; their craving for drink overrules their best intentions, they continually struggle with temptation and yield continually to it; they feel themselves in a continuous conflict and dissension with their own better selves, and gradually fall in a state of deep melancholy and suicidal tendency from which CHRONIC ALCOHOLISM. 107 only a fresh resort to their one remedy, whisky, liberates them for the time being. And as they grow from bad to worse, the higher they stood, the lower they fall, until at last they do not shrink from committing crimes in order to gratify their un- governable craving. Dipsomania occurs in the form of a repeatedly recurring rage for drinking, which often is preceded by unpleasant sensations in the lower part of abdomen, nausea, vomiting, want of appetite, general depression, gone feeling all over, and trembling sensa- tion about the heart. This condition often terminates in an at- tack of madness. The psychical degeneration, which differs in different patients, produces varied forms of insanity: sometimes forms of exaltation with changing and absurd delusions, sometimes forms of melan- choly with religious mania, delusions of persecution, and some- times mere tranquil dementia. Besides these psychical disorders we find others affected with different degrees of paralysis of mo- tion and sensation. Paralytic dementia is one of the commoner terminal diseases of chronic alcoholism, as also apoplectic and epileptic attacks occasionally occur during its course. In some patients color-blindness of green and bluish-green, amblyopia and amaurosis in various degrees with atrophy of the optic nerve has been observed. The chief ailment, however, is a chronic gastric catarrh, which makes digestion almost an impossibility and interferes entirely with the general nutrition of the body. We therefore find the liver almost always affected, ending in cir- rhosis; the kidneys suffer with morbus Brightii, and some patients die with anæmic symptoms. The sexual functions are at first little affected; in one case, I know of, the sexual desire is almost hightened to satyriasis; in the later stages, however, sterility attacks both sexes. The children of alcoholic parents exhibit very often a predisposition to psychical disorders and inherit a badly constituted nervous system. Children begotten in drunken- ness are said to be epileptics from their birth. The post-mortem appearances vary greatly; there have been found: pachymeningitis hæmorrhagica; atrophy of the cortical substance; fatty degeneration of the ganglionic cells, of the vol- untary muscles, of the heart, liver and kidneys; thickening of the coats of the veins; thickening of the mucous membrane of the stomach and sacrum; flat erosions, hyperæmic vessels and increased pigmentation of the mucous membrane of the stomach; 108 BRAIN. granulated condition due to interstitial development of increased connective tissue or cirrhosis of the liver. THERAPEUTIC HINTS.-Confirmed drunkards are no doubt hard cases to manage. Some we will not be able to reform, unless we can take them entirely out of their wonted associations and sub- mit them to moral treatment; others probably may be approached if we succeed in producing in them a disgust for whisky, and ac- custom them to the use of milk as main diet. Still others, per- haps all, will be relieved of many of their symptoms by a careful selection of one or the other of the following remedies. Angelica, in 15 drop doses of the tincture, three times a day, has caused disgust for liquor. Amm. carb. et caust., in nervous, torpid asthenic cases; in peri- odical hallucinations; in amblyopia. Arnica, during the delirium, when he imagines that he will be arrested; also when after the cessation of trembling, formication and subsultus tendinum there still remains a weakness or sense of being asleep of the whole muscular system, slowness of com- prehension, ringing in the ears or fog before the eyes. Taken in the first dilution, it has also caused a decided disgust for liquor. Arsen., cachectic paleness; habitual redness of the conjunctiva; sudden loss of strength; anxiety in pit of stomach; great restless- ness; affections of the heart; oppression of the chest, even suf- focative spells, especially on moving and at night; emphysema of the lungs; dry cough, or difficult, tough expectoration. Nausea and vomiting; great thirst; tongue dry and intensely red at least on point and edges, or whitish coated; watery diarrhoea, worse after midnight. Tobacco chewers. Carb. veg., digestive troubles, with burning in stomach; heart- burn, acidity, belching of rancid taste, all worse after eating; re- tarded stool, hard and insufficient; cachectic paleness of face; chilliness. China, lienteric diarrhoea; dropsical affection; exhaustion. Ferr. met., earthy paleness of the face, or bloated face, easily reddening; roof of mouth always pale. Vomiting of food un- digested; hydræmic conditions. Kali bichr., especially in complaints of beer-drinkers. Kali brom., headache, with dizziness; staggering as if intoxi- cated; stupefaction; sopor; muscular weakness; anesthesia of CHRONIC ALCOHOLISM. 109 pharynx and velum palati and external skin; sight weakened and hearing impaired. Gastralgia; vomiting; colic; consti- pation. Kreos., habitual vomiting of undigested food; of large quanti- ties of sour, acrid fluid, or of white, foamy mucus; diarrhoea pro- fuse, colorless, or greenish watery, fetid. Laches., worse in the afternoon or after sleep; constant talking and jumping from one subject to another; cannot bear anything tight around the neck; great weakness; tremor of hands; liver affections. Natr. mur., hypochondriacal melancholy; headache (migraine); thin, nervous individuals prone to outbursts of passion; craving for liquor; digestion easily disturbed by slight dietetic or mental causes, with furred tongue, or map tongue; great thirst; slow digestion; vomiting of clayey substances; stool hard and re- tarded; venous congestion of liver, pancreas and uterus; flutter- ing of heart; cutting pain in urethra after urination. Nux mosch., dulness, heaviness and pressure in the head; dizzi- ness and sleepiness; heavy sleep, with clairvoyance and perform- ance of accustomed work without any recollection when awaking; mind absent, knows not where he is or what to answer; dryness. of skin, nose, mouth and throat; flatulency; retarded stool, or diarrhoea; liver troubles; strangury after beer; dyspnoea; chilli- ness. Worse from cold and damp air. Phosphor., great mental and physical exhaustion; trembling of the limbs when trying to use them; jerking of single muscles; arms powerless, legs paralyzed; vertigo, with loss of conscious- ness; indifference even towards the dearest friends; forgetfulness and stupidity in a measure that the patient does something else than what he intended; monomania de grandeur et de la richesse; idiocy. Inclined to diarrhoeic stools and flatulency; dry, scaly skin. Worse in cool and damp weather. Pulsat., is a better antidote to whisky than even Nux vom. Selen., craving for liquor. When Sulphur seems indicated and does not help. Sulphur, very important for many complaints as its known symptoms of the head, stomach, intestinal canal, liver and kid- neys abundantly show. Sulph. ac., vomiting in the morning; acidity of stomach; burn- ing in oesophagus and stomach; sour, acrid or foul eructations. It has been successfully used in subduing the craving for liquor 110 BRAIN. by taking for two or four weeks, daily three times, from 10 to 15 drops of Acid. Halleri, which is a mixture of one part of sulphuric acid with three parts of alcohol. Tart. em., gastric catarrh, with great uneasiness in the stomach; nausea and vomiting of tough, slimy and bilious matter; watery diarrhoea in small quantities; fulness of pit of stomach and ab- domen, with pressure as of stones; great thirst; loss of appetite, even disgust for any nourishment; tongue moist and whitish coated; bad taste and frequent eructations. Bronchial catarrh, with mucous rattling, tough and difficult expectoration; op- pression of the chest necessitating the patient to sit up in bed. Opium and Morphine-Poisoning. The habitual use of opium has in thousands of cases been brought about by the criminal ignorance and recklessness of physicians, who know not what they are doing, when they pre- scribe laudanum or morphine for any and every little pain, or use it as hypodermic injections. The habit of opium eating has so alarmingly increased, that it is necessary to mention here also this artificially induced misery of frail human nature. It is not necessary to go into the details of Opium symptoms; they can be found in our provings. Its chronic effects may be summed up in the following: "General emaciation, pale, shrivelled com- plexion, dry skin, looking like fish-scales, relaxation of the mus- cles, failure of appetite, disturbed digestion; at the commence- ment obstinate constipation, followed later on by dysenteric diar- rhoea. Superadded are fanciful, discontented temper, giddiness, headache, sleeplessness, all possible eccentric neuralgias, failure of memory, understanding, energy and will; patients become untrustworthy and are very regardless of truth, especially when they are questioned about their habit; also paralysis and diseases of the bladder." All this is gradually produced by the direct in- fluence of opium upon the substance of the nerves, and it is there- fore in accordance with the nature of opium-action, when post- mortems do not show any particularly characteristic anatomical changes. Hyperæmia of the brain is most constant; sometimes an accumulation of fluid is found in the subarachnoid spaces and in the ventricles; sometimes, also, sanguineous effusions of greater or less extent in different parts of the brain. The bladder is generally found distended. All other anatomical conditions seem accidental and not due to opium-poisoning as such. OPIUM AND MORPHINE-POISONING TUMORS. 111 THERAPEUTIC HINTS.—In acute poisonings the stomach-pump is a safer and surer means to remove the poison than any of the usual emetics, because the latter often fail to produce vomiting on account of the insensibility of the nerves of the stomach caused by opium, and also because the patient escapes by its application a possible gastritis, which often follows the adminis- tration of Tart. em. and other irritant substances. By its means the stomach can be washed out with green tea, coffee or sage tea, by which a less poisonous compound (tannate of morphine) is formed. In order to prevent complete narcosis it is well to make the patient walk about for hours, or to apply painful stimulation to the skin, the cold douche-bath and the like. After sopor has set in, the walking about forbids itself; we ought, however, conduct as much fresh air to the face and head as possible. In this state injections of a tea of oats have been recommended. Bellad. is no doubt the best antidote against acute poisoning. Even the old school acknowledges it and uses hypodermic in- jections of Atropine. Chamom., when after abuse of morphine to lull pain, sleepless- ness ensues and the suffering grows intolerable notwithstanding. Ipec., only lately shown as efficient for the cure of the habit of opium eating. Fifteen drops of the tincture were given at a time until improvement set in. Nux vom., often indicated in cough and diarrhoea after previous use of so-called cough and diarrhoea mixtures, all of which most generally contain opiates. Tumors of the Brain and its Membranes Consist of morbid growths in the connective and epithelial tis- sues of the blood-vessels and their sheaths, which either retain the character of the affected tissue, or become altered by modifi- cation of the newly-formed elements and by changes in their relations to the connective tissue and vascular distribution. Their CAUSES seem to be a hereditary predisposition, abuses of spiritual drinks, blows and falls of all kinds, syphilis and tuber- culosis. They occur much more frequently in men than in women. Tumors which retain the character of the affected tissue, are: Glioma, formed by proliferation of the neuroglia, greatly re- 112 BRAIN. sembles normal brain tissue, and is therefore not easily distin- guishable; when it assumes a more mucous character, it is soft and closely resembles myxoma; when its structure is harder, it resembles and is allied to sarcoma. It grows slowly, may finally undergo fatty degeneration and is found usually in the white substance of the cerebral hemispheres and especially their pos- terior lobes. Hyperplasia of the pineal gland presents a solid, grayish-red, slightly lobulated or else smooth, round tumor, which may grow as large as a walnut or even larger; its histological elements are somewhat larger and firmer than in the normal. Psammona or sand tumor is an inflammatory proliferation of the cellular tissue in which a calcareous deposit takes place; it usually grows from the dura mater commonly at the base of the skull, is a hard, hemispherical tumor, white and smooth and of the size of a cherry-stone. Melanoma takes its origin in the pigment cells of the pia, is small in size, but may be multiple; is of rare occurrence. Neuroma, a genuine hyperplasia of the gray substance, occurs in sizes from a millet-seed to that of a pea and is found on the ventricular surface, in the white substance, or on the outer surface of the brain. Hyperplasia of the anterior half of the pituitary gland. Cysts may be the result from apoplectic effusions, abscesses and softening. Aneurisms are of frequent occurrence, especially upon the large vessels at the base of the brain, and usually in consequence of atheroma; when bursting they cause fatal apoplexy. Cholesteatomata consist partly of hardened epithelial cells and partly of epithelial cells which have undergone fatty degenera- tion; they unite, as Rindfleish says, "the structure of an epithelial carcinoma with the harmlessness of a wart or weal." They are generally found in some hollow at the base of the skull or in some recess of the brain. Tumors by which the affected tissue is changed in its char- acter, are: Tubercles, gray, yellow, or yellowish-white, hard tumors, which frequently grow larger than a hazel-nut; their favorite position is the gray substance, especially of the cerebellum; they occur most frequently in childhood. Miliary tubercles are a frequent concomitant or source of meningeal inflammation. TUMORS. 113 Carcinoma appears usually as primary fungus hæmatodes on the outer or inner surface of the dura. When starting from the outer surface it rapidly softens and pierces the skull bones and then spreads on the external surface of the skull (fungus duræ matris); when originating on the inner surface its growth is entirely directed towards the brain; it never penetrates the dura, except at the natural openings for the nerves, such as the olfac- tory, optic, etc., hence the growing in and out of cancers in the orbits on the perforated plate of the ethmoid bone, in the spheno- maxillary fossa and so on. Sarcoma is either a hard, dense, homogeneous mass, which can easily be detached from the surrounding tissue, or is of a soft, medullary consistence, which constitutes a transition to a myx- oma or glioma. Myxoma forms a very soft gelatinous mass, which frequently breaks down into cysts containing a mucous fluid; they may attain the size of a man's fist, and are met with only occasionally in the cerebral hemispheres. Syphilitic tumors are not common; they generally resemble the gummata of other parts, being composed chiefly of greyish semi- translucent matter, which is liable to become opaque and crum- bling on undergoing a caseous transformation. SYMPTOMS.-One should suppose that the pressure of any of these tumors should manifest itself more or less by various out- ward symptoms. But this is not always the case. Large tumors have been found post-mortem, and not a single symptom did be- tray them during life. It is remarkable how the system, even the brain, may become accustomed to an abnormal growth, when it is invaded slowly. Yet there are symptoms in many cases which should rouse our suspicion in this direction. They are: "Depression of spirits, melancholy, rarely maniacal attacks, men- tal derangement, aphasia, sleepiness; amblyopia and amaurosis, with the appearance of choked disk and neuroretinitis; inequal- ity of the pupils; strabismus; violent headache, often accurately localized; monolateral anesthesia, usually in the form of anæs- thesia dolorosa; neuralgia; monolateral paralysis of varying de- gree, gradually increasing; jerking, quivering; cramps of the affected groups of muscles, developing sometimes into epileptoid attacks." Further on: "imbecility; total want of energy; sopor, comatose condition; wide-spread anesthesia; very hesitating speech; paraplegia; incontinentia urinæ et alvi, or else reten- 8 114 CRANIUM. tion; increased temperature of the body; symptoms of men- ingitis; apoplexy." Glioma is to be thought of when there is: "preceding consider- able injury of the skull; slow progress of the symptoms and hence relatively long duration of the illness; intercurrent apo- plexies; good state of nutrition." Tubercular tumors, when there is "a hereditary predisposition to tuberculosis; occurrence in childhood; tuberculosis of other organs; commencement of the symptoms after acute febrile dis- eases, for instance, measles; complication with meningitis.” Carcinoma, when there is "a rapid progress of the symptoms; perforation of the bones of the skull; carcinoma in other organs.' Notwithstanding all this, the DIAGNOSIS of brain tumors will in many cases remain problematic and is often impossible. THERAPEUTIC HINTS.-Little can be said. In all cases we must be governed by the totality of the symptoms, even if we should suspect a tumor. When a considerable injury of the skull has preceded, we will have to choose a remedy accordingly. When tubercles are suspected, compare what has been given under meningitis tuberculosa. In case of carcinoma, compare: Calc. carb. or phosph., Arsen., Carb. an., Bellad., Laches., Phosphor., Silica, and many others. DISEASES OF THE CRANIUM AND ITS INTEGUMENTS. "" a. ABNORMAL LARGENESS OF THE HEAD May be caused by hydrocephalus, hypertrophy of the brain and by pseudo-formations within the cavity of the skull, when they perforate the skull. To this are to be added morbid conditions of a more external nature. Dropsy of the Scalp. This is a collection of serum either in the cellular tissue (cel- lular dropsy) or between the aponeurosis and the pericranium (apo- HYPERTROPHY-BRUISED HEAD AFTER BIRTH. 115 neurotic dropsy). When the watery fluid collects in the cellular tissue, it is apt to spread down to the face; and on pressure with the finger it leaves a pit; as is seen on all parts of the body, where dropsical effusions exist within its cellular tissue. When it is underneath the aponeurosis or the galea capitis, the swelling is tight, elastic, fluctuating, and leaves no pit on pressure, and never spreads over the ears or eyelids, and this for obvious anatomical reasons. Both forms exist without cerebral symptoms, and may be the consequence of either a general dropsical condition, or of erysipelas, external injuries, stings of insects, eruptions, and so on. Hypertrophy of the Skull. This may either involve a part only of the cranium, in which case it forms exostosis or bony protuberances; or the whole skull, whereby the bony walls may attain a thickness of one inch and a half. Both forms cause an enlargement of the head, and are mostly found as a concomitant to rhachitis or syphilis. When they grow from the inner plate of the skull, they do not cause an external enlargement of it, and are therefore not recognizable with any degree of certainty. The Bruised Head of a Child after Birth, Caused by the pressure during birth, is either an extravasation of lymph or blood into the cellular tissue; in which case it is called caput succedaneum; or it is an extravasation of blood between the bones and the pericranium, causing the affection called thrombus neonatorum. The Caput succedaneum may extend over the fontanels or sutures of the bones; it may even be formed on any part of the head suf- ficiently exposed to a great pressure of the pelvis, or the forceps, during labor. It has a soft, doughy feel, and the outer skin looks bruised. The Thrombus, however, is confined generally to the parietal bones, and never extends over the sutures of the bones, because there the pericranium adheres firmly to the skull. It feels elastic and fluctuates, and shows no discoloration of the external skin. Both forms are in their nature bruises, and ought to be treated, should treatment be necessary at all, like bruises. Arnica will 116 CRANIUM. usually do what is required; in some cases, however, Bar. mur. and Mercur. have been successfully applied. b. ABNORMAL SMALLNESS Of the head is found in idiots. It may be partial or general, congenital, or caused after birth, before ossification is completed. Always, however, it will be found in connection with an imper- fect development or derangement of the brain. c. AFFECTIONS OF THE SKULL WITHOUT EN- LARGEMENT. The cranium consists of two tables, which run parallel with each other, and are separated by an intermediate cellular struct- ure, which is called diploë. The whole, however, consists of eight different bones, which are connected to each other by sut- ures. Before these sutures consolidate, there are, of course, on those places where different bones are to meet, larger or smaller openings, which are called fontanels. At the time of birth, how- ever, as a general thing, only one of these fontanels exist, and that is the anterior opening, whilst the posterior and parietal open- ings have already closed. The anterior fontanel closes normally in the second year of life. If it stays open much longer than two years, it shows a want of proper nutritive action in the system; if it grows larger, dividing the frontal bone and parting the parietal bones, it is a sign of chronic hydrocephalus, or of hypertrophy of the brain. If you lay your hand softly upon it, or watch it closely, you will observe a constant motion up and down, a kind of breathing of the brain. Screaming or coughing causes momentary distention and protru- sion of the integument over it. If, however, as in cases of men- ingitis, this opening swells out permanently, it is a sign of exudation of serum in the brain. Its suddenly sinking in denotes a collapse of the brain, which is soon followed by death. In like manner, the posterior fontanel, by a morbid process of absorption of the already-formed bony substances, may reopen; or several holes may form near by-the bony structure withering away gradu- ally, leaving only the integuments. This is called the Soft occiput or Craniotabes. It has been observed mostly towards the end of J ATROPHY OF THE SKULL. 117 the first year, especially in children of rhachitic or scrofulous parents. It is doubtless a deep-seated, constitutional disorder, and can be successfully treated only by a careful study of all the symptoms. Nevertheless, Sulphur, Calc. carb., Calc. phosph. and Silic. might often be indicated. If not checked, it frequently be- comes complicated with meningitis, or pneumonia, or tubercu- culosis and diarrhoea, which soon end the scene. To this I may add- Atrophy of the Skull, This may be a consequence of internal pressure from carci- noma within the cavity of the skull, which may even perforate the cranium; or from hypertrophy of the brain; all of which have already been mentioned. We also meet with inflammation of the skull or ostitis, with all its sequela caries and necrosis—which is mostly of a syphilitic or tuberculous origin, or is caused by external wounds badly treated. THERAPEUTIC HINTS.-Caries call for Asaf., Calc. carb., Calc. phosph., Fluor. ac., Pulsat., Silic., Sulphur, and other remedies. d. DISEASES OF THE INTEGUMENTS. The integuments of the cranium consist of the following five different layers: 1. The external skin or derma is covered thickly with hair, and contains innumerable sebaceous and sudoriparous glands, of which the former secrete an oily, fatty substance, and the latter are the organs of perspiration. 2. The subcutaneous cellular tissue, in which the net-work of the larger blood-vessels and nerves lies imbedded, and which con- joins the derma to 3. The aponeurosis; which is expanded tightly over the cra- nium Under it is found- 4. The second cellular tissue, which consists of loose mashes and connects the aponeurosis only loosely with 5. The pericranium, which is the immediate covering of the bones, and which, although very thin, is nevertheless of great strength. It transmits numerous blood-vessels into the bones. • 118 SCALP. In diseases of the scalp, all or single of these different layers may be affected. Erysipelas of the Scalp and Face. Erysipelas is an acute febrile disease, characterized by a pe- culiar inflammation of the skin and enlargement of the neigh- boring lymph-glands, which is accompanied by more or less severe general symptoms. It is contagious and inoculable, and arises spontaneously under conditions not accurately determined; in the latter case it is called Idiopathic. When spreading by its own contagion which diffuses itself through the air or is carried by linen or instruments previously used for dressing patients with erysipelas, or by flies-it is called Traumatic, and is mostly found in the surgical wards of hospitals. As the slighest scratch may be the recipient of the poison, the disease is often communi- cated to nurses and physicians. Recent writers on this subject do not make any distinction between these two forms, and assert that the idiopathic form also arises from some insignificant injury, which only could not be discovered! This is driving the desire for simplification rather too far. There are a num- ber of cases especially on face and scalp which arise without any scratch or wound, and under conditions where infection is entirely out of question. In fact the whole complex of symp- toms shows that it is not a local but a constitutional disease in no less degree than measles, scarlatina and other febrile diseases. Da Costa in an excellent treatise on the internal complications of acute erysipelas (American Journal of the Medical Sciences, Oct., 1877, p. 321, etc.) admits as much, and also prints a whole series of cases observed by himself, in which he found that the idiopathic form was almost invariably attended by albuminuria, which in the traumatic form was either entirely absent or present only in a decidedly less marked degree. Hahnemann considered ery- sipelas as one of the acute outbursts of a psoric taint. He was probably correct even in this. "Erysipelas, like phlegmonous inflammation, affects the skin in its whole thickness and the sub- cutaneous cellular tissue. All the layers of the corium and of the subcutaneous cellular tissue are oedematous, swollen, and penetrated by large, finely granulated, white blood-corpuscles. The meshes of the connective tissue in which these cells are em- bedded are very dedidedly separated by them and by the fluid ERYSIPELAS. 119 which uniformly permeates the tissues. The most important distinctive feature of erysipelas is its disposition to spread only by creeping uninterruptedly onwards without making jumps,' or as Billroth has it, "it spreads like water in blotting paper." When on the scalp or face it is limited mostly to a more or less extensive portion of the skin of the head and face and seldom descends over the neck to the trunk; on other parts of the body it is apt to spread over larger surfaces. Its local SYMPTOMS are frequently preceded a day or two by a feeling of general malaise, chilliness and feverishness. Then the part affected begins to feel hot and tense; the skin reddens and swells, and becomes very sensitive to the touch. At the same time the adjacent lymphatic glands commence to swell. The in- flamed portion assumes a red, smooth and shiny appearance, which is, however, darker and duller on the scalp than on other parts, and to the touch it gives the impression of a hard, stiff, caked mass. The inflammation gradually creeps on until it reaches from side to side of the scalp, down into the face, and even to the neck and shoulders. On the second or third day, generally, the redness and swell- ing reach their height, and, at this stage, in some cases, the epi- dermis becomes raised and filled with a yellowish, limpid fluid, sometimes tinged with blood, in the shape of large blisters— Erysipelas bullosnm--which either dry up, or burst and become covered with crusts. During the height of the disease, the patient has high fever, with evening aggravations; his sleep is restless and full of dreams; he sometimes becomes delirious. On the fourth day the red- ness and swelling gradually subside on the places first attacked; while those parts which were invaded later stand yet in full bloom. By-and-by, however, they grow paler, softer, and assume a wrinkled appearance, as the swelling leaves; the crusts dry off, and on the whole surface the epidermis peals off in large flakes; the entire process lasting from about eight days to two weeks. But this is not invariably its course. Just in its very nature, to creep on, lies its danger. It may, by continuity of tissue, wander to the mucous membrane of the nasal and pharyngeal cavities, cause an oedema of the glottis, and affect the larynx, the bronchial tubes, and even produce pneumonia and pleuro- pericarditis. An extension of erysipelas to the meninges (erysipelatous men- J 120 SCALP. ingitis), or to the brain tissue (cerebritis) which, on account of the violent brain symptoms, in former days was supposed to be the cause of death in many cases, has by later observers not been found, even though numerous post-mortems of typical cases have been instituted in search for it. Da Costa found only "some ful- ness of the vessels of the membranes, a kind of venous tur- gescence, yet not extreme," but no sign of any kind of inflamma- tion. An explanation of the violent brain symptoms has been variously tried—the assumption of blood-poisoning, as in other exanthematic fevers, is probably the most rational. The tongue usually is covered with a white creamy coat, which dries gradually, becomes dirty yellow and, when the fever is pro- tracted, blackish and crust-like; there is nausea and vomiting; sometimes diarrhoea and, what seems very remarkable, in rare cases profuse intestinal hæmorrhage, in consequence of ulcers in the duodenum, which generally have proved fatal, and remind one of similar symptoms which are occasionally observed after severe burns of the skin. In almost all idiopathic cases there is albuminuria. The fever, accompanying erysipelas, is character- ized by a sudden rise of the temperature to even 104° F. or higher often within from 8 to 12 hours, still rising to 105.8° and in some cases to 107.6° F. Exceptionally, however, the tempera- ture shows periods, even for the length of a whole day, of marked depression, after which again a sudden rise takes place. When re- covery approaches, it usually sinks as rapidly as it rose, and may attain its normal standard within a few hours or in a single night; then desquamation of the epidermis, in the form of large or branny scales, and wrinkling of the skin terminate the local process. However, even after this in some cases a renewed sud- den rise of temperature has been observed. The hair usually falls out, but quickly grows again. The skin too recovers its normal state; only upon the eyelids, the scrotum, the prepuce and vulva, where it is naturally tender, it may in severe cases undergo a more or less extensive gangrenous destruction, and its duration be prolonged to several weeks, even months. Unlike to other infectious fevers, erysipelas leaves a very great susceptibility for renewed attacks. Not a few persons are subject to a periodically returning form-the so-called Habitual erysipelas, which mostly affects the face or lower extremities. The nature of its contagium is not all known; it seems, how- ever, to possess great tenacity. ERYSIPELAS. 121 The PROGNOSIS of erysipelas is favorable, as long as it does not spread to internal organs. THERAPEUTIC HINTS.-The external application of raw cot- ton to the inflamed parts, to keep off the air, as in burns, I have found decidedly beneficial. The terrible itching is sometimes alleviated by the application of rye-flour. Apis, spreading down to the face with great oedematous swell- ing of the eyelids, forming reddish, watery bags under the eyes; stinging, pricking, burning; smooth or blistered; thirst or no thirst. Bellad., especially right side; eruption smooth, shining, streaked, of bright red color; brain symptoms prominent; sometimes nausea, gagging, wretching; or coughing; drowsy but cannot sleep. Borax, mild form; left side; painful when laughing with sen- sation as if covered by cobwebs. (Bönninghausen.) Pale, red oedematous swelling from left lower eyelid down to cheek; anx- iousness; childbed; after Apis and Rhus tox. had failed. (Fellger.) Euphorb., highly prized by Dr. H. Boskowitz. It helped after Graphit. had failed. (W. E. Payne.) Hydrast., wandering from left side of nose to right over whole face and scalp; intense pain in the lumbar region; chills down the back; extremely restless; disturbed by noise; delirium ; urine suppressed. Laches., purplish, leaden hue; tongue dry, glossy, tremulous; visions, and delirious talk as soon as he shuts his eyes; aggrava- tion from noon till midnight. Pulsat., the ears are especially affected; during damp, wet weather. Rhus tox., vesicular form; spreading from left to right; burn- ing and itching; nasal and pharyngeal cavities inflamed; great restlessness; pain in back and limbs, worse in rest; after getting wet. Ver. vir., right side of head and face much swollen and cov- ered with large blisters; headache; high fever; no sleep; no appetite; intermitting attacks of nausea; occasional vomiting of the water drank. It was applied low, externally and internally. Still other remedies may be indicated. Arsen., irregular progress; disposition to internal organs; terrible restlessness and sinking of strength; fainting; pain in 122 SCALP. the bowels and hæmorrhage, as sometimes occurs in large burns. Camphor., great exhaustion; coldness of skin; breathing scarcely audible or visible. Bönninghausen has recommended it for the initial symptoms, low and frequently repeated. Canthar, large blisters, irritable and burning; after Rhus tox. had failed. Post-erysipelitic chronic prickling of the skin. Chamom., suppuration of the cellular tissue; low externally and internally. Crot. tigl., œdematous swelling of eyelids; large and small blisters; intermediate skin cracked and peeling off; violent burning. Cuprum, sudden sinking of the swelling and changing into a bluish color; violent brain-symptoms. Graphit., tendency to repeated attacks of erysipelas bullosum; also when new aggravations come on during the same attack; constrictive headache in occiput; perspiration does not relieve. Habitual erysipelas, often alternating with tettery eruptions. Ipec., retrocession of eruption, with vomiting. Kali carb., from right to left side; oedematous swelling under the eyebrows. When touched ever so slightly on his feet, he jerks them up much frightened; he talks of pigeons flying in the room, which he tries to catch with his hands; he gets regularly worse about 3 o'clock A.M. After previous attacks. Sulphur, psoric taint; helps often when all others fail; habitual form. Phosph. ac., traumatic form, where the periosteum is affected. Ruta, in combination with wounds. Silic., when the bones are injured. Gangrænous destruction, hints to: Arsen., Carb. veg., Cinchon. and Sec. cor. Schüssler recommends Natr. sulph. for the smooth form with or without vomiting of bile, and Kali mur. for erysipelas bullosum. Eczema Capitis, Humid Tetter or Scald. "A non-contagious affection, characterized by the eruption of minute vesicles in great numbers, and frequently confluent, upon a surface of irregular form and usually of considerable ex- tent. The vesicles are so closely aggregated in some situations as to give rise to one continuous vesicle of great breath." (Wilson.) They dry and form thin scales, or else break and discharge a ECZEMA-IMPETIGO. 123 watery or milky fluid of different consistencies, which, by con- creting, give rise to thinner or thicker crusts. It is acute and chronic in its nature, and may appear on any part of the body. According to its appearance, location, or severity and obstinacy, it has received a variety of names, which gives a nomenclature most remarkably confused and confounding. It is called ekthema, porrigo, tinea with various adjectives, and, if chronic, psoriasis. In order to simplify the whole, we will just remember, that eczema exhibits the following characteristics: It is a vesicular erup- tion, in clusters, often confluent, discharging limpid or turbid and milky fluid, which forms crusts of different thickness, is acute or chronic, mild or severe, situated here or there. It may be confounded with Impetigo, Because its appearance so closely resembles this latter as to force upon the mind the impression that they are the same disease. And, indeed, impetigo, derived from ab impetu-a bursting forth with violence is nothing but a pustular eczema; so that, in order to distinguish between the two, we must know what is a vesicle and what is a pustule. By vesicle is understood a very small blis- ter, containing a transparent, limpid fluid; a pustule means a pimple, containing pus. The difference between eczema and im- petigo lies then in the pyogenetic (that is, pus-forming) character of the latter. If both are found together, covering large patches on the scalp, their distinction is quite difficult, unless we say: the hardened coverings of the excoriations of eczema are thin scabs, because growing out of a limpid, thin fluid-lymph; while those of impetigo are tense and thick, greenish-yellow, or brownish crusts, on account of their being formed from pus. THERAPEUTIC HINTS.-Calcar., Lycop., when the eruption yields a thick and mild secretion. Arsen., Natr. mur., Rhus tox., when it looks angry, excoriated. Baryt. carb., Graphit., Natr. mur., Rhus tox., when it causes falling out of the hair. Lycop., Psorin., when it smells very badly and causes lice. Natr. mur., when situated on the boundaries of the hair on the nape of the neck. Clemat., Petrol., when on the neck and occiput. 124 SCALP. Hepar sulph., when the eruption itches worse in the morning, when rising, with burning and smarting after scratching-like- wise after external application of salves: Clemat., Graphit., Hepar sulph., Lycop., Natr. mur., Rhus tox., Staphis., Thuya, for moist eruptions. Arsen., Calcar., Mercur., Sepia, Silic., Sulphur, for dry crusts. Mercur., when the lymphatic glands are inflamed. Baryt. carb., when the lymphatic glands are swollen and painless. Arsen., nightly burning and itching, relieved from external warmth. Baryt. carb., falling off of the hair; glandular swelling on the neck and under the lower jaw. Bromium, eruption covering the scalp like a cap; oozing pro- fusely and smelling badly; cervical glands swollen. Calc. carb., during teething; scrofulous habit, swollen glands of the neck; burning worse after washing; small wounds suppurate easily; sweat after eating or drinking anything warm; worse about new moon. Cicuta, thick yellow crusts. Clemat., the eruption looks angry and inflamed during the in- creasing, and is dry during the decreasing moon. -Crot. tigl., vesicles and erysipelatous inflammation around the crusts; itching, and burning after scratching. Graphit., eruption with sticky secretion; causing falling out of the hair; commencing behind the ears and spreading over the scalp and face, especially on chin; chronic lachrymation; fluor albus; worse after washing. Hepar, especially back part of head; itching; worse in the morning; falling out of hair and leaving bald spots; crusts dry on some and moist on other places with inflamed surface and pus underneath; hard, knotty pimples like small furuncles in the face and other parts of the body; scrofulous ophthalmia; en- larged glands on nape of neck; frequent urging to stool and dif- ficult discharge; sour smelling sweat at nights. Hydrastis, especially on margin of hair in front; oozing after washing; all secretions tenacious, ropy and profuse. Lycop., crusts with lice between the crevices; underneath oozing of bloody or purulent fluid; badly smelling; sore and moist behind the ears; often eruptions on other parts of the body. Skin dry, raw, chapped and cracked; disturbed sleep with sudden loud screams; emaciation. DANDRUFF. 125 Mercur., stinging and burning; surroundings inflame after scratching; salivation and sore gums. Mezer., eruption dry and scaly, extending over forehead, ears and neck; or thick leathery crusts with pus underneath, matting the hair, and breeding vermin; violent itching, worse in bed and from touch. Natr. mur., raw surface; the discharge is corroding, eating away the hair, without forming thick crusts. Especially on the boun- dary of the hair on the nape of the neck. Petrol., crusts on scalp; soreness behind the ears; tetter on nape of neck, breast and knees; chapped skin; hands and fingers full of bloody rhagades during winter. Psorin., badly smelling, yellowish, moist crust with lice; terri- ble itching; sadness; don't want the head uncovered; the whole body has a filthy smell, even after bathing. Rhus tox., often indicated; the crusts are thick with greenish, fetid pus underneath and fresh pimples on the surroundings; stiffness of neck and swollen glands on nape of neck and axillæ; itching worse at night. Staphis., crusts are moist, offensive, and itch violently; on scratching the itching is relieved, but appears immediately at some other place. Sulphur, dry or moist crusts; eruptions, pimples on different places of the body; eyes inflamed with photophobia; face bloated, pale; cervical glands swollen; stool undigested, diarrhoea early in the morning; belly bloated: sleepless nights on account of itching; easily bleeding after scratching. Viola tric. (Jacea), thick crusts and oozing of profuse yellow fluid, matting the hair together; frequent involuntary urination; the urine smells like cat's urine. Dandruff Is an eczema with but scanty exudation, not sufficient to raise the epidermis into vesicles; it merely loosens it, when it dries and peals off in scales. The scalp underneath remains congested, and thus new scales are constantly reproduced. It may extend over the whole scalp even down to the eyebrows, the whiskers and the beard, or be confined to patches only of irregular form and variable dimensions. The most effective remedies against small, brany scales are according to Jahr: Bryon., Sulphur, Calc. • 126 SCALP. carb., Kali carb., Arsen., Alumin. For the pealing off of large scales, the same author recommends: Phosphor., Lycop., Sulphur, Calc. carb., Nitr. ac. Seborrhoea Capillittii. "The secretion of the sebaceous glands in the foetus is greater · during intra-uterine life than subsequently, and we meet it at birth on the body generally, where it constitutes the vernix caseosa. This abundant secretion continues on the scalp during the first year of extra-uterine life, and if the sebum is allowed to collect there and gather dirt and dust from without, we may have finally crusts several lines in thickness, and the whole hairy scalp may be enveloped in a thick layer of sebum. When the crusts remain for a long time, the seborrhoea is generally compli- cated with eczema, for the collected mass of sebum decomposes, macerates and irritates the skin, and produces redness and moist- ure on it. The same disease appears also as thick scales, which cause the hair to adhere to one another in little bundles (psoriasis. amianthacea). In adults it forms one of the commonest varieties of scurf, or dry scales, which are formed in large quantities, and in old people it is seen in connection with senile decay. The scalp is for the most part devoid of hair, and covered with a dirty, yellowish-brown, easily removable crust. It may also be a part of syphilis." (Lilienthal's Skin Diseases, p. 118.) THERAPEUTIC HINTS.-These crusts are best dissolved by the application of oil or grease, and afterwards removed by washing with castile soap. The internal use of Sulphur, a dose of a high potency occasionally, corrects the disposition for this abundant secretion. For adults Phosphor., Calc. carb., Natr. mur., Graphit., Vinca min., Mercur., have been recommended. Favus, Honey-comb Ringworm, Tinea favosa or Maligna, Porrigo favosa or lupinosa, Is a vegetable parasite, the achorion Schoenleinii. "It used to be classed among the pustular eruptions, because it first appears as a small yellow spot, the sheath of the hair being filled with the fungous growth; but it has no tendency to suppurate. It grows with great rapidity, and forms large, hard, dry crusts, FAVUS, ETC. 127 which have a peculiar mouse-like odor. It is most liable to be confounded with impetigo, but it requires only moderate care to determine whether the crust be hardened pus or an independent growth. The distinction is based upon the presence or absence of secretion; be the crust of impetigo ever so dry, some trace of purulent secretion is sure to be met with; and if removed by a poultice, the moist, exuding surface cannot be mistaken. Know- ing this fact, we have no need to particularize the rounded form, the cracked, broken-looking surface, and all the other characters resembling honey-comb, which the older writers were obliged to enumerate." (Barcley.) The scalp is its most usual place of de- velopment, but it is sometimes found upon the nape of the neck, or in front of the ear, and even upon the arms. "The pathology of favus is best understood by considering it essentially to be a form of abnormal nutrition, with exudation of a matter analogous to, if not identical with, that of tubercle, which constitutes a soil for the germination of cryptogamic plants, the presence of which is the pathognomic of the disease. Hence is explained the frequency of its occurrence in scrofulous persons, among cachectic or ill-fed children, and the impossibil- ity of incubating the disease in healthy tissues, or the necessity of there being scaly, postular and vesicular eruptions on the in- teguments previous to contagion." (Bennet, Lilienthal's Skin Diseases.) This view is born out by actual clinical experience. Jahr says: "Notwithstanding its parasitic nature it has been cured by the sole internal administration of Sulphur, Calc. carb., Rhus tox., and Arsen., and Teste considers the treatment of this affection the triumph of Homœopathy, recommending: Sulphur and Dulcam. for the humid form in children of blonde and fresh complexion. Viol. tric., in alternation with either of the above when the itch- ing is very violent. Oleand., when there is intense itching and an insupportable nocturnal burning after scratching; affection of the mesenteric glands with swelling, hardness and tension of the abdomen, and frequently loose and undigested stools. Hepar sulph., when extending to the nape of the neck or the face; ophthalmia with or without ulceration of the cornea, etc. Besides compare Arsen., Baryt. carb., Bromine, Calc. carb., Dulcam., Graphit., Hepar., Mercur., Mezer., Rhus tox., Petrol., Staphis., Sulphur, Viol. tric., under Tinea capitis. 128 SCALP. I Lapp. maj., grayish-white crust over head, face and neck; swell- ing and suppuration of the axillary glands. Phosphor., the skin of the denuded scalp is clear, white and smooth. Vinc. min., spots on head, oozing, matting the hair together; the hair falls out in single spots, while hair grows on it. Tinea, Herpes tonsurans, or Ringworm of the Scalp. The hair falls out in a patch of a circular form, leaving the skin of the head perfectly smooth. It is a microscopic fungus, known as trichophytum tonsurans, that invests the roots of the hair and destroys them. Cases are reported as having been cured by Graphit., Phosphor., Arsen., Tellur., Sepia, and others. Alcohol is said to destroy the parasite. The Wen Is an encysted tumor of varying size; from that of a small pea to the size of a walnut, and even a small orange. "The sebaceous or fatty substance in these sacs or cysts is va- riously altered in its qualities and appearance. Sometimes it is a lympid fluid-like serum, and contains crystals of stearine; at other times it is soft and white, of a pappy consistency; again, it is yel- lowish, and resembles beeswax. Sometimes it contains epidermal scales and hairs. Sometimes the contents of the cyst are exceed- ingly fetid; and the fetor is increased when the tumor inflames." (Wilson). Under the pressure of the finger they feel elastic, and are movable under the skin. THERAPEUTIC HINTS.—Thus far have been successfully applied: Baryt. carb., Bellad., Calc. carb., Caustic., Clematis, Phytol., Silic., Sulphur, Thuja. The Teleangiectasia, or Vascular Nævus, Mother's Mark, Is a dilatation of a portion of that fine net-work of capillary ves- sels which everywhere pervade the derma, and cellular tissue. Such dilatations may occur in either of them. They form red, easily compressible, flat tumors, of different sizes. times stationary, but more frequently increase They are some- slowly in size; THE HAIR. 129 and we often find enlarged blood-vessels in their vicinity. They generally appear on the scalp, and still oftener on the forehead, but also on other parts of the body. THERAPEUTIC HINTS.-Condur., Fluor. ac., Strontian, Sulphur, Silic., Thuja. Phosphor., when they bleed easily. The Hair. Alopecia-its falling off-may originate in various conditions. If it consists in a total atrophy of the hair-follicles, the hair of course will never grow again; if it is only a partial atrophy, the hair grows thin. A transient deficiency in the nutrition of the hair-follicles, as it occurs in several illnesses, such as typhoid fever, pneumonia, puerperal fever, chronic headaches, syphilis, does not hinder the hair from growing again, as soon as these dis- turbances have passed away. • · The Alopecia circumscripta or Porrigo devalcans has its cause in a parasite, the microsporon audonini, which attacks the hair in isolated patches, and the denuded spots are left clean and polished and of a marble whiteness; it is not considered as contagious. Alopecia in consequence of erysipelas, seborrhoea and different eruptions of the scalp, disappears after these disturbances are healed. Cosmetic means also may bring on alopecia. Baldness is more or less an attribute of old age; it is found oftener in men, than in women; it also is seen in younger individuals in consequence of hereditary disposition. THERAPEUTIC HINTS.-Kali carb., Natr. mur., with great dryness of the hair. Carb. veg. after Kali carb. Hepar sulph., Phosphor., Sepia, Silic., after chronic headaches. Kali carb., Nitr. ac., after nervous fevers. Phosph. ac., after great anxiety and grief. Besides these compare Ambra, Amm. carb., Baryt. carb., Calc. carb., Conium, Fluor. ac., Graphit., Lycop., Natr. mur., Sulphur, Zincum. For bald patches: Aloes, Arsen., Phosphor., Vinca minor. The cutting of the hair is often attended with great effect upon the general system. Colds in the head are a very frequent conse- quence, and in children even spasms may result therefrom. But 9 130 SCALP. there are also cases on record where it proved beneficial to patients, relieving them of headache, and in one case even from a sort of mania. The changing of color into gray and white is usually a process of age; but grief, sorrow, and worriment may bring it on much before its time, and sometimes in a very short time. There are a number of cases related where this change took place during one night in consequence of terror, or other violent emotions of the mind, so that the poet says: "O nox! quam longa es, quæ facis una senem!" But of late, these instances have been doubted, because they are not well authenticated. However that may be, so much is certain, that strong mental emotions have a great effect upon the discoloration of the hair. THERAPEUTIC HINTS.-Bad consequences of cutting the hair are mostly removed by Bellad. or Bryon. The process of growing gray and white we best leave undis- turbed, unless we choose remedies for its next causes. All of the so-called cosmetic means are hurtful, sometimes dangerous; and the vain will be punished for his vanity. The Plica polonica-matted hair-as is here and there found in Poland, is, according to Hebra, an eczema of the scalp, forming -crusts, and matting the hair together in a most hideous manner. EYES. CONSIDERING the eye as a whole, we find its general appearance frequently altered by disease. Without dwelling upon the lan- guage which the mental emotions-fright, terror, joy or sorrow, love or hatred-speak through them, we observe: An unnatural lustre of the eyes in fevers; and A brilliancy in consumptives. Glassy eyes are characteristic, in children, of inflammation of the mesenteric glands; and, if accompanied with dark, dry lips and tongue, dry skin, and great restlessness, of an acute inflam- mation of the stomach. In fevers they indicate great danger, or critical changes. Dull eyes are frequently observed in febrile conditions of the system; during catamenia, in catarrhal and other affections. Sunken eyes are the consequence of an absorption of the fat cushions, whereupon the eyeballs rest and turn in their sockets. This takes place in all diseases which are accompanied with great loss of blood or other vital fluids. Exophthalmus or protruding eyes, when not congenital, is a characteristic sign of Basedow's disease. In treating the particular diseases of the eye, I shall condense in a small space what is important for the general practitioner in his daily practice; the specialist will necessarily have to con- sult special works on this subject. LIDS AND LACHRYMAL APPARATUS. Inflammation of the Eyelids. It may be of various character. A simple inflammation may be the consequence of a cold. It usually commences on the edge and thence spreads over the whole lid to the margo orbitalis, 132 LIDS AND LACHRYMAL APPARATUS. where it abruptly ceases. By this it is distinguished from ery- sipelas, which is apt to diffuse itself further and further. The lid is hard, swollen, and red, sometimes covered with little blisters. A graver form is the Phlegmonous inflammation, or Abscess of lid. Commencing as a little, firm nodule, it often extends over the eyebrow and cheek, and the lid may attain the size of a pigeon's egg. If not checked in the onset, it terminates in the formation of an abscess which breaks either outside or, in rarer instances, perforates the conjunctiva. If this abscess forms at the inner angle of the eye, near the lachrymal sac, it has been termed Anchylops. The CAUSES are: injuries (wounds or blows upon the eye); severe conjunctivitis, or erysipelas; spontaneous develop- ment has also been observed. A third form is the Tinea tarsi, Ophthalmia tarsi, or Blepharitis marginalis, etc., which consists of an inflammation of the edges of the eyelids. In its simplest form it shows merely a slight redness of the edges and some gluing together of the lids in the morning. This may increase, however, to ulceration, thickening and hard- ening of the whole margin of the lids, when it is termed Tylosis. The conjunctiva and the Meibomian glands usually participate more or less in this inflammation and if the ulceration extends to the hair-follicles, the lashes loosen and fall out. In places where the destruction is not too extensive, the lashes grow again, but thin- ner, crooked and often inverted, which state is called Trichiasis ; or there forms a double row of cilia either along the greater por- tion of the lid, or chiefly at one point; this is called Distichiasis. This faulty position of the cilia is generally accompanied, or soon followed, by a certain degree of inversion of the eyelid, and per- haps by a shortening and incurvation of the tarsal cartilage, which state is termed Entropium, though in simple trichiasis or distichiasis it is not always present. "Entropium may also result from spasmodic contraction of the orbicularis muscle, especially in elderly persons, where the skin of the eyelids is abundant and lax." (G. S. Norton). When, however, by extensive ulceration of the edges and consequent cicatrization the apertures of the Mei- bomian follicles become closed and obliterated, the lid's margin thickens, and shows a tendency to become everted. This grows the more apparent, when the conjunctiva also is involved in the inflammatory process. And, if to all this a certain degree of atrophy and relaxation of the orbicularis associates, the some- what everted lid no longer covers the eyeball, but sinks away INFLAMMATION OF THE EYELIDS. 133 from it and the punctum lachrymale becomes exposed. This state of things is termed Ectropium. "Ectropium may also result from paralysis of the facial nerves, tumors, caries of the orbit, etc., but the most frequent cause is from cicatrices in the vicinity of the lids." (G. S. Norton.) Blepharitis marginalis occurs often as a consequence of hyper- metropia or myopia, but very frequently it is associated either with, or caused by, conjunctivitis or corneitis, affections of the lachrymal canal, as stricture, blennorrhoea, etc. Its intensity is much aggravated by dirt and want, by exposure to wind, cold, bright glare, or an impure, smoky atmosphere. THERAPEUTIC HINTS.-Simple inflammation of the lids is easily arrested by: Acon., after exposure to cold winds. Apis, with oedematous swelling and stinging pain. Bellad., bright, shining redness; right side; photophobia. Chamom., red swelling after a cold. Pulsat., with catarrh in the head. Rhus tox., from left to right; dull redness; watery vesicles. Phlegmonous inflammation requires besides one or the other of the above: Hepar, pricking and throbbing pain, worse from cold and con- tact; anchylops. Laches., purplish hue. Merc. sol., pain worse at night. Pulsat., anchylops. Silic., after Hepar, when suppuration has taken place, and the patient wants to have his head wrapped up. Blepharitis marginalis is often very obstinate and difficult to treat. When caused by hypermetropia or myopia, suitable eye- glasses are the remedy; when caused by dirt and want, their re- moval ought to be attended to; washing and cleaning the lids with luke-warm water is a daily requirement. Remedial agents are quite as necessary. Alum., dryness of lids, worse in the morning; absence of lachry- mation. Arsen., burning, acrid lachrymation, excoriating the lids and cheek. Calc. carb. and jod., lids swollen and hard, indurated, also after styes; tonsils enlarged. 134 LIDS AND LACHRYMAL APPARATUS. Carb. ac., when caused by parasitic fungi, embedded around the hair follicles. Cinnab., discharge in the morning; dull pain from the inner canthus over the eye, or around it. Caustic., better in the open air; warts on the eyebrows, upper lid or nose. Digit., lid-margin slightly swollen and pale red; inside of lids yellowish-red; burning of the lid-margin; photophobia; lachry- mation and mucous discharge. Euphras., suppurating lid-margins; constant winking of lids; profuse, acrid, burning lachrymation, or very acrid, thick or yellow discharge, excoriating lid and cheek; fluent coryza, which is mild. Graphit., dry crusts on the ciliæ, and scales on the margins; the outer canthi are often the most affected part; they crack and bleed easily; moist eczema on the head and behind the ears, cracking and bleeding. "It is the most frequently indicated remedy for chronic ciliary blepharitis, and a more rapid cure can usually be effected by its local application at the same time of its internal administration. I use it locally in some unguent, as cosmoline, about eight grains to the ounce." (G. S. Norton.) Hepar, upper lid-margins unevenly rounded, swollen and red; tough mucus in lashes and canthi; scleral conjunctiva injected with red vessels running towards the cornea, where they form little vesicles with turbid secretion, lachrymation; pain in the evening, agglutination in the morning; right eye worse; small pimples or little furuncles on the face, or elsewhere, in complica- tion with tinea. Kali carb., swelling of lids; edges, canthi and caruncula red and swollen; lachrymation and pain from bright light; pressing pain in front of head and temples into the eyes, with heat in face and head; after eating, pressure in stomach, belching; nausea and emptiness in stomach; gagging and vomiting of slime; pressure and anxious feeling in chest; face pale, dirty gray. Magn. mur., when accompanied with pimply eruption on the face, which comes and goes, but is worse after supper, in a warm room, and before the menses. Merc. sol, lids smart, are sore and red, especially upper lids; worse at night in bed, from warmth and cold, and from the glare of a fire. Merc. cor., indurated lids; secretion thin and excoriating; noc- turnal aggravation. INFLAMMATION OF THE EYELIDS. 135 Mezer., accompanied by tinea capitis of thick, hard crusts, from which pus exudes upon pressure. Natr. mur., after the application of nitrate of silver; after mea- sles; acrid lachrymation, excoriating the lids and cheeks and making the skin glossy and shining; eczema. Nux vom., after previous drugging and when worse in the morning. Petrol., pain in the back of the head, rough skin; diarrhoea only during the day. Phosph. ac., lid-margins swollen, red and rounded; lashes par- tially falling out; pus particles on lashes and in canthi; itching and burning; sensitiveness to candle-light; difficult opening of the eyes in the morning. Psorin., from right to left; worse mornings and during the day; old chronic cases; offensive discharges from the eyes; photopho- bia; strumous diathesis. Pulsat., worse in the evening and in a warm room, better in the open air; lachrymal apparatus affected; styes, and acne in the face. Rhus tox., lids oedematously swollen; copious, acrid and serous discharge, corroding the adjacent parts of the cheeks. Sepia, "small pustules, like acne, on the edge of the lids; tight feeling in lids; aggravation morn and eve." (G. S. Norton). Silic., objects appear as if seen through a fog, ameliorated by wiping the eyes; fluent coryza, corners of mouth cracked; offen- sive sweat of feet. Staphis., lid-margins dry, with hard lumps and destruction of the ciliary roots; small tarsal tumors. Sulphur, lid-margins thick, granulated and rounded; dry crusts in lashes; sharp, sticking pains, as if pins or a splinter of glass was sticking in the eye; morning agglutination; glandular swellings on the head and neck; eruption on the face; pale and puffed face; abdomen hard; disturbed digestion; worse in the evening and gas-light; cannot bear to have the eyes washed. Tellur., eczema impetiginoides on the lids, with pustular con- junctivitis; much purulent discharge from eyes; offensive otor- rhoea. Thuja, dry, branny eruption upon the lids, chiefly about the ciliæ; lashes irregular and imperfectly grown; eyes weak and watery. Anchylops will best be met in the beginning by Apis., Bellad., Hepar, Pulsat., or Rhus tox. 136 LIDS AND LACHRYMAL APPARATUS. Trichiasis may require operative measures; but cases have been cured without them. Acon., has been successfully applied in a case of trichiasis and entropium. Borax, has the symptom, but no verification to my knowledge. Graphit., may soften the scars. Natr. mur., after abuse of nitrate of silver. Sepia, eyelashes gone; edges raw and sore; eversion of puncta; eyes full of matter. Thuja, dry, branny eruption upon the lids, chiefly about the ciliæ; lashes irregular and imperfectly grown; eyes weak and watery. Entropium is surely amenable to internal treatment, if recent. Acon., acute inflammation with dryness and burning. Calc. carb., has cured cases of senile entropium. Merc. cor., Rhus tox. and Sulphur, are oftener indicated than Lycop. Natr. mur., after abuse of nitrate of silver. Sepia, acute blepharitis. Ectropium has been cured by: Apis, stinging pains and great oedematous swelling of lids and conjunctiva. Arg. nitr., tear-points greatly inflamed and prominent. Hamam., during the course of a severe conjunctivitis—by exter- nal application of "Pond's Extract." Merc. cor., Nitr. ac. and Sulphur, have been successfully employed. Rhus tox., sac-like swelling of the conjunctiva; oedematous swelling of the lids; ciliæ fall out; acrid lachrymation in the morning and in the open air. Lids are spasmodically closed; on opening them, protrusion of a thick red swelling, and yellow purulent discharge. Hordeolum, Stye. It is in its nature a small furuncle, forming in the connective tissue near the edge of the lid, and has its name from its fancied resemblance to a grain of barley. It appears as a red, hard swelling, which rapidly increases until it suppurates and breaks, either outside or inside of the lid margin. In some cases it is attended with considerable pain, and swelling of the whole lid. Some persons are subject to repeated outbreaks of this furuncular TUMORS OF THE LID. 137 inflammation. We find it most frequently in youthful individ- uals of rather delicate health with a tendency to acne, or in persons addicted to free living or dissipation. If by frequent re- lapses it induces inflammatory changes in the Meibomian glands, and is followed by fatty or chalky degeneration of their contents, it is called Chalazion, THERAPEUTIC HINTS.-Pulsat., most frequently used and indi- cated; it often arrests its growth. Hepar, if Pulsat. has not been sufficient to prevent suppuration. Staphis., often found useful and especially when the stye does not suppurate and break, but remains a hard nodule. Upper lid: Alum., Caustic., Ferrum, Mercur., Phosph. ac., Sulphur. Lower lid: Phosphor., Rhus tox., Senega, Staphis. Right side: Calc. carb., Canthar., Natr. mur. Left side: Colchic., Lycop., Pulsat., Staphis. For removing the disposition: Amm. carb., Calc. carb., Ferrum, Graphit., Sulphur, Thuja. Chalazion: Calc. carb., Conium, Graphit., Pulsat., Sepia, Silic., Staphis., Thuja. Tumors of the Lid. Chalazion has been mentioned under styes. "It is mostly situ- ated at some distance from the free margin of the lid and gener- ally most manifest on its inner surface, lying close beneath the conjunctiva. In rarer cases the tumor points outwards and lies close beneath the skin, which is frequently somewhat reddened and thinned over and around it. It occurs far more frequently in the upper than in the lower lid. (Walton). Sebaceous tumors occur most frequently at the outer and upper margin of the orbit, close to the eyebrow. Their contents are suet-like and sebaceous, consisting of broken-down epithelial cells, fat molecules and hairs; sometimes they are softer and more oily. The whole is encased in a cyst wall, the posterior portion of which is somewhat thickened and hypertrophied. Warts occur occasionally on the edges of eyelids. Fatty tumors (wens) are of rare occurrence. "They may be recognized by their smooth, circumscribed, somewhat lobulated form, and are firm and elastic to the touch." 138 LIDS AND LACHRYMAL APPRATUS. Epithelioma "is the most frequent in occurrence of all malig- nant tumors of the lids; arises as a small nodule near the edge of lid, and is painless, slow in its progress and at last ulcerates. The skin around the ulcer is not swollen and discolored as in lupus. The slowness of its growth and the history of the case distinguish from syphilitic ulcer." (G. S. Norton). THERAPEUTIC HINTS.-Encysted tumors have been cured by: Calc. carb., Grapit., Silic., Staphis., Thuja; warts by: Caustic., Thuja; wens by: Baryt. carb., Graphit; epithelioma by: Apis, Hydr. ac., Laches. (G. S. Norton). Dacryocystitis Is an acute inflammation of the lachrymal sac, which frequently reaches its acme in a few days and is very painful. Its swelling may extend to the cheek, eyelids and even conjunctiva. In less severe cases, or after the acute inflammatory symptoms have passed away, pus may be squeezed out of the puncta; but when the swelling and thickening of the lining membrane closes the passage, or the opening into the sac becomes somewhat displaced by it, the pus can not escape, and if left alone, will finally force its way through the skin. After the discharge of pus, the inflam- mation subsides either entirely, and the opening heals, or there remains a chronic inflammation of the sac, with subsequent re- newals of acute attacks, or the aperture in the skin does not firmly cicatrize, but merely scabs over, while fresh pus is col- lecting, which again forces its way out at the same place, thus finally leaving a fistulous opening, through which a thin, muco- purulent discharge and the tears constantly ooze-Fistula lachry- malis. Or again the sac may undergo ulceration at one point and the matter escape into the neighboring cellular tissue, thus giving rise to a secondary sac or pouch, which may break, where- by another more or less extensive fistulous opening is established, often very obstinate and intractible, especially if the bony struc- ture is likewise diseased. Of chronic cases there are instances where several such pouches burrow beneath the skin in different directions. THE CAUSES.—This inflammation is often merely an extension of conjunctivitis, especially the granular form, or of nasal catarrh; it may be produced by periostitis and caries of the nasal bones BLENNORRHEA OF THE LACHRYMAL SAC. 139 1 in scrofulous or syphilitic persons, or may occur as a primary affection, being then generally due to exposure to cold and wet. "Its most frequent cause is a previous stricture of the nasal duct or blennorrhoea of the lachrymal sac." (G. S. Norton.) THERAPEUTIC HINTS.-Instrumental aid may be required, but often bad cases have been cured by internal treatment alone. For dacryocystitis, at the beginning, Pulsat., or Apis, when there is oedematous swelling and stinging pains, but Bellad., Hepar, and Silic. may also be indicated. We will, no doubt, have to consider its causes (conjunctivitis, nasal catarrh, etc.), and then compare the corresponding remedies. Fistula lachrymalis: Bellad., inflammation of the lachrymal duct; intolerance of light; profuse lachrymation; lid edges in- flamed and agglutinated; morning and evening a gritting sensa- tion in the lids; aggravation in the evening. Bromine, Calc. carb., Caustic., Fluor. ac., Hepar, Laches., Natr. mur., Petrol., Pulsat., Sulphur, Silic., disorganization of the walls of the sac; denudation of the internal horny wall and closure of the nasal canal. Blennorrhoea of the Lachrymal Sac Is another consequence which may follow acute inflammation of the lachrymal sac, in fact it is a chronic inflammation of that organ by which its walls become either thickened and hypertro- phied, or thinned and greatly distended, secreting constantly a thin, glairy, viscid fluid, which flows down the nasal duct, or oozes up through the puncta. When the sac gets filled with this secretion, we observe it as a swelling of varying size and hard- On pressure its contents discharge through the puncta, and the finger sinks in as the sac is being emptied. During warm and dry weather the patient usually experiences very little inconvenience, while on exposure to cold and damp winds the trouble increases, inducing fresh inflammatory action. In this way it comes to pass that strictures are formed either in some part of the nasal duct, or of the canaliculus near its opening into the sac. ness. • Its CAUSES are like those of dacryocystitis-conjunctivitis, nasal catarrh, periostitis or caries of the nasal bones; also obstructions in the lachrymal passages either above or below the sac by a 140 CONJUNCTIVA. narrowing, obliteration, or eversion of the puncta; or by contrac- tion or stricture of the canaliculus or of the nasal duct; or by polypi or other growths which compress and obstruct the duct. THERAPEUTIC HINTS.-Compare the previous article and also those which treat of its causes. Stannum, "is one of the most important remedies, especially if the discharge is profuse, thick and of a yellow white color." (Geo. S. Norton.) Firm strictures require instrumental aid. CONJUNCTIVA. Catarrhal Ophthalmia Is an inflammation of the conjunctiva which may extend into the Meibomian ducts, the canaliculi, and the ducts of the lachry- mal gland. In its mild form it shows merely a slight hyperemia with a sensation of grit in the eye, itching, stiffness and heaviness of the eyelids with or without sticking together in the morning; there is only exceptionally some mucus excreted and found col- lected at the inner canthus either fresh or dried into little yellow- ish or brownish crusts. It is aggravated by exposure to cold winds, when lachrymation is produced. Usually of a chronic nature, it is found especially in persons of ill health, and is often difficult to cure. In its acute form the blood-vessels are much enlarged and ap- pear as a vascular net-work of brick-dust, or of bluish or lilac hue, especially on the ocular portion of the conjunctiva, while on the palpebral portion it is less marked. Often it is accompanied by spots of extravasated blood within the meshes of the membrane, which swells, and has, especially on its palpebral portion, a villous appearance, being due to the engorged state of the villi, an ap- pearance which must not be confounded with granular conjunc- tivitis. At first there is an increased flow of tears which after a while is replaced by a secretion of mucus, which by degrees gets thicker and is either whitish or yellowish. If it assume a puru- lent character, the mere catarrhal ophthalmia passes into the purulent form. Chemosis is very rare; photophobia, pain and impairment of vision do not occur in the catarrhal form. In severe cases the eyelids participate in the inflammation; usually CATARRHAL OPHTHALMIA. 141 both eyes are effected, not, however, always simultaneously; the second often becomes involved when the first is getting well; it always shows an evening aggravation; and is apt to recur. Its CAUSES are: mechanical and chemical irritation; getting cold and wet; excessive strain of the eyes by artificial light; extension from inflammatory processes of neighboring parts; measles, scar- let fever, small-pox; sometimes it appears epidemic. It is infectious. THERAPEUTIC HINTS.-If caused by some foreign body, this ought to be removed. Acon., reduces the inflammation caused by a piece of steel or cinder and facilitates its removal, if that could not be effected before the inflammation had fully developed. If there remains still some inflammation after Acon., Sulphur will cure it. Acon. is also indicated at the beginning of any ordinary ca- tarrhal conjunctivitis, where there is great dryness, burning and heat in the eye and where it has been brought on by exposure to sharp, cold winds. Apis, œdematous swelling of lids and skin over orbits with red- ness, heat and sensitiveness to external covering; stinging pains. Arg. nitr., profuse discharge approaching a purulent character; feels better in the open air, worse in a warm room. Arsen., lids spasmodically closed; conjunctiva of a dark, violet color; secretion thin and acrid with burning pain, worse at night. Bellad., right eye; throbbing pain; hot tears or dryness of the eyes; light is painful; nose sore from coryza; headache and simi- lar Belladonna symptoms. Chamom., often for infants after exposure to cold while bathing and washing. The children cry much; have colic and green stools; also during dentition. Extravasation of blood sometimes. Conium, right eye bloodshot; aches on lying down to sleep; thirsty; sweat on head, face and neck. Crocus, feeling in the eyes as after weeping with a correspond- ing appearance, extending from left to right eye; feeling of some- thing alive and moving in the abdomen. Digit., chronic; a yellowish redness of the palpebral conjunctiva. Euphras., acrid tears and profuse, acrid, thick and yellow dis- charge; blurring of vision relieved by winking; coryza with burning and pain in the frontal sinuses; after exposure to cold and during the first stage of measles. Graphit., chronic; thin, acrid discharge; external canthi crack 142 CONJUNCTIVA. and bleed easily; nose sore and excoriated, with crust on the nostrils. Merc. sol., blenorrhoea, thin and acrid; great swelling of lids; sensitive to touch; worse in a warm room or in the cold air, and in damp weather; also from evening till midnight; no relief from sweat; frequent relapses. Nux vom., the inner canthi are more inflamed than other parts; bloody exudation; smarting like salt; all worse in the morning. Pulsat., bland, moderately profuse, white discharge; worse in the warm room; in the evening; from reading; better in the open air. Rhus tox., oedematous swelling of the lids; chemosis of con- junctiva; great restlessness; after getting wet. Sepia, muco-purulent discharge in the morning and dryness in the evening; the conjunctiva is of a dull, red color with some photophobia and swelling of the lids, especially in the morning. Sulphur, acute and chronic; sharp, darting pains, like pins piercing the eye; severe pain darting through the eye back into the head, from 1 to 3 A.M., waking the patient from sleep; fever- ish and restless at night. . Zincum, the inner half of the eye is the most affected part, with much discharge; worse in the evening and in the cool air. Purulent Ophthalmia. Commencing with mere congestion, itching and dryness, par- ticularly at the inner corner, it gradually augments to intense in- flammation of the whole conjunctiva with considerable mucous secretion, which soon is changed into a purulent discharge, dis- solved in the tears. The lids swell and become slightly everted, the conjunctiva is dark red and the single blood-vessels are no longer to be seen. The parts affected feel hot and scalding with neuralgic pains which may extend to the temple and forehead. As the disease progresses, Chemosis sets in, that is an infiltration of the conjunctival and subconjunctival tissue, and in addition we observe spots of extravasated blood. In this way the con- junctiva swells often to a degree that it overlaps the cornea, but shows itself most prominently at the lateral sides of the eyeball, where it receives the least pressure from the eyelids. The in- flammation generally spreads to the areolar tissue of the orbits together with the tunica vaginalis oculi, causing a slight protru- PURULENT OPHTHALMIA. 143 sion of the eyeball; the eyelids swell still more and the upper overlaps the lower, while the protruding conjunctiva always everts the lower and sometimes both. The protruding part of the conjunctiva is very marked in its villous appearance. If cured in this stage, the eye may escape serious injury. But if it goes on the palpebral papillæ may undergo a change which is called granulation, of which later; the cornea may be rendered opaque by interstial changes, or it may be destroyed by soften- ing and ulceration; the iris may inflame and adhere to the cornea; the vibrous body, the retina, and the choroid may be partially or quite spoiled; the sclerotica may become softened; the crystalline lens, when not discharged through the perforated cornea, becomes quite yellow; and all this destructive process may run its course in a space of time from a few days to three weeks. This dreadful disease is most common and severe in hot cli- mates; in temperate latitudes it is found more especially in the army, navy, in workhouses, prisons and among the poor; it is chiefly endemic and spreads by infection. Gonorrhoeal ophthalmia, which has been developed by infection from urethral pus, cannot be distinguished from the purulent form, except by the history. It is one and the same kind of inflammation, only intensified, destroying the eye with great rapidity. Ophthalmia neonatorum "is essentially the same disease as pu- rulent ophthalmia in the adult, merely modified by the undevel- oped tissues of the babe, and the activity of the growing processes, the infant organism, but it is generally more severe." (Walton.) Usually about three or four days after birth it commences with some slight redness of the lids and slight discharge; the eyes are kept closed; light is distressing; then gradually the lids swell, and the purulent discharge becomes profuse, when the whole train of symptoms, above described, may be considered as fairly set in motion. But fortunately not all cases are of this virulent nature; simple catarrhal inflammation, caused by chilling the child when bathing or washing it, or using strong soap, which irritates the eyes-may as well commence at that time; the pu- rulent form originates from leucorrhoeal or gonorrhoeal dis- charges of the mother transmitted to the eyes of the child during parturition. 144 CONJUNCTIVA. THERAPEUTIC HINTS.-As in all three forms of purulent oph- thalmia the discharge is poisonous; great care should be taken as to cleanliness in nursing such cases. Apis, œdematous swelling of the lids and adjacent cellular tis- sue; conjunctiva congested, puffy, chemosed; lids everted, vil- lous; cornea grayish, smoky, opaque; burning, stinging pain; photophobia and hot lachrymation. Arg. met., purulent; infant; any effort to separate the lids caused a drawing-in of their edges. (After Sulphur and Calc. carb. had been without effect.) Arg. nitr. Allen and Norton have witnessed the most intense chemosis with strangulated vessels, most profuse purulent dis- charge and commencing haziness of cornea with a tendency to slough, subside rapidly under this remedy in its 30th potency internally, and at the same time a solution of five or ten grains to two drachms of water of the 1st, 3d or 30th dilution as an ex- ternal application. The very absence of subjective symptoms, with the profuse purulent discharge and the bulging lids from a collection of pus underneath or from swelling of the sub-con- junctival tissues, and not from infiltration of the connective tis- sue of the lids themselves (as in Rhus or Apis), indicate this drug. Arsen., is characterized by a thin and corroding discharge with great burning pain and restlessness; after abuse of nitrate of silver. Calc. carb., profuse, yellowish-white discharge; ulceration of cor- nea; oedema of lids; later opacities of cornea; well-known Cal- carea symptoms; after working in the water. - Chamom., ophth. neonatorum; lids much swollen, conjunctiva bleeding when separating the lids; child cries much; wants to be carried about; has colicky pains and green discharges. Euphras., compare catarrhal ophthalmia. Hepar, purulent secretion in scrofulous subjects; lids swollen, spasmodically closed, bleeding easily on attempting to open them and sensitive to touch; intense photophobia; throbbing pain, better from external warmth, worse from any draught of cold air. Ulceration of cornea and hypopion; affection of Meibomian glands. Lycop., ophth. neonatorum; copious discharge of pus; the lids are puffed out by pus beneath; the conjunctiva looks like a piece of raw flesh. Merc. sol., ophth. neonatorum; thin, excoriating secretion from GRANULAR OPHTHALMIA. 145 the eyes; green, diarrhoeic stools with straining; soreness of anus; jaundice; syphilitic and gonorrhoeal infection. The other mercurial preparations have also been successfully used. Natr. mur., especially as an antidote to nitrate of silver, so frequently abused. Nitr. ac., especially as an antidote to mercurial and syphilitic poison. Pulsat., ophth. neonatorum; profuse and bland discharge; from gonorrhoeal poison; all worse in the evening and better in the open air. Allen and Norton found it of great benefit as an in- tercurrent remedy when Arg. nitr. seemed to give out. Rhus tox., oedematous swelling of lids, and of conjunctiva; great restlessness; after getting wet; commences on the left eye. The discharge is profuse, or tears are gushing out of the eye. Sulphur, often in chronic cases with an outspoken psoric cachexia. The gonorrheal and syphilitic form may require besides the remedies mentioned: Cannab., Cinnab., Carb. veg., Kali bich., Phytol., Tart. emet., Thuja. Granular Ophthalmia. "Under granular ophthalmia are classed two different forms of conjunctivitis, follicular and granular. The former is an accu- mulation of lymphoid elements. It never involves the deep structures of the lids or surrounding conjunctiva, and, therefore, disappears without leaving cicatricial changes. It is character- ized by round or oval, pale red prominences, often arranged in rows in oculo-palpebral folds, especially lower and accompanied with some catarrhal symptoms of conjunctiva. True granular conjunctivitis is a much deeper and more serious form of inflammation. It involves deeply the stroma of conjunctiva (palpebral), as is shown by the proliferation of papillæ and development of so-called granulations. It always leaves scars behind, causes pannus, serious results to vision, entropion, trichiasis and other disorders, which is not the case in follicular conjunctivitis. It also especially involves the upper lid. It may be acute or chronic. The two diseases may be found together." (G. S. Norton). By the continual friction of the granules upon the cornea the latter may become hazy, rough or semi-opaque and vascular, a 10 146 CONJUNCTIVA. state which is known under the name of Pannus, though this opacity and vascularity of the cornea may also be produced by trichiasis, or any friction of the lid-edges. The granular eyelid is usually attended with great sensitiveness to light, cold air, wind, dust and smoke; reading, writing and sewing causes pain in the eyes and an increase of redness; there is mistiness of sight; rainbow colors around luminous bodies and finally, when the cornea more and more degenerates and even deeper portions of eyeball become involved in the inflammatory process, sight may be considerably damaged. CAUSES.-Being not a specific disease, it usually is the conse- quence of neglected conjunctivitis, which has become chronic. We find it, therefore, most frequently among the poor, and as in all ophthalmias the secretion is infectious, it too is propagated by infection, and consequently most prevalent where large masses of people are crowded together. "But the commonest of all ex- isting causes, is the use of nitrate of silver in substance for the primary inflammation, or in lotions or salves, of such strength as to be highly irritating." (Walton.) - THERAPEUTIC HINTS.-Acon., in acute aggravations by over- heating or exposure to dry, cold winds. Alum., upper lids are weak and hang down loosely. • · Arg. nitr., being so often the cause of granular lids, it surely must do good, where it has not been abused; compare the for- going chapters. Arsen., see purulent ophthalmia; lids spasmodically closed; palpebral conjunctiva inflamed, raw and suppurating; cornea degenerated; on the face a fine eruption; under the eyes excor- iated places by the acrid discharge, which are sometimes covered with crusts. Aurum, with pannus; great photophobia; hot, burning tears when attempting to open the eyes; excoriation on the cheeks and swollen glands on the neck; after the abuse of Mercury. Bellad., acute aggravations with great photophobia. Calc. carb., with pannus; caused by working in the water; deafness or ear discharges; sweat on forehead; thick, red nose with acrid discharge, or nose stopped up; swollen upper lip; swollen glands on neck; large abdomen; desire for boiled eggs. Euphras., with or without pannus; profuse lachrymation and thick discharge, excoriating lids and cheek. PHLYCTENULAR OPHTHALMIA. 147 Kali bich., with pannus; everything appears slightly red; eyes feel better when lying on the face. Merc. præc. rub., with pannus; old chronic cases. Merc. protojod., with pannus, and superficial ulceration upon it. Merc. bijod., “of great value in old cases of granular lids and pannus." (G. S. Norton.) Natr. mur., the most important remedy after cauterization, espe- cially with nitrate of silver. Nux vom., often gives great relief after many other crude drugs have been employed. Petrol., with pannus; occipital headache; roughness of skin; scrofulous habit. Pulsat., papillary trachoma without pannus in tearful females; with evening aggravation and amelioration in the open air. Rhus tox., with pannus and profuse lachrymation. Sulphur, when other remedies fail to act; often better indicated by other than eye-symptoms; the psoric tendency of the patient and his dislike to water and the like. Thuja, granulations large, wart-like; pain worse at night, after midnight. The following remedies are mentioned favorably: Alumen exsiccatum, Caustic., Chin. mur., Chin. tan., Cinnab., Conium, Cupr. al., Cupr. sulph., Hepar, Merc. sol., Natr. phosph., Sepia, Tart. em., Zincum. Phlyctenular Ophthalmia. The phlyctenula commences as a little vascular patch, at the summit of which the epithelium is raised by serum into a vesi- cle; the conjunctiva swells, the vessels enlarge, profuse lachry- mation ensues, and a catarrhal discharge is produced. By this time the vesicle bursts and a little ulcer is formed which secretes an opaque grayish substance, under which the ulcer may heal, if the inflammation does not extend, before the repair is effected. The phlyctenulæ appear most frequently at the corneo-scleral border, sometimes also on the cornea, and exceptionally on the oculo- palpebral or palpebral conjunctiva. They appear either singly or there may be several scattered about or in groups, and sometimes disposed in a circular manner, partially surrounding the cornea. Ordinarily the redness is only on one side of the eyeball, where the eruption is located; sometimes the whole conjunctiva is 148 CONJUNCTIVA. inflamed. At its outbreak it is attended with stinging and itch- ing; photophobia is not very great, but increases as the inflam- mation is nearer or at the cornea. GURN CAUSES.-Ill health, debility; hereditary weakness, impure air, insufficient diet and clothing, want of exercise; exposure to wet and cold. THERAPEUTIC HINTS include those for pustular keratitis and so-called ophthalmia scrofulosa. Apis, eyelids puffed; conjunctiva chemosed; cornea grayish, smoky, opaque; pain burning-stinging. Arsen., lids spasmodically closed; conjunctiva and cornea pus- tulous and ulcerated; lachrymation and discharge excoriating the surrounding parts; burning pain; nose and upper lip exco- riated by acrid discharges; great restlessness and thirst. Aurum met., great photophobia; hot, burning tears; cutting pain through the eyes, sensitive to touch; swollen glands on neck; after mercurial poisoning. Baryt. carb. and jod., enlarged cervical glands. Calc. carb. and jod., scrofulous subjects; from exposure to wet, and worse during damp weather; complication with deafness; swollen glands, etc. See previous chapters. Caustic., pain relieved by external pressure; yellow face; warts on nose or eyebrows. Chamom., compare under purulent ophthalmia. Cinnab., pain from inner canthus across the eyebrows or around the eye. Conium, great photophobia without much imflammation of the conjunctiva. Crot. tigl., with a corresponding eruption on face and lids. Euphras., compare previous chapters. Graphit., often indicated in the chronic and acute form; the external canthi are cracked and bleed easily when opening the eyes; intense photophobia. Hepar, ulcers on cornea; intense photophobia, lachrymation and great redness, even to chemosis; pain throbbing, better from external warmth; scrofulous, cross children; abuse of mercury. Hypopion. Kali bichr. and hydr., absence of pain, of photophobia and red- ness; secretion of a stringy character. Merc. sol., ulcers, and chalk-white appearance of the cornea; PHLYCTENULAR OPHTHALMIA. 149 lids swollen and spasmodically closed; intense photophobia; ex- coriating lachrymation; pain worse at night; excoriation of nose; ulcers on tongue; eruption on face and head; aching in the bones; syphilitic subjects. These symptoms fit more or less to other mercurial preparations, of which there have been used with success- Merc. corr., when the acridity seems still more intense. Merc. nit., has been used with great success by Dr. Liebold in this form of inflammation, whether acute or chronic. Merc. præc. rub., differs little from the others. Merc. protojod., when the tongue has a thick, yellow coating at the base. Natr. mur., lachrymation and discharge acrid and corroding; after the abuse of nitrate of silver. Nux vom., after much drugging; morning aggravation. Psorin., chronic cases with psoric taint. Pulsat., phlyctenulæ confined to the conjunctiva. Compare former chapters. Rhus tox., pimples and vesicles on the cornea; great photopho- bia and intense inflammation; eruptions on head and face; swel- ling of glands behind the ears. Compare previous chapters. Sepia, complication with uterine affections; aggravation morn- ing and evening. Silic., suppurating and perforating ulcers on the centre of the cornea, without blood-vessels running towards it; neuralgic pain in supraorbital nerve; phlyctenules on the boundary of sclera and cornea, recurring often. After vaccination. Sulphur, very often indicated by the general state of the patient, or when other remedies fail to relieve. The pain is sharp and piercing through eye into the head; worse at nights; eruptions on other parts of the body; swollen glands; diarrhoea early in the morning; water and washing aggravate, and there is a general dislike to being washed. Tart. emet., photophobia and herpetic eruptions. Tellur., complicated with offensive otorrhoea. Zincum, persistent redness, especially at the inner angle and worse in the evening and in the open air, remaining after pustu- lar keratitis. Still other remedies have been found useful: Arg. nitr., Bapt. tinct., China, Chloral, Cuprum al., Ferrum, Ferr. jod., Hyosc., Kreos., Laches., Lycop., Magn. carb., Mezer., Nitr. ac., Petrol., Phosphor., Podoph., Sulph. jod., Thuja. 150 CONJUNCTIVITIS. Diphtheritic Conjunctivitis. Like diphtheritis of the pharynx, it is an inflammation of the entire conjunctiva, which becomes tumefied by a corpuscular in- filtration of newly-formed cells into the subepithelial connective tissue, so abundant as to compress the blood-vessels and arrest the circulation and nutrition, in consequence of which the con- junctiva degenerates into a necrotic mass, and is thrown off in pus-like secretion. On examining the eye, the conjunctiva ap- pears as if covered with a felted flocculent membrane of a pale yellowish or grayish hue, especially on the palpebral conjunctiva and on the oculo-palpebral fold. The eyelids are swollen, hard, stiff and hot. Often the internal parts participate in the inflam- matory process. After six to eight days the active inflammation subsides, the exudation dissolves and is thrown off as a pus-like discharge, when finally the injured parts heal and become cica- trized, involving sometimes the cartilage and deeper tissues of the lids, and causing entropion, symplepharon, secondary corneal affections, etc. It ought to be born in mind, that the diphtheritic conjunctivitis is the most destructive form of external inflamma- tion of the eye and that its discharge is extremely contagious. CAUSES.-In Northern Germany it has appeared as an epidemic; in this country only sporadic cases have been seen. Some say, purulent ophthalmia may be converted into this form by the improper use of escharotics; it may be inoculated and it may be idiopathic, its cause lying in constitutional conditions, and be complicated with diphtheria in the throat, with scarlet and puer- peral fevers, and even with measles. It may attack young and old. THERAPEUTIC HINTS must be more or less identical with those given under Diphtheria, which compare. Croupous Conjunctivitis "Is much more common and should be distinguished from diph- theritic. The lids are swollen (usually oedematous), but not firm and hard, as in diphtheritic. The false membrane is present to a greater or lesser extent and more or less adherent, but it is on the surface of the conjunctiva (especially palpebral) and does not leave cicatrices behind, while in the diphtheritic form the exuda- PTERYGIUM. 151 tion is in the stroma of the conjunctiva and cicatrization always results. Croupous conjunctivitis is therefore much less serious than diphtheritic, though the former may pass over into the latter. THERAPEUTIC HINTS.—Acet. ac. is particularly the remedy when the membrane is yellow, white and very dense, tough and adherent. Arg. nitr., after degeneration of the membrane has set in and the discharge is more purulent. Kali bichr., if the membrane is loosely attached and comes off in strings and threads." (Geo. S. Norton.) Pterygium. This is a triangular or wing-shaped adventitious growth on the ocular conjunctiva. Starting with its broad base at the cor- ner of the eye, it reaches with its apex (seldom the middle, and still more seldom crossing the middle) of the cornea. It is loosely connected with the conjunctiva. It generally makes its appear- ance at the inner-rarely at the outer-corner of the eye. Very rarely it appears on the upper or lower part of the eyeball. These growths are of different consistency and color: some look red, inflamed, and are full of blood-vessels; some are quite thin, almost transparent; and still others are thick and of a whitish or yellowish hue. Their origin is usually due to a chronic inflammation of the conjunctiva, and therefore always preceded by increased vascu- larity of the spot of the conjunctiva in which it appears. Tropi- cal influence is considered as an excitant. It appears after the adult period; but there are also congenital cases. THERAPEUTIC HINTS.-Arg. nitr., pink color; discharge from the eye; inflammation better in the open air, unbearable in a warm room, with pain at the root of the nose. Arsen., dryness and burning in the eye; or acrid lachrymation and discharge. Calc. carb., from exposure to wet and cold. Zincum, thick and vascular; conjunctiva injected; lashes in- clined to turn inward; external canthi sore and cracked; eyes feel sore in cold air, better in a warm room; itching and lachry- mation at night; green halo around candle-light; rush of blood to the head over face, followed by perspiration over body; press- ure across the root of the nose and supra-orbital region. (Dunham.) 152 CORNEA. Still other remedies have proved useful: Chimaphila, Laches., Nux mosch., Psorin, Ratan., Spigel., Sulphur. CORNEA. Corneitis, Keratitis. Inflammation of the cornea is always attended by some degree of inflammation of the surrounding conjunctiva and sclerotica. Ordinarily its epithelial layer is first affected; it becomes visible by the molecular cloudiness of its cell contents and the prolifera- tion of the cells themselves; this is followed by a subepithelial infiltration which may involve the true corneal elements. In this way the cornea swells; the epithelial layer becomes rough and loses its polish, and the anterior portion of the true cornea assumes a general dulness or grayish opacity of different degrees. The blood-vessels, in fine net-work superficially arranged, follow the opacity from the circumference, being formed in the exuded material, whereby the cornea is reddened; they communicate with the blood-vessels of the conjunctiva. This affection is al- ways accompanied with photophobia, lachrymation, blepharo- spasm and pain; the amount of interference with vision depends on the amount of the opacity over the pupil. Its causes are either mechanical or chemical irritations. When phlyctenulæ form on the cornea, the affection is usually called Strumous or Scrofulous ophthalmia; it is frequently associ- ated with phlyctenules or pustules on the conjunctiva, as de- scribed under "phlyctenular ophthalmia," which compare. When the inflammatory symptoms are more chronic in char- acter and the destructive effects are deeper and greater, it is termed Diffuse or Parenchymatous corneitis. "The cornea has then lost its natural polish and resembles a piece of glass that has been breathed on. Or it may have a more stippled aspect, with greater roughness, whereby there is more haziness. With this there is a deep-seated, streaked or speckled whiteness or yellowishness, arising from interstitial deposits of materials in the true cornea. The true corneal tissue is not long pervaded by opacity in any form, before such opacity commences to be injected with blood-vessels, which may be few and isolated, or numerous and close, looking like a red patch." (Walton.) Pain, photophobia, and plepharospasm seldom exist, except in CORNEITIS, KERATITIS. 153 the beginning of the disease. Its spoiling effects may be changes in the curves of the cornea causing myopia or astigmatism; or limitation of vision; adhesion of the iris to the cornea; changes in the deeper parts of the eye; even atrophy of the eyeball from ophthalmia. CAUSES.-External injuries to the cornea and constitutional derangements, especially hereditary syphilis. When by long-continued mechanical irritation from cicatrizes of the eyelids, from the contact of the cilia in trichiasis and entropium, from granular conjunctivitis the cornea becomes in- flamed, cloudy and vascular, or even vascular granulations ap- pear, especially on the upper half of the cornea in consequence of the greater irritation of the upper lid—we have Pannus. As the vascularity increases, the cornea is ultimately surrounded by a thick tumefied network of varicose vessels, interspersed with numerous reddish-brown granulations. When in consequence of inflammation suppuration takes place between the layers of the corneal laminæ, we have an Interstitial abscess of the cornea, which appears either as a yellowish spot with whitish circumference in any part of the cornea, or as a deposit of pus diffused throughout the cornea, so that the whole looks yellow. The pus may gravitate to the lower margin of the cornea, forming there a curved line which resembles the white mark at the root of the nail, hence it is called Onyx. When in consequence of inflammatory proliferation of the epi- thelium of the posterior elastic membrane of the cornea an exu- dation of mucus and pus corpuscles takes place into the anterior chamber, we have Hypopion. The quantity of this exudation may be merely recognizable or may fill both chambers of the eye. Its color is usually creamy, but it may be streaked red with blood, or altogether red from the same. In changing the direction of the head from the perpendicular, the loosely lying mass shifts its position in the chamber and is therefore readily distinguished from onyx. G When, however, in consequence of inflammation of the con- junctival layer of the cornea, its substance becomes rough and is cast off or exfoliated, and the breach constitutes an ulcer, we then have a surface abscess, or as it is termed Ulceration of the cornea The ulcer may appear at any part of the cornea; it may be superficial or deep, even penetrating the cornea. The surround- ing conjunctiva and sclerotica become vascular, and the more 1 154 CORNEA. so as the ulcer is nearer the margin of the cornea. Deep ulcera- tion excavates the cornea and the spot becomes covered with a pus-like material; it may perforate the cornea, when the aqueous humor flows off; it may be associated with onyx or hypopion. The subjective symptoms are those of interstitial conjunctivitis, and its causes the same. Iritis is no uncommon complication. It may result in opacity of the cornea (Leucoma, Macula corneæ), or in spherical or conical protrusion of the remaining posterior por- tion of the corneal tissue, and of the posterior elastic lamina, when it is called Ulcerative corneal staphyloma; or the ulcerated surface may heal over and cicatrize, leaving, however, the cornea still protruding. This is called Cicatricial corneal staphyloma; its most prominent part is the thinnest and the surrounding cornea is often curved in several directions and affected with superficial and interstitial opacity. The staphyloma may burst. When in case of perforation of the cornea the iris falls against or into the gap, it either protrudes through the opening, or in case of cicatri- zation of the opening, the cornea yields in consequence of the intra-ocular pressure and gradually bulges forward, giving rise to a Partial staphyloma of the cornea and iris; a total destruction of the cornea by sloughing or ulceration causes Total staphyloma of the cornea and iris, in which process mostly the neighboring portion of the sclerotica, and in time, the whole anterior half of the globe becomes involved. THERAPEUTIC HINTS.-Keratitis, when caused by mechanical irritation requires: Acon., and later Sulphur; Euphras. with a feeling as if a hair were hanging over the eye; Symphitum, with a feeling as if the lid were moving over a ball. Besides may be indicated Arnica, Calend., or Hamam. When caused by chemical irritation we will have to look for the corresponding antidotes of the different chemicals. Arnica is most important in prevent- ing suppuration. Phlyctenular corneitis requires the same treatment as detailed under phlyctenular conjunctivitis. Diffuse or Parenchymatous corneitis. Merc. sol. and other mer- curial preparations are the most important. Besides compare: Apis, stinging burning pain and oedematous swelling; Arsen., burning pain and restlessness; Aur. mur., hereditary syphilis;· "I have found it more commonly indicated than any other remedy." (Geo. S. Norton.) Baryt. jod., greatly enlarged cervi- CORNEITIS, KERATITIS. 155 val glands and bone-pains at night; Calc. carb. and jod., stru- mous habit; Cann. sat., Hepar, promotes absorption; Sepia, uter- ine disturbances; Sulphur, promotes absorption. Pannus. Apis, Arg. nitr., Arsen., Aurum, Bellad., Cannab., Chin. mur., Euphras., Graphit., Hepar, Kali carb., Merc. sol., protoj. and præc. rub., Natr. mur., Petrol., Pulsat., Rhus tox., Sulphur. For particular indications compare granular ophthalmia and the following. Ulceration of the cornea. "Bandaging is of the very greatest im- portance in the treatment of ulcers of the cornea. See page 205 Allen and Norton's Ophthalmic Therapeutics." (Geo. S. Norton.) Act. rac., sharp, neuralgic pains through the eye into the head. Apis, stinging-burning pain and oedematous swelling. Arg. nitr., profuse discharge; halo around the light; darting pain through eye, morning and evening; better in open air; worse in warm room. Arsen., burning, acrid, profuse lachrymation; photophobia; pain worse after midnight; with restlessness; better from warm applications. Asaf., iris affected with pain in the direction from within out- wards; better from rest and pressure. Aurum, with pannus; great photophobia and profuse, scalding lachrymation; pains go from without inwards; cervical glands enlarged and inflamed. Calc. carb. and jod., for scrofulous children with large heads, open fontanels, slow dentition; pot-belliedness; frequent ca- tarrh of nose and bowels; pale face; enlarged tonsils and cervi- cal glands. Chamom., cross, peevish children who want to be carried about all the time, etc. Chin. mur., with pannus; severe intermitting pains; anæmic conditions of malarial origin. Cimic. See Act: rac. Cinnab., pain above the eye, extending from the internal to the external canthus, or running around the eye. Conium, superficial ulceration with intense photophobia and a gush of tears whenever the spasmodically closed lids were forced open; with all this but little redness of the conjunctiva. Crot. tigl., pain in the supra-ciliary region at night and vesi- cular eruption on the face and lids. Euphras., burning flow of corrosive tears and a feeling of a foreign substance in the eye, as of a hair; blurring of the eyes 156 CORNEA. relieved by frequent winking; is followed well by Calc. carb. and later by Silic. Graphit., great photophobia; profuse lachrymation; superficial or deep ulcers; hypopion; lids red and sore, covered with scales; chronic eczema on head, behind ears, on face. The external canthi are prone to crack and bleed. Hepar, torpid ulceration; hypopion; also profuse lachrymation or want of lachrymation; great redness. of cornea and conjunc- tiva; throbbing pain, better by warmth, worse by cold, or un- covering the eye in the evening. Strumous, outrageously cross children; chilliness, desire to be covered; mercurial poisoning. Kali bichr., indolent ulceration without photophobia or red- little pain; slight (if any) discharge of a stringy character. Kali carb., ulcer in centre; no photophobia; pale, fat and flabby children. ness; A Merc. cyan., trachoma with pannus; intense pain in eyeball, orbit and supraciliary region and head; worse on lying down; nocturnal pains in the joints; syphilitic origin. Merc. prot., serpiginous superficial ulceration of the cornea; much vascularity and photophobia; tongue yellow at base. (Geo. S. Norton.) Merc. sol., and other mercurial preparations compare under phlyctenular conjunctivitis. Natr. mur., acrid tears and discharge; sharp piercing above eye on looking down; after cauterization. Nitr. ac., is often indicated after Calc. carb., or Pulsat. Nux vom., Pulsat., compare previous chapters. Rhus tox., after getting drenched; compare former chapters. Secale, worse from warm applications. Silic., deep ulcers; sloughing ulcers; hypopion; the patient wants to have his head wrapped up; after vaccination. Sulphur, acute and chronic form; hypopion; otorrhoea; eczema; affection of the bones. Cannot bear being washed. "The pains of Sulphur are usually sharp and stitching, as if a needle or splinter were sticking in the eye. They do not extend into the head, with the exception of the shooting pain through the eye into the head from 1 to 3 A.M." (Geo. S. Norton.) Thuja, syphilitic origin; hypopion; pain over the eyes, as if a nail were being driven in. Vaccin., with small-pox and after vaccination; also Variol. Opacities have been cured especially by Calc. carb.; but the SCLERITIS, SCLEROTITIS. 157 following have also been successfully employed: Apis, Aurum, Cannab., Chelid., Crotal., Cupr. al., Euphras., Hepar, Kali bichr., Natr. sulph., Nitr. ac, Phosphor., Pulsat., Rhus tox., Silic., Spongia and Sulphur. Staphyloma. Notwithstanding several denials from persons who did not know anything about it, Apis did cure, or to say the least, did reduce under my own observation a staphyloma to a degree, that the eye regained its former usefulness. Years after the same doubts were thrown upon Dunham's cure of a pterygium. Although such doubts do not alter the facts, yet they do injury by disheartening the young physician from even trying to do his best. It seems scarcely necessary to mention, that Apis, in order to be successful, must correspond with the symptoms of the case. Schelling cured a staphylomatous protrusion by Euphras. and Lycop. (Allg. H. Ztg., 36, 148), and so did Stapf by the gradual administration, according to the symptoms, of Sulphur, Calc. carb., Nitr. ac., Pulsat., Euphras., and Senega; there remained at last a mere slight opacity of the cornea and some distortion of the iris; the protrusion of the cornea had been entirely removed (Arch. 18, 2, 45). Bellad., Hepar, Mercur. and other remedies may also be indi- cated, but if we give up before trying, how shall we find out? Hypopion has been cured by: Hepar, Silic., Sulphur, Thuja. SCLEROTICA. Scleritis, Sclerotitis. Inflammation of the sclera takes place around the cornea and is usually circumscribed, especially between the insertion of the recti muscles; it is characterized by a bluish-red elevation, due to increased vascularity and lymphoid infiltration in the episcle- ral tissue, and by bright red vessels on the surface; it is usually painful to touch. Although at times complicated with choroiditis, it is not always a sign of hyperæmia of the choroid, because there are severe cases of choroiditis without any scleral complication, and vice versa severe cases of scleritis without choroidal affection. When the uveal tract is involved it is usually the iris or ciliary body and not the choroid, as both (iris and ciliary body) are supplied by the anterior ciliary vessels in common with the sclera. (Norton.) 158 IRIS. ! Repeated attacks of scleritis tend in time to interfere with the nutrition of the sclera, in consequence of which the tunica be- comes thin, blue and bulging, either in whole or in part, consti- tuting an Anterior staphyloma of the sclera and choroid, which again may terminate in suppuration within the globe, spon- taneous bursting and atrophy of the eyeball. THERAPEUTIC HINTS. (Allen's and Norton's Ophthalmic Therapeutics). Acon., acute stage; violent aching, dragging, tearing pains in the eyeballs; contracted pupils; photophobia. Eye sensitive to touch and feels hot and dry. After exposure to cold, dry air. Kalmia, sclera inflamed; vitreous filled with opacities; glimmer- ing of light below one eye, especially on reading with the other. Mercur., the sclera is thinned and blue; aching in the eye all the time, but worse at night; some pain around the eye if the iris has become involved. Flabby tongue, offensive breath, night pains; syphilitic origin. Gadg Silic., pains severe, extending from the eyes to the head, relieved by wrapping up the head; aching in the occiput corresponding to the eye affected. Thuja, has often shown itself useful in all forms of this affec- tion; the sclera becomes soft in consequence of extension of inflammation of the cornea and iris; tenderness of the globe; intolerance of light; general cachectic condition, either scrofulous or syphilitic; long deprivation of fresh air. Besides are recommended: Coccul., Pulsat., Spigel. and Sulphur. If in spite of these remedies staphylímatous degeneration of the sclera ensues, iridectomy must be made, unless still other remedies are found, to check this morbid process. IRIS. Iritis. Iritis is of frequent occurrence and is usually uncomplicated with inflammation of the neighboring tissues. It very rarely extends from the ciliary body and the choroid, but may extend to these structures. Tenderness of the eyeball to pressure is not marked in iritis, unless the ciliary body is involved. Simple Plastic iritis is characterized by ciliary neuralgia, almost IRITIS. 159 always worse at night, photophobia, lachrymation, dimness of vision, ciliary injection, chemosis, iris discolored, aqueous, hazy, sluggish, pupil contracted, and adhesion of iris to lens-posterior synechia. In Parenchymatous iritis the iris is more swollen and vascular with more exudation in pupil. In Suppurative iritis the lids are oedematous, there is more chemosis, and pus in the anterior chamber. In Syphilitic iritis we have secondary symptoms of syphilis and often gummata on the iris. Rheumatic iritis is like plastic, only the episcleral injection may be more marked. Traumatic iritis is like plastic. Serous iritis is characterized by a deposit of lymph on the pos- terior surface of the cornea, which takes a pyramidal shape with apex toward the centre of the cornea, cloudiness and hypersecre- tion of the aqueous humor, dilated pupil, deep anterior chamber and slight photophobia, lachrymation, ciliary injection. (Geo. S. Norton.) THERAPEUTIC HINTS. "In the treatment of iritis Atropine is, I believe, of the greatest importance. The pupil must be kept dilated, or you are almost certain, in the great majority of cases, to have serious results, as posterior synochia remaining after the inflammation has been subdued. Dry warmth and rest are also very important aids in the treatment." (Geo. S. Norton). Acon., rheumatic form, after exposure to cold winds with great dryness and heat in the eye. Arnica, rheumatic and traumatic form. P Arsen., burning pains worse after midnight, better from warm applications. Asaf., syphilitic form and after overdosing with mercury; severe throbbing, or burning, or sticking pain from within out- ward, better from rest and pressure. Aurum, syphilitic form and after the abuse of mercury and pot- ash; pain in the orbital bones, pressing from above downwards, or from without inwards, worse on touch; great mental depression. Bellad., rheumatic form; pressing pain around the eye, or stitching pain above or beside the eye, as if it were torn out or pressed in; pains come and go, with flashes of light or dark spots with light margins, or dark fog before the eyes; severe ver- tigo and headache even to loss of consciousness. 160 IRIS. Bryon., rheumatic form; the pain is worse from moving the eyes and also in the evening and at night; there is shooting pain in the head, and pain as if the head should burst on stooping. Calend., traumatic iritis. Cedron, supra-orbital neuralgia, periodical. China, periodical pains; after loss of vital fluids and of malarial infection. Cinnab., syphilitic form; pain commences at inner canthus, ex- tending across the brow, or passing around the eye; nocturnal aggravation; intermitting pain. Clemat., pressing pain in the eyes, photophobia and lachryma- tion, worse in the open air; heat in the eyes. Coloc., rheumatic form; around the cornea a bluish-white ring; photophobia; no lachrymation; tearing pain in eye and sur- roundings; worse in the evening and at night. Conium, excessive photophobia without corresponding redness of eye. Euphras., rheumatic form; aching and occasional darting pain in eye, worse at night; iris adhering. Gelsem., serous form with choroidal exudation. Hamam., traumatic form with hæmorrhage into the anterior chamber. Hepar, with corneitis or hypopion. Characteristics see in for- mer chapters. Kali jod., syphilitic form. After abuse of mercury. Mercur. and its various preparations, syphilitic and other forms; tearing, boring pains in the bones around the eyes; worse at night; sclerotitis and conjunctivitis; sweat without relief; bad smell from mouth; frequent spitting of saliva; tenesmus. Merc. corr., is commonly indicated by the symptoms of iritis more than any other drug. (Norton.) Natr. mur., pupil contracted; iris discolored; violent stitches in the temples on looking into the light or when the light is changed; on reading or writing the letters run together; sight much impaired. Nitr. ac., chronic syphilitic form with very little pain (Norton); also after abuse of mercury; pain worse on any change of tem- perature, at night and on touching the parts. Nux vom., rheumatic and syphilitic form; after drugging; pain worse in the morning. Petrol., syphilitic form with occipital headache. CHOROIDITIS. 161 Pulsat., rheumatic form; pain worse in the afternoon and even- ing; cries easily and is worse after crying. Rhus tox., rheumatic and traumatic form; lids swollen and spasmodically closed; lachrymation; conjunctiva chemosed; pain worse at night; after getting wet; rainy weather; after Bryon. Silic., with hypopion and corneitis. Spigel., rheumatic form; excessive pain in and around the eye, especially on moving; sometimes periodically from morning till noon, and then abruptly ceasing. Sulphur, rheumatic and other forms; with hypopion; relapsing cases; psoric tendency; pain worse in the evening and at night; ears often affected. Tereb., rheumatic form; after suppression of perspiration of the feet; urinary symptoms. Thuja, syphilitic form; condylomata on the iris; wart-like ex- crescences on the iris; pain better by warmth. Besides have been successfully employed: Arg. nitr., Crot. tigl., Hyosc., Iodum, Lycop., Plumbum, Stilling., Zincum. CHOROIDEA. The choroid is a dark brown vascular coat, which lies within and in contact with the sclera, and between it and the retina; its proper structure terminates anteriorly where the ciliary body commences, which forms the connecting link between it and the iris. Choroiditis "is usually found uncomplicated with inflammation of other por- tions of the uveal tract. In Choroiditis disseminata the eyes feel weak and vision is blurred. The ophthalmoscope shows a yellowish-red nodule in the choroid in the first stage which soon atrophies, leaving a white spot sur- rounded by a rim of proliferated pigment. Other spots follow, and as they have a tendency to coalesce they form large atrophic plaques. The haziness of the vitreous is not marked unless the choroiditis is of the syphilitic variety when the haziness of the vitreous is a very prominent symptom, as is the non-tendency of the spots to run together. Choroiditis suppurativa (panophthalmitis) is usually the result 11 162 CHOROIDEA. of foreign bodies or injuries and its course is generally rapid, destroying the eye. Characteristic symptoms are: cedematous swelling of the lids, chemosis, protrusion of the eye, hypopion, synochia posteriora, white reflex from the fundus, tension in- creased, eye sensitive to touch, loss of vision, very severe pain, fever and vomiting. Sclerotico-choroiditis posteriora or Posterior staphyloma is found in myopia, especially high degrees, and is characterized by a white crescent around the optic nerve entrance, especially outer side, which corresponds to the bulging of the sclera at that point. It may, however, be irregular and extend around the optic disc. When it is progressing the myopia increases, vision becomes more impaired, black, floating spots appear before the sight and the edges of the crescent are not as well defined. It is a congeni- tal trouble and is increased by overuse of the eyes. Cyclitis usually passes over into irido-cyclitis or irido-choroiditis. A prominent symptom of irido-choroiditis is the increased tension. in its early and diminished tension in its late stage." (G. S. Norton). THERAPEUTIC HINTS.-Aurum., serous exudation between the choroid and retina; haziness of the vitreous; sensitiveness to light and touch; pressive pain in eye from above downward or from without inward; pain in the bones around the eye. After abuse of mercury or potash. Bellad., often indicated by congestion towards the head; eyes sensitive to light; halo around the light; various flashes of light, sparks, etc., before the eyes. Bryon., serous exudation; following rheumatic iritis; eyeball sore to touch and motion; darting pains through the eye into the head. Gelsem., serous choroiditis; iritic complications; vision varies from day to day or from hour to hour; sometimes fever, with thirstlessness. Kali hydroj., syphilitic origin; disseminate variety. Merc. corr. or sol., disseminate form; iritic complication; syph- ilitic dyscrasia; tendency to adhesion; nocturnal aggravation of the pains, both in and around the eye. Nux vom., after use of stimulants; aggravation in the morning. Phosphor., luminous appearance before the eyes, especially red; after sexual excesses; bright light, natural or artificial, hurts the eyes; they feel better in the twilight. GLAUCOMA. 163 Prun. spin., with or without iritic or retinal complication; severe pain in the eyeball, as if it were being pressed asunder, or else shooting and cutting pain through the eye and corresponding side of head, or crushing pain. Pulsat., when corresponding to the general disposition of the patient. Sulphur, chronic state; sharp, darting pains; after suppression of eruptions; psoric taint. Besides, the following remedies have been useful: Acon., Arsen., Coloc., Hepar, Ipec., Psorin., Ruta, Silic., Sol. nig. In Sclerotico-choroiditis posteriora has been found useful: Bellad., flushed face and throbbing congested headaches; pho- tophobia. Crocus, pain from the eye to the top of the head; also pain from left eye darting to the right; sensation of cold wind blow- ing across the eyes. Mercur., usual indication. Phosphor., muscæ volitantes, flashes of light before the eyes. Prun. spin., pains in eye as if pressed asunder, or sharp and starting, in and around the eye. Spigel., sharp, stabbing pains through the eye and around it, often commencing at one point and then seeming to radiate in every direction. Thuja, often called for in strumous and sycotic persons. Besides compare: Carb. veg., Kali jod., Lycop., Physostigma, Ruta and Sulphur. In Choroiditis suppurativa compare: Acon., Apis, Arsen., Hepar, Phytol., (traumatic origin, lids very hard, red and swollen; con- junctiva chemosed and pus in the interior of the eye; severe pain). Rhus tox, is the most important remedy. Lids oedematous, much chemosis, photophobia and profuse gush of tears on open- ing the spasmodically closed lids, hypopion, pains at night, etc. (Norton.) Also: Asaf., Bellad., Mercur., Sulphur. ang In Hæmorrhage compare: Arnica, Bellad., Cinchon., Crotal., Hamam., Laches., Phosphor., etc. Glaucoma. 1. Acute form.—Its onset may for hours, days, weeks, months, even years, be premonitioned by one or the other, or several of the following symptoms: a halo, gray or colored, or a circle or 164 CHOROIDEA. several in the same or different colors around candle light or lu- minous objects; flashes or wheels of light in the dark, as well as in the light, with or without intercurrent obscurations of sight; periodic dimness of sight, or dimness of a part of the visual field; rapid increase of presbyopia, ciliary neuralgia, headaches. The at- tack itself often commences suddenly with severe throbbing pain in the eyeball and the corresponding side of the head; the eyeball is very sensitive to touch; flashes of a vivid red or deep orange color appear before the eyes with great photophobia, increased by exertion, or anything that quickens the heart's action, even the taking of food. The eyeball shows signs of inflammation in different degrees of intensity, such as: lachrymation and intolerance to light; swelling and redness of the eyelids; con- junctivitis with serous chemosis, but scarcely any purulent dis- charge; hyperemia of the sclerotica and congestion of the anterior ciliary veins; the cornea is hazy and a little roughened, or even vesicular in spots, or sometimes opaque interstitially; its sensibil- ity is more or less lost in parts or in its entire structure. The iris loses its color, acquiring a slate-like aspect and is pushed against the cornea; the pupil becomes dilated, irregular and fixed; its color is less black than usual, but more of a drab color, show- ing sometimes even a shade of green. The eyeball, on palpation, feels harder than natural. The vision gradually grows duller, a thick fog appears before the eye in daylight and at night prismatic colors surround the candle light. The visual field usually com- mences to contract on the inner side and after a while all vision is lost. Ophthalmoscopic inspection reveals: haziness of the vit- reous body; in hæmorrhagic glaucoma, which is rare, there is hæmorrhage either from the disc, the retina or the choroidea, singly or combined; excavation of the optic disc, called glaumatous cupping, with dilatation of the retinal veins and pulsation of the central retinal arteries. 2. The subacute form, or chronic glaucoma, shows all the symp toms above enumerated, only not so sharp and definitely marked, although leading in an insidious and slow manner to the same results. Glaucoma always begins in one eye, and is very apt to develop in the other, in the course of months or years. Its causes have not been sufficiently explained and the nature of the glau- comatous tension of the eyeball is also not fully established. Post-mortem examinations have revealed: obliteration of Schlemm's canal (Kniess); closure of the drainage channels GLAUCOMA. 165 (Weber); atrophy of the ciliary body, and atrophy or adhesion of the iris (Brailey), all of which are supposed to be more or less concerned in producing the increased tension of the globe. THERAPEUTIC HINTS.-Iridectomy, first recommended by Dr. von Graefe, is by some considered as the only remedy worth speaking of, while other eye-surgeons recommend frequent tap- ping of the cornea, and the newest of all is sclerotomy. Whichever may be preferred or deemed necessary, in this I agree entirely with Walton, when he says: "Treatment by practical surgery alone is not enough; it should be but a part, an auxiliary of a therapeutic system, embracing those details which help so much in subduing the abnormal conditions which are common to other affections and to glaucoma. I allude, of course, to the abnormal conditions of inflammation of the uveal tract, particularly cho- roiditis, to neuro-retinitis and hyalitis." (Page 1172.) Arg. nitr. See Advance, October, 1879. Aurum, pressure from within outward, and from above down- ward in eyeball; heavy, dull aching of the globes; upper half of an object invisible; showers of bright, star-like bodies appear in the upper dark section; bright, floating streaks and dots in gas- light before the eyes. Bellad., pain in and around the eye, of a pressing nature, as if the eye were being pressed into the head, or sometimes as if the eye were being torn out; the eyes feel hot, dry and stiff, as if they might protrude. Bryon., the eyes feel as if pressed out, often attended with sharp shooting pains through the eyes and head; they feel sore to touch and on moving them. Cedron., severe shooting pain along the course of the supra- orbital nerve. Coloc., severe burning, aching, sticking, cutting pain in the eye and around, always relieved by firm pressure, and by walking in a warm room, worse by rest at night and upon stooping. Eserine is much used at present and in some cases seems to act well. (Norton.) Phosphor., halo around the light, and various lights and colors flashing before the eyes. Prun. spin., severe crushing pain in the eye as if pressed asun- der, or sharp shooting through the eye and corresponding side of the head. 166 OPTIC NERVE AND RETINA. Rhodod., periodic pain in and around the eye, worse before a storm and better after the storm commences. Spigel., sharp and stabbing pains through the eye and head, worse on motion and at night. Besides should be compared: Arnic., Arsen., Chamom., Coccul., Collin., Conium, Crot. tigl., Gelsem., Hamam., Kali carb. and jod., Mercur., Nux vom., Phytol., Sulphur and Val. of Zinc. OPTIC NERVE AND RETINA. The optic nerve and the retina may, each of them, be the isolated seat of morbid derangement, the first usually from some cerebral disturbance, the latter from intra-ocular disorder; but either of them, if extensively affected, will also affect the other. We speak therefore of Neuro-Retinitis as an inflammation of the optic nerve, the optic disk and the retina, a separation of which into different forms would be of little practical use. Its SUBJECTIVE SYMPTOMS are: haziness or fogginess in various degrees; reduction of acuteness of direct and indirect vision; contraction of the visual field; blind spots in the visual field; distortion of objects looked at; subjective appearances of light, so-called sparks, or flashes, or photopsia; subjective play of colors, colored spectra, or chromotopsy; the latter two may occur even when the case has proceeded to absolute blindness. Still all these symptoms may occur also in various other intra-ocular diseases and the only sure way of making a diagnosis is with the oph- thalmoscope. The OPHTHALMOSCOPIC SYMPTOMS are: optic disc swollen and outlines ill-defined, retina hazy and vessels veiled here and there; tortuous appearance of the veins which are dark and full; usu- ally hæmorrhage, most frequently observed in the retina, seldom in the disc; occasionally whitish dots scattered in groups or dull glistening patches in the semi-opaque retina. There are no ex- ternal objective symptoms, unless other ocular tissues are drawn into the morbid process. It may lead to partial or complete atrophy of the retina. Its CAUSES are: Albuminuria, and then it is called Retinitis albu- NEURO-RETINITIS. 167 minurica; hæmorrhage into the retina and white spots here and there, especially of a stellate arrangement in the macula lutea are characteristic and early symptoms of this form. Syphilis, and then it is called Retinitis syphilitica; it can be diagnosed only by the precedence or presence of some other mark of constitutional syphilis. Diabetes, and then it is called Retinitis diabetica, with similar appearance as retinitis albuminurica; Leucemia (Retinitis leucæmica); great pallor of the retinal vessels; hæmorrhages in retina(Retinitis apoplectica); deposits of pigment in retina (Retinitis pigmentosa); contraction of field of vision, night-blindness and deposits of pigment in retina extending from periphery to centre of fundus. Direct and reflected rays of artificial light or of the sun, and overstraining the eyes under imperfect or unsteady light, also traumatic injuries. There are other affections of the optic nerve and of the retina which too may cause impairment of sight or even total blindness, without showing externally any objective symptoms. Such affec- tions were, before the ophthalmoscope was known, classed under the terms Amblyopia (impaired sight) or Amaurosis (what renders obscure, dark). These terms have of late been stricken out of the books, because where there is impaired sight or loss of vision there can now, by the use of the ophthalmoscope, be found also a corresponding change in the optic nerve or retina, a pathological cause of amblyopia or amaurosis, from which the affection receives its proper name. THERAPEUTIC HINTS.-Acon., total blindness produced sud- denly by taking cold. Ammoniacum, after severe blows upon the head, sight impaired ; smoke before the eyes, shaping in different circles, most distinctly on white ground; the margins of the circles are gray and become black upon sudden motions of the eye; better in clear, worse in cloudy weather; persons in a distance he cannot recognize; by candle-light their faces appear dark. Apis, albuminuria, after scarlet fever. Arnica, after a violent blow, loss of sight. Arsen., after abuse of liquor and tobacco; urine scanty and albuminous. ; Aurum mur., after scarlet fever and during childbed (albumi- nuria); sudden loss of vision, with cold perspiration, small pulse, quick and irregular breathing. 168 OPTIC NERVE AND RETINA. Bellad., optic disc swollen and outlines ill-defined, retinal ves- sels large and tortuous, blue and bluish-gray film seems to cover fundus. (Norton.) Hæmorrhage of retina, with suppression of menses; cerebral congestion; sudden heat of head; vertigo, burning and throbbing pain; noises in ears and illusions of vision, while the rest of the body is cold and shivering; pulsation of carotids. After suppressed scarlet eruption. Bryon., eyes feel full and sore on motion or to touch. Cactus, with heart troubles. Cinchon., sudden blindness with violent pain in occiput, extend- ing into the eyes; irritability of entire spine; spleen swollen and painful to pressure; rumbling in the abdomen; sour vomiting; constipation. Crotal., hæmorrhages in retina. (Norton). Gelsem., thirst for light; after apoplexy, congestion to the head; albuminuria during pregnancy, after diphtheritis. Kali hydr., syphilitic form. Laches., hæmorrhage of retina; albuminuria. Merc. corr., albuminuric form, especially during pregnancy. Merc. sol., sensitiveness of the eyes to the glare of a fire. Nux vom., abuse of stimulants and tobacco. Phosphor., photopsies and chromotopsies, as halo around the light; dryness of the nose; after sexual excesses. Pulsat., "choked disc," great swelling of optic papillæ and en- largement of vessels; vision nearly lost, with severe headache, only relieved in the open air. (Norton). Menstrual difficulties. Secale, photophobia; suppressed secretion of tears; stitching pain in the eyes; dilated pupils; blue and fiery dots flying before the eyes. Sulphur, suppressed itch. For impaired sight (amblyopia) and blindness (amaurosis) the following remedies also have been found useful: Alum., Baryta carb., Bovista, Calc. carb., Chelid., Crotol., Cyclam., Elaps, Hepar., Ignat., Kali acet., Lycop., Natr. mur., Ruta, Santon., Sepia, Thuja, Zincum. Hemiopia, Or half vision, is a contraction of the visual field, either on the two right or on the two left sides of the eyes, in consequence of an affection of either the right or the left optic nerve tract before HEMIOPIA-HEMERALOPIA-HYPERÆSTHESIA RETINÆ. 169 the crossing at chiasm; blindness of the opposite sides of each retina, occurs when the optic nerve fibres are disturbed at the chiasma, that is at the point where the nerve fasciculi cross each other. Upper half blindness denotes an insensibility of the lower portion of the retinal nerve fibres, and is usually dependent upon a detachment of retina or embolism of branch of central retinal artery. Scotomata, or blind spots, are insensibility of certain cor- responding parts of the retina. THERAPEUTIC HINTS.-Upper half blindness: Aurum, Digit., Phosphor.; right half blindness: Cyclam., Lith. carb., Lycop.; half vision either side: Bovista, Calc. carb., Caustic., Chin. sulph., Lob. infl., Lycop., Mur. ac., Natr. mur., Sepia, Viol. od. Hemeralopia, Night-Blindness. The patient sees well enough, as long as there is enough stimu- lus of bright light; but he cannot discern objects any more, as soon as the amount of light required by him is withdrawn; be it daylight or candle-light. It is most common among sea-faring men. The glare from the sea seems to be the exciting cause added to some constitutional weakness; but it is also found occa- sionally with harvesters and soldiers, where fatigue and exposure to the glaring sunlight seem the elements in its production. THERAPEUTIC HINTS.-Cases have been cured by: Arg. nitr., Bellad., China, Hyosc., Lycop., Pulsat., Ran. bulb., Stramon., Sulphur, Veratr. Hyperæsthesia Retina. We understand by it an oversensitiveness of the optic nerve and retina; even a small amount of light cannot be borne and sometimes its impression lasts too long. This may be caused by irritation of the optic nerve and retina, with or without ciliary irritation. Ciliary irritation is usually accompanied by lachry- mation and pain in the eyeball, and associated with many affec- tions of the cornea and conjunctiva; this affection is usually spoken of as Photophobia. When the overexcitement of the optic nerve and retina does not depend on external conditions, we have, with or without intolerance to light, subjective appear- 170 LENS. ances before the eyes, such as sparks, bright white, or colored patches, flames, colored rings, chromatic clouds, so-called phos- phenes, also known under the name of Photopsia and Chromotopsy; and in some instances a too long duration of the impressions, especially from bright objects, which continue to affect the optic nerve even after the eyes have been turned to some other object, whereby confusion arises and the objects seem to dance. THERAPEUTIC HINTS.-For this affection a great number of remedies may present themselves for consideration. We shall have to weigh carefully all the symptoms of the case. Perhaps one or the other of the following may be indicated: Acon., Bellad., Cinchon., Conium, Gelsem., Hepar, Hyosc., Ignat., Lact. ac., Merc. sol., Natr. mur., Nux vom., Phosphor., Pulsat., Sulphur, Tart. em. LENS. Cataract, Is loss of transparency of a part or of the whole, either of the crystalline lens (lenticular cataract), or of the capsule (capsular cataract), or of both (capsulo-lenticular cataract). In the course of physiological development the lens commences to change after the age of about thirty-five years to greater density, more coloration and loss of convexity, and in the senile eye the pupil has lost its blackness, appears cloudy or of a light amber tint, or brownish yellow, yet without loss of transparency. This ought to be borne in mind. The cataractous changes are different. Consisting in atrophy from loss of nutrition, the lens fibres are converted into different solid and fluid materials; the nucleus becomes hard and dry, while the cortex may be soft- ening to the state of a semi-fluid pulp, with remains of opaque fibres, molecular substance and fatty tissue, especially in its hy ermature state. This is the nature of the so-called Hard cataract. The Soft cataract consists of a conversion of the lens tissue into a paste-like material, or a degeneration of it into a soft substance of a thin milk-like color with granular flocculi, corpuscles and fatty material. The former is the cataract of adults, elderly and old people; the latter is met with from birth to puberty. The cataractous changes of the capsule are probably the result CATARACT. 171 of inflammatory action; they are mostly attended by a secondary degeneration of the lens, or vice versa accompany a fluid degen- eration of the lens. In Traumatic cataract, which originates in consequence of a blow or other external injury to the eye, the capsule is nearly always opaque, and the cataract is of the soft kind; in the uncomplicated cataract of the aged, however, it is seldom altered. The OBJECTIVE SYMPTOMS of these different affections can clearly be elucidated only by the ophthalmoscope. They are im- portant to the eye-surgeon, who will consult special works thereon, but even the naked eye is capable of detecting opacities of the lens. The following are the SUBJECTIVE SYMPTOMS: As soon as the opac- ity upon either the lens or the capsule is dense enough, to interfere with the rays of light, the first symptom is indistinctness of sight or mistiness; at first distant objects are seen as if through a mist or fog, or a bit of glass that had been breathed on; after awhile this mistiness envelopes near objects also. The adjusting power is lessened, because of the lens losing its elasticity. The patient now sees better in twilight; then the pupil expands and more rays are allowed to pass through the lens. For this reason the patient shades his eyes in bright light and derives benefit from wearing goggles. In some cases there is even intolerance to bright light. In other cases the objects appear doubled or even farther multiplied, and are seen in fantastic forms. This arises when portions of the lens still remain transparent, but vary in the degree of their density, whereby an irregular astigmatism is produced. Muscæ, of all shapes and sizes, and sometimes in showers are of frequent occurrence; but flashes, stars, fiery circles, bright metallic light, bright spectra like silver must be attributed to other diseases of the eye; they have nothing to do with the cataractous affection of the lens. CAUSES." Defective nutrition," merely expresses, in other words, what cataract consists of, but does not tell the cause which in fact we know not. We can merely state, that cataract has been observed to develop after external injuries of the eye; in consequence of diabetes; after fever; in consequence of other diseases of the eyes, either active or of a low type; in consequence of hereditary influences. After one eye has been attacked, the other is likely to follow. THERAPEUTIC HINTS.-Under certain circumstances the best 172 SIGHT. and quickest relief can be afforded only by an operation, but there is no doubt that homœopathic treatment has succeeded not only in checking further development, but also in clearing up existing opacities of lens and capsule. The following are the most important remedies: Ammon. carb., (right eye); Baryta carb.; Bellad., (after acute in- flammation of the eye); Calc. carb., (scrofulous individuals); Cannab.; Caustic., (constant inclination to touch and rub the eye, which seems to relieve a pressure in it); Conium, (old persons); Euphras., after Sulphur, (congenital cataract); Lycop., (after typhus; sup- pressed menses); Magn. carb., (from left to right; previous disposi- tion to headache and furuncles); Phosphor.; Saccharum Sacchari, (in several cases of old age); Sepia; Silic., (after inflammation of the eye; preceding ringworms; suppressed sweat of feet); Sulphur, (from right to left; after cutaneous eruptions, especially suppressed itch. According to Jahr main remedy). "Dislocation of the lens often results from injury and may be spontaneous. It is most commonly dislocated backward into the vitreous, though it may lie in the anterior chamber or even under the conjunctiva. The lens may be seen in any case lying in its unnatural position. When in the vitreous, the tremulous condition of the iris will call attention to the trouble."—(Geo. S. Norton). • SIGHT. Refraction and Accommodation. A luminous body sends off rays of light in all directions, and in whatever direction they go they always move in straight lines, unless interfered with by a medium of different density. When entering a lens they are bent towards its thicker portion; a bi- convex lens converges them to a focus; a biconcave lens scatters them for the same reason. Now when parallel or even slightly divergent rays of light from an object enter the pupil, and pass through the crystalline lens of the eye, they are bent by this body towards its thicker part and are thus focussed upon the retina. In this bending and gathering of the rays of light to a focus upon the retina consists what is technically called the Refraction of light. It is a purely mechanical process conditioned by the transparency and biconvexity of the lens, which like any REFRACTION AND ACCOMMODATION. 173 other biconvex lens, focusses the parallel and divergent rays of light at a certain distance, according to the amount of its con- vexity, that is according to its refractive power. When an object is sufficiently near the eye to emit divergent rays, it is said to be at a finite distance; when, however, it is sufficiently far away to emit parallel rays of light to the eye, it is spoken of as being at an indefinite or indeterminate distance. In either case the rays are not entirely and equally parallel, and consequently the focus must vary in its distance behind the lens, either fall in front of, or behind the retina. Only if an object were brought in the exact position from which its rays could be focussed upon the retina, it could be seen distinctly. We know, however, from experience, that for a normal eye such exact position of objects as to distance, in order to see them, is not required. The healthy eye possesses a faculty by which it brings both parallel rays and rays in various degrees of divergency, to an accurate focus upon the retina; it sees clearly and distinctly at different distances, adapting itself for the position of the object looked at; and this is called its power of Accommodation or Adaptation. The nearest distance to the eye at which a small object can be seen distinctly by the maximum of accommodation, or by its greatest effort to see, is termed "the near point of vision;" the farthest distance at which anything can be clearly discerned, is "the far point of vision." These points vary in different eyes; the interval between the near and the far point is termed the range or territory of accommodation. Now the question arises, How is this accommodation of the eye to the various distances of objects effected? As the lens is only a passive agent of refraction, and as upon its form depends the distance where the transient rays are focussed, we must look for the means by which this change in the form of the lens is effected. And here all the latest researches agree in this, that the constant variations in the curvings of the lens, as accommo- dation for near and far objects requires, are brought about by the ciliary muscle of the eye. Associated with this ever-changing form of the lens by means of the ciliary muscle are also pupillary movements-contraction for near objects to cut off the lateral rays of light, and dilatation for distant objects, the sphincter pupillæ and the ciliary muscle being in a functional connection by nerve-fibres; and to this may be added the action of the recti muscles, which in accommodat- 174 SIGHT. ing for near binocular vision, turn the eyeballs inwards, while for perceiving distant objects, they place them parallel. Presbyopia, or Old Sight. The constant change in the curvings of the lens, as accommo- dation requires, can readily be effected only so long as the lens is sufficiently soft and yielding. As, however, the lens in the course of years grows denser and therefore less capable of being acted on by the ciliary muscle in the process of accommodation, and as also its shape becomes flatter and in consequence its re- fractive power reduced-the near point of vision gradually re- cedes, that is to say: If we were able all along to see an object distinctly at a distance of four or five inches, etc., because of the greater convexity to which the lens could be shaped by the cil- iary muscle for such purpose, we now have to hold the same ob- ject further off, in order to receive a distinct visual impression, showing that the lens is not capable any more of being shaped convex enough to gather the divergent rays of the near point to a focus upon the retina. The near point of vision has receded to eight, twelve or sixteen inches. Withall this, distant objects are discerned as accurately as before. This is Presbyopia—a diminu- tion of accommodation for near objects, with diminution of re- fraction, consequent on age. C This natural change in the crystalline lens commences in early life and gradually increases with advancing years. Generally about the age of forty, the near point is eight inches from the cornea, and at about forty-five years it recedes to twelve or six- teen inches. In some instances the change sets in suddenly, so that a month or even a week will make all the difference in the condition of the eye. In such cases we should bear in mind that a rapid increase of presbyopia is also a prominent symptom of glaucoma. Still later the far point for distinct vision, too, declines, and the focal range is thereby lessened. With the loss of range, there may be loss of acuteness of vision, arising from retinal ob- tuseness. Presbyopia requires convex glasses, which ought to be changed as often as the progress in the change of the crystalline lens demands it. Lenses will not afford any help to distant vision, unless there be hypermetropia combined with it. - HYPERMETROPIA-MYOPIA. 175 Hypermetropia. This affection is caused by a congenital, often hereditary mal- formation of the eyeball, which is smaller than in the emmetropic eye; its antero-posterior diameter is shorter than that of a nor- mal eye, consequently the parallel rays of light entering the pupil do not unite and form a focus on the retina, but fall behind it, and were the sclerotica removed posteriorly, they would converge to a point behind its boundary. Therefore, it is still farther im- possible for divergent rays to be properly refracted for the func- tion of sight. Only rays that have been artificially rendered convergent by a convex lens, are properly focussed upon the retina. Slight degrees of this affection are often masked by the great accommodating power of the lens during youth; an abnormally distant position of the near point, however, in young persons may be taken as a very conclusive evidence of the presence of hypermetropia; after manhood the marked removal of the near point, the loss of acuteness of vision, the very decided assistance afforded to far vision by a convex lens, and the strong glasses needed for seeing small type confirm its presence. "In hypermetropia, asthenopic symptoms, as; eyes tire easily, blurring of vision, aching in and over the eyes, etc., after using for near work, occur early and require immediate selection of the proper convex glass." (Norton). Myopia, or Short-sightedness, Is the opposite condition to hypermetropia. The antero-poste- rior diameter of the eyeball is longer than in the emmetropic or normal eye, hence distant or parallel rays of light are brought to a focus before they reach the retina and the image which is formed on the retina is blurred and indistinct. Only divergent rays, that is, rays coming from near objects, are accurately fo- cussed on the retina. While, therefore, the myopic eye can see near objects, it cannot see distant ones well without optical aid. The myopic far-point is always at a definite distance; in bad cases it may be within a few inches of the cornea; there is in such cases little difference in the distance between it and the near point. The two are in proportion to each other, the further the far-point, the further also the near-point and vice versa. 176 SIGHT. "Myopia may be produced by a spasm of the ciliary muscle and must not be confounded with an elongation of the antero- posterior axis." (Norton). The disposition to myopia is almost invariably congenital and hereditary; it is, therefore, a most uncommon occurrence for myopia to appear after the fifteenth year of age, and it is never acquired after the twentieth in eyes that are normal. Its development is favored by the tension of the eye, which is inseparably connected with looking at near objects where, by the constant and strong action of the internal recti muscles to pro- duce the necessary convergence of the optic axis for the requisite position of the corresponding portions of the retina, the eyeball gradually is drawn into a more or less oval shape, which finally may amount to the formation of a posterior staphyloma by atro- phy of the choroid and sclerotica. Myopia is, therefore, essen- tially an accompaniment of civilization, where it prevails chiefly among those classes who, from childhood on, have had to use their eyes continuously in reading and writing or other close work. In old age, when the lens grows flatter (see Presbyopia) the near-point recedes and consequently the myopic can often read again without the aid of glasses. This gain in sight is not an actual improvement of the eye; its myopic defect remains the same, but the flattening of the lens by age lengthens the focal distance which now reaches the retina. The myopic eye can be relieved by concave lenses, which ought to be selected carefully and not used too strong. Astigmatism. "The term astigmatism is used to express a state of sight re- sulting from want of symmetry in the anterior portion of the eyeballs. The rays of light do not unite by convergence and form in a regular manner in one point or focus on the retina, but reach it partially or irregularly, some of them coming to a focus in front of it, or not forming any focus, whereby circles of dispersion or diffuse images fall on the retina, and indistinctness of vision is produced." (Walton.) This irregularity in focaliz- ing the rays of light is mainly due to assymmetry of the cornea, and in some cases also to that of the lens. The patient usually holds objects close to his eyes, as a myopic; the lines of adjoining ASTIGMATISM-ASTHENOPIA. 177 letters seein to cover each other; parallel lines in different direc- tions, one set for instance being vertical and another horizontal, do not appear equally distinct but blurred; things at a distance are sometimes seen double, and a square figure will have the ap- pearance of an oblong; in high grades of astigmatism there is chromatic aberration, so that luminous objects sometimes appear surrounded by variously colored borders. Astigmatism may be combined with myopia or hypermetropia. It is often hereditary or may be caused by the removal of the pupil from its central position either from accident, disease or in consequence of an operation; by the slightly irregular manner in which the cor- neal flap may heal after an operation for the extraction of cata- ract; by the irregularity in the corneal curves produced by in- flammation of the cornea; by the dislocation of the crystalline lens from accident or disease. Its remedies are carefully selected cylindrical glasses, and in case of inflammatory diseases of the cornea or traumatical causes, carefully selected medicines. Compare Corneitis, etc. Asthenopia. "This may be defined to be inability to maintain the adjust- ment of the eye for short distances, for a sufficient period without fatigue." (Walton). The asthenopic eye gets tired when em- ployed any length of time in reading, writing or other close work, especially by insufficient or artificial light; the ciliary muscle, which is the muscle of accommodation, cannot stand the strain required by the smallness of the objects and the close approxi- mation of the eyes to them; it relaxes and the crystalline lens flattens, whereby the focus from the objects is changed and the objects become indistinct and blurred. A little rest relieves it all; the ciliary muscle is ready again for shaping the lens to the necessary convexity—but soon gives out again. At last a pressure and fulness is felt in the eyes and a tension and pain in the forehead; sometimes the pupils become contracted and the con- junctiva reddened. The cause of all this is want of sufficient refraction in the eyeball, which is principally found in a hyper- metropic formation of the eye, and therefore there is a close relationship between the two affections; in pure forms of astheno- pia, according to Walton, hypermetropia is never absent. This form is called Accommodative asthenopia. Asthenopic symptoms + 12 178 SIGHT. will also occur when the ciliary muscle, in consequence of illness or exhaustive diseases, becomes paretic, or when the internal recti muscles, from relative or absolute deficiency of power, can- not maintain the proper convergence of the eyes for near sight; this is called Muscular asthenopia. The accommodative form depends chiefly on the degree of the existing hypermetropia; it may develop itself at the early age of ten. The muscular form depends more on general conditions of the system, and as excit- ing causes may therefore be mentioned for the first: long-con- tinued application of the eyes to close work, especially by insuffi- cient light; and for the second: general debility; mental troubles; dissipation, etc. THERAPEUTIC HINTS.-The accommodative form requires con- vex glasses for the relief of the existing hypermetropia; the muscular form also needs correction of the usually existing ano- maly of refraction by suitable glasses. A study of the general state of the debilitated system will be required for the selection of the corresponding remedy. Acon., eyes hot and dry from overuse; relieved temporarily by cold water. Apis, stinging pain and lachrymation. Arg. nitr., blepharitis; hypermetropia and weakness of the cili- ary muscle. Calc. carb., fatigue and pain from using the eyes; on looking at near objects they become indistinct and blurred; general Calcarea symptoms. China, debility after exhausting sickness. Cina, spasmodic twitchings of the orbicular muscle; twitchings in the muscles of the face; from intestinal irritation by worms or otherwise; after masturbation. Cinnab., pain from inner canthus, extending above and around the eye. Conium, cannot bear bright light or heat. Euphras., blurring of vision relieved by winking. Gelsem., especially in the muscular form from weakness of the external rectus. Ignat., nervous, hysterical females; onanism. Jabor., asthenopic symptoms, especially dependent upon an irritable condition of the ciliary muscle. (Norton). Lilium, pain in forehead; photophobia; blepharitis; astigmatism. MYDRIASIS. 179 Natr. mur., stiff and drawing sensation in the muscles upon moving the eyes; the eyes smart, itch and burn; feel best on being kept shut and pressed upon; muscular form. Nux vom., after dissipations. Phosphor., dull pain deep in the eyes; black spots before the eyes, especially when looking at bright objects and by artificial light; better in twilight. Rhodod., weakness of internal recti; darting pains through head and eyes, worse before a storm. Rhus tox., after great strain of the eyes; muscular form. Ruta, aching in and over the eyes after straining the eyes at fine work; heat in the eyes and lachrymation after close work; accommodative form. MUSCLES ANd nerves. Mydriasis. This is a dilatation of the pupils. The iris is chiefly composed of non-striated muscular fibres, arranged in a circular and in a radiating direction. The circular fibres are supplied by the third nerve, and act as a sphincter pupillæ, while the radiating fibres are supplied by the sympathetic nerve, and increase the aperture when stimulated to contract. Mydriasis may therefore be caused either by a paralysis of the third nerve or by stimulation of the sympathetic. One of the differences between the two is, that with the paralysis of the third nerve there almost always is asso- ciated a paralysis of the ciliary muscle, which more or less de- stroys the power of accommodation. Its exciting CAUSES may be either peripheral, from exposure to cold winds, blows, etc., or cerebral, in consequence of effusion into the ventricles of the brain, concussion of the brain, basilar meningitis, diseases of the cerebellum, apoplectic effusions at the base of the brain, glaucoma and certain narcotics. Myosis "Is a persistent regular contraction of the pupil below its medium size, with immobility and without change of structure in the iris or in the eye." (Walton). It is caused either by a paralysis of the sympathetic nerve or by an irritation of the third. In the 180 MUSCLES AND NERVES. : first case there probably are diseases of the neck, or in the spinal cord, which involve the cervical sympathetic, at the bottom of the trouble; in the latter case the cause lies in morbid conditions of the brain, which irritate the third nerve. Special THERAPEUTIC HINTS cannot be given. Mydriasis, as well as myosis, are mere symptoms of other more deeply seated disorders, which must be studied accordingly. Our repertories show a number of remedies for both of these symptoms. Ptosis, or Falling of the Upper Eyelid. This affection may be due: 1st, to a paralysis of the levator pal- pebræ muscle, which is under the control of the third cerebral nerve; 2d, to a loss of muscular power in the levator, consequent on age; 3d, to a falling of the eyebrow, in consequence of paraly- sis of the occipito-frontalis muscle; 4th, to a congenital deficiency of the levator palpebræ; 5th, to a hypertrophy of the palpebral integument; or, 6th, to chronic ophthalmia with granular eyelid. THERAPEUTIC HINTS.—The most frequently indicated remedies are: Caustic., Gelsem., Hyosc., Nux vom., Plumbum, Rhus tox., Sepia and Zincum. A congenital deficiency of the levator palpebræ cannot be reached by any medicine. For granular eyelid, compare the corresponding chapter. Strabismus, or Squint. 'Strabismus is a deviation of the visual axes. The axis of the one eye being directed to the object desired to be seen, while that of the other is turned too much inwards, (internal squint) or out- wards (external squint)." (Walton.) Internal squint is the most frequent of the two. It may arise from more or less paralysis of the external rectus, generally of the one eye, exceptionally of the two; or from some functional change, some shortening, at first dynamically, afterwards at a varying period, organic shortening, with or without hypertrophy of the internal rectus; from lesion of the brain or of the ocular nerves in cases of inflammation, softening, apoplexy, hydrocephalus, scrofulous tubercles, epilepsy; from intestinal irritation by worms; during teething; from visual defects, in consequence of inflam- mation within the eye or of the cornea; from diseases which (( - * STRABISMUS-NYSTAGMUS. 181 damage the function of the external rectus, such as tumors, trau- matic or specific inflammations, abscesses, neuralgia. Its most frequent cause is hypermetropia. The External or Divergent squint seldom appears before puberty, except in connection with a diseased brain. It mostly arises from some form of impairment of vision affecting either one or both eyes, or from a difference in the refraction of the two eyes, or some disparity between them in the function of sight, all of which is commonly associated with myopia. Its direct cause in most cases is paralysis of the motor oculi nerve. The external rectus muscle is influenced in the same way by effusion in the orbit, tumors and all mechanical lesions of its muscles, and by cerebral disorders like the internal muscle in inward squint. THERAPEUTIC HINTS.-Cerebral irritation with corresponding symptoms require: Agar., Bellad., Cicuta, Gelsem., Hyosc., Nux vom., Stramon., Sulphur. Alum., recommended by Jahr if Bellad. and Hyosc. have failed. Cicuta, after convulsions. Calc. carb., after ophthalmia, or overstrain by close work; stru- mous subjects. Cyclam., after unsuccessful operation; after convulsions, or measles. Intestinal irritation from worms or other causes require: Cina, picking of nose; restless sleep; grating of teeth; short hacking cough through the night. Cyclam., see above. Sepia, nocturnal enuresis during first sleep. Spigel., itching at the anus. Sulphur, nightly itching of the skin; cutaneous eruption; con- stipation. Suitable glasses may be of great help. Surgical operation is required where there is an organic short- ening of the internal or external rectus; paralytic squint is least benefited by it, and in mere nervous disturbance it is not called for at all. Nystagmus, Trembling of the Eyeballs. It is an involuntary, rhythmical motion of the eyeball, mostly from side to side, sometimes in an oblique direction, without im- • } 182 MUSCLES AND NERVES. pairment of the muscular movements. These oscillatory motions are nearly always permanent during the waking hours, but do not interfere with the simultaneous action of the two eyes; some- times they are associated with internal squint. The disease nearly always arises in infancy, and is frequently seen in connec- tion with congenital cataract, or other states of the eye which impair sight. It is common to the Albinos, when there is an absence of the pigmentum nigrum. Although ascribed to a morbid condition of innervation, its true nature is unknown. Luscitas, or Fixed State of the Eyeball, Is limited or lost power of movement of the eyeball, which re- mains in a fixed position either with or without deviation from the orbital axis, and cannot in any degree follow the movements of the other eye. Luscitas is a symptom either of paralysis of the third nerve, when the eyeball is turned outward by the abductor muscle, or of paralysis of the abductor, when the eyeball is turned inside—all consequences of brain-disease, chronic hydrocephalus especially. But external causes, such as injuries to the muscles of the orbit or to their nerves, tumors, staphylomatous enlarge- ments of the sclerotica, may also fix the eyeball in any direction. Morbid Winking Is a clonic spasm of the orbicularis palpebrarum muscle, and fre- quently found in connection with severe conjunctival irritation; sometimes it is of constitutional origin. Twitching of the Eyelids, or Quivering, Nearly related to the above, may effect one lid or both. It some- times is so slight that it cannot be seen, but may plainly be felt; although annoying, it seldom is attended with pain, and is usually the consequence of deranged digestion or feebleness from overwork. Blepharospasm. The eyelids are violently and persistently closed. It is nearly always associated with intolerance of light and discharge of tears. NEURALGIA OF THE EYE. 183 Its sources are various. They may arise in the eye itself, or in other organs, and transmit their influence to the brain at the origin of the portio dura, through the fifth nerve, the optic the vagus, the sympathetic, or directly from cerebral disturbance, Thus we see it produced by trichiasis, strumous conjunctivitis, corneitis, retinitis; carious teeth, supra-orbital neuralgia; a blow on the head or other injury; hysterical irritation. It may affect one or both eyes, it may last a long time uninterruptedly or in spells; it may be associated with spasm of the facial muscles. THERAPEUTIC HINTS.-Nystagmus-Hyosc.? Morbid winking has been relieved by Agar. and Ignat. Twitching by Cina, Physost. Blepharospasm by Bellad., Viola tric., Symphitum (after a blow), and other remedies, which must be selected according to the individual state of the patient. Compare the chapters which treat of its sources. ļ Neuralgia of the Eye. It is usually an affection of the ophthalmic and superior maxil- lary division of the fifth cranial nerve, which supply the eyeball the ocular appendages, and the circum-orbital region. One or the other of the branches of these nerve-trunks may be affected. Most frequently we find it located in the upper eyelid, the middle of the eyebrow, the nasal extremity of the superciliary arch, the inner canthus or the temple; or it follows in the direction of the supra and infra-orbital nerves; or it is entirely intra-ocular without any affection of the nerves radiating from the orbit. The first of these varieties is often intermittent or remittent and may become chronic; it may alternate with nervous pains in other parts of the body. The CAUSES are frequently obscure, often however traceable to malarial influences or exposure to cold. The second variety may arise out of the effects of the fangs of carious upper back teeth. When the pains are deep-seated, its origin is intra-orbital or even intra-cranial and may arise from thickening of the dura mater, orbital or cranial exostoses, aneu- risms or tumors. THERAPEUTIC HINTS.-These different forms and causes show that not a few remedies may present themselves for our considera- 184 ORBIT. tion. However, to avoid repetition, I refer to the chapter on neuralgia of the face. ORBIT. Orbital Cellulitis. "Inflammation of the orbit is usually severe and acute in character; is marked by great swelling of the lids, extensive chemosis, protrusion of the eyeball and intense pain in and around the eye, aggravated on any movement of the eye. Move- ments of the eyeball are impaired. Pus soon forms, when we have an abscess in orbit, which may perforate through lids or conjunctiva. The inflammation may extend to the eyeball, pro- ducing a panophthalmitis, or to the brain, or may cause caries of orbit, etc. General febrile disturbances usually accompany the above local inflammation. Trauma is the most frequent cause. It may result from extension of inflammation in neighboring parts or from constitutional diseases. THERAPEUTIC HINTS.-Acon., Apis, Hepar, Laches., Mercur. and Silic. may be indicated, but Rhus tox. is most frequently indicated." (Geo. S. Norton). Basedow's or Graves' Disease; Exophthalmic Goitre, Is characterized by palpitation with accelerated pulse, swelling of the thyroid gland, and exophthalmus or protrusion of the eye- balls. In its nature it has been considered by some as a morbid crasis, by others as a heart disease and by still others as a neuro- sis of either the cervical sympathetic or the cervical medulla spi- nalis and medulla oblongata. I feel, therefore, at liberty to treat of it here as anywhere else. Autopsies have shown a considerable development of fat be- hind the eyeballs, which causes their protrusion; also at times fatty degeneration of the eye-muscles, probably caused by disease and stretching; and atheromatous changes of the ophthalmic artery. Changes in the sympathetic and its ganglia have not at all been of a uniform nature, and in some cases have been want- ing altogether. SYMPTOMS.-Usually this disease develops itself very slowly, BASEDOW'S OR GRAVES' DISEASE. 185 though some few cases of sudden origin have also been observed. Its first symptom. in a majority of cases is palpitation conjoined with acceleration of the pulse, without any abnormal symptoms of the heart on physical examination; occasionally there are epigastric pulsation, increased force of the pulse in the carotids and their larger branches, especially the thyroids, and a whir- ring and blowing that may be heard by auscultation before the struma is developed, pulsation of the retina and in rare cases pulsation of the liver. Some weeks or months later, slowly or rapidly, struma is developed, a soft, elastic swelling of the entire thyroid gland, which, however, does not attain to a very great size and is moreover subject to frequent changes. The surface of the tumor is often marked by veins, greatly dilated and crowded with blood, and auscultation reveals loud blowing sounds, often increased during systole. Struma seldom appears before palpita- tion and still more rarely is it wholly absent. Exophthalmus, the third prominent symptom, makes its appearance soon after the struma—in a few cases before it and still more rarely as the initial symptom, preceding the struma and the palpitations. It always attacks both eyes, but sometimes appears on the one eye earlier, or remains at least more prominent than on the other. It seldom is wholly wanting, while in other cases it forms the only cardinal symptom, when it is associated with other kinds of general disturbances. In degree it varies greatly, from a slight prominence of the eyeballs to an excessive protrusion of the same, that no part of the globe is covered by the eyelids and even may amount to a luxation of the globe. The eyes protrude; the eyeballs have an unusual lustre, appear stiff and gradu- ally lose their mobility in part or wholly. But this pro- trusion is not at all times the same, it increases and decreases proportionately to the force of the pulsations of the heart, and sometimes may be diminished by light pressure upon the eyeball. Von Graefe has observed, that "the upper lid loses its power to move in harmony with the eyeball in the act of looking up or down," and he considers it a pathognomonic sign of exophthalmus, which how- ever others do not admit, as its occurrence, although frequent, is not constant. As a secondary group of symptoms in some cases may be mentioned: dryness of the conjunctival sac, distention of the conjunctival veins, and conjunctivitis; the lachrymal secre- tion is often increased. In bad cases: insensibility, diffuse desic- cation or even perforation of the cornea. Ophthalmoscopic ex- - 186 ORBIT. amination usually shows dilatation and increased tortuosity of the retinal veins, and in some cases spontaneous pulsation of the retina. The temperature of the body has been found increased to 101.8° F. in some cases, while in others it remained entirely normal. Also nervous disturbances have been observed, but they are so varied and so little characteristic, that they may be omitted without injury to the diagnosis of this malady. Its du- ration is protracted; months and years may pass with alternate improvement and relapse; some cases get well; others hasten to a fatal issue by the consecutive changes of the heart, the perma- nent increased labor of which leads to dilatation of both ventricles and compensating hypertrophy. In other cases marasmus and other intercurring diseases or complications may end the scene. Women are more subject to it than men; in childhood it is rare, it occurs mostly during the time of puberty and climacteric years, seldom later. As predisposing CAUSES have been men- tioned: chlorosis, anæmia, and neurotic tendencies; as exciting causes have been found: injuries, traumatic or otherwise, and mental excitement, violent fright. THERAPEUTIC HINTS.-As this affection is not poor in symp- toms and mostly of long standing, by a careful examination we will be able to detect leading symptoms for one or another remedy, even not mentioned below. Amyl nitr., frequent flushes of face and head; oppression of chest; tumultuous palpitation. (Olfaction.) Badiaga. (Norton.) Bellad., has cured cases in allopathic hands, although the doses applied were certainly too massive, as they produced headache, nosebleed and angina. Calc. carb., in combination with a diet of nitrogenous substances relieved greatly in a case of pronounced lymphatic constitution. Ferrum, in cases with disturbances in the sexual sphere, scanty or suppressed menses and great nervousness. Lycopus, has relieved the protrusion of the eyes and the cya- nosis, but had no effect upon the glandular enlargement, which yielded to Iodine. Natr. mur., depressed vegetative vitality; despairing, hopeless feeling about the future; dryness of the mouth; sore tongue; map tongue; chronic constipation with hard stool; chlorotic symptoms, with dirty, flaccid, torpid skin; fluttering of the heart; intermitting and irregular pulse. BASEDOW'S OR GRAVES' DISEASE. 187 Secale has been successfully used by the old school. Spongia, easily frightened, especially at night, as if suffocating. It appears from this, that the most efficient remedies used thus far were such which are capable of acting especially upon the heart and the thyroid gland; under certain circumstances, there- fore, Baryta carb., Bromium, Cact. grand., Phosphor., Silic. and Sulphur may likewise be indicated. : EARS. • Analogy between the Ear and the Eye. At first sight, these organs appear so entirely unlike each other, that it would seem scarcely possible to discover any analogy be- tween them; yet on closer inspection, the similarity between the two is quite striking. As I consider this similarity in the structure of the eye and ear of great importance in clearing up the rather occult affections of the ear (the treatment of which is often very difficult), I shall point out, with some detail, the following remarkable features of similarity between the organ of sight and the organ of hearing. The pinna corresponds to the upper and the tragus to the lower eyelid. In animals the auricle is even movable, to collect or re- ject sounds, as the eyelids are to take in or to keep out the light. The eyelashes are represented by the bristly hairs at the mouth of the meatus externus; to keep out dust and insects. The meatus externus is lined by a semi-mucous membrane, secreting earwax, corresponding to the conjunctiva of the eye, which secrets eye-butter; both are subject to similar inflamma- tions and mucous or purulent discharges. The membrana tympani, corresponds not only in function, but also most strikingly in structure, with the cornea. It collects sounds, while the cornea collects light; and it is, at least, of a half-transparent texture. The diseases to which it is liable cor- respond with those of the cornea: inflammation, thickening, ulceration and perforation. Immediately back of this membrane, in the middle ear or tym- panum, we find the ossicula auris, by which sound is broken and communicated to the auditory nerve, in the labyrinth, just as light, by means of the crystalline lens, is refracted upon the optic GENERAL OBSERVATIONS ON THE EAR. 189 nerve. The middle ear or tympanum, with its ossicula, corre- sponds, therefore, precisely to the anterior and posterior chamber of the eye with the lens. Still further back we come into the labyrinth of the ear, which is filled, in its membranous portion, with a limpid fluid, first well described by Scarpa, and which corresponds to the vitreous humor of the eye; while the numerous filaments of the two branches of the auditory nerve, the vestibular and cochlear nerves, spread out into a nervous membrane, closely resembling that of the retina, so that the labyrinth of the ear corresponds to the posterior part of the eye with its vitreous humor and its retina. The nerve-membrane of the ear terminates in fine fibrils or ciliæ (Corti's mechanism), and the retina in a layer of rods and cones. There is one appendix to the ear—the Eustachian tube—which starts at the tympanum, and opens into the lateral wall of the throat, and there is also one appendix to the eye-the lachrymal duct-which starts at the inner canthus of the eye and opens into the nose; while lastly both organs are situated in close proximity to porous bones: the ear on the mastoid portion of the temporal bone, and the eyes below the frontal sinuses of the frontal bone. · This striking similarity in the structures of the ear and eye at once brings the diseases of the ear (by comparing them with those of the eye) nearer to our comprehension, and may even influence the choice of a remedy in a given case. General Observations on the Ear. The auricles grow pale from fright, chills, spasms, loss of vital fluids, exhaustion and frost. A marked paleness of the left auricle denotes inflammation of the spleen. Redness of the auricles is found in congestive and inflammatory conditions of the head and ears. Flushes are caused by mental emotions; or occur before bleed- ing of the nose, delirium, apoplexy. An habitual or frequently-occurring redness of the auricles denotes disturbed actions in the abdominal organs; or else menstrual and hæmorrhoidal affections. Hyperæmia of the auricle, and sometimes of the middle ear, is often associated with the climac- teric period. A striking redness of the auricles in new-born children is a sign of premature birth. 190 AURICLE. Small, inflammatory, purplish, suppurating spots on the auricles are a sign of chronic syphilis. A slight inflammatory, painful redness of the upper part of the auricle is often the forerunner of an attack of gout. Swollen auricles, if inflammatory, are caused by erysipelas, in- juries, eruptions; if habitual, not inflammatory, it is a sign of scrofulous conditions; if œdematous, a consequence of abscesses or Bright's disease. The auricles are: Hot, in inflammatory and congestive conditions of the head and ears, also in consequence of great exertion of the voice, and in diseases of the larynx. Cold, in chills, spasms, and from exhaustion. Auricles habitually cold are found in weak and chlorotic individuals. In hysteric persons, cold auricles are the forerunners of a hysterical spasm; while in delirium and mania they denote a cessation of the paroxysm. Discharges from the ears may originate either in the meatus auditorius externus, in the middle ears, (the tympanum), or in the cavity of the skull. They are of various characters. If, after a fall or external injury of the head, there be a discharge of blood, it denotes a fracture of the skull. The ears bleed also in scorbutic affections; from too great a pressure, or from insuffi- cient pressure of the atmospheric air, (cannon-shot; on high mountains;) from too great exertions in screaming, coughing, vomiting, straining, blowing musical instruments. Pus or ichorous matter is the product of a previous inflamma- tion, either in the meatus auditorius or in the middle ear. In rare cases the pus comes from an abscess in the brain, which has broken through the petrous portion of the temporal bone. Thin earwax is, in most cases, the consequence of a chronic in- flammatory state of the meatus auditorius externus. THE AURICLE. Eczema. Various kinds of eruptions may befall the auricle, either spread- ing to it from adjacent parts or originating there. From among them eczema is the most common, differing in no way from its kind on other parts of the body. We meet it in its acute as well as in its chronic form, and very often associated with similar EXAMINATION OF AUDITORY CANAL. 191 • ? eruptions on the scalp, or face or other parts of the body. It may affect the entire lobe, or select only certain portions of it; the sharp crevice behind the ear, where the auricle joins the mastoid process, is frequently its favorite seat. THERAPEUTIC HINTS.-Baryt. carb., Calc. carb., Graphit., Hepar, Lycop., Merc. sol., Nitr. ac., Oleand., Petrol., Rhus tox., Sulphur, are the main remedies. For particulars compare Eczema of the Scalp. By their position the auricles are naturally exposed to various external injuries, from blows, cuts, heat or cold, and they also are not unfrequently the seat of depositions of urate of soda in ar- thritic patients. Their lower lobe is often disfigured by hyper- trophy or little, round, hard tumors in consequence of previous piercing. THE AUDITORY CANAL AND THE DRUMHEAD, OR MEMBRANA TYMPANI. Examination of these Parts. The canal is not straight but curved on its anterior and lower wall and often obstructed by hair growing from its cartilaginous walls. The drumhead is placed obliquely across the canal at its furthest extremity which it shuts off from the middle ear. In consequence of the crooked structure a simple look into the ear does not give us a full view of its walls nor of the drumhead. We have to straighten its curved course and push aside obstruct- ing hair or other impediments, as far as possible. This can best be done by an ear-speculum, which consists of a simple funnel- shaped tube, made of polished metal. There are usually three of different diameters fitted together, for the purpose of giving choice to select that which best corresponds to the dimensions of the canal under examination. Its application is the following. Draw the auricle upwards and backwards, and insert the tube by gentle turning and twisting into the meatus as far as it can be done without using force or causing pain. Keep it then in its position and illuminate through it the parts to be examined. The best light is clear daylight or lamplight; the direct rays of the sun may be too dazzling. In order to prevent the inter- vention of the head of the observer with the rays of light an ordi- nary laryngoscopic mirror or reflector fixed upon the forehead of he observer, or one of shorter focus made for the purpose of aural C 氤 ​· AUDITORY CANAL AND DRUMHEAD. • 192 requirements, or, for preliminary examination, even a common hand-looking-glass can so be held as to reflect the rays of light into the tube, that by a little management and turning of the ear-speculum we are enabled to inspect already the drumhead and the walls of the external canal in all their parts. The membrana tympani, or drumhead, is a thin, semi-transpa- rent, parchment-like membrane, spread obliquely across the ex- ternal auditory canal at its farthest extremity. In its normal state its surface, as seen through the ear-speculum, appears con- cave. Its shape is that of an irregular oval disc, the long axis of which is directed from above downwards; it is attached to a well- marked bony groove upon an elevated ridge upon the bony canal -the Annulus tympanicus, being fixed to it by a cartilagenous ring —the Annulus cartilaginus, just as is the crystal of a watch to its bezel. It is composed of "three distinct structures, the external layer being a prolongation of the skin of the meatus externus, the internal being derived from the mucous membrane of the middle ear, while between these two comes the fibrous layer, and which is itself composed of two distinct layers, the one external, the fibres of which radiate; the other internal, the fibres of which take a circular course." "When we look at the healthy membrane, we may observe at its uppermost edge a whitish prominent part, the short process of the malleolus, and extending from this downwards and back- wards nearly to the centre of the membrane; we see a whitish or pale yellow stripe, and which is the malleus handle, widening out at its lower end into the form of a spatula. In front of and below the manubrium we see a triangular reflection, the cone of light, its apex being at the umbo, or deepest point of the convex- ity of the membrane, its base forwards and downwards towards and slightly short of the periphery; and then we may, on look- ing closely, sometimes see shining through the membrane the promontory of the middle ear, and the long process of the incus.” (Cooper). The color of the membrane is a peculiar gray of different shades, conditioned by its transparent nature, by the bodies which lie behind it and the light which strikes upon it. If the mucous membrane which lines its internal surface, or that of the entire middle ear is congested, we find the natural gray mixed with a faint or deep red; or with a yellowish tint when the - EARWAX. 193 · middle ear is filled with yellowish secretion. Indeed pathologi- cal changes have a marked influence upon the color of the mem- brane. So also is the natural soft gloss of the membrane greatly altered or even extinguished by pathological processes. The brightest reflection from the healthy membrane is the "cone of light,” a triangular reflex of light in the anterior and inferior quarter of the membrane, which has its apex in the umbo and its base near along the periphery of the membrane; it is analo- gous to the reflex of light of the cornea. Its locality and bright- ness too changes from various pathological conditions. The External auditory canal is lined by a continuation of the ex- ternal skin, which grows thinner as it approaches the drumhead, but is not changed to a mucous membrane. It is studded by nu- merous sebaceous and ceruminous glands from which the earwax is derived. Earwax Diminished or Increased. The lining of the auditory canal being a continuation of the external skin, great dryness of the same is usually found in per- sons whose skin in general is of a dry nature. It seldom has anything to do with nervous hardness of hearing. It may, how- ever, be in connection with turbid processes within the middle ear, especially the drying up and hardening process of its mu- cous membrane. An increase of earwax may be caused by frequent picking and boring with hard instruments in the ear, whereby a congested state of its lining membrane is induced; we find it in persons whose scalp produces much sebaceous secretion and who are in- clined to sweat easily about the head; it is sometimes connected with a chronic eczema of the canal. Its accumulation usually goes on slowly and the forming of hard plugs of cerumen takes frequently a long time, the patient being not at all aware of their formation, until a gradually increasing deafness reminds him of something wrong in his ears. In other cases indurated earwax causes quite annoying symptoms. Besides hardness of hearing, amounting sometimes to deafness, there is great itchiness of the meatus, or a feeling of fulness and heaviness in the head, or there are spells of pain deep in the ear, and in some cases even serious attacks of vertigo. These attacks of vertigo in conse- quence of hardened earwax are caused by its pressure upon the 13 194 AUDITORY CANAL AND DRUMHEAD. drumhead, which is propagated by the chain of the ossicula to the fluid of the labyrinth. It is a symptom also of other affec- tions of the labyrinth. The hardened plugs of cerumen consist either of an amorphous, dark brown-red mass, principally made up from the secretion of the sebaceous and ceruminous glands, or they are strongly mixed with scales of the epidermis and in old persons with hair; some old plugs, which shine like mother-of-pearl, are mixed with choles- terin; and in still others we find an admixture of cotton, seeds, dirt and other substances from the surrounding atmosphere. There are, however, cases where the hardened masses which ob- struct the auditory canal have originated in the middle ear, and consist of dried pus mixed with blood, in consequence of catarrh of the middle ear and perforation of the drumhead; in still other cases the plugging up material consists of accumulated masses of fungi or the formation of polypi. All this must be borne in mind. Deafness from hardened plugs of cerumen will certainly be cured by the removal of this obstruction, while in complications with affections of the middle ear this is, by far, not so certain. Here the tuning fork will give us the best in- struction. When deafness is caused by mere obstruction of the external meatus, the tuning fork vibrating on the vertex is heard better in the obstructed ear, contrary to the patient's expectation. When, however, we find that it sounds louder in the ear which is not affected or is heard, at least, no better in the obstructed ear, we may assume that there is some complication in the inner ear, and need not expect a full return of hearing after the re- moval of the obstruction. THERAPEUTIC HINTS.—Plugs of hardened earwax must be re- moved and to do this there is nothing so expedient and harmless as injections of luke-warm water, by a suitable ear-syringe. It is not necessary to do it forcibly and if, as in some cases, the plug is very hard, and adheres very tightly to the walls of the canal, it is better to take for its accomplishment two or three sittings and in the meantime have the hardened substances softened by occasional application of warm water, than to try to force it in one sitting. "Carbonate of soda added to the warm water hastens the removal of cerumen." (Houghton.) Often the hearing may be worse and a feeling of fulness come on after the first sitting, in consequence of the swelling of the hardened mass, and the en- FURUNCLES OF THE EXTERNAL CANAL. 195 • tire closing up of the canal. The patient ought to be advised of this possible seeming aggravation. After the earwax is removed it will always be advisable to put some cotton or wool into the ear in order to protect the drumhead from shrill sounds and cold. But why does the earwax accumulate and harden in some persons, and not in others? There surely must be some consti- tutional reason for it, which we must try to mend, otherwise the same process will go on again. The following remedies must be considered: Carb. veg., "has served me well in malsecretion of cerumen with exfoliation of dermoid layer of meatus." (Houghton.) Discharge of flesh-colored, offensive moisture from right ear; deficient or badly-smelling cerumen. Conium, accumulation of earwax, looking like decayed paper (scales of epidermis) mixed with pus or mucus, or blood-red; hardness of hearing ceasing when the wax is removed and re- turning with the wax. Graphit., in young persons with habitual herpetic eruptions in the meatus; or meatus dry and scabby. Laches., want of wax; ears very dry. Mur. ac., accumulation of wax which is dry and hard, and of a brown-red color, with hardness of hearing. Petrol., large quantities of thick or thin wax; sensation of rush- ing of water in the ear; old aged persons. Furuncles of the External Canal. They correspond entirely to boils on any other part of the body. Starting at first as an inflammation of a hair-follicle or of a glandular follicle, by spreading, the surrounding subcutaneous connective tissue is drawn in the same process and a limited ab- scess is formed. In the auditory canal their size is naturally still more limited; they may, however, for a time completely close the canal, until they break and discharge the core. They are quite painful and sometimes we find several together or fol- lowing each other. They correspond to styes on the eyelids. As a diagnostic sign from abscesses, Cooper states, that when they discharge, the pillow case in the morning will be studded over with stains so closely resembling small sized buttons, as to de- ceive the most clear-sighted at a distance. THERAPEUTIC HINTS.-Hepar, Merc. sol., Pulsat., Sulphur. 196 AUDITORY CANAL AND DRUMHEAD. 66 Picric ac. is as near a specific for small furuncles in any part of the body as any remedy can be. In the meatus externus it aborts the furuncle if seen early and mitigates, if advanced, as well as corrects the habit." (Houghton.) "Furuncles in exter- nal auditory canal dependent upon mental overwork." (Geo. S. Norton). Otitis Externa, or Diffuse Inflammation of the Auditory Canal. In its Acute form it commences frequently with itching, heat and a sensation of dryness in the ear, which gradually changes to a dull pain or a boring and tearing deep in the ear, and being generally worse in the night, deprives of sleep and causes fever- ish restlessness. In severe cases the pain may extend all around the ear and to the corresponding side of the head. A jar from sneezing or coughing, or the motion of chewing or gaping make it worse. The hearing grows duller in the degree in which the outer lining of the drumhead becomes involved. On inspection we find it congested and swollen and also the lining of the canal; gradually exudation ensues, which at first is watery but finally becomes yellowish and purulent. With the establishment of otorrhoea the pain decreases, the epidermis loosens and the canal fills up with the products of desquamation. This state of things may gradually wear off and heal, or it may become chronic; the otorrhoea may continue for years. Usually Chronic otitis externa takes its origin in an acute attack as described above; but there are cases where such acute and painful out- breaks are not remembered; very often the commencement dates back to infant life. Sometimes the otorrhoea ceases for a time, especially during summer, but comes back again with damp and cold weather or from any other exciting cause. This form is often characterized by the presence of fungi. Chronic otitis may lead to ulceration, deep opacity and extensive thickening of the drumhead, to narrowing of the external canal by hyperostosis, to polypous growths within the canal, or to an extension of the in- flammatory process to the middle ear or the neighboring dip- loëtic bony structures, or even to the dura mater and brain. Deafness of various degrees is a usual concomitant. The CAUSES of external otitis are various. Acute and chronic exanthemata; eczematous eruptions; pemphigus; irritating sub- EXAMINATION OF THE MIDDLE EAR. 197 stances; fungi of the aspergillus kind; exposure to cold draughts. Most liable to its attacks are children. The PROGNOSIS of an acute attack may be called favorable; the chronic form is mostly difficult to manage. THERAPEUTIC HINTS.-As soon as otorrhoea has commenced, great care should be taken to keep the ear clean. Occasional in- jections of luke-warm water, administered carefully, are of great benefit. "Aurists are now beginning to advise dry applications, avoiding warm water, except in acute troubles." (Houghton.) As regards the remedies, compare Otitis Media. THE MIDDLE EAR. The cavitas tympani is bounded exteriorly by the drumhead; interiorly by the wall of the labyrinth; its roof divides it from the brain; under its floor, which is very irregular in shape and greatly varying in thickness and compactness in different per- sons, even sometimes in the two ears of one and the same per- son, lies the vena jugularis interna; on its posterior wall we find the inlet to the antrum mastoideum, and on its anterior wall, nearer to the roof than the floor, just opposite to the antrum mas- toideum, is the mouth of the Eustachian tube. The entire cavity is lined by a mucous membrane, which is smooth, whitish, very thin and tender. It does the service of the periosteum, as it contains the vessels which nourish the bony structure underneath. The antrum mastoideum and the numerous air-containing cells of the mastoid process are a kind of air-reservoir and reso- nator, a very important appendix to the middle ear, as by it the sonorous vibrations are more or less controlled. The Eustachian tube on the other hand is the draining canal for the secretions of the middle ear, and also its ventilation tube. For its outlet, which in grown persons resemble the mouth-piece of a trumpet, opens into the naso-pharyngeal cavity, where it is constantly ex- posed to the stream of atmospheric air during respiration, by which communication the air in the middle ear is kept in the nearest possible equal tension with that of the atmosphere. Examination of the Middle Ear. 1. By means of the Ear Speculum.-We can ascertain by its appli- cation the color and condition of the drumhead. When it is of 198 THE MIDDLE EAR. a reddish tinge, there is inflammation of its inner lining, in con- sequence of catarrh of the middle ear; when it bulges there is an accumulation of mucus or pus behind it; when it is perforated we may be able to view the condition of the ossicula behind it. 2. By means of Valsalva's Method. This consists of a forced ex- piration by the patient himself, by keeping mouth and nose tightly shut. The effort of blowing without allowing the air to pass out either of the mouth or the nose forces it into the Eus- tachian tubes, through which it enters into the ears where it causes a sense of fulness and a crackling in the drumheads, which from the internal pressure are made to bulge, provided the Eu- stachian tubes be pervious. If this sense is not produced, or only in one ear, we know that then and there the Eustachian tube or tubes are closed. This method requires intelligent pa- tients. "In many cases the testimony of the patient is negative as regards the passage of air, when test with the watch shows that it did pass into the tympanum." (Houghton.) 3. By means of Politzer's Method. This consists of blowing, by means of an india-rubber bag with a tube, a current of air into one or both nostrils of the patient in the moment when he is made to swallow a sip of water. The nostrils, of course, must be held shut so that the current of air cannot return through them, while the act of swallowing closes the upper portion of the pharynx, preventing the air from escaping through the mouth. Thus it has to pass through the Eustachian tubes into the ears of the patient, of which he will be cognizant by a cer- tain fulness and pressure in the ear, or in case of perforation of the drumhead, by a whistling sound and a simultaneous ejection of collected mucus into the external meatus. This method, too, requires intelligent patients, but it excels over Valsalva's method in this, that it acts more energetically. "Politzer's method of inflation can be made available without the use of water in most cases by directing the patient to close the mouth and blow steadily as in the act of whistling, or blow- ing out a candle. In children the tympanum can usually be in- flated without either expedient; a forcible emptying of the air- bag will dilate the Eustachian tube and fill the cavity."— (Houghton.) 4. By means of Catheterism.—It consists of blowing air into the middle ear by means of an Eustachian catheter. Here are Kra- iner's directions for the introduction of this instrument. "As a EXAMINATION OF THE MIDDLE EAR. 199 rule, the catheterism of the Eustachian tube should be accom- plished with one of the catheters of size 1 to 4, introduced through the corresponding nasal meatus of the ear, that is to be examined. For this purpose the patient is to be placed upon a chair with a common back, or with one somewhat higher than usual, in order that the head may be supported." "After the patient has blown his nose (partly for the purpose of clearing away a too abundant secretion, partly, in case the nose is too dry, to moisten it, and thus enable the instrument to slide along it with greater facility), we dip the catheter into pure olive oil, and blow through it to assure ourselves of its permeability. The head of the patient is then fixed with the left hand; the catheter is held with the thumb and finger of the right hand close to the funnel-shaped extremity, in such a manner that the ring attached is downward; the beak is placed in the nasal meatus, resting upon its floor, close to the septum, with the convexity upwards. From this point it is pushed backwards with a very light hand, sweeping as much as possible along the floor of the nostril, with continual elevation of the handle, till the instrument becomes horizontal and its extremity rests against the posterior wall of the pharynx. The thicker the catheter, the more easily are these movements executed." "Irregularities in the form of the inferior turbinate bone and strong lateral displacement of the septum may render the first introduction of the catheter very difficult, and test severely the delicacy of the sense of touch in the hand of the operator. As the point of the beak arrives at the posterior wall of the pharynx, the funnel-shaped end of the catheter is to be raised a little above the horizontal line, and at the same time to be lightly with- drawn. The beak then sinks and rests upon the posterior wall of the soft palate, which at that instant contracts, performs a swallowing movement, raises itself, and when assisted by a quarter turn upon its axis from within outwards, lifts the beak of the instrument into the tube." "If this rapid movement is not successful in the hands of an inex- perienced person, the beak of the catheter must be conducted back to the upper part of the pharynx, in order that it may be slowly drawn forwards and turned at the same time laterally a quarter turn upon its axis towards the outside, by which means the ring of the funnel-shaped end is directed horizontally. It now slides over and into the swelling of the tube itself, where the beak of ** 200 THE MIDDLE EAR. " the catheter is directed, with its cavity against the anterior swelling of the tube, and here it hooks into it and can be clearly felt to be grasped by it upon quickly withdrawing it. The catheter lies here quite conveniently, being in no way a source of annoyance to the patient, even in speaking, in swallowing, or in any of the movements of the head. For the sake of security we now elevate the beak of the catheter above the horizontal line, directing it upward and outward, the position of the beak being determined and rendered evident by the direction of the ring upon the funnel-shaped end." After a successful introduction of the instrument, the operator blows either with his mouth or by means of an india-rubber ball into the tube, through which the current of air is trans- mitted into the middle ear. On listening during this operation by either putting the ear to the ear of the patient, or by means of an otoscop, we hear the air rush in and beat on the drumhead, which produces a harsh sound when the drumhead is very dry, and a soft or moist sound when the drumhead is moist. A thin, interrupted, or whistling sound indicates an obstruction of the Eustachian tube; a rattling noise, as from some distance, in- dicates that the Eustachian tube is lined with mucus; a rattling sound, which appears to originate nearer, indicates a collection of mucus or pus in the middle ear; a fine, sharp whistling, with ejection of pus into the external meatus, indicates perforation of the drumhead; a distant, faint and indistinct noise proves that the air does not reach the middle ear at all, either because the catheter is not correctly inserted into the outlet of the Eustachian tube, or because there exists an obstruction in the tube which the air-douche cannot overcome. 5. By means of the Watch.-If we want to ascertain the distance at which a patient is able to hear, we must use an instrument which gives a sound always of the same nature and strength, and which can easily be held at different distances from the ear, to be examined. Such an instrument is the watch. We com- mence by holding it at a distance and bring it gradually nearer to the ear until its tick is perceived; the reversed order might give rise to mistakes. As soon as the patient can indicate the tempo of the tick, we are sure that he hears it, and we know the distance in which he hears by exact measurement. 6. By means of the Tuning-fork.-It is a known fact, that the sound of a watch or a vibrating tuning-fork, when placed on the EXAMINATION OF THE MIDDLE EAR. 201 bony structure of the head or on the teeth, is heard at once louder as soon as we shut the ears, by lightly inserting one finger into each ear. If we close only one ear, we hear the sound louder on this side than on the other. This physiological fact has been made use of in the diagnosis of ear diseases, where, in some cases, it gives valuable hints. The same effect, namely, which is produced by closing the ear with a finger, must be brought about by any morbid obstruction within the ear which interferes with the normal conduction of sound. And what prevents the sound from entering into the ear, must necessarily prevent the sound-waves also from passing out of the ear, when produced by and conducted to the inner ear by vibrations of the skull-bones; consequently they must be reflected back to the labyrinth and thus be perceived doubly as loud. The causes, which may act similar to an artificial closure of the external meatus, are various. It may be a collection of ceru- men, a foreign body, or a furuncle in the external canal, or ob- struction of the Eustachian tube, or myringitis, or thickening of the drumhead; it may be a collection of secretion about the ossicula, or a want of flexibility, or even a partial destruction of the same, or a softening or thickening of the membranes of the fenestræ to the labyrinth. In any of these conditions the patient will surely hear the tuning-fork, which, by the way, gives the best and truest results, when placed on the median line of the top of the head, loudest in that ear which is thus affected. If the patient, on the contrary, should hear the tuning-fork better in the sound or comparatively well ear, and less distinctly in the affected one, we may assume with tolerable probability that the affection of the bad ear consists of a loss of sensibility of the Acusticus in the labyrinth. However, even here we must not be too rash in our conclu- sions, and remember that there is a great difference in the ca- pacities which patients, and even persons in health, manifest with regard to their power of distinguishing the vibrations of a tuning- fork placed upon the head. Aged persons as a rule have much less capacity of perceiving the vibrations of a tuning-fork, than persons below fifty years of age. It will be well in all cases to place the tuning-fork as a controlling experiment, also upon the front teeth of the lower-jaw. A peculiar observation of Von Troelsch is, that the tuning-fork, when placed on the head, very quickly ceased to vibrate in cases of a very unfavorable nature. 202 THE MIDDLE EAR. Otitis Media. Under this name I intend to treat what Von Troelsch has separately and elaborately described as simple catarrh and puru- lent catarrh of the middle ear. Both forms represent an inflam- matory state of the mucous lining of the cavity of the middle ear, the mastoid cells and the Eustachian tube, either in part or in toto. The first is the lighter form, producing a mucous secre- tion which, however, at times may be mixed with pus and blood; the second is the more serious form, characterized by its puru- lent secretion, and mostly ending in perforation of the drum- head. It may be the result of simple catarrh, and I do not find any characteristic signs by which the two could positively be distinguished from each other at the commencement. G The catarrh of the middle ear is either acute or chronic. Its Acute form is mostly very painful; only exceptionally it runs its course without pain, especially in tuberculous individuals. The pain is felt deep in the ear, is sometimes excruciating and ex- tends over the whole of the affected side of the head; it is usu- ally not increased by pulling at the auricle or by pressure upon the parts before the ear, but gets decidedly worse from swallow- ing, or any quick movement of the head, or any concussion from a hard step, and at nights. If the mastoid process becomes in- volved, there is pain in that region and sensitiveness to pressure, and according to Cooper, even at an early stage “we can find a little gland situated midway over the mastoid process and on a line with the anterior opening of the auditory canal, immedi- ately behind the auricle, become tender and swollen, while its immediate surroundings are insensitive to pressure." This in- flammatory process is further attended by high fever and sleepless- ness, when it may indeed simulate an acute meningitis; by deaf- ness of various degrees, developing either suddenly or gradually, and caused by the exudation which covers the ossicles and de- stroys their natural mobility; by "catarrh in the head." In fact it may have spread from a catarrhal inflammation of the naso- pharyngeal mucous membrane, through the Eustachian tube into the middle ear. There is no age exempt from it, but in childhood it is espe- cially prevalent, though it is often not recognized. I might for its diagnosis in little children draw the attention to the following SYMPTOMS: high fever; great restlessness; cry- OTITIS MEDIA. 203 ing and screaming without apparent cause, sometimes in spells or incessantly for days. The child gets worse from any motion, especially of the head, from being rocked, from swallowing and especially when sucking. In fact it cannot be made to suck, it lets the nipple go at each attempt of drawing. Often the little ones bring their hands automatically to the affected side of the head. In some cases the pressure of the exudation within the ear causes vomiting, somnolence alternating with great restless- ness, delirium, partial or entire loss of consciousness, convulsions of the limbs or of the facial muscles. If all this is complicated with an exanthematic fever, or typhoid fever, pneumonia or bronchitis, its diagnosis is indeed difficult. A nasal catarrh or an angina might better lead to its discovery. At all events it will be well to try the application of warm water to the ears in suspicious cases, which gives more or less relief if the ears are affected. An examination of the auditory canal in otitis media by the ear speculum reveals a slight redness of the canal near the drumhead; the drumhead itself appears slightly reddened from its congested mucous layer inside, or sometimes shining and red, like a polished copper-plate; afterwards or sometimes from the first its mild lustre grows dimmer or is lost entirely and with it also the cone of light. When the secretion in the middle ear increases, the drumhead is marked by single radiating blood- vessels and partial bulging, especially of its upper and posterior portion. Sometimes the collected pus shines through the drum- head and gives it a yellowish appearance. Externally we find swellings of the glands around the ear and redness and swelling of the naso-pharyngeal mucous membrane. Otitis media termi- nates often in perforation of the drumhead. Its CAUSES are exposure to cold, which especially in persons prone to catarrhal affections, will often excite this complaint. We find it frequently associated with tuberculosis, syphilis, exan- thematic fevers, typhoid fever, diphtheritis and croup; we must not lose sight of it during the process of dentition. It yields in most cases kindly to homoeopathic treatment. THERAPEUTIC HINTS.—Acon., excruciating pain often in the whole affected side of the head with high fever, dry skin, an- guish, crossness and restlessness; great sensitiveness to noise; auricles hot and red; meatus externus dry and red; drumhead red, almost copper-colored, with visibly engorged and throbbing vessels; after exposure to cold wind. 204 THE MIDDLE EAR. Arg. nitr., ulceration of the drumhead; muco-purulent dis- charge from the ear; naso-pharyngeal inflammation. Arnica, deep pain and heat extending to the mastoid process; feeling of being bruised, about the ear; stitches in and about the ear; hardness of hearing. Traumatic origin; from getting chilled after being heated; typhoid fever; pyæmic symptoms. Arsen., typhoid symptoms with suppression of discharge; lym- phatics inflamed; high temperature; collapse; profuse, cold per- spiration; pyæmia; pain relieved by warm applications. Burn- ing, itching and crawling in external meatus; red, burning pus- tules in the canal and upon the auricles. Bellad., sticking in and behind the ear; digging, boring and tearing; coming and going suddenly, extending to the throat; inflammation of the throat; ringing, buzzing and roaring in the ear; face flushed; eyes brilliant and staring; congestion to head; delirium; deafness or sensitiveness to light and noise; auricle red and sensitive to touch; erysipelas of scalp. Drumhead con- gested, enlarged vessels covering its entire surface. After expos- ure to cold draughts; cold footbaths; having the hair cut; den- tition. "The frequent instillation of warm water (as warm as it can be borne), either alone or with the addition of a few drops of Bellad., will usually relieve the terrible pains while the remedy is ad- ministered internally." (Norton.) Borax, stitch-pains with involuntary starting; lancinating head- ache; itching in the ear; mucous discharge; ear hot; external meatus swollen. Children fret and cry and fear downward mo- tion. Calc. carb., beating pain, with knocking, buzzing and roaring; pain from ear to neck and under jaw; worse from evening till midnight; better from perspiration; thick discharge; swelling of lymphatic glands about ear and neck; perspiration about the head; scrofulous subjects; sensitiveness to cold and damp air; period of dentition; teeth carious and bluish-black at the roots. Capsic., itching deep in ear; shooting, pressing pain in and about the ear; deep-seated pain under the ear, opposite the angle of the inferior maxillary, not extending down the jaw; mas- toid process swollen; middle ear and mastoid cells filled with pus; external meatus closed; drumhead perforated. "Capsic. is specially valuable in acute necrosis of mastoid pro- cess, or in acute symptoms arising in chronic diseases of the OTITIS MEDIA. 205 mastoid. The full pulse, fever and haggard look of the patient are marked features of the picture of the drug. In abscess of the mastoid in very young children it has not proved as effec- tive." (Houghton.) Chamom., catarrhal inflammation; pain in paroxysms; excru- ciating; patient beside himself from pain; irritable and cross; screaming. Auricle red and hot; face changing color, now red and hot and then again pale; or only one cheek red and the other pale; hot sweat about the head; green, colicky discharges from the bowels; dentition. 1 - Ferr. phosph., catarrhal affection of the Eustachian tube and ear, often combined with catarrh in chest, or bowels, or both. Gelsem., catarrhal inflammation at the beginning; cold in head and closure of Eustachian tube; tense, dull, bound, giddy sensa- tion in head with chilliness; stupor, drowsiness. Kali carb., stitch-like pain and drawing, especially behind the right ear; head and right ear hot; face pale, sometimes flushed; strong fever with dizziness; chilliness, shuddering; anxiety in chest; weary in all the limbs. Kali hydr., otitis in rickety children with great tenderness of the head. Merc. sol., deep-seated, tearing and shooting pain, extending to the malar or inferior maxillary bone; worse from evening till midnight, by warmth in bed; enlarged, sensitive cervical glands; stomatitis or ulcerated sore throat; tongue large, flabby, in- dented; fauces inflamed; perspiration from least exertion; oti- tis accompanied by facial paralysis. - Merc. dulc., especially when the Eustachian tube and mucous membrane of the pharynx are affected. Natr. sulph., sharp, lightning-like stitches in the ear; catarrhal affection from damp and rainy weather, cold bathing, playing on wet ground; hydrogenoid constitution. Nux vom., great pain in ear; hardness of hearing with roaring, singing and other noises; auditory canal dry and sensitive; cold in head; itching in Eustachian tube; headache; vertigo; period- ical nausea and vomiting; constipation; creeping chilliness. Bet- ter in warm, worse in cold and damp weather. Phosphor., painful gathering, first in left and then in right ear, and shooting pains through ear worse at night; stopped up feel- ing in ear; itching in ears; rather deaf in left ear; deafness to human voice; reëchoing of his own words. When the ear gets