Digitized by the Internet Archive in 2017 with funding from University of Illinois Urbana-Champaign Alternates https://archive.org/details/compendofpractic00hugh_0 HUGHES’ COMPEND OF PRACTICE. FIFTH PHYSICIANS’ EDITION. TO PHYSICIANS. The several essential qualities which a good Visiting List should possess are, compactness, convenience of arrangement, and strength to resist the unusual hard wear it receives. These qualities are all com- bined in Lindsay & Blakiston’s Physicians’ Visiting List, which has now been published for forty-three years, and no better evidence of the practical worth of this book can be offered than the uniform increase in popularity it has enjoyed with each successive issue. One of its chief features is its size ; it measures 6 y& x 3^4 inches, and the smallest size weighs but 3^ ounces and is only 0 of an inch thick. The large sizes are a little thicker and heavier; it is, however, the smallest and lightest Visiting List published. Our many years’ experience has enabled us to put it together in the best manner, and to add many im- provements during the past few years. It is arranged for 25, 50, 75 and 100 patients per day or week, interleaved and plain, dated, undated and monthly. Prices range from 75 cents to $3. Complete circular will be sent you upon application. P. Blakiston, Son & Co., Medical Publishers and Booksellers, 1012 Walnut Street, Philadelphia. A COMPEND OF THE PRACTICE OF MEDICINE BY DAN’L E. HUGHES, M.D., CHIEF RESIDENT PHYSICIAN PHILADELPHIA HOSPITAL; PHYSICIAN-IN-CHIEF, INSANE DE- PARTMENT, PHILADELPHIA HOSPITAL; LATE DEMONSTRATOR OF CLINICAL MEDI- CINE IN THE JEFFERSON MEDICAL COLLEGE OF PHILADELPHIA; FELLOW OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA, ETC. FIFTH PHYSICIANS' EDITION. THOROUGHLY REVISED AND ENLARGED. INCLUDING A VERY COMPLETE SECTION ON SKIN DISEASES AND A NEW SECTION ON MENTAL DISEASES. PHILADELPHIA: P. BLAKISTON, SON & CO., IOI2 WALNUT STREET. 1894 . Copyright, 1894, by P. Blakiston, Son & Co PRESS OF WM. F. FELL <& CO. 1220-24 SANSOM STREET PHILADELPHIA Aug. 42 g Mrs. JH Finch. L>l(s /? ' 34 - PREFACE TO FIFTH EDITION The steady demand for the Compend of Medicine is practical evidence of its usefulness and has stimulated the author to make the fifth edition the most complete of any like book. It was not the original intention that it should in any way replace any of the text- books upon the Practice of Medicine. It was written as a compend for the aid of the student, to be used in connection with a larger treatise. The book has however somewhat outgrown the original plan and I find a large number of Physicians use it. I have endeav- ored to make it more useful to them without affecting the arrangement which has made it so popular with the student. In the fifth edition the entire book has been thoroughly revised and the recent dis- in the principles and practice of Medicine incorporated There has also been added a section on mental diseases, a subject daily forcingits importance upon the general practitioner. No medical student’s education should be called complete without some know- ledge of insanity, the increase of which is the alarm of the evening of the nineteenth century. D. E. H. v 00 Uj v &. 6 & : i 6 -d I A ( 2-4 cd * ? ^ U/ / i ' ^ • / ^ 1 W, # CONTENTS. T ¥u^dt INTRODUCTION. FEVERS, General Treatment of Fevers, ....... Continued Fevers, Periodical Fevers, Eruptive Fevers, DISEASES OF THE MOUTH, DISEASES OF THE STOMACH, DISEASES OF THE INTESTINAL CANAL, . . INTESTINAL PARASITES DISEASES OF THE PERITONEUM, DISEASES OF THE BILIARY PASSAGES, . . . DISEASES OF THE LIVER, DISEASES OF THE KIDNEYS, DISEASES OF THE BLOOD, ACUTE GENERAL DISEASES, DISEASES OF THE RESPIRATORY SYSTEM, DISEASES OF THE NASAL PASSAGES, . . . DISEASES OF THE PHARYNX, DISEASES OF THE LARYNX, DISEASES OF THE BRONCHIAL TUBES, . . DISEASES OF THE LUNGS, DISEASES OF THE PLEURA, DISEASES OF THE CIRCULATORY SYSTEM, DISEASES OF THE NERVOUS SYSTEM, ... vii PAGE 9 15 16 16 36 47 63 7i 88 121 124 131 *34 142 172 185 219 238 2 43 248 263 286 3*3 3i9 363 viii CONTENTS. PAGE DISEASES OF THE CEREBRAL MEMBRANES, 364 DISEASES OF THE CEREBRUM, . 370 DISEASES OF THE SPINAL CORD, 403 DISEASES OF THE NERVES, 427 GENERAL OR NUTRITIONAL DISEASES, 434 MENTAL DISEASES, 450 DISEASES OF THE SKIN, 475 INDEX, 553 COMPEND OF THE PRACTICE OF MEDICINE. INTRODUCTION. The Principles of Medicine constitute what may be termed Medical Science. The Practice of Medicine is the exercise of medical art, and embraces all that pertains to the knowledge of, prevention, and cure of the diseases for which the physician is called upon to direct treatment. Disease may be defined as any departure from the normal standard of structure or function of an organ or tissue : Organic disease , when associated with an organic change in the affected part; Functional disease , when the abnormal phenomena are inde- pendent of any apparent structural lesion. The study of disease, whether organic or functional in character, is termed Pathology. Pathology explains the origin , causes , clinical history , and nature of the various morbid conditions which may disturb the economy. The study of individual diseases constitutes Special Pathology , while the study of the morbid conditions common to a greater or less number of diseases constitutes General Pathology. Nomenclature , or the naming of diseases, is a subdivision of gen- i 9 JO PRACTICE OF MEDICINE. eral pathology. The value of nomenclature as applied to disease is that the name chosen shall express the morbid condition involved, as well as its location. If the morbid condition be an inflammation, the suffix itis is added to the anatomical name of the part affected ; thus, if the disease be an inflammation of the peritoneum, it is termed peritonitis. If the morbid condition is catarrhal, such as a transudation or flux, the liquid escaping upon a mucous surface, the suffix rhoea is used ; thus, a catarrhal inflammation of the intestinal tract is termed diar- rhoea and enterorrhoea. If the morbid condition be a flow of blood or hemorrhage from a mucous surface, the suffix rhagia is used ; thus, a hemorrhage from the small intestines is termed enter orrhagia. If the morbid condition be pain without inflammation, the suffix algia is used. The various forms of neuralgise being an example, thus, neuralgia of the stomach is termed gastralgia. If the morbid condition be in the blood, the suffix cemia is used. Thus, Ancemia is impoverishment of the blood ; Ur cemia, the morbid accumulation of urea in the blood ; Septicoemia , putrid infection of the blood ; Pycemia , purulent infection of the blood. If the morbid condition be in the urine, the ending nria is used to indicate it. Albuminuria , when albumin in the urine ; Hcematuria , when blood in the urine ; Oxaluria , when oxalates occur in the urine. If the morbid condition be a dropsical affection, the prefix hydro is added to the part affected. Thus, a dropsical accumulation in the peritoneum is termed hydro-peritoneum. If the morbid condition be that of air in an unnatural part, the prefix pneumo to the name of the part is used, as \xv pneumo-thorax . If the morbid condition be an inflammation of the membrane investing the part inflamed, the prefix peri is made use of. Thus, for an inflammation of the investing membrane of the kidney the term is perinephritis. Inflammation of the connective tissue surrounding an organ is designated by the prefix para. Thus, parametritis for inflammation of the connective tissue about the womb. A termination in oma signifies a tumor, as in sarcoma or carcinoma. The suffix pathy is used to designate a morbid condition of a part, without indicating its particular character, an example being the use of the term encephalopathy. INTRODUCTION. 11 Morbid Anatomy, or pathological anatomy, is the study of the changes in the tissues and fluids of the body appreciable to the naked eye or with the aid of the microscope. Histology is the study of the minute anatomy of the tissues and fluids of the body with the microscope. Pathogenesis is the study of the origin and development of pathological processes. Lesions ( Icedo , to hurt) are appreciable anatomical changes. Etiology is that subdivision of general pathology which treats of the causes of disease. The knowledge of the cause of any morbid action is of value in the prevention, management, and removal of disease. The Causes of disease may be divided into internal , external , ordinary , specific , primary , secondary , predisposing , and exciting. Examples of internal or intrinsic causes are those having their origin in the mind, such as prolonged mental application, intense or long-continued emotional excitement, long-continued mental depres- sion, and the possession of and concentration upon a predominant idea. Other examples are the accumulation of certain products in the blood, such as urea, uric acid, or lacid acid. External or extrinsic causes are such as infectious miasms, viruses, poisons, wounds, and injuries. An ordinary cause is one to which all are more or less exposed, such as atmospherical changes. Specific or special causes are those producing a distinct and specific disease, such as the bacillus tuberculosis , causing Tuberculosis ; comma bacillus , Asiatic Cholera ; oscillaria malarice , Malaria. A contagious disease is one whose causative agent is a specific poison that, introduced into the system of another, will give rise to the same disease. An infectious disease is also due to a special cause that under certain conditions is capable of unlimited increase or multiplication. An infectious disease may or may not be contagious. An example of a primary cause is any external traumatic injury. A secondary cause is well seen in the secondary pericarditis result- ing from an accumulation of urea in the blood, the retention of the urea in the blood being due to a diseased kidney. A predisposition to disease is a special liability or susceptibility to its occurrence, and may be either inherited or acquired. Inherited or constitutional predisposition to certain diseases is also 12 PRACTICE OF MEDICINE. termed Diathesis ; an example is in the offspring of phthisical parents, who are said to be of a phthisical diathesis. Acquired predisposition is such as arises from — I. Habits : Strain upon the nervous system resulting in nervous diseases, or the changes resulting from alcoholic and other excesses. II. Age : Children are very liable to catarrhal disorders. Young adults, to fevers and perverted sexual disorders. Middle age, to heart, kidney, and digestive disorders, and cancer. Old age, to degeneration of the heart and vessels. III. Occupation : Miners, weavers, and cutlers, lung diseases, or painters and printers to lead colic. IV. Sex : Women, emotional nervous diseases. Men, as more exposed, rheumatism and pneumonia. V. Race : Negro, phthisis and scrofula ; often exempt from malaria. Exciting causes are those giving rise to morbid conditions in those already predisposed to certain diseases, but lacking the action which determines their occurrence ; to wit : persons predisposed to acute rheumatism, on being exposed to certain atmospheric changes have an attack ; fear has produced chorea; anger has caused jaundice; worry has produced cardiac troubles. The Clinical History of disease includes all the symptoms and signs which may occur from the period of incubation until its final termination. Symptomatology is the study of the signs and symptoms of disease or such alterations in the healthy functions giving evidence of the existence of a diseased condition or perverted function. Symp- toms may be either subjective or objective. Objective , when evident to the senses of the observer, as redness, swelling, high temperature, or disorders of locomotion. Subjective , when felt or known only by the patient, such as pain, numbness, vertigo, or nausea. Physical signs are, strictly speaking, objective symptoms, requir- ing for their elucidation special methods, such as inspection , mensura- tion :, palpation , percussion, and auscultation. These are chiefly used in examinations of the chest and abdomen. Associated with the study of symptomatology should be considered the complications and sequelce of disease. INTRODUCTION. 13 Complications are certain conditions which may arise in the course of the original disease, but are not regarded as a necessary accompani- ment of the disease ; thus hemorrhage from the lungs or haemoptysis is a complication of tuberculosis ; intestinal hemorrhage, the most frequent complication of typhoid fever. Sequelce ( sequor , I follow) are the morbid phenomena left as a result of a disease ; thus, valvular disease of the heart often results from an attack of acute articular rheumatism. The Period of Incubation is that interval between the entrance of a poison into the system and the manifestation of the symptoms. The Prodromes are the earliest recognizable symptoms ; as the rigors or chills during the invasion of fever, and the various aura pre- ceding an epileptic attack. An acute disease is one in which the invasion. is sudden and rapid, and as a rule severe ; when the symptoms develop less rapidly and are less intense the disease is said to be sub-acute ; when gradual or slow in development, duration, and intensity, the disease is said to be chronic. It must be borne in mind, however, that there may be disturbed action in every intermediate degree between these extremes. Pathognomonic is the term applied to such symptoms as belong to one particular disease, and are therefore characteristic of it, thus, the rusty sputum of pneumonia, the eruption of variola. The Termination of a diseased action may occur in one of three ways, to wit : Cure , Secondary Processes , or in Death. Cure may occur by — I. Lysis, or slow return to health. II. Crisis , abrupt termination, usually with a critical discharge. III. Metastasis , or changing from one location to another. Secondary processes is when the diseased action is substituted by a new morbid process, to wit : Rheumatism followed by endocarditis ; apoplexy by cerebral softening. By Death is meant a complete cessation of tissue change occurring by I. Asthenia, or an ever increasing debility, to wit : phthisis, cancer, Bright’s disease. II. Ancemia, or insufficient quantity or quality of blood. III. Apncea , or non-aeration of blood, to wit : acute lung diseases or croup. 14 PRACTICE OF MEDICINE. IV. Coma, death beginning at the brain, to wit : uraemia, narcotic poisoning, cerebral hemorrhage. Diagnosis of disease, or the discrimination of diseases, implies a complete, exact, and comprehensive knowledge of the case under consideration, as regards the origin, seat, extent, and nature of all its morbid conditions. A direct diagnosis is made when the morbid condition is revealed by a combination of clinical phenomena, or some one or more pathog- nomonic symptoms. A differential diagnosis is the result when the diseases resembling each other are called to mind and eliminated from each other. A diagnosis by exclusion is by proving the absence of all diseases which might give rise to the symptoms observed, except one, the presence of which is not actually indicated by any positive symptoms. Prognosis of disease is the ability or knowledge to foretell the most probable result of the condition present, and involves an amount of tact or knowledge only acquired by prolonged clinical experience. Treatment. The ultimate and most important object in the study of medicine, from a practical point of view, is to be able to cure , relieve , ox prevent disease. This does not consist solely in the admin- istration of drugs, but requires strict and faithful attention to diet and hygiene. When the object is to prevent disease, such as smallpox by vacci- nation, it is called Prophylactic or Preventive treatment. When disease is to be broken up, although already begun, such as aborting the chill of malaria, it is called the Abortive treatment. When the disease is allowed to run its natural course without attempting its removal, but being constantly on the alert for obstacles to its successful issue, such as the generally adopted plan of treating continued fevers, it is called Expectant treatment. When the disease is incurable, and removal of marked suffering is the object, it is called Palliative treatment. When marked weakness and prostration are to be overcome, it is called Restorative treatment. FEVERS. 15 FEVERS. Fever is a condition in which there are present the phenomena of rise of temperature , quickened circulation , marked tissue change , and disordered secretions. The primary cause of the fever phenomena is still a mooted ques- tion, and is either a disorder of the sympathetic nervous system giving rise to disturbances of the vaso-motor filaments, or a derangement of the nervous centres located adjacent to the corpus striatum, which have been found, by experiment, to govern the processes of heat pro- duction, distribution, and dissipation. Rise of temperature is the preeminent feature of all fevers, and can only be positively determined by the use of the clinical ther- mometer. The term feverishness is used when the temperature ranges from 99 0 to ioo° Fahr. ; slight fever if ioo° or ioi° ; ?noderate t 102° or 103° ; high if 104° or 105° ; and intense if it exceed the latter. The term hyperpyrexia is used when the temperature shows a tendency to remain at 106° Fahr. and above. Quickened circulation is the rule in fevers, the frequency usually maintaining a fair ratio with the increase of the temperature. A rise of one degree Fahr. is usually attended with an increase of eight to ten beats of the pulse per minute. The following table gives a fair comparison between temperature and pulse : — A temperature of 98° F. corresponds to a pulse of 60 “ “ 99 ° F. 70 “ “ ioo° F. “ “ 80 “ “ ioi° F. “ “ “ 90 “ “ 102° F. “ 100 0 O “ 1 10 *■ “ 104° F. 120 ‘ •* 105° F. “ “ “ 13 ° “ “ 106 0 F. “ 140 The tissue waste is marked in proportion to the severity and dura- tion of the febrile phenomena, being slight or nil in febricula, and excessive in typhoid fever. The disordered secretions are manifested by the deficiency in the PRACTICE OF MEDICINE. 16 salivary, gastric, intestinal, and nephritic secretions, the tongue being furred, the mouth clammy, and there occurring anorexia, thirst, con- stipation, and scanty, high-colored, acid urine. GENERAL TREATMENT OF FEVERS. 1. Reduce the temperature. The cold bath or cold pack will do this most decidedly, but entails much labor, and is not altogether free from danger, and so its use is advised only in proper cases. Cool sponging is of decided value. Quinina , in gr. xx doses repeated, rarely fails. Antipyrine , gr. xx repeated, and antifebrin , gr. x-xv repeated, are also recommended, but their tendency to depression must be watched. 2. Lessen the circulation. If the pulse be full, strong, and rapid, use aconitum , or veratrum viride. If the circulation be weak, stimu- lants with digitalis or caffeina are indicated. 3. Attend to the secretions. Remove the waste of the tissues by diuretics, diaphoretics, and, if particularly indicated, laxatives. It is better for every fever that the skin should be moist, than that it should be harsh and dry. It is better that the urine should be abundant, than that it should be scanty and thick with tissue waste. Watch the stools that you may judge whether the food, be it solid or liquid, is being digested. The free use of water is beneficial in promoting the various secretions. 4. Nourish the patient. “ Don’t starve a fever.” Administer milk, beef-tea, animal broths, peptonized and other light nutritious food, in small quantities, but at frequent intervals. Alcohol is only indicated in long-continued fevers or those of asthenic type. Check or discontinue alcohol when its odor is notice- able on the breath. 5. Watch the nursing. Much of the success in the management of fever patients can be attributed to good, sensible nursing. Through it are secured the five important essentials of every sick-room ; to wit: cleanliness, cheerfulness, regularity, ventilation, and light. CONTINUED FEVERS. All continued fevers are characterized by a steady progress of the febrile movement, without either a too decided rise or fall in the tem- perature to modify the impression of a continuous action. FEVERS. 17 SIMPLE CONTINUED FEVER. Synonyms. Irritative fever ; febricula ; ephemeral fever ; synocha. Definition. A continued fever, of short duration, mild in charac- ter, not the result of a specific poison, rarely fatal, but when death does occur, presenting no characteristic lesion. Causes. Fatigue, mental and physical ; exposure to the sun, great heat or cold ; excesses in eating and drinking resulting in an attack of indigestion ; excitement and violent emotion. Most common in childhood. It is not a miasmatic fever, neither is it contagious. Symptoms. Onset sudden with an abrupt feeling of lassitude , followed by a decided chill or chilliness , a sudden and rapid rise of temperature , quick, tense pulse, headache , dry skin , great thirst , coated tongue , costive bowels , and scanty , high-colored urine. Cases due to errors in diet are accompanied by nausea and vomiting. Attacks occurring during childhood, due to excitement, fright, or the emotions, may be associated with convulsions. The temperature may within an hour or two reach 103° F., or more, when slight delirium may occur. The affection has no constant or characteristic eruption. Duration. From twenty-four hours to six or seven days. Termination. Usually within a few hours, to a day or two, the temperature rapidly falls to the norm, an instance of crisis ; or it may continue for several days, gradually falling to the norm [lysis). Herpes about the lips and nostrils are often observed at the close of an attack. Convalescence is rapid. Diagnosis. Unless the fever can be attributed to some one of the causes that give rise to it, a doubt as to its character may exist for the first twenty-four hours, after which time it can hardly be mistaken for any other disease. The following is a familiar instance of this affection. A child, apparently in the best of health, at play, or, may be, at school, suddenly complains of nausea and may vomit, the skin becoming hot, dry, and flushed, or soon covered with an erythematous rash ; the pulse is quick and tense, there is headache, pains in the limbs, and great fretfulness or nervousness. The axillary tem- perature may reach I02°-I04° F. The whole aspect is most alarming. A laxative is administered, the surface sponged with a tepid lotion, sleep follows, during which there may be free perspiration, and the following day the child is and continues perfectly well. Prognosis. Recovery, without sequelae, the rule. 18 PRACTICE OF MEDICINE. Treatment. Rest in bed. If evidences of gastro-intestinal dis- order be present, order a dozen or more powders containing hydrar- gyri chloridi mite , gr. l /e ; sodii bicarbon ., gr. ij ; pulv. ipecac , gr. ^ one every two hours ; some hours after the last powder has been taken, an enema or a seidlitz powder . Much comfort follows sponging the surface with tepid or cold water and the use of saline diaphoretics and diuretics. If the pulse be very quick, add small doses of aconitum. Cases not associated with digestive disorder have the fever and ner- vous symptoms relieved by acetanilidum , gr. ij-v, according to age, every two or three hours. Liquid diet is most palatable. Cases in which nervous symptoms or insomnia are prominent should have a few doses of potassii bromidum during the day, or a bedtime dose of trional , gr. v-xx. During convalescence tonic doses of quinince sulphas or tinctura nucis vomicce. INFLUENZA. Synonyms. La grippe ; grip ; contagious catarrh ; epidemic catarrhal fever. Definition. An acute, specific, infectious fever, moderately contagious ; sporadic, epidemic, and pandemic ; associated with catarrhal inflammation of the respiratory tract, sometimes of the digestive, always accompanied with disturbances of the nervous system and a debility out of all proportion to the intensity of the fever and the catarrhal processes and apt to be attended with serious complications and sequelae. The disease was almost unknown upon the appearance of the pandemic in the winter of 1889-90. Causes. A specific poison, the bacillus of Pfeiffer , which is unin- fluenced by soil, climate, season, or atmospheric changes. The mode of development of the remarkable outbreaks of influenza is not yet understood. One attack rather predisposes to another attack. Morbid Anatomy. There are no characteristic anatomical lesions. Symptoms. The clinical history of this disease presents the greatest variations as regards intensity, from the most trifling indis- position in one, to an illness of the gravest kind, terminating in death, in another. The onset is, in the majority of cases, sudden, with a chill followed FEVERS. 19 by fever , the temperature reaching ioi° to 103°, a quick , compressi- ble pulse, and severe shooting pains in the eyes and frontal sinuses and myalgic pains in the joints and muscles. The chill and fever are rapidly followed by chilliness along the spine , pain in the throat , hoarseness , deafness , coryza , sneezing , injected , watery eye, and a dry, irritative, laryngeal cough , sometimes becoming bronchial. The tongue is furred, there is anorexia , epigastric distress, nausea , vomit- ing , and oftentimes diarrhoea. In some instances the digestive symp- toms are the most prominent, when dysentery may occur. Associated with either the respiratory or digestive form of attack may be marked disturbances of the cerebro-spinal functions, or these latter may be the most prominent symptoms present. The above symptoms are always associated with depression of spirits, and a debility altogether out of proportion to the intensity of the fever and the catarrhal phenomena. Delirium is rare, but marked hebetude and cutaneous hypercesthesia are common. Duration. The fever declines in from four to seven days, when begins a protracted convalescence. Relapses frequently occur, and second, third, or even more numerous attacks in the same individual may be observed, the susceptibility of the system after an attack being remarkable. Complications. The most frequent are those associated with the respiratory organs. Severe bronchitis, associated in the feeble or aged with fever, typhoid delirium, and tendency to oedema of lungs. Croupous and catarrhal pneumonia are frequent and fatal complications. Cerebro-spinal meningitis also noted. Sequelae. A persistent headache ; neuralgia ; neuritis ; insomnia ; melancholia ; mania ; enlargement of lymphatic glands. The great increase in pulmonary phthisis since the pandemic of 1889-90 is more than a coincidence. Diagnosis. Isolated cases may be mistaken for a “bad cold. ” But when epidemic, the sudden onset , marked general catarrh , and decided prostration should prevent error. At the onset of an epidemic Dengue will be remembered. Cerebro- Spinal Fever has many symptoms in common with the nervous form of influenza. Prognosis. Recovery is the rule when it occurs in the healthy and vigorous, according to Pepper less than one-half of one per cent, die. Grave when the very young, the very old, or those suffering from 20 PRACTICE OF MEDICINE. organic disease, such as Bright’s disease, fatty heart, emphysema, or the tubercular diathesis, are attacked. Treatment. No specific. During the prevalence of the epi- demic influence exposure to cold should be avoided. Support the system and pursue a purely symptomatic method of medication. All measures, of whatever kind, which tend to depress the general nervous system, or the functional activity of the respiration, and espe- cially the heart-power, are to be avoided. Patients should be kept in bed until fever declines or longer. The catarrh , pains , and cough are at least ameliorated by the fol- lowing : — R . Pulvis ipecacuanhae et opii, . . . Potassii nitrat., . . . . gr. v . . . . gr. v. Every three hours. Or— R . Phenacetin, Pulv. camphorae, Caffeina citrat., . . . . gr. iij • • • • gr- j . . . gr.j. Every two or three hours. During the last pandemic the disease was frequently aborted in those of vigorous health by a few ten or fifteen grain doses of anii- pyrine , although in those of feeble resisting power much harm resulted from the indiscriminate use of this drug. Dr. Roland G. Curtin warmly recommends salicinum as coming “ as near to being a specific as we can get with the drugs now in our possession.” Quinina in full doses at the very onset often aborts the disease. I have seen excellent results in neuralgic cases with cinchonidincs salicylas, gr. v every four hours. The frequent inhalation of tinctures benzoin comp., 3ss-j, in aquee but., Oj, relieves the naso-pharyngeal and bronchial catarrh. If the brojichial symptoms become troublesome, use — R . Ammonii muriat., grs. x Strychninae sulph., gr. Syr. ipecac., TT^v Spts. frumenti, f^ss Aquae chloroformi, % iss. M. p. r. n. The complication of pneumonia requires prompt stimulating treat- ment. Dr. Pepper recommends strychnines sulph. in full doses as FEVERS. 21 the most important remedy against this complication, and suggests the following combination as often valuable : — R . Morphinae sulph., gr. j Quininse sulph., gr. xxxvj Strychninae sulph., gr. ss Acid. phos. dil., f ^ iij Glycerini, f^v Aquae., q. s. ad f ^ iij. M. S. A teaspoonful four to six times daily, in water. During convalescence administer strychnines sulph., gr. four times daily. Always have in mind that influenza is often the exciting cause of a phthisical development in those so predisposed. TYPHOID FEVER. Synonyms. Enteric fever ; gastric fever ; nervous fever ; entero- mesenteric fever ; abdominal typhus ; autumnal fever. Definition. An acute, self-limited, infectious febrile affection, due to a special poison ; characterized by insidious prodromes ; epistaxis ; dull headache followed by stupor and delirium ; red tongue, becom- ing dry, brown, and cracked ; abdominal tenderness, early diarrhoea, and tympany ; a peculiar eruption upon the abdomen ; rapid prostra- tion and slow convalescence ; a constant lesion of Peyer’s patches, the mesenteric glands, and of the spleen. Causes. Predisposing and exciting. The chief predisposing causes are Age and Season. It is claimed by Pepper that a particular susceptibility exists in certain individuals and families to typhoid fever. The most frequent age is between fifteen and thirty years, and cases are rarely seen in those of forty-five years and over. I have seen well-marked cases with typical symptoms at eighteen months and at five years of age. The autumn months show the most cases, and particularly following a hot and dry summer. The exciting cause is a special typhoid germ, the bacillus of Eberth. The poison usually results from the decomposition of the typhoid stools and the sputum, although it has been claimed that the disease may be generated under certain undetermined circumstances, de novo , from ordinary filth and decomposition. 22 PRACTICE OF MEDICINE. The atmosphere is never impregnated with the fever germ. The poison gains its entrance into the system by means of infected water, milk, ice, meat, or other food. The germ is easily destroyed by thorough disinfection of the stools and sputum with heat, mercuric bichloride, or acidum carbolicum, but it is to be borne in mind that extreme cold will not destroy the typhoid germ. Pathological Anatomy. The specific anatomical lesions of typhoid fever are invariably present, and are so characteristic that an examination of the body after death will in any case make known the nature of the disease, even had the symptoms been 'unknown. These lesions consist in changes in the Peyerian patches and solitary glands , which may be divided into well-defined stages, as follows : — First. Stage of Infiltration , or Swelling from infiltration and ex- cessive proliferation of their cellular elements ; the surrounding mucous membrane is also infiltrated with cells. The Peyer’s patches are thickened, hardened, and elevated above the mucous membrane. The number of patches and glands involved is from three or four up to nearly the entire number. The above changes have been noted as early as the second day. Second. Stage of Necrosis , Softening , or Sloughing of the solitary and agminate glands. Not all the patches necessarily slough ; in a certain number of them the morbid changes are arrested before soften- ing. This stage constitutes the anatomical changes of the second and third week. Third. Stage of Ulceration following and depending directly upon the softening and sloughing, the sloughs gradually separating, begin- ning at the periphery of the swollen gland and finally, at about the end of the third week, become detached, leaving ulcers of various sizes. Fourth. Stage of Cicatrization , or in rare cases perforation. The ulcer gradually diminishes in size, the surface becoming covered with a delicate layer of granulations, which is soon transformed into con- nective tissue and covered with epithelium, the resulting scar being slightly depressed. The gland-structure is never regenerated. The Mesenteric glands become infiltrated, enlarged, and softened, but seldom ulcerate. The Spleen also enlarges and softens, the increase in size beginning in the middle of the first week, reaching its height at the end of the second week, the organ being twice or three times its normal size. FEVERS, 23 There are, besides, parenchymatous degenerations , or granular changes in all the tissues of the body. Symptoms. Stage of Prodromes. — The onset is insidious, with a feeling of general malaise , vertigo, headache, particularly occipital pain, disordered digestion, disturbed sleep, epistaxis , depression, and muscular weakness, followed by a chill or chilliness , the patient being unable to designate the day when the symptoms began. In rare instances the disease begins abruptly with a chill, followed by high fever ; this is particularly the case in malarial districts. The exact duration of these premonitory symptoms is not known, and may be said to vary from a few days to two or three weeks. First Week , dates from onset of the fever, when are present increas- ing temperature, frequent pulse, headache, listlessness, the eyes closed as if asleep, coated tongue, nausea, diarrhoea (there may be con- stipation), the abdomen moderately distended and, upon pressure in the right iliac fossa, gurgling sounds and tenderness. Upon the seventh day a few reddish spots resembling flea bites appear upon the abdomen, chest, or back. Second Week. The foregoing symptoms are exaggerated; fever continuous, frequent and compressible and dicrotic pulse, tympanitic, tender abdomen, gurgling in the right iliac fossa, nocturnal delirium, severe and constant headache, often stupor, a short cough with dis- tinct bronchial rales on auscultation, irregular muscular contractions {subsultus tendinum), sordes upon the teeth and lips, the tongue loses its coating and becomes more or less dry, the diarrhoea continuing. During this stage deafness develops, often increasing until profound, and continuing into convalescence. Disturbances of vision are fre- quent in pronounced cases. The spleen increases in size. Third Week. Fever changes from continuous to remittent ; the evening exacerbations continue as high as the preceding week, the morning fall growing more decided each day, but all the other symptoms remain about the same until near the end of the week, when a marked amelioration begins. In a fair proportion of cases all the symptoms grow worse toward the end of the second or during the third week. The prostration is extreme, the stupor so marked that it is hardly possible to rouse the patient, the tongue dry, hard, cracked, and covered with a brown crust, sordes collect on the gums, teeth, and cracked lips, the pulse rapid and feeble, the respirations shallow and quickened, retention 24 PRACTICE OF MEDICINE. of urine , which contains albumin, and the stools voided involun- tarily, and bedsores developing, this condition terminating in death, or passing thus into the fourth week. Fourth Week. The fever decidedly remits ; almost normal in morning, the pulse becoming less frequent and more full, the tongue gradually becoming clean, the abdomen lessens in size, the diarrhoea ceases, the patient passing into a slow convalescence, greatly ema- ciated, which condition may continue for several weeks. Analysis of Symptoms. The temperature record of typhoid fever is characteristic. The fever on the morning of the first day may be stated at 98.5° F., evening 100. 5 0 ; second morning 99.5 0 , evening 101.5 0 ; third morning 100. 5 0 , evening 102. 5 0 ; fourth morn- ing 101.5 0 , evening 103. 5 0 ; fifth evening 104.5 0 . From that time until end of the second week, the evening temperature ranges between 103° and 105°, the morning temperature being a degree or more lower. During the second or third week hyperpyrexia, or fever above 105° F., may develop and adds to the gravity of the attack. A high temperature during the third and fourth week is of grave import. Diarrhoea is the principal intestinal symptom ; if absent, the lesion is slight. The stools are at first dark, but early in the second week they become fluid, offensive, ochre-yellow in color, resembling “ pea soup,” and may be streaked with blood. They number from three to fifteen in the twenty-four hours. Constipation occurs more frequently than is supposed. I have seen fifty cases with constipation within the past five years. The urine has the ordinary febrile characters. Retention is very common. Ehrlich describes a reaction which he believes is rarely met with save in typhoid fever. In examinations of the urine by Ehrlich’s diazo-reaction in fifty cases of typhoid fever in the wards of the Philadelphia Hospital the reaction was found in thirty-eight. It has also been found in a number of other conditions, particularly those having gastro-intestinal symp- toms. Eruption is almost constant. Consists of from five to twenty small, rose-colored spots on the abdomen , chest, or back, sometimes on the limbs, appearing in crops, lasting about five days, disappearing on pressure and at death. Returning with relapses. Eruption day from the seventh to the ninth. FEVERS. 25 Rarely spots of a delicate blue tint — the “ taches bleuatres ” of French authors — are observed. Nervous symptoms are, pronounced headache , early and severe, dullness of intellect soon following, passing into drowsiness and stupor , with great prostration. Deafness pronounced. Sight im- paired, in grave cases double vision. Deliriwn low and muttering, generally pleasant in character; always present in marked cases. Coma vigil is a grave symptom, the patient lying perfectly quiet with eyes open, taking no heed to his surroundings. Muscular symptoms are developed late in the second or early in the third week, and consist of irregular contractions or subsultus ten - dinum , and are the result of the great debility. The reverse of mus- cular contractions, to wit, perfectly motionless in bed, attempting no muscular effort of any kind, is a grave sign. Convalescence shows great debility and emaciation, great anaemia, and great nervousness often very protracted. It is during convales- cence that great irritability of the heart, profuse night sweats, and insomnia occur, and in women loss of hair. Complications. Intestinal hemorrhage is the most frequent and at times the most critical of any of the complications of typhoid fever. The hemorrhage may occur any time between the fourteenth and twentieth day ; a sudden decline of the temperature to the norm or below frequently precedes the passage of blood by stool. The hemorrhage is due to the erosion of a vessel during the ulcerative action. Perforation makes the case almost hopeless. Peritonitis without perforation adds to the gravity, but not necessarily fatal. Lobar pneu- monia, hypostatic congestion , and bronchitis are frequent occurrences. Albuminuria and acute nephritis may occur, as may phlegmasia dolens. Bedsores are frequent, resulting from the impaired nutri- tion, emaciation, and pressure over bony prominences, and the diffi- culty of keeping patient clean. Ulceration of tongue and mucous membrane of cheek is sometimes seen. Sequelae. Paralysis — either mono- or paraplegia — due to an acute neuritis. Post-febrile insanity occurs more frequently after typhoid than any other febrile condition, save perhaps influenza. Acute Ne- phritis associated with oedema. Alopecia complete or partial. Trans- 2 20 PRACTICE OF MEDICINE. verse markings of the nails . Tuberculosis may develop in those predisposed. These sequelae of typhoid fever are all the result of the impaired nutrition and great prostration. Relapses are common. The symptoms all return abruptly; the duration is half the time of the original attack ; occur at the end of the fourth or beginning of the fifth week. Not so fatal as generally supposed. Abortive typhoid fever are cases of mild character, having many of the typical symptoms, running its course in about two weeks. The so-called walkhig cases are often of this character. Diagnosis. An error that is constantly being made is that of confounding typhoid fever with the typhoid (depressing) symptoms or condition developing during the course of many acute diseases. The absence of the characteristic diarrhoea , the peculiar eruption , and the typical temperature record should prevent the error. Enteritis has intestinal derangement and fever alone. Peritonitis , abdominal symptoms only, with constipation. Acute miliary tuberculosis often mistaken for typhoid fever, an error difficult to prevent at times. Meningitis lacks the intestinal symptoms and fever record. The so-called typho -malarial or 7nalario-typhoid fever has many symptoms in common, but lacks the diarrhoea, eruption, and tempera- ture record. Prognosis. A positive prognosis cannot be made. Favorable indications are constipation, slight diarrhoea, low temperature, and moderate delirium. Unfavorable symptoms are obstinate and severe diarrhoea, early high temperature, marked nervous symptoms with coma vigil or stupor, albuminuria, and repeated intestinal hemor- rhages. The prognosis is always more favorable in winter than in summer. When death occurs it is usually during or about the third week, the result of exhaustion, cardiac failure, or some complication. The mortality in typhoid fever in private practice is about one death in twenty ; in hospital practice it varies from one death in five to ten cases, although the cold-bath treatment has greatly reduced the hos- pital mortality. Treatment. There is no specific treatment for typhoid fever. FEVERS. 27 The indications are to sustain life and meet the urgent and dangerous symptoms as they arise. Flint held that, as it was a self-limited disease, “ if the patient can be kept alive, after three, four, or more weeks, recovery will take place provided there be no serious complication. In a case of severe uncomplicated fever the patient is in a situation not unlike that of a person in danger of drowning not far from or perhaps very near the shore. If he drown it is because his strength gives way before the shore is reached. As a person in this situation requires only to be buoyed up by some support, so the fever patient in a similar emerg- ency may only need supporting measures to live.” It is important to secure intelligent nursing , a quiet, airy sick- room with an average temperature of 65° Fahr., and the most scrupulous cleanliness of patient, bedding, and utensils. The patient must go to bed from the first moment of suspicion that typhoid fever is developing, and remain in bed until convalescence is well established. The stools and urine must be disinfected the moment voided, and quickly discharged into a sewer or buried. The diet should be nutritious and liquid at intervals of every two or three hours. Diluted inilk is the best article, but broths, soups, liquid peptonoids, coffee, and cold milk and tea may be alternated. A word of caution, however, as to the quantity of food administered. The amount should be small, as the digestive capacity of the patient is greatly lessened by the febrile phenomena. Much harm results in typhoid fever from stuffing the patient. The tendency to bed-sores must be borne in mind and treated. The use of finely powdered boric acid over irritated parts will often pre- vent the development of sores. Attention should be given to the mouth, and the dryness and tendency to collection of sordes prevented by frequently washing the mouth with glycerine and water or weak boric solution. The following remedies have advocates, claiming that they modify the course of the disease ; hydrargyrum , iodu)n , acidum carbolicum , mineral acids, argentum nitras , and ergota. A mild case of the disease will do well with acidum hydrochlori- cum dilutum , n\^x-xx, well diluted, every four hours, alternated with quinines sulphas , gr. ij. 28 PRACTICE OF MEDICINE. Cases with high temperature and costive bowels are sometimes wonderfully benefited by the following : — R. Hydrargyri chlor. mite, ..... . . . gr. Pulv. ipecacuanhse, gr. ^ Pulv. opii, . . gr. i Sodii bicarb., gr. j Repeated every three or four hours, and quinince sulphas, gr. ij, every four hours. The present so-called “ specific treatment ” of this disease consists in the administration every second evening, until four doses are taken, of hydrargyri chloridi mite , gr. vij-x, which seemingly lessens the .fre- quency of the stools in the later stages of the attack, although slightly increasing them at the time. Also administering from the beginning of the attack — R. Tinct. iodi., £ ij Acid, carbol. liq., gj. M. Sig. — O ne, two, or three drops in ice water, every two or three hours, after food. The reduction of temperature is one of the most important indica- tions in the majority of cases of typhoid fever. There is now no doubt that the former views regarding the amount of fever a patient could stand for one or two weeks are responsible • for the high mor- tality in this disease. A temperature of 103° to 105° for a dozen days is dangerous and should be combated. Among the measures that have been used are the calomel powders mentioned above, or anti- febrin , gr. iij, every two hours in the afternoon until 102° is reached, or phenacetin , gr. x, repeated in three or four hours, or quinines sulphas, gr. xv-xx, morning and night. A strong prejudice has arisen against quinina within the last few years, nevertheless, I know I have seen great benefit from its use, and strongly recommend it. Cold sponging with water alone or alcohol and water is often of great value in mild cases. The cold pack is a very powerful antipyretic and, in cases with tem- perature of 104° or 105°, in which the cold bath cannot be employed, can be made use of. The bed should be protected by a rubber cloth, and the patient, with his clothing removed, should be wrapped in a sheet wrung out of cold water. The surface should be rubbed briskly through the sheet, and from time to time cold water is freely sprinkled over the sheet. Friction must be continued during the pack, FEVERS. 29 and ice cloths or cap placed on the head. The duration of the cold pack is determined by the temperature and the reactive powers of the patient. It is often well to administer an alcoholic stimulant or a hypodermic injection of strychninae sulphas before the pack and, may be, after. The cold bath after the method of Brand, or “ tubbing,” has proven most prompt and decided for reducing temperature. It consists in the systematic employment of general cold baths with frictions whenever the temperature reaches 102. 2° F. As often as the tem- perature, taken every three hours in the mouth or rectum, is over 102.2 0 , the patient receives a bath lasting fifteen or twenty minutes. He wears a thin muslin garment or, wrapped in a sheet, he is given a stimulant and carefully lifted into the bath of 65° or 70°, some cold water being poured over his head and shoulders to lessen the shock ; the head rests on an air pillow, the body submerged to the neck. During the whole period of the bath the patient must be briskly rubbed. The friction and affusion are of value in preventing chill and cyanosis. After the bath the wet linen is quickly removed and the patient placed in bed, wrapped in dry sheet, and covered with a blanket. A stimulant is again given after the bath and if tendency to cyanosis or heart failure a hypodermic injection of strychnina. The temperature is taken after patient is placed in bed and again in half to three-quarters of an hour, and if not then 102° is not again taken for three hours. The good effects of the bath are, reduc- tion of temperature, with the intellect clearer, the stupor lessens, the muscular twitchings diminish, insomnia overcome, sleep usually fol- lowing a bath, and a general stimulating effect upon the heart and nervous system. Diarrhoea should not be checked unless it exceeds three or four stools in twenty-fours, when may be used — R. Bismuth subnit., gr. xx Acid, carbol., . . . Tinct. opii deodorat., Mucil. acacise, . . Aquse, gtt- j gtt. x-xv M. SlG. — Every three or four hours. Or— R. Cupri sulph., . . . Extracti opii, . . . SlG. — In pill, every four hours. g r - V* gr- X M. 30 PRACTICE OF MEDICINE. Or — R . Salol, gr. iij Bismuth, salicyl., . gr. v. M. Sig. — I n powder after each stool. Or — R . Acid, sulph. aromat., . . • ....... n^xv Tinct. opii deodorat., . YX\x. M. Sig. — -I n water every three hours. For Tympanites : cold compresses or an ice bag to the abdomen. Rarely, a turpentine stupe is of value. Page recommends the gentle introduction of a catheter far up the rectum to relieve a powerless bowel, as urine is drawn from a paralyzed bladder. Tympany with constipation is relieved by the use of olei terebinthince , gtt. x, olei ricini , gtt. xv, in emulsion every three or four hours. For Thirst : cooling drinks in moderation, or pellets of ice slowly dissolved in the mouth. Headache : cold to the head, mustard to the neck, and foot baths: if these fail to relieve, morphina or atropina hypodermically. Delirium : if from debility, increase the stimulants ; other causes, use morphina , if active. Insomnia , if of long duration, use trional gr. xv-xxx. Restlessness and coma vigil , stimulants , and ice cap. Debility : food every two or three hours ; do not permit sleep to in- terfere with nourishment. Stimulants are indicated early, the best guide being the heart’s action; an average amount would be gvj spls. vini gallici , per diem, or chloroformi , nyj-v, every hour or two, well diluted, or moschus, gr. x, repeated p. r. n. The bladder should be examined at each visit. Intestinal hemorrhage : at once morphina, gr. hypodermically, and ext. ergotce fid., fgj, repeated p. r. n., or Monsell's solution, gtt. ij-iv, every two hours, or acidum tannicum. gr. ij-v, with pulv. opii et ipecacuanhce, gr. iij every hour, and cold to abdomen. Perforation and peritonitis : at once morphina sulphas, gr. , hypodermically, followed with extractum opii, gr. j every hour, hot applications to the abdomen and bold stimulation. Lobar pneumonia and bronchical catarrh : dry cups and the use of the following : — R . Ammonii muriat, 3 ij. Strychninae sulph., gr. Spts. chloroformi, sjjss. Aq. lauro-cerasi, . . . . . q. s. ad. f J; iv. M, Sig. — D essertspoonful every two, three, or four hours. FEVERS. 31 Convalescence : The patient must be most guarded in exercise or mental occupation. Liquid diet for ten days to two weeks after normal afternoon temperature. Cardiac palpitation and excessive sweating are not infrequent, and can be controlled with a combination of quinina and belladonna . If the stools continue quite liquid with a little bright blood now and then, showing some remaining ulceration, use argentum nitras in pill form with nucis vomicce or strychnina. The addition of extract of malt or porter to the diet is of value in a prolonged convalescence. TYPHUS FEVER. Synonyms. Contagious fever ; ship fever ; jail fever ; ex- anthematic typhus (German) ; petechial typhus ; spotted or putrid fever. Definition. An acute, infectious, febrile, epidemic disease ; highly contagious , and characterized by sudden invasion, profound depres- sion of the vital powers, sickening odor, and a peculiar maculated and petechial eruption, favorable cases terminating by crisis about the fourteenth day. No lesion. Cause. A special infecting germ, the character of which is un- known, but which is influenced by filth and overcrowding. Rarely seen in the United States except in seaports, where brought by emi- grants. Pathology. No constant lesion peculiar to the affection. Blood is profoundly altered, dark, thin, with lessened fibrin ; tissues dark, soft, and flabby. Symptoms. Begins abruptly ; chill followed by violent fever , temperature within a few days reaching 104° to 105° F. ; a frequent, bounding pulse , soon becoming small, weak, and rapid ; the cardiac impulse and first sound almost effaced ; severe headache, followed by violent delirium ; from the fifth to the seventh day, a coarse, red, dif- fused, measly eruption , with a mottling of the skin all over the body, except the face, not disappearing on pressure ; the face has a uniform deep, dusky flush, the skin has a glazed appearance, the pupils con- tracted, the eyes injected. With the development of the disease there is cutaneous hyperczsthesia, muscular soreness, and tenderness over the tibia. There is great prostration, great muscular feebleness, vertigo , tremor, and subsultus ; co 7 isiipation the rule. End of the second week, 32 PRACTICE OF MEDICINE. the temperature suddenly declines and the patient passes into a rapid convalescence. Complications. Pneumonia and swollen parotid glands are common. Diagnosis. From typhoid fever , the age, season, onset of the disease, character of the eruption, and the intestinal symptoms. Measles begin milder, with coryza and cough, and never have such pronounced nervous phenomena, but there occurs an early eruption, appearing on the face. Cerebrospinal fever has many symptoms in common, and but for the rarity of typhus in this country would be more puzzling. The headache and rigidity of the muscles of the neck are much more pro- nounced in cerebro-spinal fever and the prostration less than in typhus fever. The eruption of typhus is characteristic and should prevent error. Prognosis. Unfavorable indications : high temperature, frequent pulse, early stupor, presentiment of death. Favorable : youth, mod- erate temperature and pulse, and mild nervous phenomena. The duration about two weeks ; 7nortality varies from five to thirty- five per cent. Treatment. Symptomatic. As typhus fever is distinctly conta- gious, isolation is imperative, with immediate removal and disinfec- tion of the patient’s excreta. All cases are benefited by small doses of the mineral acids alternat- ing with quinince sulphas. For high temperature , cold sponging, cold pack, or full doses of quinina. Also, antipyrine , antifebrin , or phenacetin , or the systematic use of the cold bath or “ tubbing,” as now used in typhoid fever. For the headache and delirium cold to the head. In the young and strong, a few leeches to the temple, and chloral , with or without the bromides. For constipation, mild laxatives. Debility : alcohol early and in full doses, or spiritus chloroformi in drachm doses whenever danger of collapse. Convalescence : such tonics as quinina and strychnia. FEVERS. 33 CEREBRO-SPINAL FEVER. Synonyms. Epidemic cerebro-spinal meningitis ; epidemic cere- bro-spinal fever ; spotted fever ; cerebro-spinal typhus. Definition. A malignant epidemic fever, characterized by head- ache, vomiting, painful contractions of the muscles of the back of the neck, retraction of the head, hyperaesthesia, disorders of the special senses, delirium, stupor, coma, and frequently an eruption of petechia or purpuric spots — a subcutaneous extravasation of blood. Lesions of cerebral and spinal membranes are found at \\\z post-mor- tem. Cause. A special micro-organism, of oval shape, occurring mostly in pairs and faintly tremulous, resembling those found in pneumonia and erysipelas, though hardly identical. Bad hygiene seems to favor the development of this affection, but can hardly be considered its cause. The disease seems to have a predilection for the young. Occurs most frequently in the winter months. Slightly if at all contagious. We have no positive knowledge of the manner in which the virus gains entrance into the system. Pathological Anatomy. The extent of lesion present in a given case depends upon the duration of the illness. In cases rapidly fatal, it is probable that the individual is overwhelmed by the poison ere the characteristic anatomical changes have had time to develop. The changes in this disease are twofold : those due to the direct action of the infecting poison upon the blood, producing the group of symptoms constituting the fever and complications, and those giving rise to the local inflammation, viz. : Hyper cemia of the membranes of the brain and spinal cord, followed by an exudation of lyrnph and an effusion of serum , resulting in pressure on the brain and cord. The inflammatory changes are more marked in the membranes at the base of the brain than elsewhere. The lungs, spleen, stomach, liver, kidneys, and bladder are in various stages of congestion If the patient survive long enough inflammatory changes occur ip , v the cranial and special nerves and the organs of special sense. ^ Symptoms. Divided, according to the severity of the lesion, into three groups : the common form, the fulminant , and the abortive . The Common Form begins abruptly with a chill , excruciating head- ache , persistent nausea , vomiting , vertigo , and an overwhelming sense • 3 34 PRACTICE OF MEDICINE. of weakness. Within a few hours the muscles of the back of the neck become rigid and retracted (tonic spasm), with decided pain upon moving the head ; this rigidity and retraction soon extends to the back, when opisthotonus occurs. There is great restlessness, and the surface of the body becomes highly sensitive ( hypercesthesia ). Cramps in the muscles of the legs and elsewhere, and spasmodic twitchings of the lips and eyelids come and go, and, finally, convul- sions or delirium occur. Intolerance of light, and in some cases amaurosis , more or less deafness , loss of sense of smell and taste soon following. The temperature and pulse records are irregular. From the first day to the fifth an eruption of petechiae or purpura occurs in the majority of cases, and also an herpetic eruption begin- ning as herpes labialis appears. The tache cerebral is usually to be obtained. The disease reaches its height in from three to eight days, and passes into stupor and coma , or ameliorates and passes into a protracted convalescence. The Fulmuiant Form. Severe chill , depression , and in a few hours collapse. The patient is overcome by the poison and never reacts. The Abortive Form consists of one or more pronounced character- istic symptoms during the course of an epidemic. Complications. Pneumonitis; endocarditis; pericarditis; typhoid fever ; pleuritis ; intestinal catarrh in infants. Sequelse. Result from thickening of either the cerebral or spinal membranes. Persistent headache ; blindness , or deafness , partial or complete ; mental feebleness ; chronic hydrocephalus ; epilepsy, or different forms of spinal palsies. Diagnosis. Typhoid fever begins slowly, has a characteristic temperature record, without so intense headache, muscular rigidity, opisthotonus, vomiting, early delirium, ending in coma. Typhus fever has higher fever, is of longer duration, and has a peculiar measly eruption, is not attended with muscular rigidity and retraction, hypersesthesia, nor disorders of the special senses. Tubercular meningitis is not epidemic, has no characteristic erup- tion ; is preceded by long prodromes, and runs a tedious course. A congestive chill resembles the fulminant cases in suddenness of depression, but the latter has not the history of the former. Inflammation of the meninges of the cord is due to exposure to cold or syphilis, and is not attended with cerebral symptoms or an eruption. FEVERS. 35 Sinallpox in the first days, with the severe lumbar pains, headache, vomiting, and rash, may cause error. Prognosis. Varies according to epidemic ; from twenty to fifty, and even seventy-five per cent. die. Treatment. There is no abortive plan of treatment for cerebro- spinal fever, nor can the antiphlogistic treatment of the inflammatory symptoms be advised. Like the infectious diseases in general, sus- taining measures are indicated in all but the most sthenic cases. Nutritious and easily assimilated food, such as milk, eggs, meat- juice, and broths, should be given at regular intervals night and day. If food cannot be taken by the mouth, nutritious enemata should be substituted. The drug that holds the highest place in the treatment of this dis- ease is oj)ium. The hypodermic use of morphina , gr. % to }4 every two or three hours ; or extractum opii , gr. j every hour until stage of effusion, when quinina in tonic doses, and potassii iodidum are indicated. Prof. Da Costa alternates potassii bromidum with opium , especially in children. Ergota in the early stages would seem to be indicated, but in practice it is of little or no value. Caution in the use of the coal-tar products must be exercised, as the relief of pain and spasm may be the onset of the stage of collapse instead of the beneficial effects of these drugs. Locally , cold compresses to the head and spine is a most valuable measure, continued for hours at a time. For sequelce , potassii iodidum , a course of hydrargyrum , oleum morrhuce, and flying blisters along the spinal column. v > RELAPSING FEVER. jLcy ■ Synonyms. Febris recurrens ; famine fever; bilious typhoid fever ; spirillum fever. Definition. An acute infectious, contagious , epidemic, febrile disease, self limited, characterized by a febrile paroxysm, lasting about six days, succeeded by an entire intermission of the same duration, which is in turn followed by a relapse similar to the first seizure. Associated with alterations in the viscera, and by the presence in the blood of a specific micro-organism — the spirillum of Obermeyer. No specific lesion. Cause. A specific poison; contagious; acquiring the greater 36 PRACTICE OF MEDICINE. activity the more filthy, crowded, and unhealthy the population amid which it prevails. Pathological Anatomy. During the febrile paroxysm only, the blood contains minute cork-screw-shaped organisms ox spiral filaments — spirilli , constantly twisting and rotating — the spirillum Obermeieri. The spleen is enlarged and usually covered with a fresh fibrinous exudation. The capsules present a mottled appearance. The splenic pulp is more or less softened and swollen and shows enlarged Malpighian bodies. The liver and kidneys are swollen and con- gested. Symptoms. No prodromes . Onset abrupt, with fever, 102 0 - 104° ; frequent, rather weak pulse , headache, nausea, vomiting , and lancinating pains in limbs and muscles, marked in the calf of the leg ; second day, feeling of fullness and pressure in right and left hypo- chondrium, due to swollen liver and spleen ; jaundice is frequent ; seventh day fever ends by crisis ; fourteenth day symptoms return in milder form, continuing about four days, when enters slow convales- cence, much emaciated. No eruption . Several relapses may occur. Diagnosis. Yellow fever has many points of resemblance, but has a shorter febrile stage, remission not so complete, vomiting late and characteristic, normal spleen, and the late appearance of yellow color. Remittent fever begins with a decided chill, followed by fever and sweats, and not the progressive rise of temperature till the fifth or seventh day. ^ Prognosis. Recovery the rule, but protracted, and decided emaciation results. Treatment. Expectant. Act on secretions ; nourish patient and meet urgent symptoms. For fever, antipyretic doses of quinina, which, however, has no power to prevent the relapses; for pain, hypoder- mic injections of morphina ; for nausea and vomiting, acidum carboli- cum or cerii oxalas ; during remission, ferrum and quinina in tonic doses. PERIODICAL FEVERS. These affections are characterized by the distinct periodicity of the phenomena, having intervals during which the patient is wholly or nearly free from fever . FEVERS. 37 INTERMITTENT FEVER. Synonyms. Ague ; chills and fever ; malarial fever ; swamp fever. Definition. A paroxysmal fever, the phenomena observing a regular succession ; characterized by a cold, a hot, and a sweating stage, followed by an interval of complete intermission or apyrexia, varying in length according to the variety of the attack and the presence in the blood of the haematozoa of Laveran. Cause. The presence in the blood of a specific vegetable micro- organism. Klebs and Tommasi-Crudeli claim to have isolated a germ — Bacillus Malarice — from the low-lying atmosphere over marshes and from the soil, which produced a malarial paroxysm with enlarged spleen in an inoculated rabbit. Laveran discovered a germ in the human blood of patients suffer- ing from malarial fevers which is now known as the hcematozoa of Laveran, and which has since been found always present in malarial attacks. These germs are true parasites and exhibit several varieties of form and size, and it is possible that there may be several species which are capable of causing the distinct types of the disease, as ter- tian, quartan, intermittent, or remittent. Laveran describes the chief forms of the haematozoa as consisting of amoeboid spherical bodies with nuclei ; crescentic shapes with nuclei ; rosettes ; and flagellate bodies. Laveran considers the para- site as a single but polymorphic organism, and a particular form of the germ is peculiar to a particular type of the disease. Osier, who has devoted much time to the study of the subject, “believes that different forms of the germ belong to distinct species, and that they are not all different stages in the development of one microbe.” The period of incubation varies from a few days to weeks, months, or even years, an auxiliary condition, such as exposure to cold, over- exertion, excesses in eating and drinking, or great excitement, often being necessary to give efficiency to the special cause. Either sex and all ages are susceptible to the poison. The mode of infection is not positively understood. It often enters the system in the inspired air, and no doubt also in contaminated drinking-water or other fluids. Pathological Anatomy. Blood dark, from the formation of pigment (Melanczmia). Spleen engorged and swollen ( Ague cake). Liver swollen and engorged during paroxysm. 38 PRACTICE OF MEDICINE. Varieties. Quotidian when a daily paroxysm ; tertian when every other day ; quartan when it occurs first and fourth days ; octan when weekly ; duplicated quotidian when two paroxysms daily ; duplicated tertian , two every second day ; double tertian , daily paroxysm, but more severe every second day. Dwnb ague , or masked ague, presents irregularity of the characteristic phenomena. Symptoms. Each paroxysm has three stages, the cold , hot , and sweating Cold stage begins with prodromes , lassitude, yawning, headache and nausea, followed by a chill ; the teeth chatter, skin pale, nails and lips blue, the surface rough and pale, the so-called goose-skin , or cutis anserina , nausea, and great thirst, while the thermometer in the axilla or mouth shows a decided rise of temperature , 102° F.- 104°; these phenomena continuing from one-half to an hour. Hot stage begins gradually, by the shivering ceasing, the surface becoming hot and flushed, the temperature rising to 106 0 F., or more, pulse full, headache , nausea , intense thirst , dry , flushed, swollen skin, scanty urine , and other phenomena of pyrexia , continuing from one to eight or ten hours. Sweating stage begins gradually, first appearing on the forehead , then spreading over the entire surface; the fever lessens , the tem- perature rapidly falling to 99 0 or 98°, pulse less full, headache lessens, and a general feeling of comfort exists, sleep often following ; dura- tion of the sweating from one to four hours, when the intermission occurs, the patient apparently well, except for a feeling of general debility. The occurrence of the next paroxysm depends upon the variety of the attack. The paroxysm may be ushered in by a decided pain in one or more nerves, instead of the cold stage, to wit : “ brow ague." Diagnosis. No difficulty when the characteristic chill, fever , and sweats occur and enlarged spleen, and the presence of the bacillus in the blood. Hectic fever. Distinguished by its irregularity, and occurring secondary to an organic disease ; spleen usually normal size, and absence of bacillus in blood. Pycemia produced by other causes than malaria. Nervous chills show .an absence of the temperature rise. Prognosis. Recovery the rule. Without treatment many cases FEVERS. 39 end favorably after several paroxysms, others passing into the chronic form, or malarial cachexice. Treatment. Cold stage can be averted and the other stages greatly modified by a hypodermic injection of either morphince sulph ., gr. yi-\i , ox pilocarpines hydrochloras, gr. or chloroformi spts., f£j, by the stomach. Hot stage, cool drinks and cold sponging. Sweating stage , when excessive, sponging with alumen and hot water. Intermission ; at once a brisk purgative, followed by cinchona in some form, the most efficient being quinince sulph., gr. xx-xxiv, in solution or freshly-made pills, in one or two doses, three to five hours before the expected paroxysm. Many substitutes are lauded to re- place the salts of cinchona bark, but without a doubt quinina is a specific in the strictest sense of the term. After the paroxysms are broken up, use liq. potassii arsenit., gtt. v-x, t.d., for a long time, or tinct.ferri chloridi, gtt. xx, every four hours, or a combination like the following : — R. Ferri reducti, Quininge sulph., aa gr. xlviij Acidi arseniosi, gr. j 01. pip. nigr., gtt. xv. M. Ft. pil. No. xxiv. SiG. — One pill after meals, continued for one month or longer. Relapses being common, quinina should be given on the second or third day fourth to the sixth, twelfth to the fourteenth, and nineteenth to the twenty-first days. If the spleen be enlarged, and it usually is in long-continued cases, or those becoming chronic (marked anaemia, gastric distress, consti- pation with depression of spirits associated with headache coming in paroxysms are the prominent symptoms of the cachexia), use locally ung. hydrargyri iodidi rubri and internally ergota, or ergotine (aq. ext.) hypodermically over the splenic region, and tonic doses of quinina, ferrum, and arsenicum . REMITTENT FEVER. Synonyms. Bilious fever ; bilious remittent fever ; marsh fever ; typho-malarial fever. Definition. A paroxysmal fever, with exacerbations and remis- sions, but in which the temperature is constantly above the normal ; 40 PRACTICE OF MEDICINE. characterized by a moderate cold stage (which does not recur with each paroxysm) ; an intense hot stage, with violent headache and gastric irritability ; and an almost imperceptible sweating stage, which is frequently wanting. Cause. The presence in the blood of a specific vegetable micro- organism, either the Bacillus malaria (Klebs and Tommasi Crudeli), or the hcematozoa of Laveran ( vide Intermittent Fever). Pathological Anatomy. Blood dark ( Melancemia ) ; spleen enlarged, soft, filled with blood, and of an olive color ; liver congested and swollen, and of a bronze hue ; the brain hyperaemic and olive- colored ; gastro-intestinal canal markedly hyperaemic. Symptoms. Cold stage : moderate chill , the temperature rising one or two degrees, coated, dry tongue, oppression at the epigastrium , slight headache , and pains throughout the body. Hot stage : persistent vomiting, furred tongue, full pulse , rising to ioo or 120, flushed face, injected eye , violent headache, pains in limbs and loins, hurried respiration , the temperature rising to 104° F., or 106 0 . The bowels costive, stools tarry and offensive, the urine scanty, high colored and ureaic, and the surface becoming yellowish. Deli- rium occurs when the temperature is very high. Sweating stage : after six to twenty-four hours, the above symptoms abate, and slight sweating occurs, the pulse , headache, and vomiting subside, and the temperature falls to ioo° F., or 99 0 F. This is the remission, during which the symptoms of a mild pyrexia are present. After some two to eight or twelve hours, the symptoms of the hot stage return, generally minus the chill, and this is termed the exacerbation, which is in turn again followed by the remission. Duration. From seven to fourteen days the average. Fre- quently the fever ceases to remit , and instead becomes continuous , the symptoms resembling, if they are not identical with, the typhoid state, whence the term typho-malarial fever, or malario-typhoid fever. Sequelae. The malarial cachexia results when the poison has not been eliminated from the system. Persistent headache and vertigo are the results of the intense meningeal hyperaemia that sometimes occurs. Diagnosis. In intermittent fever each paroxysm begins with a chill, while the chill seldom recurs in remittent fever ; a distinct intermission follows each paroxysm of the intermittent form, while a fevers. 41 remission occurs in remittent, the thermometer showing that the fever does not wholly disappear; during the intermission the patient is apparently well ; such is not the case in the remission of remittent fever. Typhoid fever is mistaken for remittent fever, but the absence of the characteristic temperature record, diarrhoea, eruption, tympanites, deafness, and severe prostration should prevent such an error. A diagnosis can always be made absolutely by an examination of the blood. Prognosis. Uncomplicated cases are favorable. Treatment. Quinines sulphas , gr. xvj-xx per diem, is the remedy. Better administered during the remission, if possible. If an irritable stomach prevents its administration by the mouth, use it by the hypo- dermic method or in a suppository . During the hot stage, cool spong- ing, cold to the head, and if a tendency to cerebral congestion, dry or wet cups to the nape of the neck and — R . Tinct. aconit. rad. , gtt. j-ij Liq. potas. citrat., . . . 3 ij Liq. ammon. acetat., ^ij. M. Every two hours. During the remission, relieve the intestinal canal with — R . Hydrargyri chlor. mite, gr. v Sodii bicarb., ...*•■ gr. v Pulv. ipecac,, gr. M. In pulv. p. r. n. The same precautions are essential after the paroxysms are broken up, to prevent their return on the septenary periods, that were recom- mended for intermittent fever. For convalescence: Ferrum, arsenicum, and strychnina are indi- cated. PERNICIOUS FEVER. Synonyms. Congestive fever; malignant intermittent fever; malignant remittent fever. Definition. A malignant, destructive malarial fever, which may- be of the intermittent or remittent form ; characterized by intense congestion of one or more internal organs, together with dangerous perversion of the functions of innervation. 42 PRACTICE OF MEDICINE. Cause. A high degree of malarial poison. ( Vide Intermittent Fever.) Varieties. Gastro-enteric ; thoracic; cerebral ; hemorrhagic ; algid. Symptoms. Any of these varieties may begin either as an inter- mittent or remittent fever ; again, the first paroxysm is rarely per- nicious, but appears as the ordinary malarial attack. The gastro-enteric variety has as distinctive features, intense nausea and vomiting , purging of thin discharges mixed with blood, tenesmus , burning heat in stomach, intense thirst, frequent, weak pulse, face, hands, and feet cold, with shrunken features , and an intense depression of all the vital forces. This condition continues from half an hour to several hours, when either an inter- or a remission occurs. Thoracic variety often combined with the one just described. Its characteristic features are due to overwhelming congestion of the lungs, such as violent dyspnoea, gasping for air, fifty to sixty respira- tions per minute, oppressed cough with slight amount of blood-streaked sputa, frequent, weak pulse, cold surface, and terror-stricken features. Duration same as the above. Cerebral variety, due to intense congestion of the brain ; sometimes effusion of serum into the ventricles, or even rupture of small blood- vessels. Characterized by violent delirium, followed by stupor and coma, slow , full pulse , the surface either flushed or livid. Cases may either resemble apoplexy — comatose variety, or acute meningitis — delirious variety. Duration same as the other forms. Hemorrhagic variety, or the yellow disease, as it has been termed, begins as an ordinary inter- or remittent fever, soon followed by signs of internal congestion, to wit : nausea, vomiting, dyspnoea, severe pains over liver and kidney, continuing for a few hours, when the surface suddenly turns yellow and bloody urine is voided, after which an inter- or remission and marked abatement occur, to be sooner or later followed by a second paroxysm, which is more severe, with signs of cerebral congestion. Blood may also escape from other parts than the kidneys. Algid variety is characterized by intense coldness of the surface, while the rectal temperature ranges from 104° to 107° F. The attack begins with a chill, which is soon followed by fever of variable dura- tion, when the body becomes cold, the axillary temperature falling to 90°, 88°, or even 85° F., a cold sweat covers the surface, the tongue is FEVERS. 43 white , moist , and cold , the breath is zVy, the 2/0z‘c and death within two weeks, but such cases are rare. Diagnosis. Duodenal ulcer presents symptoms so akin to those of gastric ulcer that a differential diagnosis is impossible. Chronic gastritis is often confounded with gastric ulcer ; the dis- tinctive points are, absence of vomiting of blood, no localized con- stant pain aggravated by food, and no tenderness in the back ; while the symptoms of indigestion are marked and persistent, with, as a DISEASES OF THE STOMACH. 79 rule, a history of spirit drinking, and the age of the patient — middle life ; ulcer in the young. The points of distinction between gastric cancer and gastralgia will be pointed out when considering those affections. Prognosis. Not very unfavorable. Recoveries are frequent. The dangers are perforation, peritonitis % or fatal hemorrhage. Treatment. Give the stomach as complete a rest as possible ; this is accomplished by rectal alimentation, or where it cannot be carried out, an exclusive milk diet, adding lime-water to enable the stomach to better retain the milk, or a strictly skimmed-milk diet, to which may also be added lime-water ; the amount of milk should be one or two ounces every two hours. Rest in bed is paramount, and should be enforced. F or pain, small doses of morphina should be used as needed. For hemorrhage , hypodermic injections of ergota are most reliable. Plumbi acetas , gr. j-iij, arrests the bleeding and exercises a favorable influence over the ulcer. For the ulcer , liquor potassii arsenitis gtt. j-ij every five hours, has given excellent results in several cases treated by the author ; bis- muthi subnitras , gr. xx-xxx, combined with sodii bicarbonas, gr. iij-v, three times a day, often does well ; argenti nitras , gr. X - K> every four hours, or argenti oxidum, gr. ss. every four hours, are at times beneficial. For the associated anaemia, ferrum and arsenicum , alone or com- bined, are indicated. Ferri albuminate would seem to be particularly indicated, or the following : — R . Pulv. ferri albumin atis, gr. ij Sodii arseniat., gr. M. Ft. pil. or capsule, taken 3 or 4 times daily. The bowels must be kept soluble. If perforation and peritonitis result, full doses of opium are indicated. GASTRIC CANCER. Synonyms. Cancer of the stomach ; gastric carcinoma. Definition. A peculiar malignant growth, occurring for the most part at the pyloric extremity of the stomach, making constant pro- gress, destroying the gastric tissues and infecting the lymphatic 80 PRACTICE OF MEDICINE. glands; characterized by disorders of digestion, pain, vomiting, marked anaemia, and terminating in all cases by the death of the patient. Cause. Hereditary. Develops after forty years, for the most part. The question of a cancer germ is gaining ground. Pathological Anatomy. Cancer of the stomach is the most common form of cancer. It is, as a rule, a primary cancer. The variety is most commonly the scirrhus , next in frequency, medullary , the least frequent, colloid. As regards the location, eighty per cent, occur at the pylorus. It originates usually in the tubules , rapidly infiltrating the remain- ing tissues, thickening everywhere as it progresses, and either remains a hard nodulated mass or undergoes ulceration. The hard nodulated growth at the pylorus constricts the orifice, resulting in dilatation of the stomach. The lymphatic glands adjacent to the stomach are ir, filtrated, secondary cancers resulting. Ulceration into an artery causes hemorrhage into the peritoneum, resulting in local peritonitis. Complications. Fatty heart; thrombosis; tuberculosis. Symptoms. The development of gastric cancer is insidious with indigestion , progressive in character, associated with marked acidity , flatulency, and a fetid breath. The majority of cases have vomiting , occurring immediately after eating, if at the cardiac orifice, and some hours after if at the pylorus ; if much dilatation of the stomach develop the vomiting occurs some days after eating. The rejected matter is food in various stages of digestion, associated frequently with black grumous masses of altered blood and tissues. Hemorrhage is frequent, rarely profuse, usually oozing of blood altered into a dark brown or black color — “coffee-ground” vomit. Absence of hydrochloric acid in the stomach is a very constant observation in gastric cancer. Pain, marked and constant, dull, heavy, increased by pressure or food, seldom lancinating. Marked anaemia and e7naciation are present, the surface having an earthy or fawn color. (Edema of the ankles is an early diagnostic symptom in carcinoma of the stomach, often occurring as early as the third month, and may progress to a general anasarca. A tumor is found in three-fourths of the cases, occupying the epigastric region, not moving with inspiration. As the carcinoma progresses, the lym- phatic glands enlarge, particularly the supra-clavicular and inguinal DISEASES OF THE STOMACH. 81 glands. Jaundice frequently occurs, and the liver is enlarged. The urine often contains albumin. The duration of the disease is about one year, the patient dying from exhaustion , peritonitis , or hemorrhage , the mind clear but despondent. Diagnosis. The continuous presence of free hydrochloric acid in the stomach is a diagnostic sign of great value in excluding the probable existence of gastric cancer. Chronic gastric catarrh differs from gastric cancer, in the absence of a tumor, bloody vomit, characteristic pain, peculiar color of the surface, dropsy and the rapid emaciation. Gastric ulcer differs in the character of the pain, age of the patient, large amount and color of bloody vomit, the absence of a tumor, and progressive emaciation. Still the diagnosis is often difficult. Abdominal tumors may raise the question of a gastric cancerous tumor ; the points of distinction are the characteristic symptoms of gastric cancer, and that abdominal tumors, especially of the liver and spleen, the ones most apt to cause error in diagnosis, are influenced by inspiration, while tumors of the stomach are not so influenced. When a scirrhus of the pylorus lies upon the aorta, a pulsation may be communicated to it, raising the question of aneurism of the abdominal aorta , but the expansile pulsation of aneurism (Corrigan’s sign) is wanting, as are the other symptoms of the affection, and if the patient is made to rest upon his hands and feet, the stomachic tumor falls away from the aorta and pulsation ceases. Mikuliez claims that, by the use of his gastroscope , regular rhyth- mical motions can be seen when the pylorus is not the seat of cancer, and that such movements are absent when it is the seat of cancer. Prognosis. Unfavorable. Internal medication offers no hope, the patient usually succumbing from starvation. Gastric carcinoma occurring under thirty years of age is rapidly fatal, not conforming to the usual symptoms as seen later in life ; the characteristic cachexia is commonly absent and hasmatemesis is rare. Treatment. We possess no means of arresting the disease, although it is but fair to mention that in Germany condurango in the form of decoction is recommended as a specific in some cases. I have faithfully used the fluid extract with some benefit for the accompany- ing gastritis, but without effect on the tumor. “ Six operations have 7 82 PRACTICE OF MEDICINE. been practiced for the relief of stenosis of the pylorus : ist. Pylorec- tomy ; 2d. Gastro-enterostomy ; 3d. Gastrectomy ; 4th. Gastrostomy ; 5th. Duodenostomy ; 6th. Digital divulsion of the pylorus.” Professor Billroth has excised the pylorus, thereby prolonging life ten months. For acidity and fetor of the breath , acidum carbolicum , gr. , or carbo animalis purificatus, gr. x-xxx, affords some relief. For vomiting , bismuth and opium , or lavage or the washing out of the stomach. For pain , morphina , or the following, recommended by Osier : R. Morphinae sulph., gr. j/g Sodii bicarb. gr. v Bismuth subnit gr. x. M. Sig. — R epeated p. r. n. Avoid stimulants. GASTRIC DILATATION. Synonyms. Gastrectasis ; pyloric obstruction ; pyloric stenosis. Definition. An abnormal increase of the cavity of the stomach, with the walls either hypertrophied, or decreased in thickness ; char- acterized by pronounced indigestion, vomiting of partly digested and partly decomposed food at intervals of a day or two, and noisy mov- ing of flatus within the abdomen (borborygmus). Causes. Most common cause a stricture of the pylorus, the result of cancer ; pressure of tumor against the pylorus, preventing exit of stomachic contents. Loss of muscular tone, occurring in anaemia. Prof. Bartholow cites cases resulting in excessive beer-drinkers, who drank thirty to forty glasses of beer habitually, every day. Pathological Anatomy. When obstruction exists at the pylo- rus, the whole organ is dilated, with hypertrophy of the muscular layer of the stomach. In dilatation without pyloric obstruction, the muscular layer is thinner than normal, paler in color, and presents signs of fatty degeneration ; the mucous membrane is also pale, thin, and without rugae. Symptoms. Those of the disease producing the obstruction plus those of obstinate chronic gastric catarrh, with characteristic vomiting ; the cavity having a greatly increased capacity, large accumulations take place, which are rejected every day or two, partly digested and partly decomposed. Regurgitation of partly digested aliment, acrid, DISEASES OF THE STOMACH. 83 acid, and offensive, is very common. Bowels constipated , the stools hard and dry. Physical signs of gastric dilatation are : on inspection , abnormal prominence of the whole epigastric region, with a tumor in the pylo- ric region which seems to be connected with the stomach ; percussion , if empty, tympanitic note extending to or below the umbilicus, hav- ing a metallic quality ; if the stomach be filled, high-pitched flat note ; auscultation , splashing and rumbling sound, the succussion sound being distinct if the body be shaken. Diagnosis. Copious vomiting of food partly digested, once in twenty-four hours or less often, epigastric distress and pain resulting from foul smelling and acid eructations and from obstinate constipa- tion. Penzoldt’s modification of Piorry’s method of determining gastric dilatation is to withdraw the contents of the stomach by means of the oesophageal tube and then refilling the stomach with fluid. By noting the lower limit of percussion dullness thus produced, the lower bor- der of the stomach can be accurately determined. Treatment. Regulated diet. Restrict the use of fluids, using a “ dry diet ” exclusively. If the result of pyloric stenosis, one of the operations mentioned for pyloric cancer may be indicated. Regardless of the cause, washing out the stomach with the stomach tube, every day or two, gives relief, and, if no stricture be present, administer strychnina or nux vomica , and very favorable results may follow. GASTRIC HEMORRHAGE. Synonyms. Haematemesis ; gastrorrhagia. Definition. Gastric hemorrhage is not, strictly speaking, a dis- ease, but a symptom ; still, vomiting of blood occurs under such a variety of conditions, that a separate consideration is desirable. Causes. Ulcer of the stomach ; cancer of the stomach ; scurvy ; purpura ; haemophilia ; hemorrhagic malarial fever ; congestion of the liver or spleen ; vicarious at menstrual period ; yellow fever ; toxic gastritis. Symptoms. Added to the symptoms of the cause of the hem- orrhage, are a feeling of faintness and sinking at the pit of the stom- 84 PRACTICE OF MEDICINE. ach , followed by the ejection of blood of a black , grumous, or coffee- ground appearance. Rarely, and then generally in gastric ulcer, the ejected blood may have a bright red appearance, the gastric juice not having had time to act upon it. If the amount of blood escaping into the stomach is large, blood will be voided by stool. Diagnosis. He7norrhage from the lungs may be confounded with gastric hemorrhage. In the former, the blood is red, is coughed up, not vomited, and is associated with a history of pulmonary dis- ease. The chief point of distinction between pulmonary hemorrhage and the vomiting of red blood is, that in the former you can discern rales on auscultating the chest, and they are absent in the latter. Prognosis. Depends entirely upon the cause, the most unfavor- able being the result of either gastric ulcer, or cancer, or haemophilia. Treatment. Complete rest in bed. Ice , internally and applied in bladders over the epigastrium and along the spine, or hot water , as hot as can be borne, in quantities of four to six ounces at very fre- quent intervals. Hypodermic injections of morphina quiet the patient’s fear, and at the same time have a constringing effect upon the vessels. Extrac- tum ergotce Jluidum or ergotin hypodermically after the patient is quieted, or liquor ferri subsulphatis , gtt. j-v, well diluted by stomach. Cases resulting from congestion of the liver or spleen are benefited by saline purgatives. Allow no food by the stomach for several days, nourishing the patient by rectal alimentation. The hemorrhage controlled, the future treatment is guided by the exciting cause. GASTRALGIA. Synonyms. Cardialgia ; gastrodynia ; stomachic colic ; spasm of the stomach ; neuralgia of the stomach. Definition. A painful condition of the sensory nerves of the stomach, induced by various sources of irritation ; characterized by violent paroxysms of gastric pain and spasm, associated with feeble cardiac action, and symptoms of collapse. Causes. The affection belongs to the group of neuralgine. The most important factor in its causation is general nervous depression ; other causes are gastric cancer or ulcer, malaria, rheumatic or gouty DISEASES OF THE STOMACH. 85 diathesis, anaemia, and certain articles of diet. Occurring in chronic nervous affections, the so-called “gastric crises.” Symptoms. Like most neuroses, gastralgia is distinguished by its paroxysmal character. Romberg thus describes an attack : — “ Suddenly, or after a feeling of pressure at the praecordium, there is sever z griping pain in the stomach, usually extending to the back, with a feeling of faintness , a shrunken countenance, cold hands and feet, and an intermittent pulse. The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out , like a ball, or retracted , with tension of the abdominal walls. There is often pul- sation in the epigastrium. External pressure is well borne, and not unfrequently the patient presses the pit of the stomach against some firm substance, or compresses it with his hands. Sympathetic pains often occur in the thorax, under the sternum, and in the oesophageal branches of the pneumogastric, while they are rare in the exterior of the body.” “The attack lasts from a few minutes to half an hour or longer; then the pain gradually subsides, leaving the patient much exhausted ; or else it ceases suddenly, with eructation of gas or watery fluid, or with vomiting, and with a gentle, soft perspiration, or with the passage of reddish urine.” Besides such severe attacks, we often s ze. painful sensations in the epigastrium , of various degrees of intensity, with passing faintness or sinking at the “ pit of the stomach.” Diagnosis. From myalgia of the abdominal muscles , by the pain of gastralgia being more acute and lancinating, accompanied by nausea and vomiting and the absence of tenderness on pressure. From intercostal neuralgia , by the fact that in this affection the pain is in the left hypochondrium, with painful spots along the course of the nerve trunk and at the spine, and absence of nausea and vomiting. From gastric cancer , by the age, character of the vomited matter, constancy of the pain, the cachexia, emaciation, and the tmnor. From gastric ulcer, by the localized pain and its constancy, with tenderness and vomiting of blood, and constant dyspeptic symptoms, which is not the case in gastralgia. Prognosis. As to perfect recovery, unfavorable, but not danger- ous to life. A chronic affection, in that attacks are prone to return from time to time. The cause has much {o influence a radical cure. PRACTICE OF MEDICINE. Treatment. For the paroxysm , hypodermic injections of mor- phina , gr. , or the stomachic administration of the “com- pound of anodynes,” the so-called chlorodyne, in doses of rr^x-xxx p. r. n. The relief afforded by opium in some form is so decided that it is apt to lead to the opium habit when the attacks are fre- quent. Salicinum is a valuable remedy in this as in many other forms of neuralgia. In the interval , regulated diet and one or more of the following remedies: argenti nitras, quinina, arsenicum , bismuth salicylas, fer- rum , liquor iodii comp., or small doses of potassii iodidum. ATONIC DYSPEPSIA. Synonyms. Dyspepsia ; indigestion ; heartburn ; pyrosis. Definition. A functional derangement of the stomach, with either deficient secretion in the quantity or quality of the gastric juice ; char- acterized by disorders of the functions of digestion and assimilation and the presence of sympathetic nervous symptoms. Causes. Imperfect mastication ; bolting of food ; eating large quantities of food ; same diet long continued ; depressed nervous system, from worry and fatigue ; sedentary habits or occupations. It is often inherited. Symptoms. Perverted appetite , capricious or lost ; difficult di- gestion, a feeling of weight or fullness in the epigastrium ; acidity, from the decomposition of albuminoids; heartburn, flatulency, regur- gitation, or vomiting of portions of partly digested food or acrid fluid — water brash or pyrosis. Pain or soreness at the “ pit of stom- ach” during digestion. Tongue either clean or broad, flabby and pale, showing marks of the teeth. Bowels constipated ; urine gener- ally scanty and high-colored, with excess of urates or oxalates, or, in persons of nervous type, it is pale, of low specific gravity , and con- tains phosphates. Drowsiness after meals, with wakefulness at night, defective memory, headache, and absent mental vigor, with flashes of heat , followed by more or less perspiration. Palpitation of the heart with irregularity in rhythm. Varieties of Dyspepsia . — I. Nervous dyspepsia, atonic form, seen in active business or busy professional men, especially those of thin, spare build, of nervous temperament, who eat meals rapidly and hurry off to their business. These cases present all the marked DISEASES OF THE STOMACH. 87 nervous phenomena. II. Flatulent dyspepsia , seen in hysterical indi- viduals, and showing immense development of gas throughout the abdomen, associated with vertigo and mental worry or hypochondria. III. Acid dyspepsia , water-brash. Seen when the diet is coarse. Acidity of the gastro-intestinal canal and of the urine. IV. Irrita- tive dyspepsia. Vomiting a prominent symptom. In these cases the tongue is small, red, and pointed. Prognosis. With careful living, dyspepsia, functional in charac- ter, is curable. It has been aptly termed “remorse of the stomach.” Treatment. The most important indication is to regulate the diet. Forbid saccharine , starchy , or fatty articles of food. Eat small amounts at a time. Perfect insalivation and mastication. Rest after eating , from a half to an hour. Allow but small quantities of liquids with the meals. In the vast majority of cases forbid the use of stimu- lants with the meals. Aid digestion with fepsinum , with or without aciduni hydrochlori- cum dilutum. Stimulate stomachic peristalsis with nux vomica, gentian or cinchona. For acidity , alkalies at time of acidity. For flatulency, carbo animalis purificatus, gr. x-xx, or one or more of the carminatives, with tinctura nucis vomica before meals. For pyrosis, bismuth and pulvis aromaticus , in large doses. For vomiting , sodii bromidum in small doses, or acidum carbolicum, gr. three or four times daily, or chloral hydrate, gr. x-xv, in demulcent by mouth or rectum, repeated p. r. n. For constipation, resina podophyllum at bedtime, or Hunyadi Janos water before breakfast, hot. For ancemia, massa ferri carbonatis or ferri lactas. Irrigation of the stomach or lavage often gives remarkable relief. The drinking of hot water one-half to one pint an hour before meals is of benefit. A homely but efficient combination for atonic dyspepsia associ- ated with scanty, acid urine and constipation, is — R. Sodii bicarbonatis, sjij Tinct. nucis. vomicae, f 3 iv Tinct. capsici, f^j Tinct. rhei., f^ iss Inf. gentian, comp., ad vj. M. Sig. — H alf tablespoonful after meals, in water. 88 PRACTICE OF MEDICINE. DISEASES OF THE INTESTINAL CANAL. INTESTINAL INDIGESTION. Synonym. Intestinal dyspepsia. Definition. A derangement in the functions of intestinal diges- tion, resulting in the more or less complete decomposition of the chyme , caused by defects in the pancreatic, biliary, or intestinal secretions, or from deficient peristalsis, one or more of these, singly or combined ; characterized by abdominal pain, distention and tympanites developing some hours after meals and nervous per- turbation, anaemia and emaciation. Causes. Imperfect diet; over-eating; anaemia; deficient exer- cise ; worry ; immoderate use of tobacco or stimulants ; diseases of the stomach, intestinal tract, liver, or pancreas ; malaria. Frequently inherited. Symptoms. Intestinal indigestion may be either acute or chronic , the latter the more common. Acute variety , the result of an irritant in the duodenum, rapidly developed pain , flatulency , horhorygmi , slight feverishness , coated tongue, loss of appetite, headache, pains in the limbs, usually termi- nating in a mild attack of diarrhoea. If the attack develops rapidly, the sudden formation of gases causes a paroxysm of colic. Severe attacks are associated with disordered hepatic function, light-colored stools, slight jaundice, and high-colored urine. Chronic variety, resulting from a greater or less decomposition of the partly altered food from the stomach. Pain, varying in character, occurring from two to four or six hours after meals, with slight tenderness and some fullness in the right hypochondrium, epigas- trium, or the umbilical region. Tympanites and borborygmi are marked, the result of gaseous accumulations which have developed from the decomposition of the intestinal contents. Dyspnoea , the result of pressure against the diaphragm, is of frequent occurrence. Marked nervous phenomena develop, the result of the anaemia from deficient assimilation and from the depressing influence on the nervous system of the absorption of the “gases of decomposition,” DISEASES OF THE INTESTINAL CANAL. 89 or ptomaines ; depression of spirits , hypochondriasis , sleeplessness , disturbing dreams , headache , vertigo , buzzing in the ears , muscce vo lit antes, deficient mental application, cardiac irritability, numbness and tingling in the extremities, anomalous pains throughout the body, and in extreme cases, attacks of fainting or epileptiform and cataleptic attacks. The skin is harsh and dry, the bowels are sluggish or constipated , the urine is high colored, of increased density, decidedly acid, and, on cooling deposits lithates, uric acid and oxalate of lime crystals. Functional derangement of the liver follows after a time, adding to the general distress. Ancemia and emaciation result if the attack be protracted. Diagnosis. With our present knowledge it is usually impossible to designate forms of intestinal indigestion due to defects in the quantity or quality of either the pancreatic, biliary or intestinal secretions. Acute intestinal indigestion differs from gastric indigestion in the time of development of the various phenomena, in the latter the symptoms appearing almost immediately after meals, while in the former not appearing until two, four or six hours after. Chronic intestinal indigestion may mislead the physician if the various nervous phenomena are of a marked character, and a careful history of the case is not developed. Prognosis. Favorable if proper and early treatment be inaugu- rated, unless the result of an organic lesion. Treatment. Acute variety, the result of undigested food, is best treated by opium in some form, to relieve the acute suffering, warmth to the abdomen, and a prompt cathartic to cause its rapid expulsion, or six or eight calomel powders two or three hours apart, followed the next morning by a saline (R. Hydrarg. chlor. mit., gr. yi-fz', sodii bicarb., gr. ij ; pulv. ipecac., gr. l /e\ sacch. lact., gr. iij. M. ft. charta.). Chronic variety. Of the first importance is the diet, which should be restricted in amount and confined almost entirely to articles which are readily digested in the stomach, such as beef, eggs and milk. The hepatic, pancreatic and intestinal secretions should be stimu- lated by a course of alkalies , one of the most efficient being sodii 90 PRACTICE OF MEDICINE. phosphas , 3j-ij» three times a day, or the following excellent com- bination : R . Sodii phosphat., Acid, phosph. dil., Syr. zingib., . . . Inf. gentian co., M. Sig. — O ne tablespoonful in water after meals. Aid intestinal digestion by the administration of R. Papoid, gr. j-ij ; naphtalini, gr. j; ext. nucis vomicae, gr. M. Ft. pil. One such to be taken every four or six hours, or liquor pancreaticus , fSj-iv, or extractum pancreatis , gr. ij-vj, with sodii bicarbonatis , gr. v-x, two or three hours after meals, or fel bovis purificatum, gr. j-iij, after meals. For constipation, bitter waters, such as Bedford, Friedrichshall, Pullna, or Hunyadi Janos, or resiiia podophyllum, at bedtime. INTESTINAL COLIC. Synonyms. Enteralgia; tormina; gripes. Definition. A spasmodic contraction of the muscular layer of the intestinal tube ; characterized by acute paroxysmal pain near the umbilicus, relieved by pressure, and associated with feeble cardiac action. Causes. Constipation ; presence of indigestible food ; collections of flatus ; an abnormal amount of bile discharged into the intestines ; lead poisoning ; syphilis ; chronic malaria ; rheumatism ; hysteria. Symptoms. Romberg thus describes a paroxysm : “ There are attacks of pain, spreading from the navel over the abdomen, alter- nating with intervals of ease. The pain is tearing , cutting, pressing, most frequently twitching, pinching, accompanied by peculiar bear- ing-down pains. The patient is restless, and seeks relief in changing his position and in compressing the abdomen ; his surface may be cold and his features pinched. The pulse is small and hard. The abdomen is tense, whether puffed up or drawn inward. There are often nausea and vomiting, and desire for stool. There is usually constipation, but sometimes the bowels are regular or even too loose. Duration from a few minutes to several hours, relaxing at intervals. The attack ceases suddenly, with a feeling of the greatest relief, although some soreness remains for a few days.” Lead colic is always preceded by symptoms of lead poisoning, to DISEASES OF THE INTESTINAL CANAL. 91 wit : slate-colored skin, dark gums showing a blue line, heavy breath, with sweetish metallic taste, obstinate constipation, impaired appetite, slow pulse and contracted abdominal walls. Diagnosis. Gastralgia differs from colic, in the pain being in the epigastric region and associated with disorders of digestion. In hepatic colic , or the passage of gallstones, the pain is in the hepatic region, attended with soreness over the gall bladder, and retching and vomiting, followed by jaundice and the presence of bile in the urine. In nephritic colic the pain follows the course of one or both ureters, shooting to loins and thigh, with retraction of the testicle of the affected side, strangury and bloody urine. In uterine colic the pain is in the pelvis, and associated with men- strual disorders, in fact, a dysmenorrhcea. In ovarian colic or neuralgia, pain on pressure over the ovaries, with hysterical phenomena. Infianunatory disorders of the abdo7nen differ from colic by the presence of fever and tenderness on pressure. Prognosis. Most favorable. Death is the rarest termination possible. Treatment. Relief of pain is the first indication, and is best ac- complished by a hypodermic injection of morphina , gr. Y>~y 3 , which has the additional advantage of relaxing the spasm, thereby favoring the action of purgatives , which should soon follow. One of the best in colic, no matter from what cause, is massce hydrargyrum , gr. v-x, or hydrargyri chloridum mite , gr. every half hour until four or five grains are taken, followed by a mild saline cathartic. After the relief of the pain ancl free action of the bowels, the cause of the attack should be ascertained and corrected, to prevent future suffering. For lead colic, morphina , for the pain; oleum ricini or magnesii sulphas , 3j, every hour for the constipation, and potassi iodidum , gr. v-x, after meals, to eliminate the metal from the system. Excellent re- sults often follow a free or several small venesections in lead poisoning. Gratifying results in attacks of lead colic have been reported from tumblerful doses of oleum oliva> , repeated until some six ounces have been used. It is said to be curative in lead poisoning, in daily doses of two ounces, continued for some time. 92 PRACTICE OF MEDICINE. CONSTIPATION. Synonyms. Intestinal torpor ; costiveness. Definition. A functional inactivity of the intestinal canal, either due to atony of the muscular coat, causing lessened peristalsis, or to a deficiency of intestinal and biliary secretion ; characterized by a change in the character, frequency and quantity of the stools. Causes. Dyspepsia ; character of the food ; habits of the patient ; diseases of the stomach and liver ; malaria ; lead poisoning ; syphilis. Symptoms. In the normal condition the majority of persons have one stool each day, although it is not to be considered abnormal if more or less than that number occur. The bowels are moved every three or four days, with great straining and distress , the face often flushed , the cerebral vessels full. Or in other cases the bowels may be relieved once a day, but the stool is small and hard , causing great distress. Another group of cases have frequent stools during the day, smau and non-formed , due to retained hardened faeces acting as an irritant upon the rectum. The change in the character of the stools is soon followed by symp- toms of dyspepsia, headache, mental torpor, vertigo, palpitation on exertion, and in many cases with great distention of the abdomen. Prognosis. Death never results from functional constipation. Treatment. The successful treatment depends upon the removal of the cause and the hearty co-operation of the patient. First , the patient must have a regular hour each day for going to stool , and must remain a sufficient time to permit a thorough evacua- tion of the bowels. Second , the diet must be carefully regulated. Third , purgative mineral waters or cathartic medicines are to be used with caution , their reckless administration often doing more harm than good. Fourth , either of the following formulae, aided by the enforcement of the above rules, will give good results : — R . Ext. nucis vomicae, gr. % Ext. belladonnae alco., -gr. Ext. aloes aqua., gr. ss Pulv. rhei., gr. j Olei cajuputi, gtt. j. M. In pill, at bedtime, and after a week, every second or third night. DISEASES OF THE INTESTINAL CANAL. 93 R . Resinas podophyl,, Ext. physostig., Ext. belladonnae alco., Aloine, &a gr. X* In pill, every night, or second or third night. R . Ext. cascarae sagradae, fld., rr^xx Glycerini, rt\,xx Syr. sarsaparillae 1T\pcx. Hour after meals, or once a day as indicated. Success often follows an enema of glycerini 3j-iv, or a suppository of glycerinum. Electricity to the abdomen is worthy a trial ; one pole over abdomen the other at anus, using either galvanism or faradism. DIARRHCEA. Synonyms. Enterorrhcea ; alvine flux ; purging. Definition. Frequent loose alvine evacuations, without tenes- mus ; due to functional or organic derangement of the small intes- tines, produced by causes acting either locally or constitutionally. Causes. Those acting locally, such as indigestion , indigestible food , impure food and water , irritating matters or secretions poured into the bowels, or entozoa , cause the flux by a direct irritation of the mucous surface. Attacks of diarrhoea due to constitutional derangement may be secondary to such diseases as tuberculosis , pycemia, albuminuria , typhoid fever , or disturbances of the functions of other organs, giving rise to vicarious fluxes. Atmospheric changes as well as a sudden mental shock will predis- pose to an attack of diarrhoea. Forms. Acute and chronic. Symptoms. Acute diarrhoea presents itself in several varieties, the result of its particular cause, to wit : — Feculent diarrhoea. A few hours after meals the patient feels colicky pains and flatulency , with a desire for stool. There is often nausea , coated tongue, but seldom vomiting. The pain is generally relieved by the purging which ensues. The stools have a feculent character, are of brown fluid, containing faeces, often offensive, the 94 PRACTICE OF MEDICINE. color becoming lighter after four or five evacuations. Constitutional symptoms are wanting. This form is the result of over eating, eating too rapidly, or indi- gestion of different forms, or worms in the intestinal canal, and patients generally recover in a day or two. Lienteric diarrhcea. In this form there is, with the frequency of evacuations, a want of assimilation of food , which passes through the intestines more or less unaltered. The stools are frequent, mucous or serous , more or less covered with bile , mixed with undigested food . In this form the patients emaciate rapidly, owing to the deficient assimilation, the digested portions of the food being hurried on by the increased peristalsis of the irritated bowel. It is usually subacute in its course. Bilious diarrhoea. The stools are frequent, green or yellow , with scalding sensations at the anus and griping pains in the abdomen. Excessive biliary secretion is the irritating cause. Any of the above forms may pass into chronic diarrhcea by exciting permanent diseases of the intestines. Diarrhcea due to constitutional causes will be mentioned when speaking of those conditions. Chronic diarrhoea results from repeated attacks of the acute form, or is the result of some cachexia. The symptoms , as far as the stools are concerned, are much the same as the acute disease, except they are paler, whence it has been termed white flux ; in addition, dyspep- tic symptoms, aphthous condition of the mouth and tongue, flatulency , colic, e7naciation, and ancemia. The appetite is at times capricious, again impaired. Prognosis. Favorable in feculent and bilious forms ; unfavorable in lienteric and chronic forms when emaciation begins. Diarrhoea occurring as a symptom, the prognosis is controlled by the original disease. Treatment. Acute diarrhoea. If the tongue is heavily coated, the breath fetid, and the stools not excessive in number, it is well to clear the intestinal canal with a laxative such as oleum ricini or a sa- line. For children between one and two years of age : — R. Pulv. ipecac., gr. y 2 Pulv. rhei, . . . Sodii bicarb., . . M. . . gr. ss-ij. Every four hours until the character of the stools change. As a rule, however, the stools have become so frequent when ad- DISEASES OF THE INTESTINAL CANAL. 95 vice is sought that the time for laxatives has passed, and some one of the following combinations is indicated : — R. Salol, gr. xxiv-xlviij Bismuth subnit., Sacch. lac., gj. M. Ft. chart. No. xij. Sig. — O ne every two or three hours, reducing the dose for children. Or R . Bismuthi salicylat., gr. xxx Morphinae sulph., gr. j. M. Ft. chart. No. vj. Sig. — O ne every three hours. Or the following modification of “ Squibb’s diarrhoea mixture : ” — R. Tinct. opii deodorat., f ^viss Tinct. camphorae, fjj Tinct. capsici, f^v Chloroformi purae, f 3 iiss Spts. vini gallici, f ? j Alcoholis, ad . . . . f^iv. M. Sig. — O ne teaspoonful, p. r. n. Or the following, which I have always found successful : — R. Tinct. opii deodorat., fgvss Spts. chloroformi, fsjij Acid, sulphuric, dil., f^j Vini pepsini, ad q. s. . . f 5 iv. M. Sig. — O ne teaspoonful in water after each stool. For the bilious form : — R . Hydrargyri chlor. mitis, gr. ^ Sodii bicarb., gr. ij Pulv. opii, gr. M. In powder, every two or three hours, until eight powders are used, fol- lowed by large doses of bismuth and pepsinum. In all acute forms restricted and regulated diet are imperative, pure milk with liquor calcis being the most suitable. In adults, an opium suppository often checks a flux that is uninflu- enced by opium internally. In lienteric or dyspeptic diarrhoea a carefully regulated diet and either of the following combinations : — 96 PRACTICE OF MEDICINE. R. Pepsini glycerit., f^j Liq. potassii arsenit., rr^xxiv Tinct. opiideodorat., f% ij Aq. chloroformi ad q. s. . . f J iij. M. Sig. — O ne teaspoonful at meal time. Or:— R . Papoid, gr. xxiv Bismuth subnit., 3 j. M. Ft. chart. No. xij. SiG. — One at meal time. Chronic diarrhoea. Bismuth , gr. xxx-xl, in milk, every four hours 5 Hope' s camphor mixture , f§j every four hours, or cupri sulphas , gr. yy, ext. opii , gr. y 1 ^, every four hours, or argenti nitras , gr. ext. opii , gr. every five hours ; may all be used with more or less suc- cess; when dry tongue and great flatulency , use : — R. Ol. terebinthini, f^j 01. amygdal., express., f^ss Tinct. opii, f 3 ij Mucil. acaciae, f % v Aq. laurocerasi, fjss. M. Sig. — f every three or four hours. The diet should be nutritious in character, and moderate stimulants are indicated. Activity of the skin and kidneys should be encour- aged. All varieties of intestinal catarrh or diarrhoea are benefited by a few days rest in bed and daily hot baths. CATARRHAL ENTERITIS. Synonyms. Intestinal catarrh ; acute diarrhoea ; inflammation of the bowels. Definition. A catarrhal inflammation of the mucous membrane of the small intestines ; characterized by fever, pain, tenderness, and looseness of the bowels. When the catarrh is limited to the duode- num it is termed duodenitis. Pathological Anatomy. There first ensues hypercemia of the mucous membrane and intestinal glands, manifested by redness , swelling and oedema ; this is followed by increased secretion , and an overgrowth and desquamation of the epithelium, together with a copi- DISEASES OF THE INTESTINAL CANAL. 97 ous generation of young cells. As a result of the hyperaemia, rupture of the capillaries and extravasation of blood often occur. The swollen glands show a strong tendency to ulcerate. This catarrhal process may involve the entire tube or be limited to portions of it. If the catarrhal changes extend to the ileum , the solitary and Peyerian glands show swellings that might be mistaken for the changes of typhoid fever. Causes. A specific virus seems probable in some cases. Im- proper and indigestible food ; summer temperature and exposure to cold and wet, while perspiring, Swallowing fish bones, cherry stones, unmasticated kernels of nuts, etc. Symptoms. Begins with languor , followed by chilliness and fever , the temperature ranging at io2°-io3°, this is followed by fain, colicky and paroxysmal in character, situated above the umbilicus, localized tenderness and loose evacuations. Nausea and vomiting often occur. The bowels are at first constipated, followed by per- sistent diarrhoea; the stools contain but little fecal matter , are yellow ox greenish-yellow in color, mixed with undigested food ; if the stools are numerous, they become whitish and watery, the so-called “ rice- water ” discharges. No blood in stools. The appetite is impaired, and this, with the want of assimilation and great waste, soon produce extreme weakness and emaciation , which is always more marked in children. I have frequently noted a peculiar abdominal eruption in severe cases of intestinal catarrh, occurring as isolated dark red spots, larger than those of typhoid fever, lasting each, twenty-four hours, disappearing on pressure and with decline of fever. Duration. In mild cases, four or five days ; severe cases con- tinue more or less marked, for a week or two. Diagnosis. From colic, by the absence of tenderness and fever, and presence of constipation and its paroxysmal character. From typhoid fever , by the absence of prodromes, characteristic step-like temperature record and characteristic eruption. For points of distinction from dysentery or peritonitis , see those affections. Prognosis. Favorable, if early and proper treatment is em- ployed. Treatment. Rest the bowels by a restricted diet, such as milk and lime water, or weak mutton or chicken soups, with well boiled rice added. 8 98 PRACTICE OF MEDICINE. Keep the patient' quiet in bed, a difficult matter in the case of children. For adults , opium is the remedy, in doses to control the symptoms ; mild cases do well with— R. Ext. opii, Camphorse, In pill, every three honrs. R. Tinct. opii deodorat., Liq. potassii c it rat., Every hour until opium effect. .... 3 ij* The strength and the frequency of administration of either of these formulae must be governed by the severity of the attack. Salol gr. j-iij, and bismuth salicylas gr. x-xv every few hours, is often of value in intestinal catarrh, although my experience is favor- able to opium. If vomiting is annoying, all other treatment must be discontinued until it has been controlled, the following being usually efficient (R hydrarygri chlor. mite, gr. yi ; sodii bicarbon., gr. ij ; sacch. lac. gr. ij. M. and give every hour or two, dry, on tongue). For children : — R . Tinct. opii deodorat., gtt. j Bismuth, subnit., gr. v Mist, cretse, f^j. M. Every two hours, for a child of one year. If the case shows the least tendency to linger the acid treatment should be substituted, one of the best formulae being “ Hope’s Cam- phor Mixture.” The following, which I have used with much success in the insane wards of the Philadelphia Hospital, where at times, we see a good deal of intestinal catarrh, and which I have named “ Mis- tura Enterica,” is generally satisfactory : — R . Spts. camphorse, f j Acid, sulphurici, dil. f^iss Tinct. opii deodorat., f^j Tinct. capsici f^ss Spts. chloroformi f^ss Spts. vini gallici, q. s. ad . . f% vj. M. Sig. — O ne to two teaspoonfuls well diluted, every three or four hours. Locally. Poultices, warm fomentations, or ung. belladonnce or oleum camphoratce , give great relief. DISEASES OF THE INTESTINAL CANAL. 99 CROUPOUS ENTERITIS. Synonym. Membranous enteritis. Definition. A croupous inflammation of the mucous membrane of the small intestines; characterized by tenderness, paroxysmal pain, moderate fever, and the formation and discharge at stool of membranous shreds or casts. Causes. A disease of adult life. The female sex more liable than the male, and neuralgic, nervous, hysterical or hypochondriacal subjects are more subject to it than are other types. A peculiar state of the nervous system seems necessary to its pro- duction. It is not a frequent disease. Pathological Anatomy. A subacute inflammation of the small intestines, during which the mucous membrane becomes covered with a whitish or grayish-white, firmly adherent, membranous deposit, cemented together by a coagulable exudation, and prolonged by root- lets from its under surface into the intestinal follicles. Symptoms. Begins by feverishness , feeling of soreness and dis- tention of the abdomen ; these are followed by pains of a colicky character, severe and depressing, felt around the umbilicus , associa- ted with tenderness , continuing for half an hour, an hour or longer, •and after a longer or shorter interval occurring again ; these pheno- mena continue for a day or two, when looseness of the bowels , with dis- tressing/#^ and tenesmus occur, the stools containing mucus , with or without blood , and shreds of membi'ane or cylindrical casts of the bowel. Great relief is then experienced, although a feeling of rawness or soreness persists for a day or two. Preceding the local manifestations of the disease are attacks of hysteria, hypochondriasis, neuralgia, nervousness or excitability. The paroxysms recur at intervals of a week or two, or after several months ; as long an interval as three years between attacks is recorded. Diagnosis. Peritonitis may be suspected until the characteristic stools occur. Dysentery is excluded when the shreds and casts of membrane ap- pear. Prognosis. Favorable as to life, but one of the most difficult of diseases to eradicate. Treatment. The diet must be such as contains but a minimum of fecal- forming matter. 100 PRACTICE OF MEDICINE. Forth e pain and suffering, opium in some form is indicated, the most effective being a hypodermic injection of morphina. For constipation during a paroxysm, an emulsion of oleu?n ricini and terebinthina is of benefit. To prevent a return of the paroxysms either liquor potassii arseniiis, gtt. j-ij, before meals, or hydrargyri chloridum corrosivum , gr. g 1 ^, three times a day, with a course of oleum morrhuce , seems to answer in the majority of cases. Prof. Da Costa speaks highly of pix liquida in some form, as an alterative to the mucous membrane. Under no circumstances must the bowels become constipated. CHOLERA MORBUS. Synonyms. Sporadic cholera ; English cholera ; bilious cholera. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, of sudden onset ; charac- terized by violent abdominal pains, incessant vomiting and purging, cold surface, rapid, feeble pulse, spasmodic contractions of the muscles of the abdomen and extremities, and prostration. Causes. A disease of summer and early autumn, climatic influ- ence being an important factor. Its prevalence during certain seasons seems to indicate a specific cause. Irritants of all kinds, unripe fruits and vegetables, and fermentation of food. Pathological Anatomy. Cases in which death has occurred within a few hours present no pathological changes. Generally, however, the gastro-intestinal mucous membrane is congested and denuded of epithelium ; the solitary and Peyerian glands are swollen and prominent. The blood is thick, and dark in color; the kidneys are enlarged and congested; and in prolonged cases there are appearances of granular changes in the muscular system. Symptoms. Onset sudden and violent, and unfortunately, gene- rally after midnight , with chilliness, intense nausea , vomiting and Purging , accompanied with distressing burning or tearing abdominal pains or colic. The vomited matter at first consists of the ordinary contents of the stomach, and the stools of ordinary faeces, but soon the discharges by vomit and stool are liquid , whitish or of a green or yellowish tint ; if the attack is severe or protracted the discharges are of the “ rice-water " character. The patient is rapidly ema- DISEASES OF THE INTESTINAL CANAL. 101 dated and reduced in strength, the body shrinks, the surface cold and covered with a clammy sweat , and the pulse is feeble. Intense thirst is present, and when drink is given it is at once rejected. Aggravating the distress of the patient are severe cramps of the muscles, and especially those of the calves, and of the flexors of the thighs, forearms, fingers and toes. Termination. Mild cases often terminate favorably without treat- ment, the patient able to be around in a day or two, although weak. Severe cases, the vomiting and purging cease after some hours, but the patient remains weak, with irritable stomach and bowels for a week or two. Grave cases, the true cholera type, recover from the prostration very gradually ; reaction coming on slowly and usually passing into a typhoid condition of some weeks’ duration. Diagnosis. Asiatic cholera and cholera morbus are easily con- founded during an epidemic of the former, and there are no positive points of discrimination, unless the comma bacilli of Koch are proven to be always in the true cholera stools. Irritant poisons, such as tartar emetic, elaterium, or other sub- stances, cause vomiting and purging, similar to cholera morbus, and are only discriminated from it by the clinical history and cause. Prognosis. In the majority of cases favorable. The mortality is about five per cent. Treatment. At once, regardless of the cause, a hypodermic injection of morphines sulph., gr. Y%-]/ $, and atropince sulph., gr. y-^, to be repeated in half an hour if no improvement ; for patients who object to the hypodermic mode, opium in some form by the mouth or rectum, giving the preference to the liquid preparations. Camphora and opium combined often act well, or the “ enteric mixture ” mentioned on page 98, and if much depression, small doses of brandy or dry chainpagne. The intense thirst must not be gratified by the use of liquids, but small pellets of ice by the stomach are grateful. If the vomiting and purging continue, make use of — K . Bismuth subnit., gr. xx Acid, carbol., gr. *4 Glycerini, gtt. xx Aquae, f^iv. Every hour in water. M. 102 PRACTICE OF MEDICINE. If the vomiting is so severe that no opportunity occurs for the medicament to come in contact with the gastric mucous membrane, an enema of chloral, gr. x-xv, in some demulcent with tinctura opii deodorala, rr^x-xx, acts often like magic in quieting the distress of the tortured patient. The closer the case approaches the true cholera type, the more severe are the muscular cramps , and their treatment is indicated. Prof. Da Costa suggests — R . Chloral, g iv Cosmoline 2;j. M. To be rubbed over the affected muscles. Dr. Bartholow suggests — R. Chloral., sjiij Morphinse sulph., gr. iv Aquae, f^j. M. Sig. — 7 wenty minims , hypodermically, repeated p. r. n. Locally, sinapis in the form of poultices or the dry powder, should be applied to the abdomen, or terebinthina stupes, or the hot water bag. The after treatment depends upon the symptoms ; generally an acid mixture and a regulated diet , with tonic doses of quinina, are indicated. ENTERO-COLITIS. Synonyms. Inflammatory diarrhoea ; ulcerative entero-colitis. Definition. A catarrhal inflammation of the lower portion of the small — ileum — and the upper portion of the large intestines, with a great tendency to ulceration of the intestinal glands if the catarrh becomes chronic; characterized by moderate fever, nausea, vomiting, diarrhoea, swollen abdomen, pain and emaciation. A common dis- ease of childhood. Causes. Improper and indigestible food ; summer temperature ; impure air ; uncleanliness ; exposure to cold and damp air. Most commonly a disease of childhood. Forms. Acute and chronic. Pathological Anatomy. Acute variety ; hyperaemia, swelling, oedema and softening of the mucous membrane of the lower portion DISEASES OF THE INTESTINAL CANAL. 103 of the small and the upper portion of the large intestines, with hyper- plasia of the intestinal follicles, their excretory follicles enlarged and tumid, readily distinguished as grayish or blackish points in the mid- dle of the glands ; the patches of Peyer are also enlarged, tumefied, and project above the level of the surrounding mucous membrane, the orifices of the follicles appearing as dark points ; these patches often have an ulcerated appearance, but upon close examination such is found not to be the case. Chronic variety ; the thickening and. infiltration have extended to the submucous and muscular coats, followed by induration of the tissues, so that the walls of the intestines are often abnormally rigid. Ulceration occurs, which extends through the entire thickness of the membrane. “These ulcers, when isolated, are from one to one and a half lines in diameter, oval or circular in shape, and either have sharp-cut edges, as though the piece of mucous membrane had been cut out with a punch, or the mucous membrane bounding them is undermined.” The small ulcers often coalesce, so that large, irregu- lar ulcerated patches are formed, having for their base the submucous or muscular coats, and have a grayish-white color. The mesenteric glands are enlarged, but seldom, if ever, undergo ulceration. Symptoms. Acute form ; may develop slowly, with restlessness and fretfulness, or suddenly with feverishness , loss of appetite , thirst , nausea , moderate vomiting , and abdominal pain ; or diarrhoea may be the first indication of illness on the part of the child. Regardless of the character of the onset, the stools soon present the characteristic ap- pearance ; they are semifluid , heterogeneous, greenish , acid, mixed with yellowish fragments of ordinary faeces, and undigested casein , termed the “chopped spinach” stools. The abdomen is enlarged and tender. Emaciation is marked in proportion to the severity of the symp- toms ; in marked cases the child is reduced to a condition of the greatest debility within a very few days. Chronic form , or ulcerative entero-colitis, usually follows the acute form, the character of the symptoms being less severe, but decidedly persistent, the strength fails, the temper is very irritable, the com- plexion grows dark, sallow and unhealthy, the skin dry and harsh, and in consequence of the marked emaciation, either hangs in folds around the shrunken limbs, or is drawn tightly over the joints ; the 104 PRACTICE OF MEDICINE. abdomen is enlarged and tender, the stools numbering from six to a dozen during the day and night, consisting of the products of an im- perfect digestion mixed with mucus, serum, pus, and oftentimes blood, having a semi-fluid consistency, and an extremely offensive odor. Ulcerative stomatitis is a frequent complication adding to the dis- comfort of the patient. Duration. Acute form , from ten days to about two weeks, sub- siding gradually ; chronic form , from one to two or three months, or even longer. Diagnosis. The acute form can hardly be mistaken for any other condition, if the characteristic stools and other abdominal symp- toms are present. The chronic form has been frequently mistaken for the diarrhoea of tuberculosis, an error that can hardly occur if a physical examination of the chest has been made. Prognosis. Always a very serious malady, and proves fatal if it attacks the weak during midsummer, or when surrounded by unfavor- able hygienic conditions ; in vigorous children, who have passed through their first dentition, the prognosis is quite favorable. Treatment. For the acute form , restricting the amount of food for the first few days is of importance. Fresh, pure air, cleanliness and rest are also of great importance. Any one of the following formulae may be used with advantage : — R- Salol, gr. K"Hj Bismuthi subnit., gr. v. M. Ft. chart. Sig. — S uch a powder every two hours. Or— R . Hydrargyri chlor. mite, gr. y 2 Pulv. ipecac., gr. y 2 Pulv. opii, gr. '/ z Cretse praeparat., gr. xxiv. M. Ft. chart. No. xij. Sig. — O ne every two or three hours, to child of one year. Many cases do well with ftulvis kino comp., others with minute doses, frequently repeated, of acidum lacticum , and many others with bismuth , gr. x-xv, in milk, every few hours, to quite young children. Locally , warmth to the abdomen, with mustard, turpentine stupes or the spice poultice, made as follows : cloves, allspice, cinna7non, and anise seeds , each half an ounce, pounded (not powdered) in a mortar, DISEASES OF THE INTESTINAL CANAL. 105 and placed between two pieces of coarse flannel about six inches square and quilted in ; soak this for a few minutes in hot brandy or hot whisky and water, equal parts, and apply to the abdomen, heating again as it becomes cool. Chronic entero-colitis . Few conditions will tax the skill and patience of the physician to the same degree as will this variety. First and foremost the diet must be carefully regulated. Milk alone, or predigested, or with lime-water, in the majority of cases is the best article of diet. Should it disagree, then recourse must be had to some of the prepared foods, such as Mellin’s, Horlick’s, Ridge’s, Blair’s prepared wheat, and many others ; often the one agreeing with one patient will not agree with another. After caring for the diet, then the hygiene of the patient requires attention. Cleanliness, such as daily warm-baths, often adding with advantage sea-salt. Rest in bed for an hour or more after meals if the patient cannot be kept continually in bed. The air of the room should be fresh and pure. Amongst drugs may be mentioned bismuth and pepsinum or Sali- cinum. Or— R . Argenti nitrat., . . gr. j-iss Acid, nitric dil ., n\,xij Mucil. acaciae, . f ^ ss Aq. cinnamomi, ad. f ^ iij. M. SiG. — Teaspoonful, diluted, every three or four hours. Or — R . Acidi carbolici, gr. Tincturae iodi, gtt. j -ij Aquae menthae, .... gj. M. SiG. — Every three or four hours. Or — R . Tinct. calumbae, f ^ iij Liq. ferri nitratis, irpcxvij Syrupi zingib., f^iij. M. SiG. — One or two teaspoonfuls, according to age, every three or four hours. Or— R . Quininae muriat., gr. xxiv Acid, tannici, gr. viij Syr. limonis, f % ij Aq. chloroformi, ad. fjiij. M. SiG. — Teaspoonful every two hours. 9 106 PRACTICE OF MEDICINE. CHOLERA INFANTUM. Synonyms. Choleriform diarrhoea ; summer complaint. Definition. An acute catarrhal inflammation of the mucous membrane of the stomach and intestines, together with an irritation of the sympathetic nervous system, occurring in children during their first dentition ; characterized by severe colicky pains, vomiting, purg- ing, febrile reaction, and prostration. Cause. Age ; bad hygiene, or as it is now entitled, “ civic mala- ria;” continuous high temperature; improper food ; dentition; con- stitutional as in the feeble, delicate, nervous, or irritable. Pathological Anatomy. Resembles closely, if not identical with, the phenomena of catarrhal gastritis and enteritis, together with a powerful irritation of the fibres of the sympathetic system. Symptoms. The onset is sudden in a child previously well, or in a child suffering from a bowel affection. Begins with vomiting, purging, abdominal pain, fever, rapid pulse and intense thirst. The vomited matter is partly digested food, sero-mucus, and finally bilious, and is accompanied with distressing retching. The thirst is a marked phenomenon of the disease, and ice and water will be taken incessantly, although rejected only a few moments after. The stools are first partly fecal, but soon watery or serous, soaking the clothing, leaving a faint greenish or yellowish stain ; their odor is musty, at times fetid ; their number is from ten to twenty in the day. ♦ Pains precede the vomiting and purging, colicky in character. The fever begins at once, the temperature varying from ioi°to 105°, with morning remissions. The pulse is rapid and feeble, ranging from 130 to 160. These symptoms continue but a few hours, before rapid wasting ensues, the body shrinks, the eyes are sunken and partly closed, the mouth partly open, the lips, dry, cracked and bleeding. The child, at first irritable and restless, passes into a semi-comatose condition, the pulse becoming more and more feeble, the surface has a clammy coldness, the contracted pupils not responding to light, and the stupor deepens, death soon following, or the symptoms slowly ame- liorate, convalescence being slow and tedious. Diagnosis. The entero-colitis or inflammatory diarrhoea of child- DISEASES OF THE INTESTINAL CANAL. 107 hood is constantly being mistaken for cholera infantum. The symp- toms of the former are, gradual onset, with fretfulness , loss of appe- tite, feverishness, nausea, and moderate vomiting, soon followed by diarrhoea, the stools being semi-fluid, greenish, mixed with yellowish particles of faeces and undigested casein, with a sour odor, the “chopped spinach” stools, the abdomen distended and tender, mode- rate fever and thirst, and having a duration of about two weeks. Prognosis. Difficult to predict the result, and so care must be used in giving a prognosis. The duration of the choleraic symptoms is short, under five days, but relapses are common, and the sequelae are protracted. Treatment. Change of air of the greatest benefit. Restricted diet, and particularly for first few days, using brandy, gtt. v-x, in bar- ley water at frequent intervals. For the vomiting, large doses of bismuth ; or chloral , gr. j-iij, by mouth in demulcent, or double the amount by the rectum, or one of the following : Bismuthi subnit., . . Acid, carbolici, . . . Mist, acaciae, . . . . * • * 3 ij . . . gr. j Aq. menth. p., . . . . . .fgj. Sig. — T easpoonful every half hour, hour, or two hours. Or— R . Hydrargyri chlor. mit., gr. Bismuth, subnit., .... gr. ij-v. M. Sig. — A powder every half hour. Good results are reported from bismuihi salicylas, gr. ij, with sugar of milk every hour or two, or salol gr. i-ij every two or four hours Cases that have resisted other remedies have rapidly improved un- der the following : — R . Tinct. verat. alb f 3 ij Morphinae acetat., gr. ij Spts. vini gallici, fl|ij. M. Et adde gj to Aquae calcis, Aquae menthae, aa f !|j. M. Sig. — O ne teaspoonful, repeated every hour, if needed. 108 PRACTICE OF MEDICINE. If the fever is high, sponging with alcohol and water, the cold pack or the cool bath can be used first, and afterwards using stimu- lants. For depression , regulated nursing or feeding every two hours, and water or ice to quench the intense thirst, and cognac brandy , gtt. v-x, every hour or two, in water, by mouth or in warm enema. Locally ; over epigastrium, mustard or a spice poultice, or turpen- tine stupes. If the nervous symptoms become aggravated, small dose of potassii bromidum , or valerian , which “reduces the reflex excitability, motil- ity and sensibility,” is indicated. ACUTE DYSENTERY. Synonyms. Colitis ; ulcerative colitis ; bloody flux. Definition. An acute inflammation of the mucous membrane of the large intestines, either catarrhal or croupous in character, followed in some cases with ulceration, characterized by fever, tormina, tenes- mus and frequent, small, mucous and bloody stools. It occurs either sporadically , endemically or epidemically . Four clinical forms are described: acute catarrhal; amoebic or tropical ; croupous or diphtheritic ; chronic dysentery. Causes. Sporadic, endemic ox catarrhal dysentery, prevails most extensively in the summer and early autumn months. Sudden atmospheric changes, such as hot days and cool nights. Malaria has some connection with its causation. Errors in diet not a cause. The drinking water may be the means by which the poison gains entrance to the system. Amoebic or tropical dysentery , characterized by the presence in the stools of the amoeba coli (Losch) or Amoeba dysenterica (Councilman and Lafleur). This variety is often epidemic in the tropics. Croupous or diphtheritic dysentery is often epidemic ; frequently occurs as a terminal event in acute and chronic diseases. The causes are much those of the acute catarrhal form, acting upon a depressed system. The Amoeba coli may be seen in the stools. Dysentery is not contagious, but is infectious. Pathological Anatomy. Catarrhal dysentery ; congestion, swelling and oedema of the mucous membrane and sub-mucous tissue of the large bowel, with an over-production of mucus ; the fol- DISEASES OF THE INTESTINAL CANAL. 109 licles are enlarged, from retention of their contents, the result of the swelling; the congested vessels often rupture; the mucous mem- brane softens in patches, and is detached, forming ulcers. Recovery follows, if the destruction of tissue is small, smooth cicatrices, minus gland stricture, marking the site. Amoebic or tropical dysentery , the lesions are also in large intestines and sometimes in lower portion of the ileum. Abscess of the liver is a common complication. “The lesions consist of ulceration, produced by preceding infiltra- tion, general or local, of the submucosa, the general infiltration being due to an cedematous condition, the local to multiplication of the fixed cells of the tissue. In the earliest stages these local infiltrations appear as hemispherical elevations above the general level of the mucosa. The mucous membrane over these soon becomes necrotic and is cast off, exposing the infiltrated submucous tissue as a grayish-yellow gelatinous mass, which at first forms the floor of the ulcer, but is subsequently cast off as a slough.” (Osier.) Croupous or diphtheritic dysentery begins with intense congestion, swelling, and oedema of the mucous and sub-mucous tissue, with extravasations of blood and the whole mucous membrane covered with a firm, fibrinous exudation ; the mucous membrane softens and sloughs, leaving large ulcers and gangrenous spots. If recovery occur, large cicatrices form, which narrow the calibre of the intestinal tube. The mesenteric glands enlarge, soften, and abscesses form in them ; the liver becomes the seat of small abscesses, from embolic obstruc- tion of the radicles of the portal vein ; the heart muscles are flabby and more or less fatty. Symptoms. Catarrhal form begins gradually, with diarrhoea , loss of appetite, nausea , and very slight fever , which continues for two or three days, when the true dysenteric symptoms develop, to wit, pain on pressure along the transverse and descending colon, tormina or colicky pains about the umbilicus, burning pain in the rectum, with the sensation of the presence of a foreign body and a constant desire to expel it, or tenesmus ; the stools for the first day or two contain more or less fecal matter, but they soon change to a grayish , tough , transparent mucus , containing more or less blood and pus ; during the tormina, nausea and vomiting may occur ; the urine is 110 PRACTICE OF MEDICINE. scanty and high colored ; the number of stools vary from five to twenty or more in the twenty-four hours. The duration is about one week , the patient being much emaciated and enfeebled. Amoebic form begins gradually as the catarrhal form, or gradually as an increasing diarrhoea. Soon the stools become characteristic of the variety of the attack, being frequent , bloody , mucoid , but very fluid ; as the disease progresses the stools become yellowish- gray and liquid , containing mucus, sometimes bloody. The number of stools varies from six to a dozen or more in a day. Actively moving amoebce are found in the stools, disappearing as the stools become formed. Fever may or may not be present, or may come and go. Abdominal pain and tenesmus are present in the majority of cases. The loss of flesh and strength is marked. Abscess of liver and lungs are frequent and grave complications. Duration from six to twelve weeks, recovery tedious owing to anae- mia and loss of flesh. In every endemic or epidemic of dysentery a number of amoebic cases will occur. During the past three years I have seen probably two hundred cases of dysentery, beginning as catarrhal, but in the midst of the endemic a number of amoebic cases occurred, the con- valesence long outlasting the catarrhal variety. The croupous or diphtheritic form sets in suddenly, the stools being more frequent, containing more blood and pus, with patches of mem- brane \ even casts of the bowel , together with more or less gangrenous mucous membrane; nausea , vomiting , and great prostration, cold skin, feeble pulse and emaciation with anxious expression , the odor surrounding the patient being fetid. The occurrence of this form as a termination of Bright’s disease, lung and heart disease, must be borne in mind. The duration of the grave symptoms is three or four days, when collapse and death occur, or slow convalescence begins, continuing for weeks. Chronic Dysentery. This is really a continuation of the acute disease, the symptoms continuing the result of the ulcerated mucous membrane, or the cystic degeneration of the glandular elements of the large gut (Woodward). Rarely, dysentery develops subacutely, and thus is almost chronic from the beginning. There is seldom a DISEASES OF THE INTESTINAL CANAL. Ill characteristic stool, little colicky pain and little or no tenesmus, but a progressive loss of flesh with loose bowels, the stools containing mucus, little or no blood, undigested food, and are frothy. The number varies from two to a dozen in the day. Acute exacerbations are frequent. Duration, often months or years. Complications. Peritonitis; hepatic abscesses ; phlebitis of the intestinal veins; intestinal perforation. Diagnosis. Enteritis lacks the tenesmus and characteristic stools. Peritonitis , when idiopathic, shows higher temperature, greater ten- derness and constipation. Chronic dysentery is difficult to distinguish from chronic diarrhoea. Prognosis. Catarrhal form favorable, save in those debilitated. Amoebic form ; the mortality is higher than in catarrhal form, and in favorable cases the convalescence is slow. Croupous form ; the prognosis is always grave, for, if recovery does occur, the bowels may be crippled from loss of structure, or from narrowing of its calibre, the results of cicatrices. Treatment. Keeping in mind the following from Osier’s Practice, no case of dysentery, however mild, should be lightly considered : “ Dysentery is one of the four great epidemic diseases of the world. In the tropics it destroys more lives than cholera, and it has been more fatal to armies than powder and shot.” The patient should be confined to bed in even the mildest attack, and the stools removed at once and disinfected. In fact, the bed-pan or other vessels should constantly contain, a solution of ferrous sul-. phate (copperas) sufficient to cover the expected stool. The diet to be of the most nourishing yet bland character, adding stimulants if much prostration. The most frequently used drug, and in many cases by far the best, is opium , alone or combined with one or more astringents : — R . Ext. opii, . . . . , gr. ss Plumbi acetat., gr. ij. M. Every two hours. Or— R . Pulv. opii, gr. ss Plumbi acetat., gr. ij Pulv. ipecac., gr. if. M. Every two hours. 112 PRACTICE OF MEDICINE. I have frequently seen the character of the stools change within twenty-four hours with the Mistura enterica , viz. : — R. Acid, sulph. dil. f^iss Tinct. opii deodorat., f t ^j Spts. camphorge, f^j Tinct. capsici, f.l ss Spts. chloroformi, f.l ss Spts. vini gallici, f ^ iss. Sig. — O ne teaspoonful every two or three hours, diluted. M. In more than one instance I have seen a severe attack of acute dysentery succumb to morphina sulphas , gr. X - ,X» three or four times daily hypodermically, within three or four days. For the intense tormina and tenesmus no remedy is comparable with morphia by the hypodermic method. If the case is seen early, the very best prescription possible is — R. Magnesii sulph., gj Acid, sulph. dil., tt^x Tinct. opii deodorat., TT\, X Aquas chloroformi ad. £ij M. Every two or three hours, until faeces appear in the stools, when small doses of opium and quinina may be used. Bismuth subnit ., gr. xxx, every two or three hours, or bismuth sali- cylas, gr. xv, every two or three hours, are often successful. Dr. Loomis speaks strongly of ipecacuanha , gr., X every half hour, with sufficient opium to secure quietness. The large doses of ipecac- uanha recommended I have had no experience with. Ringer recommends hydrargyri chloridum corrosivum , gr. every hour or two, which “rarely fails to free the stools from blood and slime, although in some cases a diarrhoea of a different character may continue for a short time longer.” In children the following combination is efficacious : — R . Pulv. ipecacuanhae, gr. X Bismuth subnit., gr. v-x Cretae praep., gi*. iij. M. Sig. — E very two hours. Washing out the rectum with either tepid, hot, cold or iced water, as suggested by Prof. DaCosta, adds greatly to the patient’s comfort and to the decrease of the inflammatory process. Ice suppositories are often soothing. DISEASES OF THE INTESTINAL CANAL. 113 A one or two per cent, solution of creolin (one-half pint) as an enema often rapidly lessens the number of stools and the tenesmus. Dr. H. C. Wood recommends iodoform suppositories. “ In the cases of amoebic dysentery we have been using at the Johns Hopkins’ hospital, with great benefit, warm injections of quinine in strength of i to 5000, 1 to 2500, and 1 to 1000. The amoeba are rapidly destroyed by it.” (Osier.) Locally , poultices, stupes, etc., do no good, but if they are agree- able to the patient, they may be allowed, as they do no harm. Chronic dysentery. A carefully selected but nourishing diet, change of scene and some of the following remedies : Bismuth , gr. xxx, t. d. ; terebinthina , rr^x, every three or four hours ; argenti nitras , gr. Y~Y , three or four times daily ; or R . Cupri sulphas , gr. l /e ; ext. opiia.<\. gr. %-Yz ; ext. nucis vomicae , gr. Y> m pill* four times daily. Chronic dysentery is sometimes kept up by a trifling patch of inflam- mation or ulceration in the rectum or sigmoid flexure. There occur two or three loose stools in the morning, and then a comparatively comfortable day. The stools are preceded by some colicky pain across the lower part of the abdomen and in the line of the large bowel. The general condition, other than the anaemia and weakness, of the patient is good. Drugs by the mouth are useless to control these cases ; the medication must be made directly to the diseased part. Injections of argenti nitras , gr. iv to xx or xxx to the pint are curative; the silver maybe combined with opium (R. Argent, nitrat., gr. j ; tinct. opii deodorat., rr\,xv-xx; aquae amyli, f^iv, M). During the convalescence from all varieties of dysentery, tonics are indicated ; (R. Strychninae sulph., gr. Y ; acid, hydrochlorici dil., f^ij ; tinct. gentian comp. q. s., ad f^iv, M. S. — One teaspoonful be- fore meals in water). A course of oleum inorrhuce with syr. calcii lactophosphatis , should be used if much emaciation, . - well diluted every four hours, or calomel and soda (R. Hydrargyri chloridi mitis., gr. X; sodii bicarbonatis, gr. iij ; sacc. lac., gr. iij. M. SiG. — Taken dry on tongue every two or three hours until one dozen are used, followed by Hunyadi Janos water), or the following : — R . Sodii bicarb., pj ij Tinct. nucis vom., . . . . . fgiv Tinct. capsici, ffij Tinct. rhei, f^jss Inf. gent. comp. ad. q. s., f ijvj. M. SiG. — Dessertspoonful every four or five hours, in water. For the dry, itchy skin diaphoresis is indicated. The warm or hot bath night and morning is valuable, adding potassii carbonas , ^j to each. If the urine continues scanty diuretics should be used, a simple and efficacious one being potassii bitariras lemonade at very frequent intervals. Spiritus cetheris nitrosi , tth x-xx, diluted, is always valuable for torpid kidneys. A special plan, which is said to be effective, is with “ enemata of cold water. By means of an irrigating apparatus the large intestine is well distended with water once a day for several days. The first enema has a temperature of 6o° F., and subsequent injections are a little warmer. The increased peristalsis of the bowels and the reflex contractions of the gall bladder dislodges the mucus obstructing DISEASES OF THE BILIARY PASSAGES. 133 the gall ducts. When the bile flows into the intestine, digestion is resumed and the catarrhal inflammation subsides.” Other remedies may be conjoined with the irrigation method. For convalescence : — R. Strychnin* sulph., gr. ss Acid, nitro-hydrochlorici dil., i sjjv Tinct. gentian, co., . f^ijss. M. SlG. — Teaspoonful after meals, well diluted. BILIARY CALCULI. Synonyms. Hepatic calculi ; gall-stones ; hepatic colic. Definition. Concretions originating in the gall-bladder, or biliary ducts, derived partly or entirely from the constituents of the bile. Their presence is generally unrecognized until one or more attempt to pass along the ducts, when an attack of hepatic colic is produced. Causes. Gall-stones result from the precipitation of the crystal- lizable cholesterine , and its combination with inspissated mucus in the gall bladder or ducts. A disease of middle life, and more frequent in the obese, and in women. Gall stones are said to be common in carcinoma of the stomach or liver. Pathological Anatomy. Choiesterine is the chief constituent of biliary calculi. Commonly several stones exist, and rarely one ; as many as six hundred are recorded. They are generally found in the gall-bladder or cystic duct, rarely in the liver or hepatic duct. Symptoms. The presence of gall-stones or biliary calculi is made known only by their expulsion from the gall bladder, whence is developed hepatic colic. Hepatic colic begins suddenly, at the moment a gall-stone passes from the gall-bladder into the cystic duct. The patient is seized with a piercing, agonizing pain in the region of the gall-bladder, and spreading over the abdomen, right chest and shoulder; th z abdominal muscles axe cramped and tender ; there is nausea and vomiting , a small, feeble pulse , cool skin , pale, distorted , anxious face , with, may be, fainting, spasmodic trembling, chills, or convulsions. The paroxysm continues from an hour or two to several days, with 134 PRACTICE OF MEDICINE. remissions, but entire relief is not afforded until the stone reaches the duodenum, when the pain suddenly ceases. Jaundice usually follows the paroxysm of pain. When the calculi reach the intestines, the pain, nausea and vomiting cease, the appetite returns, and the jaundice soon disappears. Should the calculi become impacted, ulcerative perforation and consequent peritonitis follow, the calculi discharging by the intestine, stomach, or through the abdominal walls. Diagnosis. The malady should not be mistaken if severe pain, diverging from the hepatic region, and nausea and vomiting are present, suddenly terminating, and followed by slight jaundice. The diagnosis is always made positive by diluting the stools voided for the day following an attack of suspected hepatic colic, and passing them through a sieve. Prognosis. Usual termination is in health. The prognosis be- coming more unfavorable if ulcerative perforation result. Treatment. For the colic , hypodermic injections of ?norphina, gr. combined with atropina , gr. and warm fomentations over the hepatic region, are indicated. Oleum olivce , f^ij-iv, every hour or two sometimes does good. Prof. Bartholow strongly urges the following prophylactic treat- ment : Carefully regulated diet, abstinence from all fatty and sac- charine substances, daily exercise, stoppage of all excesses, and the long use of sodii phosphas, 3j, before meals, well diluted, to which may be added, if gastro-intestinal catarrh be present, sodii arsenias, gr. ^j, or aurii et sodii chloridum , gr. -fa> together with either Vichy or Saratoga Vichy water. DISEASES OF THE LIVER. CONGESTION OF THE LIVER. Synonyms. Torpid liver ; biliousness. Definition. An abnormal fullness of the vessels of the liver, with consequent enlargement of that organ ; it is termed active when arterial ; passive when venous. The condition is characterized DISEASES OF THE LIVER. ] 35 by torpidity of the digestive and mental functions, and slight jaun- dice. Causes. Active congestion ; heat, atmospherical or artificial ; habitual constipation ; malaria ; excesses in eating and drinking ; alcoholic or malt liquors. In females, an arrested menstrual epoch may give rise to an attack. Passive congestio)i ; cardiac and pulmonary diseases. Pathological Anatomy. The liver is enlarged in all direc- tions, and is abnormally full of blood. Cases due to obstructive diseases of the heart or lungs present the so-called “ nutmeg liver,” to wit : “ At the centre of each lobule the dilated radicle of the hepatic vein, enlarged and congested, may be discerned, while the neighboring parts of the lobule are pale,” the radicles of the portal vein containing less blood. Long-continued congestion establishes atrophic degeneration of the organ ; the decrease in size is confounded with the condition of cir- rhosis, but the “ atrophic liver ” is smooth, while the “ cirrhotic liver ” is nodulated. Symptoms. Active congestion ; following cause, rapidly pro- duced malaise , aching of limbs , evening feverishness , headache , depression of spirits, yellowish tongue , disgust for food, nausea, and, may be, vomiting , constipation, scanty, high-colored urine, with a feeling of fullness, weight, and soreness in the hepatic region, with dull pain extending to the right shoulder, and slight jaundice, the eye yellow, and the complexion muddy . Duration about a week. Passive congestion ; onset gradual, with a feeling of weight and fullness in the hepatic region, slight jaundice, and symptoms of gas- trointestinal catarrh. On percussion the hepatic dullness is increased in all directions. Diagnosis. Acute congestion is continually confounded with catarrhal jaundice; the latter begins with marked gastrointestinal symptoms and distinct jaundice ; in the former these are less marked. Obstructive congestion is diagnosticated by the clinical history. Atrophic or nutmeg liver will be differentiated from cirrhotic liver when speaking of the latter. Prognosis. Active congestion favorable, unless repeated attacks occur, rapidly succeeding each other, when “ atrophic degeneration ” results. Passive congestion controlled entirely by the cause. 136 PRACTICE OF MEDICINE. Treatment. Attacks due to excesses in eating and drinking — R. Sodii bicarb., gr. v Pulv. ipecac, gr. ss. Hydrargyri chlor. mit., gr. iij-v, repeated, or sodii phosphas, 3j, every four hours until free catharsis, or small doses of hydrargyri chloridum mite , with sodii bicarbonas repeated several times, followed with saline , followed by R. Acidi nitro-hydrochlorici dil. , x. Elix. taraxaci comp., f ^ ij. Before meals, and a milk diet. Attacks due to malaria ; the above purgatives followed by quinince sulph ., gr. iv, every four hours. Attacks occurring with cardiac or pulmonary diseases must be managed by treating the cause. The tendency to constipation must be overcome by the saline laxa- tive waters, to wit: Congress or Hathorn, Hunyadi Janos, or sodii phosphas , 3j-ij, three or four times daily, well diluted. Locally , in acute attacks, hot cloths or sinapisms are of benefit. In chronic cases benefit follows, elix. quinince, ferri et strychnincr, fZj, three times a day, and great comfort and support is given by the use of the “ hydropathic belt," which is made of stout muslin, shaped to the abdomen, with cross pieces of tape on the inner side, which keeps next to the skin a fold of cloth wrung out of cold water, and a piece of waterproof cloth or oiled silk, to prevent evaporation. In persons who seem to have a predisposition to attacks of con- gestion of the liver upon the slightest exposure to any of the various exciting causes, the habits and diet must be regulated, to which must be added a course of alkaline waters and regulated exercise. ABSCESS OF THE LIVER. Synonyms. Parenchymatous hepatitis ; acute hepatitis ; sup- purative hepatitis. Definition. A diffused or circumscribed inflammation of the hepatic cells, resulting in suppuration, the abscesses being sometimes single, at times double ; characterized by irregular febrile attacks, DISEASES OF THE LIVER. 13 ' hepatic tenderness, and symptoms of deranged gastro-intestinal and hepatic functions. Causes. The result of the absorption of putrid material by the portal radicles in dysentery ; ulcers of the stomach ; malaria ; blows and injuries; heat; pyaemia. Pathological Anatomy. Hyperaemia, swelling, effusion of lymph, degeneration and softening of the hepatic cells; suppuration, beginning in points in the lobules and coalescing. The abscess walls consist of the liver structure, more or less changed. The abscess may advance toward the surface of the liver, bursting into the peritoneum, intestines, stomach, gall bladder, hepatic duct or vein, or into the pleura or lungs, or externally through the abdominal walls ; after the discharge of pus, cicatrization occurs, or the pus may be absorbed, the tissues around forming a dense cicatrix. Symptoms. Very obscure. Fever simulating markedly inter- mittent or remittent fevers ; disorders of the gastro-intestinal canal, with obstinate vomiting , debility , and great irritability of the nervous system , melancholia , slight jaundice , constipation, the stools light col- ored, and if of long duration, typhoid symptoms. Locally , if the abscess is near the surface, prominence of the hepatic region , throbbing , limited tenderness , and if it tends to the surface, redness, cedema and fluctuation. The abscess may burst into the intestines, stomach, lungs, or pleura, the symptoms of which will be pronounced. Diagnosis. Hepatic abscess may be confounded with hydatids of the liver, hepatic or gastric cancer, abscess of the abdominal walls, and purulent effusion in the right pleural cavity. The differentiation is most difficult, but great aid is obtained from the use of the aspirator. Prognosis. Unfavorable. Recoveries, however, do occur. If the abscess bursts into the lungs, bowels, or externally through the abdominal wall, the case is more favorable. Treatment. Symptomatic , and when pus is present, the use of the aspirator to remove it, and sustaining treatment, quinina , ferrum , alcohol and oleum morrhuce. 138 PRACTICE OF MEDICINE. ACUTE YELLOW ATROPHY. Synonyms. General parenchymatous hepatitis ; malignant jaun- dice ; hemorrhagic icterus. Definition. An acute, diffused or general inflammation of the hepatic cells, resulting in their complete disintegration ; characterized by diminution in the size of the liver, deep jaundice, and profound disturbance of the nervous system; terminating in death, usually, within one week. Causes. Unsettled. It occurs frequently in young pregnant women, from the third to the sixth month of pregnancy. Other causes are venereal excesses, syphilis, action of phosphorus, arsenic or antimony. Pathological Anatomy. Begins with hyperaemia of the hepatic cells, with a grayish exudation between the lobules, followed by soft- ening, dull yellow color, and disappearance of the cells, fat globules taking their place ; the liver is reduced in size and weight ; the peritoneum covering the liver is thrown into folds ; the spleen is enlarged ; the kidneys undergo degeneration ; the blood contains a large amount of urea and considerable leucin ; the urine is loaded with bile pigment, and contains albumin. Symptoms. Prodromic period ; begins as a gastrointestinal catarrh, coated tongue, nausea, vomiting, tenderness over the epigas- trium, headache, quickened pulse, slight fever and slight jaundice. Icteric period ; jaundice deepens, pulse slow, headache increases, and persistent insomnia. To xcemic period ; fever, rapid pulse, more complete jaundice, pain , nausea, vomiting of blackish, grumous blood , or “coffee grounds,” tarry stools, ecchymotic patches, convulsions or epileptiform attacks, coma , insensibility, death. Percussion shows markedly decreased hepatic dullness. Duration. Short. After appearance of jaundice, about six days. Prognosis. Unfavorable. Treatment. Entirely symptomatic. Prof. Bartholow “ advises the trial of very small doses of phosphorus, as early as possible, as this remedy affects the organ specifically, and an action of antagon- ism may be discovered between them.” DISEASES OF THE LIVER. 139 SCLEROSIS OF THE LIVER. Synonyms. Interstitial hepatitis ; cirrhosis of the liver ; hob- nailed liver ; gin-drinkers’ liver. Definition. An inflammation of the intervening connective tissue of the liver, chronic in its progress, resulting in an induration or hardening of the organ, and an atrophy of the secreting cells ; characterized by gastro-intestinal catarrh, emaciation, slight jaundice, and ascites. Causes. The prolonged use of alcoholic stimulants, gin, whisky, beer, or porter ; syphilis. Pathological Anatomy. First stage ; hyperaemia of the con- nective tissue (Glisson’s capsule) of the liver, and the development of brownish-red connective-tissue elements, whereby the organ is increased in size and density; this increase of the connective tissue presses upon the hepatic cells, causing them to undergo fatty degene- ration. Second Stage ; the newly formed, imperfectly developed connective tissue contracts, causing decrease in the size and induration of the organ, its surface being nodulated. The hepatic and portal circula- tion is obstructed, from obliteration of their radicles. The hepatic peritoneum is thickened and opaque, and adhesions are formed to the diaphragm, gall-bladder, and stomach. Cases occur in which the sclerosis takes place while the organ con- tinues enlarged ; these cases are known as hypertrophic sclerosis. Symptoms. No characteristic symptoms of the early stage of the affection. Persistent gastro-intestinal catarrh , with attacks of jaundice , in a drinking man, are suspicious. Symptoms of the second stage are, abdominal dropsy , enlargement of the superficial abdominal veins , dyspepsia , localized peritoneal pain, he7norrhages from the stomach or intestines , muddy or slightly jaundiced skin and decided emaciation ; the enormously distended abdomen with thin legs are characteristic of sclerosis of the liver. Diagnosis. Atrophy of the liver , or the nutmeg liver, is almost always confounded with sclerosis ; the former occurs most commonly with obstructive diseases of the heart and lungs, and the surface of the organ is not nodulated, nor is there a history of alcoholism. Cancer and tubercle of the peritoneum have many symptoms akin to sclerosis. The points of differentiation are, great tenderness over 140 PRACTICE OF MEDICINE. abdomen, rapidly developed ascites, rapid decline in strength and flesh, absence of jaundice, absence of long-continued dyspepsia, ab- sence of hepatic changes on percussion, and the presence of tubercle or cancer deposits in other organs. Prognosis. Terminates in death. Average duration after ap- pearance of the dropsy, one year. Treatment. For the changes in the hepatic structures, little, if anything, can be done ; the following are some of the remedies re- commended, to wit: hydrargyri chloridum corrosivum, gr. three times a day ; hydrargyri chloridum mite , gr. three times a day ; aurii et sodii chloridum , gr. after meals; sodii phosphas, 3 ss-j , after meals ; potassii iodidum, after meals. The diet must be regulated, milk being the most suitable, and avoiding fatty and saccharine foods. The abdominal dropsy may be temporarily benefited by purgatives and diuretics , but sooner or later tapping becomes necessary. AMYLOID LIVER. Synonyms. Waxy liver; lardaceous liver; scrofulous liver; albuminous liver. Definition. A peculiar infiltration into, or a degeneration of, the structure of the liver, from the deposit of an albuminoid material which has been termed amyloid , from a superficial resemblance to starch granules. Causes. The chief cause is prolonged suppuration, especially of the bones ; coxalgia ; syphilis ; cancer. Pathological Anatomy. The liver is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy consistency. On section, the surface is homogeneous, is anaemic and whitish. The deposit begins in the arterioles and capillaries, finally closing them. The reaction with iodine and sulphuric acid affords a certain test of the amyloid or albuminoid deposits. After further cleansing, brush over the parts a solution of iodine with iodide of potassium in water, when they will assume a mahogany color, and if diluted sulphuric acid be added, a violet or bluish tint is produced. A pretty reaction is to take a one per cent, solution of anilin violet, which strikes a red or pink color with the amyloid or albuminoid DISEASES OF THE LIVER. 141 material, while the unaltered tissues are stained blue, thus showing a beautiful contrast. The amyloid change involves the spleen, kidney, intestines, and other organs. Symptoms. Nothing characteristic. Hepatic dullness increased, with prominence over the liver ; absence of pain ; splenic dullness increased ; emaciation and anaemia ; urine increased in amount, pale, and containing some albumin, due to amyloid changes in the kidneys. Disorders of digestion, with diarrhoea, due to amyloid changes in the intestines. Jaundice is rare. Ascites seldom occurs. Prognosis. Unfavorable. The progress is rapid or slow, depend- ing upon the cause. Treatment. No specific. Prof. DaCosta recommends ammonii murias , gr. x-xx, three times daily, for several weeks, then change for same length of time to syrupus ferri iodidum, beginning with rr\,x gradually increased to fgj after meals, then to the former again, and so on, for months. Life may be prolonged by the use of ferrum, syr. calcii lactophosphas and oleum morrhuce . HEPATIC CANCER. Synonym. Carcinoma of the liver. Definition. A peculiar morbid growth, progressively destroying the hepatic tissue ; characterized by disorders of digestion, anaemia, emaciation, jaundice, and ascites, and terminating in the death of the patient. Causes. Hereditary, when it is termed primary cancer ; exten- sion from other organs, termed secondary cancer. It is a disease of advanced life, from forty to sixty years of age. Pathological Anatomy. The most common variety of cancer of the liver is a compound of the medullary and scirrhus. The cancer cells develop from the interlobular connective tissue, and as they grow the hepatic cells atrophy, the result of the pressure of the new growth. The branches of the hepatic artery enlarge and permeate the growth, while the branches of the portal vein are compressed and atrophied, thereby blocking up the portal circu- lation. The cancer may develop in nodules or masses, or may be diffused ; the nodules vary in size, and those on the surface are rounded, with a central umbilication. The peritoneum is adherent, cloudy, and thickened. 142 PRACTICE OF MEDICINE. Symptoms. The development of hepatic cancer is preceded by a history of dyspepsia, flatulency, and constipation. Uneasiness, weight, and pain, increased by pressure, are noticed ; jaundice, ascites , occasional intestinal hemorrhages, emaciation, feebleness, ancemia, cold, dry, harsh skin , pinched features , with dejected, worn expression.. Fever never occurs. The hepatic dullness is increased, with pains on palpation, and the liver is indurated, irregular and nodulated. The duration is less than a year from the time the disease is recognized. Diagnosis. The points of differentiation are the age, cachexia, pain, and tenderness, enlarged liver with hard nodules , and rapid emaciation and progress of the disease. Prognosis. Always terminates in death. Treatment. Early, symptomatic. Sooner or later opium must be used, to relieve the terrible and persistent pain. DISEASES OF THE KIDNEYS. THE URINE. The normal quantity of urine varies from forty to fifty ounces in the twenty-four hours ; it is decreased by free perspiration and increased by chilling of the skin. Within the twenty-four hours, the least urine is passed at night, or in the early morning, very much the greater portion being passed during the course of the day. The normal color is light amber, due to urobilin; the color deepens if the quantity voided be decreased, and vice versa. In nearly all normal urine a cloud of mucus forms, after standing a short time. The normal reaction is slightly acid, due to the acid sodic phos- phate, uric and hippuric acids. After meals it may be neutral or even alkaline. The normal specific gravity v aries from 1.015 to 1.020; it is low when an increased quantity is passed, and high when the quantity is diminished. The normal odor of urine is a peculiar, well known, aromatic one DISEASES OF THE KIDNEYS. 143 it is altered by certain foods, such as the violet stench after eating asparagus, and the garlicky odor after using garlic. The most important organic and inorganic solid constituents held in solution are, urea (the index of nitrogenous excretion), from 308 to 617 grains daily ; uric acid , from 6 to 12 grains ; urates of sodium , ammonium, potassium, calcium and magnesium , from 9 to 14 grains ; phosphates of sodium, etc., from 12 to 45 grains, and chlorides of sodium , etc., from 154 to 247 grains daily. I. Quantitative test for urea, by hypobro- mite of sodium (Davy’s method). II. Tests for urates and uric acid by nitric acid. I r -1 1 Fill a graduated glass-tube one-third full of mercury, and add one-half drachm of the 24 hours’ urine ; then fill the tube evenly full with a saturated solution of hypobromite of sodium , and close it immediately with the thumb ; invert the tube and place its open end beneath a sat. sol. of chloride of sodium ; the mercury flows out and is replaced by the solution of salt; nitrogen gas is disengaged from the urea in the upper part of the tube. Each cubic inch of gas represents .645 gr. of urea in the half drachm, from which the amount passed in 24hours may be calculated. Urine containing an excess of urates and uric acid, on cooling , precipitates them (viz. : “brickdust deposits ” in “ pot de chambre”). Heat dissolves them to a certain extent. Nitric acid deprives the soluble neutral urates of their bases, and produces, at first, a faint, milky precipitate of amorphous acid urates ; adding more acid, the still less solu- ble red crystals of uric acid, resembling cay- enne pepper, are deposited. Put a small quantity of nitric acid in a test tube, and pour the urine carefully down the sides of the tube upon it, and a zone of yellowish-red uric acid and altered coloring matter will form at their union ; and a dense, milky zone of acid urates above this, which, however, dissolve upon agitation. (See albumin test.) 144 PRACTICE OF MEDICINE. III. Quantitative test for uric acid by nitric acid. IV. Test for the earthy and alkaline phosphates by the magnesian fluid. V. Test for the chlo- rides by nitrate of sil- ver. VI. Test for mucus by acetic acid and liq- uor. iodi comp. f To three ounces of the 24 hours’ urine (after being slightly acidulated, boiled, and filtered while hot) add one-tenth as much _| nitric acid ; place in a cool place for 24 hours, then collect the deposit of uric acid on a weighed filter, wash it thoroughly, and dry at 212 0 F. The increased weight represents . the uric acid in part excreted, approximately. f Heat or liquor potassce increases the cloud- iness caused by earthy calcium and magne- sium phosphates. Acetic or nitric acid clears it by dissolving them. To two ounces of urine add one-third as much of the following solution : R . Mag- nesii sulph., ammonii chloridi puri, liquor ammoniae, each one part ; aquae destil., eight parts ; if the precipitate has a milky , cloudy appearance, the quantity of phos- phates is normal ; if creamy , the phosphates l are in excess. To a convenient quantity of urine add a small amount of nitric acid, to prevent the formation of the phosphates and other salts of silver ; filter this, if cloudy ; add to this one drop of a solution of nitrate of silver (1 part to 8) and the precipitate of white cheesy lumps of chlorides of silver denotes that the amount of chlorides are normal ; if, however, only a faint milkiness occurs, the chlorides are diminished. f Mucus alone is not visible, but causes cloudiness , from having entangled mucus or pus corpuscles, epithelium, granules of so- dium urate, crystals of oxalate of lime, and uric acid in various amounts. Add to the urine a little acetic acid , or, in addition, a few drops of liquor, iodi comp. y when threads and bands of mucin are made visible. The addition of nitric acid dissolves l them. DISEASES OF THE KIDNEYS. 145 VII. Test for albu- min by heat and nitric - acid. VIII. Test for albu- min by picric acid (saturated, watery so- lution). IX. Nitric-magne- sian test for albumin. I The fluid is prepared by mixing i part of pure nitric acid with 5 - parts of a saturated solution of the sul- phate of magnesium, and filtering. X. Quantitative test for albumin. Approxi- mately. Slightly acidulate the urine, if necessary, by addition of nitric or acetic acid, and boil ; this causes a white deposit of coagulated albumin, which is not dissolved by nitric acid, unless the acid is in excess. Nitric acid causes a white deposit of coagulated albumin , which is dissolved if a large excess of acid be added. A delicate test is to put the nitric acid in the tube first, and then gradually pour the urine down the side of the tube upon it, when a white zone or ring of coagulated albumin appears. Pre- caution, see tests Nos. 3, 4, 11, and 13. f Pour a quantity of urine into a test-tube, | and add th z picric acid solution drop by drop, j and, as it passes through the urine, it is fol- lowed by an opaque white cloud if albumin j be present. The test is very striking and beautiful. If cloudiness appears some time after, instead of at the time, it shows noth- ing. The test will not detect as small an [ amount of albumin as heat or nitric acid. One drachm of the reagent is poured into a perfectly clean test-tube ; the urine should be allowed to trickle slowly down upon the j fluid ; if albumin be present in an amount as small as one one-hundredth of one per cent., this test will show a compact, dense, white layer. This is one of the best and most reliable tests for albumin. r Add a few drops of nitric acid to a pro- portion of the urine, and boil ; set this away j for 24 hours, and the proportionate depth of j the resulting deposit is the comparative in- { dication, viz. : etc. 12 140 PRACTICE OF MEDICINE. For minute traces of albumin Millard’s fluid may be used ; it is a delicate test and requires care. The fluid consists of glacial carbolic acid (ninety-five per cent.) gij ; pure acetic acid, 3 vij, liquor potassae £ij> 3vj. XI. Test for blood f Heat or nitric acid causes deposit of albu- by heat and nitric J min, with the coloring matter changed to a acid. ! dirty brown. XII. Test for blood by heat and caustic potash (Heller’s). i I l Heat the urine, then add caustic potash and heat anew. The phosphates are thus precipitated, taking with them the coloring matter of the blood, which imparts a dirty , yellowish-red color to the sediment, viewed by reflected light, and when seen by trans- mitted light, gives a splendid blood-red color. Neither the coloring matter of the blood, nor that of the bile, is precipitated with the phosphates, so that coloration of urine which shows this reaction cannot be ascribed to the presence of the latter pigments. When the quantity of blood in the urine is very large, it is of a dark or brownish-red , and after standing, forms a coagulum of blood at the bottom of the vessel. Caution. Heat or nitric acid causes co- agulation of the albumin in pus. XIII. Test for pus by liquor potassae. j' Add to the urine, or preferably to its de- | posit from standing, an equal • volume of j liquor potasses ; when well mixed, a viscid | gelatinous fluid or mass is formed, which l pours like the white of an egg, or jelly. DISEASES OF THE KIDNEYS. J47 XIV. Test for bile by “fuming” or red nitric acid. XV. Test for bile fti^ment by pure hy- drochloric and pure nitric acids (Heller’s). XVI. Test for sugar by liquor potassa and heat (Moore’s). XVII. Test for sugar by subnitrate of bismuth, liquor potas- ScE and heat. f Allow a specimen of urine and a few drops of red “fuming” nitric acid to gradually j intermingle on a porcelain dish, and a “ play of colors,” green , blue, violet , red and yellow or brown , occur, if biliary coloring matter be . present. f Pour into a test tube about 1.6 f£ of pure hydrochloric acid , and add to it, drop by drop, just sufficient urine to distinctly color it. The two are mixed. Then drop down the side of the test-tube pure nitric acid , which will “ underlay ” the mixture of hydro- chloric acid and urine. At the point of contact between the mixture and the color- less nitric acid a handsome “ play of colors 1 appears.” If the “ underlying ” nitric acid is now stirred with a glass rod, the set of colors which were superimposed upon one another will appear alongside of each other in the entire mixture, and should be studied by transmitted light. If the hydrochloric acid, on addition of the biliary urine, is colored reddish-yellow the coloring matter is bilirubin ; if it is col- ( ored green, it is biliverdin. f Add to the urine half its volume of liquor fiotasssp. ( Caution . This may give a white, flaky precipitate of the earthy phosphates, which should be removed by filtering.) Now boil ; this causes, at first, a yellow-brownish color, becoming darker if much sugar is present, due to glucic, and finally to melassic l acid. f Add to the urine half its volume of liquor potassce , and then a little bismuth subnitrate , shake and thoroughly boil ; the presence of ■ sugar reduces the salt and black metallic bismuth is deposited, or if but little sugar, a gray deposit occurs. Caution. Albumin must be absent. 148 PRACTICE OF MEDICINE. XVIII. Test fo r sugar by a solution of cupric sulphate, liquor potassae and heat (Trommer’s). XIX. Quantitative test for sugarhy Pavy' s solution, to wit : — R. Cupric sulphate, gr. 320 Neutral potassic tartrate, . . gr. 640 Caustic potash, gr. 1280 Distilled water, 20 Keep corked. XX. Quantitative test for sugar by fer- mentation and the specific gravity. f Add to the urine a few drops of a solution of cupric sulphate , and then its own volume of liquor potasses. ( Caution . On first addi- tion a light greenish precipitate occurs, which, on further addition of the reagent, if sugar or certain other organic matters are dissolved, giving a transparent blue liquid.) Now boil , and a yellowish precipitate of j hydrated cupric suboxide, occurring at once, I denotes the presence of sugar. I Caution. Albumin must be absent. Take of Pavy s solution of cupric protox- ide, recently prepared (see margin), 200 minims or a multiple of this quantity, and boil in a porcelain dish ; while boiling, add minim by minim, from a measured portion of the 24 hours’ urine, and it gives a. yellow- ish precipitate of hydrated cupric sub oxide, if sugar be present. Note carefully the gradual disappearance of the blue color, and when completed (best determined by looking through the margin of the fluid against the white porcelain dish) from the amount of urine used, determine the amount of sugar passed daily. The q\iantity of urine containing one grain of sugar being just sufficient to reduce the 200 minims of the copper solution. f Take two measured specimens from the 24 hours’ urine, and to one add a little yeast. Place each specimen in a temperature of 75 0 to 8o° Fah. ; in 24 hours, fermentation hav- ing destroyed the sugar in the one contain- ing the yeast, the difference in the specific gravity of the two specimens expresses the number of grains in each ounce of the urine. Approximately. DISEASES OF THE KIDNEYS. 149 CONGESTION OF THE KIDNEYS. Synonyms. Renal hypersemia ; catarrhal nephritis. Definition. An increase in the amount of blood in the vessels of the kidneys; when arterial, it is termed active congestion; when venous, passive congestion ; characterized by pain, frequent desire for urination, the amount of urine scanty, high-colored, occasionally containing albumin or blood. Causes. Active; from cold; irritating substances eliminated by the kidneys, as turpentine, copaiba, cantharides, carbolic acid, nitrate or chlorate of potash ; during the eruptive or continued fevers ; injuries over the kidneys. Passive ; obstructive diseases of the heart or lungs, pressure of the pregnant uterus. Pathological Anatomy. The kidneys enlarge and increase in weight ; increased redness (the color being bluish if passive ), with points of vascularity, corresponding to the Malpighian bodies, and occasionally minute ecchymoses. The abnormal hypersemia causes a catarrhal state of the ducts of the pyramids, with shedding of their epithelium. If mechanical ( passive ) obstruction continues for some time, in- crease of the connective tissue, with consequent induration and contraction results, or a form of chronic Bright’s disease. Symptoms. Active variety ; pain over kidneys and following the course of the ureters into the testicles and penis, irritable bladder , almost constant and pressing desire for urination, the urine scanty , high-colored , and occasionally bloody, with fibrin, casts and albumin ; there is, as a rule, no pain during the act of urination. The constitu- tional symptoms are headache, slight nausea, vomiting, and a general feeling of discomfort. If the condition persist, infia7nmation of the kidney results. Passive ; the kidney changes are masked by the lung or heart trouble, until dropsy , scanty , high-colored , albuminous urine is ob- served. Prognosis. Active ; if recognized and properly treated, favorable. Passive, controlled by the cause, and if prolonged, terminating in interstitial nephritis. Treatment. The most important indication is to ascertain and remove the cause. Rest of the body ; dry or wet cups over the loins ; 150 PRACTICE OF MEDICINE. dilute the urine by increasing the quantity of bland fluids consumed ; saline purgatives ; warm bath or other mild diaphoretics. Infusum digitalis is pre-eminently the remedy for congestion of the kidneys ; if great irritability of the bladder , camphora , gr. ij-iv, every four hours, combined with morphince sulph., gr. or the hypodermic injec- tion of morphina , gr. The treatment of the passive form resolves itself into the treatment of the caaise, remembering that there is too much blood in the veins and too little in the arteries. There are three ways of restoring the -circulation. By venesection, opening a large vein ; by increasing the power of the heart by the use of digitalis or strophanthus , preferably the first named ; and by dilatation of the capillaries with inhalations of amyl nitrite or the internal use of spiritus glonoini (nitro-glycerin i per cent, solution), one to three drops every four hours. The bowels should be kept soluble by salines. ACUTE PARENCHYMATOUS NEPHRITIS. Synonyms. Acute Bright’s disease; acute desquamative ne- phritis ; acute tubal nephritis ; acute nephritis. Definition. An acute inflammation of the epithelium of the uriniferous tubules ; characterized by fever, scanty, high-colored or smoky urine, dropsy, with more or less constant nervous phenomena, the result of acute uraemia. Causes. The young more liable than the aged ; cold and ex- posure ; scarlatina, diphtheria, and other infectious diseases ; persis- tent use of irritants, as turpentine, cantharides, phosphorus, ginger, and others. Blows and injuries of the back have caused acute nephritis. Pathological Anatomy. The kidneys are generally swollen, engorged, more vascular, and of red color ; in the second stage the organ remains large, irregularly red, especially the cortex ; the tubules are engorged and filled with epithelium, blood corpuscles and fibrin. The capsule is easily detached, and is more opaque than normal. If a favorable termination, the swelling lessens, the vascularity diminishes, the tubules returning to a normal condition. Symptoms. In mild cases the slowly developing dropsy , with ancemia , and dyspnoea , or simply shortness of breath, with weakness, are the only clinical phenomena present, the diagnosis being con- DISEASES OF THE KIDNEYS. 151 firmed by an examination of the urine. Usually, however, begins suddenly. Fever , with nausea and violent and persistent vomiting, dull pain over the kidneys, following the ureters ; frequent desire to urinate ; diarrhoea; skin harsh and dry ; pulse quick, tense, and full. Soon dropsy appears, the eyelids and face become puffy and swollen, followed by general oedema of the extremities, scrotum, and abdo- minal walls. If the attack follow scarlatina there are from the onset much greater pallor and general debility. Urcemic symptoms may develop any time during the attack. The urine is of high specific gravity, scanty, smoky (like beef wash- ings) in color, due to the presence of blood. Albumin is present in large quantities, and the microscope reveals casts of the uriniferous tubules, blood corpuscles, uric acid, urates and oxalate crystals, and epithelium. Duration from one to four weeks. Complications. Pericarditis, pleuritis, pneumonitis, peritonitis , and acute urcemia, from retention and decomposition of urea in the blood. Diagnosis. The history, fever, scanty, smoky, albuminous urine, with dropsy beginning in the face, should prevent any error. Albuminuria may be confounded, on account of the presence of albumin in the urine, but lacks the clinical history, usually occurring in the course of some constitutional affection, as diphtheria, cholera, yellow fever or erysipelas. Da Costa distinguishes between acute Bright’s disease and acute nephritis by the last named “ affecting only one kidney, by much greater pain and tenderness in the lumbar region, by the retraction of the testicle, and by the higher degree of febrile excitement. Then, too, the deeply-colored urine which is voided contains little or no albumin.” Prognosis. Favorable. Majority of cases recover under prompt treatment. Rarely passes into chronic Bright’s disease. Urcemic symptoms add to the gravity of the prognosis. Treatment. Absolute rest in bed until all symptoms have disap- peared. A strictly milk diet is the most suitable, but if there is much depression and weakness, may add animal broths and oysters. No tea, coffee or stimulants. Water can be used ad libitum. Cream of tartar lemonade is a useful as well as pleasant drink. Locally, dry cups over the kidneys followed by poultices — a digitalis poultice being the very best. 152 PRACTICE OF MEDICINE. The bowels should be kept soluble with morning doses of salines , or ftulv. jalapce comp., 3j, in water before breakfast, or elaterium , gr. i repeated p. r. n. Free action of the bowels assists in relieving the overtaxed kidneys, and conjoined with free diaphoresis seems almost indispensable in acute nephritis. Magnesii sulphas , in small and repeated doses, is a valuable cathartic in nephritis, as it acts upon the kidneys as well as the bowels. The most efficient diaphoretics are, the hot-air bath ox pack, or the wet sheet and blanket bath, stimulating the peripheral circulation after free sweating has occurred by rubbing with alcohol and water. For drugs, one of the very best is extractum pilocarpi fluidum, tt\,x-xxx, every three or four hours ; but as it is generally conceded that pilo- carpus acts better when administered subcutaneously, employ pilo- carpince hydrochloras gr. repeated p. r. n., by the hypodermic method. Another valuable diaphoretic is vinwn ipecacuanhce, gtt. j-iij, every half hour or so. Diuretics are of great value, indeed, often indispensable in acute nephritis. The following formula of Millard’s is suitable in the majority of cases : — R. Tinct. digitalis, fj^ss Aceti scillse, . . . f^jss Spts. aetheris nitrosi, *. . . . f jij. M. Sig. — T easpoonful every three or four hours in water. The following combination has given excellent results : — R. Potassii acetat., ^iv-vj Inf. digital., f ^ iij Liq. potassii citratis, f ^ iij. M. Sig. — T ablespoonful every four hours in water. Other reliable diuretics are digitalinum (cryst.), gr. ; caffeines citras, gr. ij-jv, or sparteince sulphas , gr. Y>-Y*' If uraemic symptoms, treat according to directions given in that section. As soon as the blood disappears from the urine, a course of ferrum, in the shape of Basham's mixture, until albumin disappears and health is restored. The following is the formula of Basham’s mix- ture : — R . Liq. ammon. acetat., Acid, acetic., . . . Tinct. ferri chlor., . Alcoholis, .... Syrup., Aquae, Sig. — D ose, f^j-f^j. f 3 v i 3 "j f^v E U f ~iv f|iv. M. DISEASES OF THE KIDNEYS. 153 CHRONIC PARENCHYMATOUS NEPHRITIS. Synonyms. Chronic Bright’s disease ; chronic croupous ne- phritis ; chronic tubal nephritis ; chronic albuminuria ; large white kidney. Definition. A chronic inflammation of the cortical and tubular structure of the kidneys ; characterized by albuminous urine, dropsy, increasing anaemia, with attacks of acute urcemia. Causes. Rarely follows the acute form, but in ever so many cases the etiology is unknown, and in the vast majority of cases it is primarily chronic or subacute ; syphilis ; chronic malaria ; alcoholic excesses ; chronic mercurialism ; lead poisoning ; opium habit ; pro- tracted suppuration ; phthisis ; hepatic disorders ; pregnancy ; some undetermined nervous condition. It is a disease of the young, rarely occurring after forty. Pathological Anatomy. A large white, or yellowish white, smooth kidney, often twice the normal size. The capsule is nowhere adherent to the organ. Upon section, considerable tumefaction of the cortical substance and the rarity of vascular striae are recognized. The medullary substance shows no appreciable alteration, its color being normal. The convoluted tubes are irregularly dilated and thickened, and filled with broken-down, granulated epithelium and fibrinous casts. In pronounced cases there is fatty degeneration of the tubular epithelium. “ The intertubular matrix is greatly thickened — a change due to hyperplasia of the connective-tissue elements, to the migration of the white corpuscles and their subsequent multiplication and fatty trans- formation, and to a quantity of fluid exudation, the product of the increased pressure in the veins.” Symptoms. The onset is gradual and insidious, and the affec- tion is seldom recognized until the appearance of dropsy, which, beginning under the eyes and in the face, extends all over the body, causing dyspnoea* from ascites or hydrothorax , although in many cases the dropsy is a late symptom, the patient becoming pale, debilitated and suffering from cardiac palpitation, increasing dyspnoea, and vomiting, all gradually developing without apparent cause ; also headache, vertigo and defective vision. The urine is scanty, high- colored, albuminous, and under the microscope showing hyaline and 13 154 PRACTICE OF MEDICINE. granular tube casts, granular epithelium, and if fatty degeneration occur, fatty tube casts and oil globules. The increase above the normal amount of the urine, as the disease progresses, must not be forgotten, when the specific gravity is low, i .010-1.015, an d the quan- tity of albumin is increased. Irritable bladder is a very constant symptom. Aticemia is pronounced, from the large waste of albumin. Gastro- intestinal disorders and vague neuralgic pains are common occur- rences. Cardiac hypertrophy is of common occurrence. Bronchial catarrh , with slight oedema of the larynx , causing husky voice, are frequent complications. Amaurosis, the result of neuro-retinitis, occurs in a greater or less degree in all pronounced cases. Urcemic symptoms occur and especially urcemic asthma (renal asthma). Complications. Pneumonitis, pleuritis, pericarditis, peritonitis, meningitis, and cardiac hypertrophy. Prognosis. Not unfavorable, unless urine persistently contains a large number of fatty tube casts and oil globules. Relapses are fre- quent, but many complete (?) recoveries are recorded. I have seen four apparent recoveries, one after twelve months’ duration, another after two years’ duration, and still another after five years’ duration, no return showing itself after two years. Treatment. It is to be borne in mind that the course of a case of chronic Bright’s disease is not continuously downward ; periods of remission often follow the most aggravated symptoms, the patient and his friends being buoyed into the hope of an early and complete recovery, when, as suddenly, an attack of acute uraemia terminates life. Rest and diet are important elements in the treatment. A patient with chronic Bright’s disease should, as far as possible, be relieved from all cares of business and spend a goodly portion of time in bed. The diet is of prime importance. It may consist of an absolute milk regimen, pure, or prepared as most palatable* or an exclusive lean meat diet, prepared by finely chopping, removing all fibrous and fatty portions, boiled quickly, salted to taste, and served hot. The use of half a pint of hot water, acidulated with lemon, before each meal is valuable. The use of diaphoretics and hydragogue cathartics are only indi- DISEASES OF THE KIDNEYS. 1 55 cated when the dropsy is marked, the skin harsh and dry, the urinary secretion scanty, and uraemic symptoms are threatening, for which administer the following : — U . Hydrargyri chlor. mitis, Pulv. scillse, Pulv. digital., ....... aa .... gr. j. M. Et ft. pil. SiG. — Three times daily for a few days. Diuresis should be promoted, if the secretion of urine is scant, by digitalis , caffeines citrata or sparteines sulphas ., internally or hypo- dermically, or spiritus glonoinis, and dry cups and poultices over the loins. Iron is preeminently the drug for this variety of Bright’s disease ; the tinctura ferri chloridum or the albuminate are the best forms for administration. The anesmia is to be treated by oleum morrhuce , arsenicum and ferrum , an excellent formula for the latter being — Strychninse sulph., 8 r - X Tinct. ferri chloridi, . . {% ss Acidi acetici purse, f 3 iss Curacose albse, ... Liq. ammonii acetat., . . SiG. — Tablespoonful every five hours, followed by a glass of cold water. To check the waste of albumin , a difficult matter, the following remedies have been used with more or less success : ergota , quinina , acidum gallicum , sodii benzoas , tinctura cantharidis , or potassii iodidum. For dropsy , purgatives, such as pulvis jalapce compositus, magnesii sulphas , and alkaline mineral waters; act on skin with vapor baths, or pilocarpince hydrochloras , gr. l /%, repeated if not much cardiac de- pression, or combining pulvis ipecacuanhce et opii , gr. iij, with potassii nitras, gr. iij-v every two or three hours, or, what is most valuable, the hot-air bath er pack. If there be great distention of the serous cavities, interfering with the respiration, the aspirator should be used. Puncture of the skin may be necessary at times, and it is well accom- plished with an ordinary cambric needle. Cases due to syphilis , if the loss of renal structure is slight, are cured by a course of hydrargyri corrosivum chloridum and potassii iodidum , with oleum morrhuce. 156 PRACTICE OF MEDICINE. interstitial nephritis. Synonyms. Chronic Bright’s disease; sclerosis of the kidneys; contracted kidneys; small red kidney ; gouty kidney. Definition. An inflammation of the intervening connective tissue of the kidney, chronic in its progress, resulting in an induration or hardening, with contraction of the organ ; characterized by frequent voiding of large amounts of pale, albuminous urine, of low specific gravity, disorders of the gastro-intestinal and nervous systems, and a strong tendency to cardiac hypertrophy and changes in the vessels. Cases of nephritis are not uncommon in which albumin is never detected in the urine. Causes. A disease of middle life, from forty to sixty years. Gout a common cause ; lead cachexia; syphilis; alcoholism; opium habit ; long-continued worry, anxiety or grief ; alterations in the renal ganglionic centres (DaCosta and Longstreth). I have slowly become convinced that the large increase of ne- phritic cases can be attributed to the widespread use of drugs of the salicylic order. Pathological Anatomy. The kidneys are reduced in size. The capsule is thickened, opaque, and adherent. The surface of the kidney is granular, with cysts of various sizes, of transparent color, scattered irregularly over the surface. On section the tissue of the kidney is tough and resistant. The cortical portion is thin, from atrophy, being only a line or two in thickness. The co?inective tissue is greatly thickened, compressing the tubules into mere threads, the glomeruli being grouped together in bunches, owing to the wasting of the intermediate tubes. The color varies, from a darkish-brown to a yellowish-gray, according to the amount of blood in the organ. The left side of the heart is hypertrophied, and there is also hyper- trophy of the muscular fibre of the arterioles throughout the body ; if the case is protracted the hypertrophied tissues undergo fatty degeneration. In many cases there occur fatty degeneration of the retinal tissues, or sclerosis of the nerve-fibre layer, changes which are termed retinitis albuminurica. The “ ganglionic centres" undergo fatty degeneration and atrophy (DaCosta and Longstreth). Apoplexy is a frequent termination of interstitial nephritis, the rup- ture of a cerebral vessel suggesting it to be a disease of degeneration. DISEASES OF THE KIDNEYS. 157 Symptoms. Onset insidious, and often marked alterations in the kidneys, heart and vessels have occurred before the disease is recognized. There are no characteristic early symptoms in the majority of cases, the disease being apparently latent, until some special outbreak cause a more thorough examination of the patient, when interstitial nephritis is detected. Any of the following symptoms may first attract attention : Frequent micturition , increased amount of urine , of a pale color , low specific gravity, containing a small amount of albumin, which may be absent for days, occasional epithelial cells and hyaline casts. No dropsy, but a little puppiness and oedema of the conjunctives — the Bright’s eye. Disorders of vision. Forcible cardiac action with high arterial tension. Attacks of vertigo, headache, disordered vision, attacks of epistaxis and disordered stomach. Progressive anaemia is a frequent symptom. Any of the following symptoms, the result of urezmia, may occur : Persistent dyspepsia, occasional vomiting, regardless of food ; head- ache, vertigo , and stupor, or drowsiness ; violent itching of the skin ; tremors , convulsions, epileptic seizures, or apoplectic attacks. The body weight declines, the skin is dry and scurfy, the strength fails, and shortness of breath on exertion is present. The termmation is usually by convulsions, coma, and death. Complications. Bronchitis ; pneumonitis ; pleuritis ; pericarditis ; cardiac hypertrophy. Diagnosis. Interstitial nephritis is most likely to be confounded with parenchymatous nephritis. The following table from Millard presents the most important points of difference between the two : — In Chronic Croupous Nephritis. The urine is always albuminous. Urine usually scanty. Dropsy and oedema almost always occur. Hypertrophy of the heart seldom exists. Specific gravity of urine usually higher than the normal. Urine darker and with less of a soapy appearance than in chronic interstitial nephritis. In Chronic Interstitial Ne- phritis. Urine not constantly albuminous. Urine usually abundant. Dropsy seldom or never present ; sometimes slight oedema. Some hypertrophy of heart with increased arterial tension almost al- ways present. Urine generally of a light color and low specific gravity. 158 PRACTICE OF MEDICINE. In Chronic Croupous Nephritis. Uraemic symptoms less frequent than in chronic interstitial nephritis. Epistaxis and cerebral hemorrhages rare. Occurs most frequently before the age of forty. Blood corpuscles and connective tissue shreds more frequently found in chronic croupous nephritis. Casts more numerous and in greater variety than in chronic interstitial nephritis ; waxy, granular, fatty, and hyaline casts occurring. Epithelia from the kidney and pus corpuscles more numerous than in interstitial nephritis. Urates and phosphates predomi- nate ; oxalates rare. Albuminous retinitis rare. Gangrenous erysipelas and phleg- menous swellings more common ; also dyspepsia and anaemia. Visceral complications, as pneu- monia, pleuritis, pericarditis, and bronchitis, not uncommon. Diarrhoea sometimes. Cirrhosis of liver rare. Atheroma of arteries rare. In Chronic Interstitial Ne- phritis. Uraemic symptoms are met with in their most pronounced form, and in severe cases usually occur. Epistaxis and cerebral hemorrhages frequent. Occurs most frequently after forty. Absent in chronic interstitial ne- phritis. Development more gradual, the health of patient often less impaired, and duration longer than in chronic croupous nephritis. Casts rare, the hyaline variety be- ing most frequently met with. Kidney epithelia and pus corpus- cles scanty, and occasionally absent. Oxalate of lime almost always oc- curs. Albuminous retinitis common. Visceral complications rare. Cirrhosis the most frequent hepatic lesion. Atheroma common. Prognosis. Pursues a very chronic course ; cases recorded under observation eleven years. If the case is seen in its incipiency a cure is possible, but as a rule we say the termination is fatal. DISEASES OF THE KIDNEYS. 159 Treatment. Regulated diet ; diaphoretics ; diuretics ; avoid alcoholic stimulants. As nearly absolute rest as patient’s general health will permit. To prevent the growth of the connective tissue, the following remedies are recommended : potassii iodidum , hydrargyri corrosivian chloridum , gr. a urii et sodii chloridum , gr. ferri iodidum , and arsenicum. Ferrum is as valuable in this as in the other forms of Bright’s disease. For urcemia, if patient is conscious, purgatives, diaphoretics , and diuretics. If unconscious, hoi air bath , morphma and pilocarpince hydrochloras , or caffeince citrata ., hypodermically, or chloroform in- halations, and watching the heart. AMYLOID KIDNEY. Synonyms. Chronic Bright’s disease ; waxy kidney ; lardaceous kidney. Definition. A peculiar infiltration into, or a degeneration of, the structure of the kidney, from the deposit of an albuminoid material, having a superficial resemblance to molten wax or boiled starch. Simi- lar changes occur in the liver, spleen, intestines, and other organs. Causes. The chief cause is prolonged suppuration, especially of the bones ; coxalgia ; syphilis ; cancer ; phthisis. Pathological Anatomy. The kidney is uniformly enlarged. It presents a pale, glistening, translucent appearance, and has a doughy consistency. On section, the surface is homogeneous, anaemic, and whitish. The deposit occurs along the renal vessels and in the vascular tufts of the glomeruli, progressing until all parts of the organ are infiltrated. When the organ is thus infiltrated, the proper structure undergoes an atrophic degeneration, the result of pressure. The reaction with iodine and sulphuric acid affords a certain test of the amyloid deposit. Brush over a section of the affected kidney a solution of iodine with iodide of potassium in water, when a mahogany color will be produced, and if diluted sulphuric acid is now added, a violet or bluish tint results. A very pretty reaction is to take a one per cent, solution of anilin violet, which strikes a red or pink color with the amyloid material, while the unaltered tissues are stained blue, making a beautiful contrast. 160 PRACTICE OF MEDICINE. Similar changes occur in other organs of the body. With the amy- loid change may be associated either parenchymatous or interstitial nephritis. Symptoms. Associated with wasting are oedema of the lower extremities and ascites , with an increased flow of urine , pale, watery, and of low specific gravity, containing albumin and hyaline casts , which are transparent. If the amyloid change be associated with other forms of renal change, the urine will show the characteristics of such condition. A profuse, watery, and persistent diarrhoea caused by the amyloid changes in the intestinal canal. Diagnosis. Differs from parenchymatous nephritis in its clinical history, and the fact of its always being associated with a suppurating disease. From interstitial nephritis , in its history, character of the urine, absence of uraemia, cardiac hypertrophy, changes in the vessels, and the fact of its association with suppurating diseases and similar changes in other organs. Prognosis. Controlled by the suppurating disease with which it is associated ; the termination, when the amyloid change is fully developed, is unfavorable, death occurring within a few months, or, under favorable conditions, not for one or more years. Treatment. Sustaining and symptomatic in character. Gener- ous diet and the persistent use of ferri iodidum , alternating with ammonii murias and oleum morrhuce. If caused by syphilis, a thorough course of potassii iodidum, ferri iodidum, and hydrargyri corrosivum chloridum, with oleum morrhuce . If of syphilitic origin, the plan of Keyes (Dr. E. L.) is to be com- mended : “ I think that a case treated from the first should receive mercury continuously in small doses (gr. ^ to gr. -^ u ), for a period not less than two and a half years, or, in any event, until at least six months have passed after the entire disappearance of the clearly syphilitic symptoms.” PYELITIS. Synonyms. Suppurative nephritis ; pyelo-nephritis. Definition. An acute catarrhal inflammation of the pelvis of the kidney ; the term pyelo-nephritis is used when suppurative inflamma- tion is superadded to the catarrhal inflammation. The disease is characterized by lumbar pains, irritability of the bladder, the urine DISEASES OF THE KIDNEYS. neutral or alkaline in reaction and milky in appearance ; if pyelo- nephritis occur, symptoms of hectic fever and exhaustion are added, the urine containing pus. Causes. Cold or exposure ; cystitis ; obstruction of the ureters by renal calculi ; pressure from a tumor ; prolonged use of bromides and other irritative drugs ; rheumatism ; sequelae of infectious diseases. Pathological Anatomy. The inflammation is catarrhal ; it is characterized by injection of the mucous membrane of the pelvis of the kidney, with slight extravasations of blood ; relaxation and soft- ening, shedding of the epithelium, and the subsequent discharge of mucus and pus. If the morbid condition has existed for some time, the kidneys, one or both, are in a process of suppuration, they are enlarged, deeply congested, except where suppuration is proceeding, when they are of a yellowish-white color — pyelo-nephritis. Pus is constantly forming, and, if there be no obstruction, flows away with the urine ; should there be an impediment to its escape, pus accumu- lates in the pelvis of the kidney, causing its distention, giving rise to the condition known as pyelo-nephrosis. The pressure caused by the obstruction finally leads to destruction of the entire organ, a mere sac, or renal cyst , remaining. Symptoms. If caused by cystitis , symptoms of this condition occur first ; if from renal calculi , its characteristic symptoms precede those of pyelitis. Begins by chilliness , feverishness , lumbar pains following the course of the ureters, frequent micturition , the urine milky in appear- ance when voided, acid or neutral in reaction, and depositing a copious sediment, whitish or yellowish-white in color, containing only a small amount of albumin, no more than is due to the pus. Cases of pyelitis due to renal calculi frequently show hemorrhages ; the urine bloody after some extra exertion. If pyelo-nephritis follow, symptoms of pyaemia supervene, to wit : fever , typhoid in character, low, muttering delirium , subsultus tendi- num t stupor , decline in strength, and loss of flesh, with perhaps a tumor in the lumbar region. If both kidneys are affected urceinic symptoms are frequent. Diagnosis. From cystitis , by history, lumbar pains and acidity of purulent urine, the urine in cystitis being always alkaline. A microscopical examination of the urine will aid the diagnosis very much. 162 PRACTICE OF MEDICINE. Perinefthritis, a disease of the loose tissue, around about the kid- neys, terminating in abscess, causing lumbar pain, increased by motion or pressure, hectic fever, sense of fluctuation over kidneys, the urine remaining normal. Prognosis. Simple cases, where no obstruction to flow of pus, recover in a week or ten days. If obstruction of the ureter, the prog- nosis is grave. Suppurative cases unfavorable. Treatment. Rest in bed. Milk diet. Free use of water to dilute the urine, and free diaphoresis. Quinina to keep down tem- perature, prevent formation of pus, and maintain the powers of life. To change the character of the secretion, Prof. Da Costa strongly recommends pix liquida ; other remedies are oleum santali, copaiba , eucalyptol , terebinthina , and cubeba. I have seen excellent results from a prolonged course of the Buffalo Lithia Springs water or the Rockbridge Alum Springs water of Virginia. For renal hemorrhage, alumen , gr. xx, repeated p. r. n., is- suc- cessful. If abscess results, aspiration , quinina , and stimulants. Extirpation of the diseased kidney has been followed with fair health. ACUTE URAEMIA. Synonyms. Uraemic poisoning ; uraemic intoxication ; uraemic coma ; uraemic convulsions. Definition. A group of nervous phenomena, which occasionally develop during the course of acute or chronic Bright’s disease, and other maladies, the result of the retention or accumulation in the blood of an excrementitious material, supposed to be urea , the flow of urine being either normal, lessened, or increased. Causes. Suppression of urine, from acute or chronic Bright’s disease, probably more frequent in chronic parenchymatous nephritis ; cystic, tubercular, or cancerous kidney ; the puerperal state ; opera- tions on the uterus, bladder, urethra, or rectum. Symptoms. Uraemic intoxication is the result of the failure of the kidneys to perform their normal function of eliminating some one or all of the poisonous elements of the urine. The toxaemia may develop suddenly, by a convulsive seizure fol- lowed by coma , or slowly and gradually. Usually the attack is pre- ceded by a decrease in the urinary secretion and slight or marked DISEASES OF THE KIDNEYS. 163 oedema in various parts of the body ; although it must be borne in mind that in rare instances, during, or immediately prior to, the ap- pearance of the uraemic phenomena, the normal urinary flow has been largely exceeded. The acute outbreak may manifest itself in a variety of ways. Gastro -intestinal variety. The patient suddenly experiences attacks of vertigo , pallor of face, nausea and vomiting , with fever , the tempera- ture varying between ioo° and 103°, pulse tense and rapid , respiration hurried , and the urine scanty with low specific gravity ; unless symp- toms are promptly relieved convulsions may occur, followed by coma and death, ox drowsiness supervene, followed by coma, which is really nothing but a profound sleep. Rarely an acute maniacal outbreak follows the gastro-intestinal symptoms. Convulsive variety. Without any appreciable prodromes, epilepti- form convulsions , with or without loss of consciousness. The convul- sions may consist of a single paroxysm, or a succession of fits may fol- low one another at intervals of a few minutes or several hours, the patient in a condition of more or less profound insensibility during the intervals. The fits almost exactly simulate true epilepsy. In this variety the temperature is nigh, from 103° to 106° or more, the pulse rapid, with or without tension, the respirations quickened. Coma fol- lowed by death is a very common ending of this variety of uraemia, or after a profound sleep of hours the patient gradually recovers his usual health. Alcoholic excesses are responsible for many of these attacks. Cerebral variety , or urcemic co?na. Develops either gradually with an increasing drowsiness associated with headache , and irritability of temper (mild mania). Nausea , vomiting and rise of temperature , often reaching 105°, rarely 107°, with rapid, full pulse, or the patient may fall suddenly into a condition of profound coma, the symptoms closely resembling an apoplectic stroke, except the high temperature. Uraemic coma is always accompanied with rise of temperature and stertor. “The stertor is peculiar; it is not the “snoring” of apo- plexy, but a sharp, hissing sound produced by the rush of expired air against the teeth or hard palate.” (Loomis.) The respirations are accelerated, the pulse rapid but minus tension. This variety may suddenly terminate fatally with a convulsion, or a deepening coma with prostration and cold, wet skin, with oedema of the lungs, or rarely, gradual recovery. 1G4 PRACTICE OF MEDICINE. Diagnosis. Uraemic conditions closely resemble a number of conditions in which convulsions and coma are prominent symptoms. Much valuable assistance is obtained in the diagnosis by a knowledge of the condition of the kidneys. Always obtain a specimen of urine at once and subject to an albumin test at least. Another valuable aid is the temperature record. I believe acute outbreaks of uraemia are always associated with a rise of tempera- ture. The temperature is the result of the irritation of the heart- centres and not due to an increased arterial pressure. Cerebral apoplexy may be mistaken for uraemic coma, or the re- verse. The chief points of distinction are, in the latter the attack is usually in patients suffering from dropsy, and that the coma is not sudden in its appearance, but is generally preceded by other nervous phenomena, such as headache, vertigo, dimness of vision, obstinate vomiting, and convulsions. Again, the urcemic stertor is a sharp, hissing sound, while that of apoplexy is “ snoring.” Apoplexy is fol- lowed by paralysis, uraemic coma is not. An epileptic seizure is preceded by the sharp cry and extreme pallor of the face, the countenance being dusky in uraemic convulsions. Prognosis. An attack of acute uraemia is always a very grave condition. The prognosis depends upon the amount of retained poison, the length of time it has been retained, and the condition of the organs of elimination. Treatment. Promptness and thoroughness is the essential point in the treatment of an uraemic outbreak. For the gastro-intestinal variety, put patient to bed and administer the magnesium sulphate enema given below and order either caffelna citrata , gr. iij, every three hours, or the spartein and pilocarpine mix- ture mentioned below. As soon as the secretions have been started give one of the following powders every two hours until a dozen or more are used, followed by Hunyadi Janos water (R. Hydrargyri chlor. mitis, gr. sodii bicarb., gr. ij ; pulv. ipecacuanhae, gr. M. et. ft. chart. No. j). For the convulsive or cerebral variety, the indications are: first , to arrest the nervous phenomena ; secondly , to promote elimination. Prof. Loomis has succeeded in meeting both of these indications by hypodermic injections of morphina , gr. repeated, if required, every two hours. He says: “The most uniform effect of morphine so administered _ is, first, to arrest muscular spasms; DISEASES OF THE KIDNEYS. 165 second, to establish profuse diaphoresis ; third, to facilitate the action of cathartics and diuretics, especially the diuretic action of digitalis.” Following the injection of morphina, diaphoresis should be pro- moted by means of the hot-air bath , or the hot-wet pack, or the hypo- dermic use of the pilocarpince hydrochloras , gr. > provided no counter-indication to its use exists, or using at the same time frequent doses of caffeince citrata , gr. iij, by hypodermic injection. The following combination has given excellent results in a number of cases when the patient was able to swallow : — he. Sparteinae sulphat., gr. iv Pilocarpinse hydrochlor. Infus. digital., . . . . M. Sig. — T easpoonful every half hour, hour, or two hours until effect. If patient is unable to use the medicine by stomach the same drugs can be used by the hypodermic method, using digitaline cryst. (R. Digitalinae cryst., gr. ; pilocarpinse hydrochlor., gr. sparteinae sulph., gr. ]/ 2 ; aquae destil. tt\,xxx. M. Sig : As dose p. r. n.) I have never observed the alarming symptoms of depression from the careful use of pilocarpine, mentioned by some observers. The production of free diaphoresis alone must not mislead the physician, as unless the sweat contains urea or its products it is only depressing, and the clinical fact is that in uraemia the eliminating function of the skin as well as the kidney is in abeyance. The convulsions are rapidly controlled by inhalations of chloroform , (although the after symptoms are badly influenced by the drug), or the internal or rectal administration of full doses of chloral , or in suit- able cases by a free venesection. It not infrequently happens that upon opening a vessel the blood does not flow, or but a few drops slowly flows from the wound. If this obtains it is almost immediately changed by a hypodermic injection of amyl nitrite , npvj, with spts. am- moniae aromaticus, tt\,xv. Diuresis is promoted by infusum digitalis , dry or wet cupping, poultices over the loins, and hot compresses of infusum digitalis over abdomen, or caffeince citrata , or sparieince sulphas , or spiritus gloi- noini. Catharsis is best promoted by elaterium , gr. y^-g-, or an Epsom salts enema. (R. Magnesii sulph., ^ij ; glycerini, ^j ; aquae bul., ^iv. M. as enema.) The febrile phenomena does not call for antipyretics. It is one of 166 PRACTICE OF MEDICINE. the nervous phenomena of uraemia and is controlled by the means employed to eliminate the poison. If symptoms of collapse develop, with cold, clammy skin, feeble, rapid pulse, and superficial respirations, at once administer atropines sulphas , gr. g 1 ^, and bathe surface with hot water and alcohol. Of late sodii benzoas , 3j-ij, during the twenty-four hours has been lauded as an almost specific in uraemic intoxication. Under the action of this remedy the paroxysms lessen in severity, the intervals grow longer, and the convulsions after a time cease entirely. Pro- found sleep is induced by it, and during this the cerebral functions are restored. When albuminuria exists, a marked diminution occurs in the quantity present, or the albumin disappears entirely. Milk , in as large quantities, diluted, as can be borne, should be the diet. The attack broken, the treatment resolves itself into that of the nephritic affection causing it. RENAL CALCULI. Synonyms. Nephro-lithiasis ; gravel ; renal colic. Definition. Renal calculi are concretions formed by the precipi- tation of certain substances from the urine, around some body or substance acting as a nucleus. Their presence may not be recognized until one or more attempt to pass along the ureters, when an attack of renal colic results ; or, by irritation, pyelitis is produced ; or, more rarely, they are voided by the urine without exciting any symptoms. By gravel is meant very small concretions (sand), which are often passed in the urine in large numbers. Causes. Occur at all ages; frequent before the fifth year, and from five to fifteen. Males are more liable than females. A special liability seems to exist in some families, but the precise etiology of calculi is not yet determined. Varieties, i. Uric acid , as calculi and gravel, and especially associated with the gouty diathesis. 2. Urates , chiefly urate of ammonium ; nearly always in childhood. 3. Oxalate of lime or mulberry calculus ; characterized by hardness, roughness, and very dark color. 4. Phosphatic calculi form as frequently in the bladder as in the kidney, and present a chalky or earthy appearance. DISEASES OF THE KIDNEYS. 167 5. Alternating calculi, consisting of alternate layers of two or more primary deposits. Anatomical Characters. In structure, a urinary calculus usually consists of a central nucleus , surrounded by the body, and outside of all there may be a phosphatic crust. The nucleus may or may not be of the same material as the rest of the stone, sometimes being a foreign body, mucus, or blood. A section generally shows a stratified arrangement, or it may be partly or completely radiated. Symptoms. The clinical signs of renal calculi are those con- sequent on the results of their presence, to wit : renal hemorrhage , renal congestion , inflammation terminating in abscess, pyelitis or pyelo- neph ritis , cystitis, or renal colic. The symptoms of retial colic begin abruptly, by severe, agonizing pain in the lumbar region following the ureters into the corres- ponding groin and thigh. Pain and retraction of corresponding testicle also of glans penis. Face pale and features pinched, the surface cold and damp. Irritability of the bladder, the urine passing in drops containing some blood. So severe is the pain at times that the patient may faint or pass into unconsciousness, or have a general convulsion. If both ureters are obstructed, uranic symptoms will arise. The paroxysm usually terminates suddenly after some minutes or hours, the stone escaping into the bladder. Prognosis. Renal calculus is attended with many dangers. It may produce extensive disorganization of the kidneys, or its passage along the ureter may prove fatal. If the stone be very large, or if more than one, the prognosis is graver. Calculus is a disease very apt to recur. Renal sand ( gravel ) and small concretions may, after more or less delay, be voided with the urine. Treatment. An attack of renal colic is best relieved by a hypodermic injection of morphina and atropina, and a warm bath or a suppository of ext. opii, gr. j, ext. belladonnce alco., gr. ss, repeated if needed. For attacks of gravel, liquor potassii citratis , f^ss, every three hours, and, if much vesical irritability, adding tinct. opii camph., f^ss-j. F or renal hemorrhage, Prof. Bartholow reports success with R . Extracti ergotae fluidi, Tincturae krameriae, .... aa .... f^ ij. M. SiG. — every two or more hours. 168 PRACTICE OF MEDICINE. I have always successfully controlled renal hemorrhages with twenty-grain doses of alumen , repeated p. r. n. For uric acid calculi , as a solvent, Buffalo Lithia Springs water or the Rockbridge Alum Springs water of Virginia, or potassii tartra- borates, “obtained by heating together four parts of cream of tartar, one part of boracic acid, and ten parts of water. A scruple may be given three or four times a day, in water, largely diluted.” For phosphatic calculi, as a solvent, ammonii benzoas, well diluted and long continued. CYSTITIS. Synonym. Catarrh of the bladder. Definition. An inflammation of the mucous membrane lining the urinary bladder, acute or chronic in its course, and of either a catar- rhal, croupous, or diphtheritic character ; characterized by rigors, moderate fever, hypogastric pain, frequent but scanty micturition, and severe vesical tenesmus, the urine containing pus (pyuria). Causes. Acute variety : long retention of urine ; foreign bodies in the bladder ; pyelitis ; urethritis ; blows over the pubes ; myelitis, and secondary to fevers or diphtheria. Chronic variety : following the acute variety ; retention the result of enlarged prostate or an urethral stricture ; calculi ; gout ; chronic Bright’s disease. Pathological Anatomy. I n acute catarrhal cystitis , there first ensues hypersemia of the mucous membrane of the entire or a por- tion of the bladder, manifested by redness, swelling, and oedema ; followed by an increased secretion of the small glands at the base of the bladder, and an increased growth and consequent desquamation of the vesical epithelium, together with a copious generation of young cells ; if the hyperaemia be decided, rupture of the capillaries and extravasation of blood occur. If the inflammation be intense, suppuration of the submucous con- nective tissue may result, and ulceration of the mucous membrane permit the submucous abscesses to empty into the bladder. If the inflammation be of a croupous or diphtheritic character, the morbid anatomy does not differ from the same variety of inflamma- tions in other mucous membranes. In chronic cystitis “ the mucous membrane is thick, blue-gray in color, and very tough. Muco-pus and viscid mucus are formed in large quantities upon its surface. The muscular wall of the bladder may sometimes be half an inch thick, and the fasciculi give a ribbed DISEASES OF THE KIDNEYS. 169 appearance to the internal surface, called the “columnar bladder.” The hypertrophy of chronic cystitis may be eccentric or concentric. In some cases diverticuli are formed, in whose walls are dilated and tortuous veins. In nearly all cases bacteria are found in abundance.” (Loomis.) Symptoms. Acute cystitis ; the onset is usually abrupt, by rigors , slight fever , loss of appetite, sleeplessness, a feeling of depression ; frequent micturition, though the urine is only voided drop by drop, and its passage followed by distressing vesical tenesmus , the result of spasm of the bladder ; pain over the pubis and in the iliac regions, of a dull character, at times becoming sharp and agonizing. Burning along the urethra adds to the distress of the patient. The urine is cloudy, of an alkaline reaction, and at times is foetid, the microscope showing epithelium , pus, and red blood corpuscles . Chronic cystitis ; the onset is gradual and insidious, and is excited by some obstacle to the evacuation of the urine, such as stricture, the presence of a stone in the bladder, or enlargement of the prostate gland. There are present dn\\ pain, frequent but scanty micturition. The urine is alkaline, containing large amounts of muco-pus or fus ; on standing, it deposits a thick, glairy, viscid sediment, in which, under the microscope, triple phosphates and large pus corpuscles, extremely regular both in contents and in shape, may be detected. Although the quantity of urine voided by the patient is small, yet if immediately after micturition the catheter is used, several ounces of foetid, cloudy, alkaline urine may be removed. Patients with chronic cystitis usually present decided constitutional debility and mental depression. Severe local pain, emaciation, and occasional bloody urine indicate ulceration of the vesical mucous membrane. Diagnosis. Pyelitis has lumbar pains following the course of the ureters, frequent micturition without the severe vesical tenesmus ; the urine, although cloudy, has an acid or neutral reaction. Prognosis. The acute variety is, as a rule, good, being controlled by the cause. The chronic variety continues for years, and after hypertrophy of the bladder is incurable. Treatment. Rest in bed is invaluable. The diet must be restricted, all highly-seasoned articles being particularly interdicted ; milk is the most suitable article. 14 170 PRACTICE OF MEDICINE. Warm applications over the pubic region are of benefit, and leech- ing and cupping over the bladder are of service. The urine should be well diluted by large draughts of pure water, and particularly the alkaline mineral waters, to wit : Farmville lithia, Buffalo lithia, Rockbridge alum, or Vichy waters. The following formulae are of decided benefit : — R . Acidi benzoici, Sodii borat., aa sjij Infusi buchu, vel Infusi uvae ursae, fjvj. M. Sig. — Tablespoonful every two hours, well diluted. Or — R. Tinct. hyoscyami., fgvj Tiuct. opii camph., fs^vj Potassii bromidi., Sodii bicarb., aa ^viij Liq. potassii citrat., q. s. f viij M Sig. — Tablespoonful every two or three hours, in water. A valuable prescription is : — R Ext. pichi fid f^j Potassii nitrat Elix. simphcis f ^ lij M. Sig. — One teaspoonful every two hours, well diluted. For the pain and tenesmus relief is afforded by a suppository of extractum opii and extractum belladonnce , repeated as needed. The vesical tenesmus is often benefited by extractum cannabis induce Jluidum , fgss, every three or four hours. Chronic cystitis. The bladder should be completely emptied with the catheter several times in the twenty-four hours. The use of eucalyptol , gtt. x-xv, every four hours, well diluted, or a good preparation of tar , or extractum grindelice jluidum, TT^xx-f^j, three or four times daily, or oleutn santali, gtt. v-x, in emulsion or capsule after meals, are valuable remedies. Acidum boricum, gr. v-xv internally, has removed pus from the urine in chronic cystitis. Washing out the bladder with the following mixture is of decided benefit : — R. Sodii borat., ^ j Glycerini, f j ij Aquae, f^ij Sig. — f Jss-iss added to warm water and injected into the bladder once or twice daily. The diet should be nutritious, but without spices of any kind. The free use of the alkaline mineral waters is of value. DISEASES OF THE KIDNEYS. 1 7 1 MOVABLE KIDNEY. Synonyms. Floating kidney ; wandering kidney ; ectopia renis. Definition. A condition of the kidney, either congenital or acquired, in which the tissues around about the organ are so lax and the renal vessels so elongated as to permit the kidney to be moved in certain directions, causing a movable tumor in the abdomen. Causes. The kidney is normally held in position by the layer of peritoneum which is attached to the anterior surface of its adipose capsule. In movable kidney, the adipose tissue in which the normal kidney is imbedded partly or wholly disappears. The renal vessels are in many cases abnormally long. Relaxation of the abdominal walls from pregnancy or other causes. The use of tight corsets or girdles about the waist ; violence ; increased weight of the organ from disease; the pressure of tumors growing in the neigh- borhood of the kidney ; the traction of hernias. The condition may be congenital or acquired, more frequently the latter. It is far more frequent in women than in men. Symptoms. Floating kidney may and often does exist without any noticeable symptoms, the condition being unknown until acci- dentally discovered by the physician while making a physical exam- ination of the abdomen. As a rule, however, patients experience a heavy, dragging pain in the abdomen, aggravated when walking or standing. There are also present gastro intestinal symptoms, more or less constant, with melan- cholia, aggravated by the mental anxiety the presence of a tumor in the abdomen causes the patient, in spite of the assurances of the physician that it is not a cancer. At times, from some unknown or unrecognized cause, the movable kidney swells and becomes very sensitive to the touch, and migrates a considerable distance from its normal position. Such an occurrence aggravates all the former symptoms mentioned. This condition has been ascribed to a twisting of the ureter and consequent retention of the urine in the pelvis of the kidney, or to a localized peritonitis, or to a partial strangulation of the kidney from compression or twisting of its blood-vessels. Hysterical symptoms are frequently observed in women suffering from wandering kidney. 172 PRACTICE OF MEDICINE. Diagnosis. The possibility of dislocation of the kidney is to be recollected in determining the nature of obscure tumors within the abdomen. The late Prof. Austin Flint based the recognition of this variety of abdominal tumor on the following diagnostic points : “ It is situated in the hypochondriac region. It has the size and shape of the normal kidney, and this may be determinable by palpation, which is most advantageously employed by placing one hand over the lumbar region and the other in front on the abdominal walls, and then making counter-pressure from one hand to the other. It is generally movable, and in some cases the organ can be restored to its proper situation.” Other tumors are to be excluded by the absence of their diagnostic characters. Prognosis. It is a rare occurrence to have a fatal termination from movable kidney per se. Treatment. Symptomatic. It is said that some of the inconve- nience and sometimes suffering attending movable kidney may be lessened by means of an abdominal bandage, belt or supporter. If attacks of pain and swelling occur, the patient should be placed in bed, have hot applications over the abdomen, and the use of opiates and attempts at replacing the organ. Extirpation of a movable kidney has been successfully performed a number of times. Nephrorraphy, an operation for fixation of the kidney by means of sutures, has been devised. DISEASES OF THE BLOOD. ANAEMIA. Synonyms. Spanaemia; hydraemia. Definition. A deficiency of red corpuscles in the blood, or of its more important constituents, such as albumin and haemoglobin, or a reduction in the amount of blood as a whole ; characterized by pallor and general weakness. DISEASES OF THE BLOOD. 173 Oligcemia is a general lessened amount of the blood. Ischcemia is a localized anaemia. Causes. Predisposing. Sex ; females, pregnancy and meno- pause ; heredity. Exciting. Deficient food, air or sunshine ; excessive work ; mental worry ; mental shock ; prolonged and frequent nocturnal emissions ; excessive nursing ; chronic intestinal catarrh ; Bright’s disease ; malaria ; syphilis ; cancer. Pathological Anatomy. Post-mortem , the tissues are thin, shrunken and bloodless. If the anaemia has been of long duration, patches of fatty change are seen in the various organs. The blood has a brighter color, the result of diminution in the number of red corpuscles and the quantity of the haemoglobin ; it is thinner than normal, and coagulates slowly and imperfectly, from diminution of the fibrino-plastic constituent. In health the blood of an adult contains about five million red cor- puscles to the cubic millimeter (the female adult about half a million less). The white cells, in health, average about ten thousand to the cubic millimeter. Symptoms. Pallor , gums, tongue, ear and conjunctivas pale. Muscular weakness , inability for exertion. Deficient appetite and impaired digestion , attacks of vomiting the result of anaemia of the medulla oblongata. Quickened respiration , irritable temper , vertigo in the erect position, attacks of swooning, hysteria , and rarely epilepsy. Irritable heart , with soft systolic basic murmurs. Nocturnal emissions in male and deficient menses in female. Marasmus in children. More or less general oedema of the eyelids and ankles. Long continued, symptoms of fatty changes in various organs, or gastric ulcer result. Diagnosis. The symptoms of anaemia are so characteristic that an error is impossible ; the cause of it, however, may be hidden. Prognosis. Favorable if treated early. If protracted, results in more or less general symptoms of fatty degenerations or ulcer of the stomach. Treatment. Remove the cause. Easily assimilated, blood-pro- ducing diet. Fresh air , sunlight and exercise short of fatigue. The anaemic patient should spend several hours in bed during the day- time. Purgatives, with stomachic tonics, to promote digestion. For the anaemia proper, per rum in some form is the most valuable remedy, always remembering that it is not assimilated if the intestines 174 PRACTICE OF MEDICINE. and liver be torpid. The albuminate of iron is a favorite form tor anaemia with weak stomach. The following alterative tonic, known as Smith’s (Dr. A. H.) “ four chlorides,” is frequently of value : — R • Hydrargyri chloridi corrosivi, gr. j-ij Liq. arsenici chloridi, fgj Tinct, ferri chloridi, Acidi hydrochlorici dil. , . . . . aa . . fgiv Syrupi, f 3 iij Aquae, ad Jvj. M. Sic. — One dessertspoonful in a wineglassful of water after each meal. Cases of anaemia with weak stomach can take the following “ iron lemonade” with ease : — R . Tinct. ferri chloridi, f£j Acid, phosphor, dil., f 3 ij Syr. limonis, f^iss Aquae, f ^ ij. M. Sig — One teaspoonful well diluted. CHLOROSIS. Synonyms. Essential anaemia ; green sickness. Definition. A pronounced anaemia met with chiefly in young girls about the age of puberty, characterized by diminution in the per- centage of haemoglobin. Causes. The true cause unknown. A disease for the most part of puberty. Most frequently seen in the ill-fed, over-worked town girls, who are deprived of sunshine and fresh air. Heredity is supposed to play a part in its causation. Hammond maintains “ that it is an affection of the nervous system, the blood changes being secondary.” Pathological Anatomy. Death from chlorosis is such a rare occurrence that little data is known. Virchow pointed out the hypo- plasia of the arterial system, many arteries being congenitally small. The body is usually well nourished and the subcutaneous fat well distributed. There is pallor of the organs and muscular system. The spleen, lymphatics and the marrow of the bones are not affected. Symptoms. The condition is associated with disorders of men- DISEASES OF THE BLOOD. 175 struation. The young girl experiences a change of disposition , be- coming morose and despondent t .rarely, hysterical , or melancholiac. “ As respects the actual condition of the sexual organs, there are two forms of derangement which happen in chlorosis ; there are the amenorrhoeic form and the menorrhagic form.” After an attack of menorrhagia or after the failure of the flow to appear, the changes occur. The complexion changes, blondes be- coming pallid, waxy and puffy without oedema ; brunettes becoming muddy and grayish in color, with bluish-black rings under the eyes. Weariness and fatigue upon the least exertion; the heart irritable, with shortness of breath, pulse full but soft, and at times pulsations in the peripheral veins. The appetite is vitiated, the digestion imper- fect ; attacks of gastralgia are frequent. A not infrequent complication is gastric ulcer. Phthisis develops in those having the slightest predisposition. Examination of the blood shows a relative decrease in quality and quantity of the haemoglobin, resulting in the blood being paler than normal. The red-corpuscles are also lighter in color and show less tendency to form rouleaux : their character also changes, not all being of uniform size, some normal, others small (microcytes), others unusually large (macrocytes), others irregularly shaped (poikilocy- tes). The number may be normal, 5,000,000 to the cubic millimeter, or the number is occasionally increased, but it is usually lessened, there being as few as 3,000,000 or 2,000,000. The white-corpuscles are usually normal in number, but in some instances their number is increased (leucocytosis). Rarely granular bodies are found in the blood which are generally regarded as the products of the degeneration of the white blood-corpuscles. Diagnosis. The disease is usually recognized at once by the color of the patient whence its common name, green sickness. The circulatory symptoms and slight oedema may be mistaken for cardiac or nephritic diseases. Prognosis. The liability to complications and also to relapses, and the lack of knowledge of the true cause, makes the prognosis always uncertain. Treatment. Three indications to be met in the treatment of chlorosis, plenty of food, fresh air and ferrum. The form of iron is immaterial. The tinctura ferri chloridi is the preparation usually prescribed. 176 PRACTICE OF MEDICINE. The following is Bland's formula, so highly lauded by Nie- meyer : — R. Pulv. ferri sulph., Potassii carbonat., purse, . . . aa . . . ss Tragacanthse, q. s. M. Ft. pil. No. xcvj. SlG. — One to three or four pills three times daily. In some instances ferrum alone does not seem to answer; in such cases the addition of arsenicum is valuable ; a good combination is — R . Ferri arseniatis, gr. Ext. nucis vomicse, gr. M. Ft. pil. No. I. SiG. — After meals. Or : — R. Liq. arsenici chloridi, fgij Tinct. ferri chloridi, f^vij Glycerini, . . fjj Elix. aurantii, q. s. ad . . . . f 3 iij. M. SiG. — One teaspoonful after meals in water. PROGRESSIVE PERNICIOUS ANAEMIA. Synonyms. Idiopathic anaemia ; anaematosis ; essential anaemia; anaemia of fatty heart. Definition. A pernicious, progressive form of anaemia, of un- known cause, usually resisting all treatment, and toward its termina- tion associated with fever. Causes. The underlying cause of idiopathic anaemia is not known. Among the exciting causes may be mentioned, pregnancy, syphilis and great worry. Pathological Anatomy. The blood is scanty and pale, with diminished red corpuscles, and haemoglobin, showing a very feeble tendency to coagulate. There is no increase in the white corpuscles. The marrow in adult bones becomes foetal, red and adenoid, and contains microcytes ; several other changes have occurred second- arily in the marrow. Secondary to the anaemia, the heart, larger arteries and certain capillary tracts exhibit circumscribed or diffused fatty degeneration. The liver, spleen, kidneys and stomach are decidedly anaemic, causing fatty changes in those organs. The skin may contain DISEASES OF THE BLOOD. 177 petechiae of a purplish or brownish tint, and internal hemorrhages are not infrequent ; retinal hemorrhage is rarely wanting. There is not much emaciation, though the pallor is pronounced. Symptoms. It begins insidiously, with increasing languor and pallor , the muscular weakness compelling the patient to take his bed. Cardiac palpitation , dyspnoea , attacks of syncope , oedema and swelling about the ankles, with petechial spots scattered irregularly over the surface ; tenderness over the sternum and other superficial bones is a frequent symptom. The appetite is wanting, and nausea and vomiting occur, asso- ciated with marked dyspepsia and persistent diarrhoea. As the disease progresses a remittent form of fever develops, the temperature fre- quently showing 102-104° F. Disorders of vision are the result of the retinal hemorrhage. The cardiac sounds are feeble and associated with soft basic or anaemic murmurs. The blood shows under the microscope the changes described in chlorosis, save the red corpuscles may be reduced to as few as 500,- 000 to the cubic millimeter. Diagnosis. Progressive pernicious anaemia is distinguished from simple anaemia and chlorosis by the greater severity of the former. From leucocythemia by the normal-sized spleen and liver, and the absence of increase in the white corpuscles. Prognosis. Unfavorable as a rule, although recoveries occur, but relapses frequent. Treatment. The employment of arsenicum either alone or combined with ferrum has considerably changed the prognosis of pernicious anaemia. The arsenicum must be pushed to the extreme point of toleration and continued for a long time. Rest in bed and a liberal nutritious diet are also essential. LEUCOCYTHEMIA. Synonyms. Leucaemia ; white cell blood ; white blood ; anaemia splenica. Definition. A condition in which there is an enormous increase in the number of white blood corpuscles, with enlargement of the lymphatic glands, spleen, and often of the bone marrow ; viz. : 15 178 PRACTICE OF MEDICINE. splenic , lymphatic , or myelogenic, and is characterized by symptoms of pronounced anaemia. Causes. The real cause and nature of the affection is unknown. Pathological Anatomy. The spleen is increased in size, den- sity and firmness ; the lymphatic glands all over the body also enlarge, but are soft to the touch, often fluctuating ; the marrow of the bones changes from its normal rose color to that of a greenish-yellow ; the liver also enlarges enormously. The blood is paler than normal, its specific gravity reduced from 1.055 t0 1*040 or lower, and the white corpuscles increased in number and in size, the red corpuscles being lessened in number and size. Symptoms. The onset is insidious and the early progress of the disease is identical with that of simple anaemia, accompanied by swelling of the abdomen and a feeling of fullness and pam in the splenic region , due to the enlargement of that organ. In the lymphatic variety , enlargement of the glands in the groin, neck, and axillary region are associated with the great pallor. In the myelogenic variety , the bones, more particularly the ribs and sternum, are tender on pressure, the patient developing a waxy appearance. In each variety the appetite is poor, the digestion feeble, the bowels loose, the patient easily fatigued, with cardiac palpitation, and dysp- noea, with oedema of the eyelids and ankles. The urine is scanty and of high specific gravity — 1 .020-1.030. Fatal hemorrhages occur near the termination of the disease. The blood is pale and watery. The white blood corpuscles are enormously increased in number. The average number of white corpuscles to the cubic millimetre normally is about 10,000. Cases.are recorded in which the number of white blood corpuscles has equaled or even exceeded the red blood corpuscles. The size of the white corpuscles varies in different cases and also in the same case. The red blood corpuscles are frequently decreased in number and size. Diagnosis. This should cause but little trouble if enlarged spleen, lymphatic glands and tender bones are associated with great pallor, and the characteristic appearance of the blood as demonstrated by a “ puncture of the finger of the patient and receiving the blood on a piece of white linen or a lawn handkerchief, and placing by the side of it a similar stain of blood from a healthy subject. The full DISEASES OF THE BLOOD. 179 color of the latter contrasts strikingly with the stain of the former, which is hardly of a blood color and translucent.” Prognosis. Unfavorable. The average duration is between two and three years. Cases of what are termed “Acute leucaemia,” proving fatal in a few months, occur. Treatment. Symptomatic. A combination of the following remedies with generous diet, fresh air, sunshine, pleasant surround- ings, oleum morrhuce and the hypophosphites have at times seemed of temporary utility, to wit : quinina , arsenicum, ferritin and ergoia. HODGKIN’S DISEASE. Synonyms. Pseudo-leukemia ; Pseudo-leucocythaemia ; lym- phatic anaemia; lymphadenoma. Definition. An affection characterized by hypertrophy of the lymphatic glands in various parts of the body, associated with marked anaemia. Cause. Unknown. Pathological Anatomy. A hyperplasia of the lymph glands interfering more or less with their functions. The enlargement may be confined to one isolated gland or a number may be affected in differ- ent portions of the body, or a number in one location may be simul- taneously affected causing a tumor varying in size from an egg to an orange or even a cocoanut. The spleen and liver are involved in two-thirds of the cases. “The marrow of the long bones may be converted into a rich lymphoid tissue ” (Osier). The red blood corpuscles are decreased in number and altered in size and shape ; the white blood corpuscles are often increased in number. Symptoms. A slowly developing anaemia with isolated or dif- fused enlargement of the lymphatic glands. As the condition develops, fever of a remittent character occurs, with feeble cardiac action and shortness of breath. Hemorrhages may occur. The patient grows progressively worse with all the associated symptoms of deficient blood, death occurring by asthenia. Diagnosis. A study of the clinical history will prevent error, as tubercular or scrofulous glands are accompanied with tubercular changes in the lungs, and do not present the same blood-changes as Hodgkin’s disease. Prognosis. Unfavorable. The progress may be slow, but it is none the less toward a fatal termination. 180 PRACTICE OF MEDICINE. Treatment. The indications are all toward a building up of the blood. Amongst the remedies recommended are arsenicum , phos- phorus, ferrum, quinina , and oleum morrhuce. Excision of the glands in the early stage may be practiced. ADDISON’S DISEASE. Synonym. Melasma supra-renalis. Definition. “The bronzed-skin disease.” Thus defined by Aver- beck : “A well-marked constitutional disease, exhibiting itself locally as a chronic inflammation of the supra-renal capsules, but in its essence consisting in a peculiar anaemic condition, always tending toward death, which is characterized by intense development of pig- ment in the cells of the rete malpighii and in the epithelium of the mucous membrane of the mouth.” Causes. Obscure. Tubercle, scrofula, and syphilis have each been given as the cause. Pathological Anatomy. A low form of inflammation, termi- nating in degeneration of the supra-renal capsule. The blood is deficient in fibrin and red corpuscles, with a slight increase of the white corpuscles. Fatty degeneration of the heart and vessels has been observed in some cases. “ The most striking change during life — the abnormal pigmenta- tion — is due to the deposition of granular pigment in the cells of the rete malpighii, in the papillary portion of the cutis, and even in the connective tissue corpuscles. No change occurs in the proper struc- ture of the skin. Similar pigment deposits occur in the mucous mem- brane of the mouth, especially along the edges of the teeth.” “ The disease of the supra-renal capsules excites an irritation of the vaso-motor system — the trophic system — which leads to the pig- mentation.” Symptoms. The onset of the disease is insidious, with a feeling of extreme languor , muscular fatigue , asthenia , indigestion , anorexia , dyspnoea , cardiac palpitation , vertigo , melancholia , and excessive drowsiness. The surface is first pale, then changes to a hue like that of melan- cemia, changing to icteroid, finally resembling the color of a mulatto, and then to a lustreless bronze . These changes also occur on the mucous membrane of the lips, tongue, gums, and mouth. Prognosis. An incurable disease. Duration, a year or two. Treatment. Symptomatic. DISEASES OF THE BLOOD. 181 HAEMOPHILIA. Synonyms. Hemorrhagic diathesis ; “ bleeder’s disease.” Definition. A congenital condition characterized by a tendency to uncontrollable hemorrhages, with or without abrasions. Cause. Hereditary. Symptoms. The bleeding appears about the period of first dentition, and consists of spontaneous hemorrhages from the mucous membrane of the nose, mouth, lungs, stomach, intestines, and genito- urinary passages, or in perfect cases hemorrhages occur directly from the fingers, toes, lobes of the ears, back of the hands or arms, without any apparent change in the skin, and continue in spite of the most powerful means, for days or weeks. Traumatic hemorrhages occur if an injury of any kind is sustained about the period of the develop- ment of the bleeding. Epistaxis is the most common form of all those named. Attacks of arthritis with fever, occur with haemophilia, resembling acute rheumatism. As a result of the great loss of blood, the subject suffers from all the symptoms of profound anaemia. Diagnosis. It is impossible to confound the “ bleeder’s disease ” with any other affection. Prognosis. Death is the usual termination within a few weeks from the time of its development, which may not be until adult life. Treatment. Entirely symptomatic. It is claimed that “ potassii chloras — an ounce of a saturated solution three times a day — com- bined with tinctura ferri chloruii will eradicate the constitutional tendency. SCORBUTUS. Synonym. Scurvy. Definition. A peculiar condition of malnutrition or amemia, gradually developing upon a dietary deficient in fresh vegetable material ; characterized by decided anaemia, debility, mental lethargy, petechiae, and a swollen and spongy state of the gums, with a ten- dency to bleed upon the slightest irritation. Causes. The disease only occurs when fresh vegetable nutriment or some appropriate substitute has been for a time partially or com- 182 PRACTICE OF MEDICINE. pletely withheld. It is held that the diet alone is not sufficient to cause the disease, the mental factor of depression of spirits, or in some cases home-sickness (nostalgia) must be associated. It is sometimes classed as an infectious disease, due to a peculiar germ, a view which is gaining ground. Pathological Anatomy. An undetermined derangement in the composition of the blood, with diminished proportion of the pot- ash salts. Spleen enlarged. The tissues are wasted and present extravasations, due to either one of or the combined presence of the following conditions, to wit : liquid condition of the blood, allowing it to escape from the vessels, alterations in the walls of the vessels, or a vaso-motor paralysis. Symptoms. General weakness, lassitude, indisposition to either mental or physical exertion. The skin is dry, rough, and of a muddy pallor, the face pale and bloated. Swelling and sponginess of the gums , with great tendency to bleed and an exceedingly offensive breath. Looseness of the teeth , hemorrhages from mucous surfaces, and extravasations of blood within and beneath the skin. The lips are pale , which is in striking contrast to the redness of the gums ; the eyes are sunken and surrounded by dark blue circles. Hemorrhages occur from the stomach, mouth, bronchial tubes, intestinal canal and vagina. The skin is dry and rough, resembling that of a plucked fowl. (Edema of the face and ankles not infrequent. Depression of the spirits is characteristic. Palpitation and dyspnoea on exertion. Urine high colored, speedily becoming foetid. The patient usually longs for fresh vegetables and fruits. Complications. Dysentery. Scorbutic dysentery is a frequent complication. It may co-exist with typhoid and typhus fever. Prognosis. Favorable, if early and properly treated. Treatment. The chief indication is the assimilation of the ali- mentary principles needed for the healthy constitution of the blood and the invigoration of the system. The juice of lemons, oranges, and other fruits ; it is wonderful what improvement will follow the use of two or three lemons daily. Anti- scorbutic vegetables, to wit : raw cabbage, cresses and raw potatoes, in conjunction with meats, milk and farinaceous food. Improve the appetite and digestion by the use of sirychnina, quinina , mineral acids and bitter infusions. Potassii chloras, locally, will relieve the oral symptoms. DISEASES OF THE BLOOD. 183 PURPURA. Synonyms. Haemorrhoea petechialis ; Morbus maculosus Werl- hofii. Definition. An acute disease, characterized by purplish discol- orations of the skin, the result of hemorrhages into the upper layers of the cutis and beneath the epidermis. When the purpuric spots are tiny, like a pin-point, they are termed petechiae ; when larger in size they are termed ecchymoses. Varieties. Purpura simplex ; purpura hcemorrhagica ; purpura urticans ; peliosis rheumatica. Causes. Not properly understood, a special germ supposed to be the cause. It may occur at any age, but is especially frequent in children and elderly people. Its occurrence after the ingestion of certain articles of diet has been observed. Symptoms. Purpura simplex is the mildest form of the affection, and is characterized by the sudden appearance of small , bright red spots — a cutaneous hemorrhage — most commonly on the legs, asso- ciated with slight lassitude, mild febrile reaction, and aching pains in the limbs. The hue of the spots rapidly fades to a purplish color and slowly disappears. Relapses are common. Purpura hcemorrhagica has in addition to the eruption of purpura simplex — the cutaneous hemorrhage — a flow of blood from the free surface of mucous membranes. The most common hemorrhage is epistaxis, slight or profuse. Other hemorrhages are hcematemesis , melcena , hoematuria , hcemoptysis , menorrhagia , and also into the sub- stance of the mucous membranes of the palate, cheek, and gums. This variety is associated with great debility and depression, moderate fever and disorders of digestion. Marked ancemia results from the hemorrhages. Purpura urticans is a combination of urticaria and purpura sim- plex . It is characterized by rounded and reddish elevations of the cuticle, resembling wheals, but which are not accompanied, like the wheals of urticaria, by any sensation of itching or tingling. They are usually seated on the legs, thighs, breast, and arms, and are inter- spersed with petechiae. They gradually form and subside within twentyffour or thirty-six hours. Relapses are frequent. This variety is also associated with malaise, moderate fever, and pains in the limbs. 184 PRACTICE OF MEDICINE. Peliosis rheumatica (Schonlein’s Disease) is characterized by multiple arthritis and a purpuric eruption; frequently the arthritic symptoms are associated with urticaria or with erythema exudativum. (Edema is often marked, as is the fever, sore-throat and general con- stitutional symptoms. The eruption is sometimes of vesicles — pemphigoid purpura. Diagnosis. The purpuric eruption in each variety of the affection is so characteristic that an error seems impossible. Prognosis. Purpura simplex and purpura urticans are favorable, but relapses are very frequent. Purpura haemorrhagica is always a grave disease, often proving fatal from exhaustion, or more rarely, from cerebral or pulmonary hemorrhage. Peliosis rheumatica is often a severe affection, but recovery is the rule. Treatment. Rest and a concentrated nutritious diet, and the moderate use of stimulants and tonics. Arsenicum in large doses is often valuable, using it in the form of liquor potassii arsenitis, to combat the resulting anaemia. The internal use of oleum terebinthince is one of the most reliable remedies for all forms of the disease. The following is an eligible formula: — R. 01. terebinthinae, f^ij Ol. amygdalae express., f3jj Tinct. opii deodorat., f 7 , ss Mucil. acaciae, t% j Aq. laurocerasi, ad . . . . f Jiij. M. Sig. — O ne tablespoonful every three or four hours. Among the other numerous remedies suggested, the most reliable have been acidum sulphuricum dilutum and tinctura ferri chloridi. Good results have followed acidum carbolicum , gtt. ij-iij every three hours, in cases seen by the author, and a particularly persistent case was cured by full doses of potassii iodidum. “ If hemorrhages that are threatened come on with a strong pulse, flushed face, headache and excitement, digitalis , quinina , and ergota are the approximate medicaments” (Bartholow.) Argenti niiras, gr. TZ , three or four times daily is of value in purpura haemorrhagica. Argentum is said to have a specific influence on thecapillary circulation by its impression on the vaso-motor nerves. Locally , to arrest bleeding, astringents and either hot or cold water or ice. ACUTE GENERAL DISEASES. 185 ACUTE GENERAL DISEASES. PAROTIDITIS. Synonyms. Parotitis; mumps. Definition. An acute specific infectious inflammation of one or both parotid and other salivary glands and the surrounding connect- ive tissue, with a very strong tendency to migrate into the mammae or testes ; characterized by pain, swelling and disordered function of the glands. Causes. A specific poison. Contagious. Occurs in epidemics, although isolated cases are seen. Males more liable than females. The most common ages between five years and puberty. As a rule, it occurs but once in the same individual. The period of incubation is from two to three weeks. Pathological Anatomy. There is inflammation of one or both parotid glands, and in severe epidemics the cellular tissue pervading the gland is involved. The catarrhal inflammation begins in the gland ducts and rapidly extends to the gland proper. There is congestion, swelling, and an infiltration of serous fluid, with more or less infiltration of the adja- cent tissues. The swelling may suddenly reach an enormous size and as suddenly decline, the gland returning to its normal condition, or, rarely, an abscess results, with partial or complete destruction of the gland. Occasionally the submaxillary gland is involved, also the mammae and testes. Metastatic parotiditis occurs secondary to severe blood poisoning, as in pyaemia, typhoid or typhus fevers, or diphtheria. The usual termination of secondary parotiditis is by suppuration and destruction of gland structure. Symptoms. The onset is rather sudden, by malaise , chill, fever, ioi°-io 3 ° F., quick pulse, headache , dry skin, scanty urine, followed within a day or two by stiffness at the angles of the jaw, swelling of th z parotid and other salivary glands, pain, increased by moving the jaws, with general oedema of the affected side of the face, at times the skin being reddened. Salivation is frequent, and occasionally deaf- ness occurs. 186 PRACTICE OF MEDICINE. The swelling and other glandular symptoms subside about the sixth or seventh day, to be followed by restoration to health, or, what is more common, the involvement of the opposite gland. At any time during the disease metastasis to the mammae , ovaries or testes is apt to occur, when the symptoms peculiar to such affections will be added. It has been noted that a continuance of the tempera- ture after the decline of the parotid symptoms has begun, usually is significant of metastasis. It is claimed that the involvement of other organs during the course of mumps is not an example of metastasis, but is a true transfer of the disease. Diagnosis. An error seems impossible. Prognosis. Simple mumps, favorable ; the chief danger being from the altered function of the mammae, ovary or testes after metastasis. Treatment. The disease being self-limited, the indications are entirely symptomatic, with attention to the secretions, although ex- tractum pilocarpi fluidum , tt^x-xxx, repeated, has been used with varying success as a specific. Locally , either cold or warmth to the affected gland, which ever is most agreeable, or equal parts of unguentum belladonnce et hydrar- gyri. If the swelling shows a tendency to linger, use small blisters over the part and administer poiassii iodidum ; if suppuration occur, evacuate pus, apply poultices and administer quinina. If orchitis occur, the use of the belladonna and mercurial oint7nent or the ice bag to the inflamed testicle, and the internal use of tinc- tura pulsatillce gtt. iij-v every hour or two, or potassii iodidum. DIPHTHERIA. Synonyms. Putrid sore throat ; malignant ulcerous sore throat ; malignant quinsy ; membranous angina. Definition. An acute, specific, constitutional disease, both epi- demic and contagious , beginning by an affection of the throat, char- acterized by a local exudation and glandular enlargements ; attended with fever, great prostration of the vital powers and albuminuria, and having for its sequelae various paralyses. Causes. A specific germ , the Klebs-Loeffler bacillus. It is pre- eminently a disease of childhood. It is apt to recur in those who ACUTE GENERAL DISEASES. 187 have once been affected. All conditions of bad hygiene increase its virulence and diffusion, although the chief cause of its spread is contagion. The poison exists in the exudation and secretions of the fauces and saliva, but not in the breath, and floats in the atmosphere at a con- siderable distance from the patient. The virus adheres to the clothing, the bedding, the furniture, and the room which the patient occupied. Th z period of incubation is from three to five days. Pathological Anatomy. The diphtheritic inflammation differs from either the croupous or catarrhal form, in that the exudation is not only upon , but also within , the substance of the mucous mem- brane. At first there is redness, which may begin in any part of the throat, associated with swelling and an increased secretion of viscid mucus. The redness^spreads over the entire mucous surface, when the exuda- tion makes its appearance. The deposit may commence from one or several points, such as one tonsil, the soft palate, or the back of the fauces, which, however, speedily extend and coalesce, forming extensive patches, or cover uniformly the entire surface. The patches are of variable thickness, which is increased by suc- cessive layers being formed underneath. The color is usually gray, white, or slightly yellow, but may be brownish or blackish, the consistence ranging from “cream to wash leather.” On removing the membrane, which is accomplished with more or less difficulty, a raw bleeding surface is exposed, and at times an ulcer, which is speedily covered with a fresh deposit. If the exudation separate itself, it is either not renewed at all or only in thinner films. The exudation or membrane, examined by the microscope, is composed of fibrin, pus corpuscles, epithelial granular cells, and the Klebs-Lceffler bacillus and other pathogenic bacteria. If the larynx , trachea , or nasal mucous membranes participate in the disease, the croupous and not the diphtheritic form of inflamma- tion occurs. Th z lymphatic glands of the neck, whose vessels originate in the faucial tissues, are enlarged and inflamed, and contain large numbers of bacteria , probably originating as the result of decomposition. 188 PRACTICE OF MEDICINE. The muscular tissue of the heart becomes soft, is easily torn, and its fibrillae are far advanced in granular degeneration. Ulcerative endocarditis has been frequently observed. The kidneys undergo a granular degeneration in severe attacks. The blood undergoes alteration, being black and fluid. Symptoms. Following the law of contagious diseases, the symp- toms vary in intensity in different cases, the prominent symptoms being often disproportionate to the gravity of the attack. The invasion may be mild , with rigors succeeded by moderate fever , headache , languor , loss of appetite , stiffness of the neck , tender- ness about the angles of the jaw , or slight soreness of the throat. In other cases the invasion is more abrupt and severe , with chilli- ness followed by great febrile reaction, 103° to 105° F., fain in the ear , aching of the limbs , loss of strength , painful deglutition and swelling of the neck, compelling the patient to take to bed from the onset. The appetite is poor, the tongue slightly coated, sometimes more or less exudation appearing upon it, the bowels being either regular or slightly relaxed. The pulse, at first full and strong, soon becomes either rapid or slow, but compressible. The urine is scanty, high colored and contains albumin. The local symptoms in the majority of cases are associated with the throat. The patient complains of a frequent and persistent desire to hawk, in order to clear the throat. On inspection the fauces are seen red and swollen and more or less covered with the diphtheritic exudation ; sometimes the tonsils and uvula are greatly swollen and spotted with exudation. In severe cases, more or less ulceration or sloughing may be observed. Not infrequently fragments of exuda- tion, the false membrane, are expectorated, with particles of the ulcer- ated tissues, having an offensive odor, which is transmitted to the breath. The lymphatic gla 7 ids of the neck are enlarged and tender, and in severe cases the tissues of the neck are greatly tumefied. Extension to the nasal cavities causes a sanious and offensive dis- charge from the nose, with attacks of epistaxis. Extension to the larynx is indicated by hoarseness or complete loss of voice, croupy cough and obstructive dyspnoea, which often becomes urgent, the breathing being noisy and stridulous, and subject to par- oxysmal exacerbations. If the inflammation extend to the bronchi, the breathing becomes still more embarrassed. ACUTE GENERAL DISEASES. 189 Duration. Ranges from two to fourteen days, an average being about nine days, although complications and sequelae may prolong its course. Relapses are not uncommon. Sequelae. Those who recover from a severe attack remain often for weeks with a pale and cachectic appearance, due to the profound blood alteration. Paralysis is a common sequela, following the mild as often as the severe attacks. Usually not occurring until the patient seems fully convalescent. Pharyngeal paralysis is the most common, causing difficulty or in- ability of deglutition , fluids regurgitating through the nose. Cardiac paralysis, bradycardia, is not infrequent, the pulsations descending to 60, 50, 40, and in a case seen by the author, to 20 per minute. Heart failure and fatal syncope may occur at any time during the disease. Diphtheritic paralysis may affect the motor muscles of the eye, causing strabismus ; the muscles of one side, hemiplegia ; of the legs, paraplegia ; and oft the bladder, leading to retention of urine or difficulty in voiding it. Multiple neuritis with the attending loss of power is a rare sequela. Sensation is also diminished in the paralyzed parts. Diagnosis. From follicular ulceration of the tonsils , which is frequently termed diphtheria, by the slight or absent systemic symp- toms, the ulcerated condition being limited to the tonsils, but often one, and the absence of glandular enlargement and following palsies. From pharyngitis , by the absence of exudation and loss of faucial tissue and constitutional symptoms. From scarlatina , by the presence of the eruption and the absence of membrane in the fauces. The association of scarlatina and diph- theria must not be forgotten. From membranous croup , by the difference in the constitutional symptoms ; croup appears sporadically and is not contagious, diph- theria being highly contagious and frequently occurs in epidemics ; in diphtheria of the larynx, the depression is clearly that of blood- poisoning, while in croup, the depression is in proportion to the mechanical obstruction of the respiration by the membranous exuda- tion. The pathology of croup is simple and easy of investigation ; diphtheria is obscure in its etiology and progress. The temperature 190 PRACTICE OF MEDICINE. record of croup is a high one until carbonic acid poisoning is immi- nent from the mechanical obstruction to respiration, while in diph- theria, the tendency to a decline in the temperature after the fourth day is nearly characteristic, regardless of the amount of laryngeal obstruction. In croup the pharynx contains no membrane, and is but slightly, if at all, inflamed, and associated trouble in the nose is of the rarest occurrence, the very reverse obtaining in diphtheria. In croup the laryngeal symptoms are from the onset, while in laryngeal diphtheria the pharyngeal symptoms almost always precede. In croup glandular involvement is a clinical novelty, as are subsequent palsies, while glandular involvement and various palsies are the rule in diphtheria. Albuminuria is the rule in diphtheria, seldom occur- ring in croup. Prognosis. Always grave, but more so in children than in adults. Its gravity, in the majority of cases, is proportionate to the local symptoms. The average mortality is about ten per cent. Favorable indications are, moderate fever, strength slightly im- paired, a good constitution, and moderate exudation. Unfavorable indications are, high fever, great depression, spreading exudation, great swelling of the cervical glands, large amount of albumin, extension to larynx and nasal mucous membranes, hemor- rhages from the fauces and nose, and an epidemic character. Treatment. No specific plan of medication has been found uni- formly successful. It is a disease of debility. The blood being more or less altered, it follows that sustaining measures should be resorted to in all cases. That the real character of diphtheria is often misunderstood, may be inferred from a perusal of the medical periodicals of the day, it being proclaimed by a number of writers that in widespread epidemics of this most dangerous and fatal malady they had employed remedies so valuable that they had not lost a patient. The diet should be of the most nutritious character from the onset, with such articles as milk, eggs, broths, and oysters, at intervals of eveiy two or three hours. If deglutition be too painful, resort must be had to nutritious enemata t the following being a suitable formula : — R. Milk, fgj Spts. frumenti, f^iv Egg. One. ^ IG - — Little salt added, beaten up and warmed. M. 19 . fow. m* CM4H \:rC^ 1 0 - 191 VSoJjk i m - t \/LA.Aa ■ j> 1 \ - » . ACUTE GENERAL DISEASES. Stimulants should be used boldly from the onset, guiding the dose by the effect ; usually, a child of two years requires from thirty to sixty minims of spiriius vini gallici or spiritus frumenti , every two or three hours; an adult from two to four drachms every three hours. It is a mistake to wait for signs of debility before using alcohol in diphtheria. Of drugs, two are warmly advocated : Ferrum and Hydrargyrum. Of the great value of tinctura ferri chloridi there is no question ; but for hydrargyri chloridum corrosivum , it has hardly realized the expectations of the profession, except in laryngeal cases. A combination of ferrum and potassii chloras, in full doses , frequently repeated, have seemed, when begun early in the attack, to modify the course of the malady, and they have the additional advantage of acting locally upon the throat as they are swallowed. A good formula is — R. Tinct. ferri chlor., gtt. v-x-xx Potassii chlor., gr. iij-v Glycerini, f^ss Syr. zingib., . . . . . ad f 3 j-ij M. Sig. — I n water every three hours, for a child of two or three years. Ferrum and hydrargyri chloridum corrosivum , repeated every second or third hour, may be combined as follows : — R . 'Hydrargyri chloridi corrosiv., gr. ^ Tinct. ferri chloridi, tt^v-x Glycerini, rq,x Aquae, ad f 3 j. M. SlG. — Every hour or two, well diluted. The efficacy of the above are greatly enhanced by the addition to each dose of tinctura belladonnce , gtt. j-v. Quinina , gr. xvj-xxiv per day for a young adult, and gr. v-x for a child, should be used throughout the disease ; if irritability of the stomach prevent its administration by the mouth, it can be used as a suppository, or locally in the form of the oleate. Calomel in small doses, combined with sodii bicarbotias every hour until the breath becomes foetid , is beneficial, and especially in cases showing a tendency to spread toward the larynx. Indeed, a tolerance to calomel seems to exist in diphtheria of the larynx. Pilocarpus has been recommended in diphtheria. I do not con- sider it a safe remedy in the majority of cases of this disease. 192 PRACTICE OF MEDICINE. Watch the urine carefully throughout the disease ; diminution in the amount is of bad prognosis. Isolation of the patient and disinfection of the clothing and uten- sils is of importance. All clothing should be soaked twenty-four hours and boiled in a two per cent, solution of carbolic acid. Inhalations of steam and hot water, and allowing the patient to suck pellets of ice, give relief. Sponges dipped in hot water and applied to the angles of the jaw are beneficial. The chief danger of communication of the poison is the air exhaled from the fauces and from the surface. Dr. J. Lewis Smith recom- mends the following plan to counteract this danger. Add four ounces of the following solution to one quart of water and allow them to simmer constantly, near the patient, in a broad surfaced tin or zinc wash basin: R. olei eucalypt., acidi Carbolici, aaf^j, terebinthinae, ,^viij. M. The vapor is strong, penetrating and prophylactic, but not unpleasant. In hot weather, or when fire is not convenient, saturate cloths a foot square with the same solution and place them on paper on the bed of the patient. Locally . Two indications to be met, one to prevent or limit the local development of the bacilli, and the other to combat the effects of the toxic material which the bacilli produce. The first question asked is, can we dissolve the membrane ? “ In laboratory, yes, in throat, no” (Da Costa). Cleanliness of the fauces is of the utmost importance, and if a non- irritating disinfectant be added, its value is enhanced. Prof. Bar- tholow “has seen excellent results from the frequent application of a solution of acidum lacticum , strong enough to taste sour, by means of a mop.” Much good is reported from spraying the throat with a fifty per cent, solution of hydrogen peroxide. Swabbing the throat with the following is valuable : — R . Acidi carbolici, rr\pcx Tincturse ferri chlor., f 3 iv Glycerini, fj§j Aq. destil., f^j M. Sig. — L ocally every three hours. Applications of corrosive sublimate to the throat are often valuable. Dr. Ernest Laplace has demonstrated that corrosive sublimate in solution slightly acidulated with tartaric acid, has its germicide prop- erty increased, as in the following 1-500 solution (R . Hydrargyri chlor. corrosiv. gr. 3.85 ; acid tartaric, gr. 19.25. M.). ACUTE GENERAL DISEASES. 193 The following, used as a gargle , or applied by a mop, is useful : — R. Potass, chlorat, ..... Acid, carbol, Tinct. myrrh, gr. ij-iv f*j Inf. cinchonae, . . . . . .f^ij. Or— R. Ext. pancreatis, 3 j Sodii bicarb., 3“j- Sig. — Add f^j to aquae f^vj, and apply with camel’s hair pencil. I think it a mistake to struggle with children over their refusal to use a gargle or allow the use of the spray, as they don’t know how to gargle and they are afraid of the spray. Much better to add plenty of glycerin to their medicine, and use no liquid for some time after swallowing the dose. For laryngeal diphtheria the same general treatment, especially the mercurial , with inhalations of lime by slacking freshly-burned lime in a vessel and directing the vapor to the child by a newspaper, or some similar contrivance, or using three parts of liquor c aids and one part of glycerin , in an atomizer , every half hour or hour, or liquor trypsin , as a spray. If these means fail, resort must be had to trache- otomy, or intubation of the larynx , which have succeeded in many desperate cases. For nasal diphtheria, the same general treatment, and syringing the nose every two or three hours with a weak solution potassii chloras, or acidum carbolicum, or hydrogen peroxide, or the following : — R. Sodii sulphit., 3 iij Glycerini, f 3 ij Aquae, fjiv. M. For the paralysis, strychnina and ferrum internally, or strychnina hypodermically, with th z galvanic or faradic current locally. ACUTE ARTICULAR RHEUMATISM. Synonyms. Rheumatic fever ; inflammatory rheumatism. Definition. A constitutional disease, characterized by fever, inflammation in and around the joints, occurring in succession, and a great tendency to inflammation of either the endocardium or peri- cardium. 16 194 PRACTICE OF MEDICINE. Causes. The predisposing causes are inherited tendency, scarla- tina, and the puerperal state. The exciting causes are exposure to cold and chilling of the body. Rheumatism rarely occurs before seven or after fifty years. The liability to the disease is increased by having had an attack. Pathological Anatomy. The blood contains an excess of lactic acid. The joints bear the brunt of the attack ; the syno- vial membrane is reddened, the vascularity of the synovia! fringes is increased, so with the synovial fluid, which is thinner, of a reddish color, containing some gelatinous coagula of fibrin, and under the microscope nucleated cells, ordinary pus cells being rarely seen. The swelling visible about the affected part depends mostly on inflammatory oedema of the connective tissue around the joint. Th ^ pain is probably due, in all cases, to stretching of and pres- sure on the elements of the tissues by the dilated capillaries and the inflammatory oedema. For the changes which ensue when the endo- and pericardium are attacked, the reader is referred to the sections on those diseases. Symptoms. Begins suddenly, generally at night, with a chill or chilliness, pain and stiffness in the joints , loss of appetite, at times, nausea and vomiting, followed by fever , the temperature soon reach- ing 102° F., to 104°, in rare cases 108 0 to no° ( the hyperpyrexia ), the pulse seldom exceeding 95 .great thirst, profuse acid sweats , scanty, high colored , acid urine, at times showing traces of albumin, the bowels constipated. The fever continues throughout the attack, show- ing marked remissions. Delirium is absent, except the hyperpyrexia occur. Sleep is prevented by the pain and the profuse perspirations. The strength is moderately well preserved. The skin is often covered with an eruption of miliaria rubra , red papules and miliaria alba, the result of irritation at the orifices of the sweat glands, from the excessive perspiration. The local ^phenomena are pain , tenderness, increased heat, swelling and redness of one or more joints; if but one joint, it is termed monoarthritis , if more than one, polyarthritis. Pain is aggravated by motion and pressure. Swelling is most apparent in those joints not covered with muscle, to wit : knee, wrist, elbow, ankle, and the hands and feet, and is proportionate to the acuteness of the attack. ACUTE GENERAL DISEASES. 195 The inflammation may abruptly cease at one or more joints, and as suddenly attack others. The disease is extremely irregular as regards the number of joints affected, although the local manifestations are controlled by an impor- tant pathological law, to wit : the law of parallelism. Corresponding joints are often affected together, and when not, the different affected joints are either on one side of the body or those on both sides which are analogous, as the knee, elbow, wrist, ankle, hip, and shoulder, are attacked together. Complications. Pericarditis, endocarditis, myocarditis, cerebral endarteritis, bronchitis, pneumonitis and pleuritis. Duration. The duration of acute rheumatism is governed entirely by the presence or absence of complications. Uncomplicated cases recover in from thirteen to twenty-one days, although they may be prolonged to five or six weeks. Relapses are frequent. Diagnosis. A typical case cannot be mistaken for any other disease, but cases running a subacute course may be mistaken for acute rheumatoid arthritis, gonorrhoeal rheumatism, or pyaemia. Acute rheumatoid arthritis attacks one joint at a time and becomes permanent, has slight if any fever, no sweats or cardiac lesions. Gonorrhoeal rheumatism is associated with a gleety discharge, or follows the sudden cessation of an acute or subacute gonorrheal discharge, attacks either the ankle or wrist only, is slowly influenced by treatment, and lacks the febrile phenomena. Pycemia is usually manifested at a single joint at the time, and is followed by suppuration and all the symptoms of hectic fever. Prognosis. Recovery is the rule in uncomplicated cases, the mor- tality being about three percent. When death occurs it usually depends upon hyperpyrexia, cardiac complication, or cerebral endarteritis. Treatment. Owing to our imperfect knowledge of the exact nature of this most painful disease, its treatment still remains either empirical or is directed toward certain prominent symptoms or com- plications. Garrod claims that “colored water” is about as potent as anything else, for it is, he says, a “ self-limited disease,” some- times running a long and sometimes a short course. Rest in bed, whether the pain forces it or not, is important. Warmth is as imperative, for which purpose the patient should be kept in blankets — no sheets — and wear woolen garments. The diet should be easily digested food, milk being the most suitable. 196 PRACTICE OF MEDICINE. Strong and vigorous patients do well with acidum salicylicum or the salicylates in large and frequently repeated doses. R . Acidi salicylici, I , , Liq. ammonii acetat., . . . Spts. aetheris nitrosi, . . . . ff iv fill Syr. simplicis, M. SlG. — Tablespoonful every three hours, well diluted. Or— R. Sodii salicylat., l\ Tinct. cinchonas co., . . . . fjt hj Elix. simplicis M. SlG. — Dessertspoonful every three interval. or four hours, till relief, when widen If benefit follows, the evidence is quickly afforded in the relief of pain and the decline of the temperature and swelling. If, therefore, after three or four days’ use of the salicylates or acidum salicylicum, as above recommended, signs of improvement are wanting, the treat- ment had better be changed for the alkaline treatment, which consists in the administration of an ounce and a half of the alkaline carbon- ates, either alone or with a vegetable acid, each twenty-four hours, until the urine becomes neutral or alkaline , when the quantity is reduced to an amount sufficient to maintain alkaline urine. The following are good formulae for the alkaline treatment : — R . Potassii bicarbonatis, g ij Acid, tartarici, gr. xxx. Dissolve in a glass of water and drink effervescing, every three hours. Or— R. Potass, bicarb., . . ^ij Succi limonis, f 3 iv Aquae cinnamomi, ad . . . . f^ss. M. SlG. — In water, every three hours. After the more acute symptoms are relieved change whichever plan of medication has been used for tinctura ferri chloridi, gtt. xx, every three or four hours, well diluted, or for full doses of Basham's mixture. Pale, feeble and anaemic patients, or attacks following scarlatina, are most favorably influenced with — R. Strychninae sulph., gr. 1-60 Tinct. ferri chlor., gtt. xx-xxx Liquor, ammonii acetat., f;|ss. M. SlG. — Every four hours, in glass of water. V. ' v^aA- ACUTE GENERAL DISEASES. 197 Or— R . Acid, salicylici, B v ”j Ferri pyrophos., ^iv Sodii phosphat., ^iij Aquae font., f’^ij. M. SiG. — Tablespoonful every three or four hours. Dr. S. Solis-Cohen has reported good results from the following combination, in anaemic and run down cases, to which he has given the name of mistura ferro-salicylata : — R . Sodii salicylatis, g iv Liq. ammonii citratis, B. P., f^ijss Acidi citrici, gr. x Olei gaultheriae, tq, xxxij Glycerini, q. s. ad f^iijss Misce adde lente, Tinct. ferri chloridi, fg iv . M. SiG. — One or two teaspoonsful every two, three, or four hours. Prof. DaCosta reports a lessened proportion of cardiac compli- cations with ammonii bromidum , gr. xv-xx, every four hours. I much prefer ammonii salicylas, gr. x-xv, in simple syrup, well diluted, every four or six hours. Subacute attacks and lingering cases are favorably influenced by cinchonidince salicylas , or — R • Lithii salicylatis, gr. xv-xx Syr. zingiberis, f^j Aq. laurocerasi, f^j. M. Every four hours. Or — R . Potassii iodidi, ^ iv Sodii salicylatis, ^ iv Elix. cinchonae, f 5 iss Infus. gentianae, fliss Aquae destil., ^j. M. SiG. — Dessertspoonful every three or four hours, diluted. Good results are reported from the use of salol, gr. v-x, every four hours, from ammonii hydrochloras , gr. xv-xx, every four hours, and from salipyrin, in solution, every four hours. (R. Salipyrin, £iij ; glycerini, f^iij ; syr. aurantii, f-Jvj ; aquae destil., ad f^vj. M. SiG. — Tablespoonful, well diluted). Whichever plan, acidum salicylicum, salicylates, alkaline or ferrum, is adopted, quinina , gr. xij-xx, per day, should also be used. 198 PRACTICE OF MEDICINE. Pain and restlessness should be controlled by opium in some form, in full doses, or atropina , gr. hypodermically. For the hyperpyrexia , quinina , gr. xxx-lx, repeated p. r. n., with the cold bath or wet pack. Locally , the affected joints should be wrapped in cotton-wool or flannel, saturated with a solution of tinctura opii , one part, and liq. plumb, subacetat. dil., two parts, or olei gaulthericE, f^j, with lin. saponis comp, f^iij, or — & . Sodii bicarbonatis, ^ ij Tinct. opii, f^ss Aquse bul., (Jij. M. Dr. Bartholow finds the application of blisters an effective method. He says : “I have small blisters, the size of a silver dollar, placed around the joint, leaving an interval between for succeeding applica- tions. It is by no means so painful and disagreeable as it appears at first sight. The blisters remarkably relieve the pain, bring about a more alkaline condition of the blood, and render the urine less acid, or bring it to neutral, or even to alkaline.” The complications are to be treated according to their character. MUSCULAR RHEUMATISM. Synonyms. According to location, to wit: cephalodynia ; lum- bago ; torticollis ; pleurodynia. Definition. An affection of the voluntary muscles, inflammatory in character, either acute or chronic ; characterized by pain, tender- ness, and stiffness of the affected muscles. It is never complicated with cardiac disease. Causes. A disease of adult life. One attack predisposes to another. Almost always due to cold or damp, or direct draught of cold air. Gout increases the tendency to attacks. Pathological Anatomy. The true nature of muscular rheuma- tism is not yet determined. Virchow suggests a “ hypersemia of, and scanty serous exudation between, the muscular striae, and in chronic cases inflammatory proliferation of the connective tissue.” Symptoms. The first attack is generally acute. Onset rather sudden, with pain in the affected muscles, with slight tenderness , and considerable stiff?iess and difficulty of i7iovement , by which also the pain is increased. ACUTE GENERAL DISEASES. J 99 The suffering may be severe and constant, or only on motion. Spasm of the affected muscles may occur. Objective symptoms are wanting, except it is evident that the patient keeps the affected muscles as quiet as possible. Fever is absent. The pain may pre- vent sleep. Duration , acute form, about one week. Chronic returns frequently, and finally becomes constant and aggravated when the weather is damp. Varieties. It may affect any or all of the voluntary muscles, but its most frequent and important varieties are : — 1. Cephalodynia . Situated in the occipito-frontal muscles. Distin- guished from neuralgia of the trifacial, or occipital nerve, by pain on both sides of the head, excited or aggravated by the movements of the muscle and by absence of disseminated points of tenderness. The muscles of the eye may be affected, and movements of that organ excite pain. If the temporal and masseter muscles are at- tacked, mastication excites pain. 2. Torticollis. Wry neck, or stiff neck. Situated in the sterno- mastoid muscles. Generally limited to one side of the neck, toward which side the head is twisted, great pain being excited on attempting to turn to the opposite side. Rheumatism of the muscles of the back of the neck, cervicodynia , may be mistaken for occipital neuralgia. 3. Pleurodynia. Situated in the thoracic muscles, and may be mistaken for pleuritis, or intercostal neuralgia, from which it is differ- entiated by the absence of the diagnostic features of each. Pain is excited by forced breathing, coughing and sneezing. 4. Lumbodynia or lumbago. Situated in the mass of muscles and fasciae which occupy the lumbar region. Most common variety. Usually affects both sides. It may set in rapidly and become very severe. Motion of any kind aggravates the pain, often becoming very sharp or stabbing in character. It is sometimes complicated with acute sciatica , when the suffering is agonizing. Diagnosis. The different varieties may be mistaken for any of the following ailments, to wit : trifacial, occipital or intercostal neu- ralgia, pains of progressive muscular atrophy, neuritis, syphilis, metallic poisons, or painful affections of the loins, arising from calculi or gravel in the kidney. A careful examination of the history is usually sufficient to arrive at a correct diagnosis. 200 PRACTICE OF MEDICINE. Prognosis. Difficult to eradicate, and in chronic cases to amelio- rate, but is not dangerous to life. Death never results. Treatment. Rest is the first indication. This is accomplished in pleurodynia by firmly strapping the affected side with broad strips of plaster, extending from mid-spine to mid-sternum. The local application to the affected muscles of hot poultices, made of two-thirds pilocarpus leaves, and one-third flaxseed meal, changing them every two hours, is the most rapidly successful treatment in acute cases. Internally antipyrin , gr. x-xx, repeated in several hours, or ammo- nii hydrochloras , gr. xv-xx, every three hours, or sodii salicylas, gr. xv-xx, every two or three hours, are each of value. Prof. Bartholow declares that lithii bromidum is almost a specific in muscular rheumatism. For the pain, and consequent sleeplessness, use — R . Pulv. ipecac et opii gr. x Potass, nitrat, gr. v-x. M. SlG. — In powder, morning and night. Or, hypodermically, at the seat of pain, morphina , gr. yi-%, and atropina, gr. p. r. n. The following liniment is valuable in many cases: — R . Quininae sulph., gr. xl 01. gaultheriae, f^j Lin. saponis co., iij. M. SlG. — Thoroughly applied several times a day. In attacks where the disease is limited to a few muscles, the follow- ing liniment is valuable : — R . Chloral hydrat., Camphorae, aa . . . Jss M. et adde Lanolin, ^j. M. SlG. — Apply locally. In all forms, but more particularly in lumbago, a few dry cups over the seat of the pain give immediate relief. Chronic cases : Rest, flannel worn next to the skin, stimulating and anodyne liniments, mild galvanism, dry heat, as ironing over the affected part with a common flat-iron, a piece of paper or towel being placed next to the skin. Internally, potassii iodidum , ammonii hydrochloras, sulphur, guaiacum or arsenicum variously combined. ACUTE GENERAL DISEASES. 201 RHEUMATOID ARTHRITIS. Synonyms. Arthritis deformans ; rheumatic gout. Definition. An inflammation of the joints, accompanied with but slight fever, without suppuration ; progressive in character, caus- ing nearly symmetrical enlargement and deformity of various articu- lations. Causes. More common in females than in males, and in the weak and anaemic. Among the causes are bad hygiene, exposure, prolonged lactation, frequent pregnancies, menopause, grief, tuber- cular diathesis, and following attacks of articular rheumatism. Pathological Anatomy. It is not rheumatism, as the blood contains no lactic acid. It is not gout, as uric acid is not found in the blood nor urate of sodium in the joints. At first rheumatoid arthritis is attended with hyperaemia of the affected synovial membrane and increase of the synovial fluid. Soon the capsular ligament becomes irregularly thickened, the synovial fluid decreasing. If the process continue, the internal ligament is destroyed, thus allowing dislocation to occur. The inter-articular fibro-cartilages ulcerate and disappear, as do the cartilages covering the ends of the bones, the ends of the bones becoming smooth and eburnated, and often greatly enlarged. Symptoms. Either acute or chronic , the latter most common. Acute form involves several joints at the same time, and is attended with slight pyrexia. Chronic form slowly involves one joint, which seemingly soon recovers, and is attacked again, and may never recover, but grows progressively worse. The joint slowly enlarges , is painful , movement exciting neuralgic pains along the limb. Soon the articulation becomes rigid or slightly movable after prolonged attempts. Redness and tenderness are wanting. Crepitation is distinct after ulceration has destroyed the cartilage. The hands are first involved, the disease spreading symmetrically from articulation to articulation, until in severe cases every joint is deformed. Diagnosis. Chronic articular rheumatism is often confounded with rheumatoid arthritis ; but the former lacks the marked structural changes and the progressive involvement of joint after joint. 1 7 202 PRACTICE OF MEDICINE. Gout differs from rheumatoid arthritis by the presence of deposits of urate of sodium in the joints, the ears, tips of fingers and the bursae over the olecranon process of the elbow, the presence of uric acid in the blood, and the decided history of acute paroxysms. Gonorrhoeal rheumatism , so-called, has symptoms akin to rheu- matoid arthritis, but the history of urethral suppuration clears up the diagnosis. Paralysis agitans , when pronounced, might be confounded with rheumatoid arthritis, if the examination were limited to the joints ; but the whole history, such as the tremor, the gait, etc., should pre- vent error. Prognosis. If early treatment be instituted, the disease may be held in abeyance for several years. After pronounced structural changes have begun, the malady is incurable, although it may remain stationary for a long time. Treatment. If treatment be instituted before serious structural leisons have occurred, the author has seen benefit in many cases by the following treatment : Oleum morrhuce carefully and thoroughly rubbed into the affected joints three times a day, with the internal use of lithii citras effervescentes 3j, three times a day, and the follow- ing tonic mixture : — R. Massae ferri carbonat., gr. v Liquor, potass, arsenit., rr^ v Vini xerici, f^j Aquae, f^j. M. x\fter meals, well diluted. Sodii salicylas is recommended early in the disease. Complete recoveries are reported from the long-continued adminis- tration in small doses of liquor potassii arsenitis. Attention to diet and hygiene are also necessary. When structural changes have destroyed portions of the joint, palliative treatment is the only indication. GOUT. Synonyms. Podagra, gout in the foot ; chiragra, the hand ; gonagra, the knee. Definition. A constitutional disease, usually inherited ; charac- terized by the sudden occurrence of a paroxysm of severe pain and ACUTE GENERAL DISEASES. 203 swelling in one of the smaller joints — the great toe usually — with the presence of uric acid in the blood, and the deposit of the urate of sodium in the structure of the joint. Causes. Predisposing ; inherited, male more than female — women after menopause. Exciting; malt liquor and wine drinking ; large consumption of animal food ; lead poisoning ; winter season. When inherited tendency, may begin early in life ; when acquired tendency, after thirty-five years. The pathological cause consists in the presence of an excess of uric acid in the blood, in the form of urate of sodium. Pathological Anatomy. Gout is characterized by the deposit of urate of sodium from the blood into the structure of joints and tissues that are not very vascular. The deposit is associated with signs of inflammation, to wit: hyperaemia, redness of the surface, with swelling and effusion in and around the affected joint. The surfaces of the joint are incrusted with chalk-like masses, consisting of urates, which become greater with each attack, finally causing great deformity. The deposit usually begins in the metatarso-phalangeal joint of the great toe, but other and many joints are soon affected. The deposits may also be found in the knuckles, eyelids, and car- tilages of the ear. “ Crystals of urate of soda are deposited in the tubules and intra- tubular tissues” of the kidneys — “gouty kidney” — and may be seen by the naked eye, the kidneys becoming small, granular and fibrous. Hypertrophy of the left ventricle and of the arteries, ending in atheromatous changes, are results of gout. Symptoms. Acute gout is rare in the United States. It occurs in paroxysms ; one year’s interval between the first and second attack ; six months usually between the second and third, after which it may occur at any time. Prodromes usually precede the paroxysm for several days, to wit acid dyspepsia, constipation, headache and lassitude. The paroxysm begins suddenly, between midnight and 2 a. m., with acute pain in the ball of the great toe, which becomes red , hot , swollen , and so sensitive that the slightest touch cannot be borne. The veins are filled, the foot, ankle and leg swollen, and the limb 204 PRACTICE OF MEDICINE. the seat of sudden spasmodic contractions, which increase the suffer- ing ; slight relief is afforded by elevating the limb. Associated with the local symptoms are chill , fever , quickened pulse, thirst , coated tongue , constipation , and scanty , acid , high colored urine, which de- posits, on cooling, a heavy brick-dust sediment. Towards daylight the symptoms ameliorate, to return again at sun- down, the severity gradually lessening, until the fourth or fifth day, when convalescence is established, the patient, as a rule, feeling better than before the attack. Chronic Gout. Either the result of acute attacks or with a greater number of joints being attacked. The paroxysms occur at any time, but develop slowly, with less pronounced local and general symptoms. Deposits are noticed, the joints becoming hard, knobby, and often distorted. The deposits or chalk-stones (urate of sodium) occur about the joints, tendons and bursas, and helix of the ear. Diagnosis. An error cannot occur if the history of the case can be obtained, to wit : hereditary tendency, age, sex (females rare, until menopause), mode of living, character of symptoms, and pres- ence of the characteristic deposits. Prognosis. Acute gout rarely fatal ; is prone to return, but much depending upon the mode of living. Chronic gout decidedly shortens life. The most serious signs are those indicating advanced renal disease, with non-elimination of uric acid. Gout influences unfavorably the prognosis from acute diseases or injuries. Treatment. For the acute paroxysms at once, vinum colchici radicis, gtt. xv-xx-xxx, every two hours, well diluted, either alone or in combination with a potassium salt, or sodii salicylas, gr. xx, every three or four hours, well diluted. While the acute symptoms of gout are not so rapidly relieved by sodii salicylas, as are those of acute rheumatism, still it is an invaluable remedy and is rapidly succeeding colchicum. After the decrease of the acute symptoms, lessen the dose, but continue the remedy for some time. Dr. Bartholow recommends the following pill : — B . Colchicinae, " gr. -fa Ext. colocynth. comp., gr. ss Quininse sulph., gr. iij. Every two or three hours. ACUTE GENERAL DISEASES. 205 For th z pain, hypodermic injection of morphina , and wrapping the inflamed joint in cotton-wool saturated with liq. plumb . sub-acetat. dil. and tinctura opii. The diet must be restricted to liquid food. For subacute or lingering cases, and in chronic gout, potassii iodi- dum is valuable. R . Potassii iodidi, 5 ij Vini colchici radicis, f 3 iv Aquae destil, fjijss. M. Sig. — T easpoonful, well diluted, after meals and bedtime. For chronic gout, regulated diet, free action on the secretions, and lithii citrus effervescentes , 3j, three or four times a day, well diluted with water; and perhaps a course of quinina,ferrum and arsenicum. To prevent paroxysm, keep secretions acting, by the free use of pure water or a good alkaline water, such as Buffalo lithia or Farm- ville lithia water, or Saratoga Vichy. The diet is of the greatest importance, and should consist chiefly of vegetables and fruit, excepting tomatoes and strawberries ; fresh meat may be used once a day, as may oysters, fish and soups. Alco- holic and malt liquors are contraindicated, as are tea and coffee ; skimmed milk should replace all the above. No eggs or dishes con- taining eggs, no pastry, hot bread or cakes, no sweetmeats, spices or condiments. Systematic exercise, especially walking, is of great advantage. Cold bathing, with caution, while the vapor or Turkish bath are of benefit. Changing from a cold to a warm climate in winter, and the use of flannel underclothing, are strongly recommended. DIABETES MELLITUS. Synonyms. Glycosuria ; melituria. Definition. A chronic affection characterized by the constant presence of grape sugar in the urine, an excessive urinary discharge, and the progressive loss of flesh and strength. Causes. Most common in males. Occurs at all ages, but most frequently between twenty-five and fifty years. It is often hereditary. Disorders of the nervous, hepatic and renal systems. Excessive use of farinaceous food and malt liquors. Sexual excesses. 206 PRACTICE OF MEDICINE. The exact pathology of diabetes mellitus differs in different cases, and in the present state of knowledge no exclusive view can be adopted. Still, there are reasons for believing that, in a large pro- portion of cases, the nervous system is primarily at fault, though the character of the lesions may differ. Pathological Anatomy. None peculiar to diabetes are yet recognized. Hyperasmia and hypertrophy of the liver and kidneys are gener- ally present, the result of increased functional activity. The changes in the lungs peculiar to phthisis are often found in very chronic cases. The changes in the nervous system are not fully determined. Symptoms. Clinically, cases differ greatly in their course and severity ; one class presenting slight symptoms and a chronic course ; another class having marked local and constitutional symptoms and running an acute course. The symptoms of a typical case may be arranged under the following heads:— Urinary Organs and Urine. Micturition more frequent and the urine increased in quantity. Pain over the region of the kidneys. The quantity of urine may amount to 4, 8, 12, 20 or 30 pints in twenty-four hours. It is usually pale, clear , and watery, having a sweetish taste and odor, the specific gravity ranging from 1.025 to 1.050. It ferments rapidly if kept in a warm place. It yields grape sugar to the usual tests, the amount present varying from an ounce to two pounds in the twenty-four hours. The urea and uric acid are increased. Albumin may be present. The increased passage of a large quantity of saccharine urine causes a constant itching, burning and uneasy sensation at the prepuce, along the urethra, and at the neck of the bladder ; in females, itching and eczema of the. vulva are common; in children, incontinence of urine is frequent. Digestive Organs. An almost constant symptom is thirst, with a dry and parched condition of the mouth. At times the appetite is excessive, again absent. The breath may have a sweetish odor, the tongue irritable, red, and often cracked. Dyspeptic symptoms are common, and occasionally vomiting. The bowels are constipated, the stools pale and dry. At times diarrhoea may occur. The patient complains of feeling very weak , languid, and of sore- ACUTE GENERAL DISEASES. 207 ness and pain in the limbs ; there is more or less emaciation , a harsh, dry skin, the countenance distressed and worn. The mind is often greatly altered ; depression of spirits, decline in firmness of character and moral tone, with irritability, are present. Sexual inclination and power are demolished. Defects of vision are present. The blood and various secretions contain sugar. Complications. Pulmonary phthisis ; Brights’ disease ; defects of vision from atrophy of the retina or the formation of a soft cataract ; boils and carbuncles, and chronic skin affections, such as psoriasis and eczema. Course. The clinical history varies in different cases. In the majority of instances the course is chronic, lasting for years, the symptoms beginning insidiously, and becoming progressively worse, with, at times, decided remissions. Occasionally the disease runs an acute course, death occurring within four or five weeks. Termination. The majority of cases ultimately prove fatal, the symptoms markedly changing, the urine and sugar diminishing in quantity, the occurrence of albuminuria , disgust for food and drink , and the development of hectic fever and a colliquative diarrhoea. The fatal result usually arises from gradual exhaustion , from blood poisoning, leading to stupor , ending in complete coma, or occasionally to delirium or convulsions, or from complications. Rarely death occurs suddenly from urcemic convulsions or urcemic coma. Diagnosis. Diabetes mellitus only exists when grape sugar is permanently present in the urine. “It is not the quantity, but the persistence of sugar which constitutes diabetes.” When are present grape sugar in the urine, with more or less increase in the urinary flow, it can be mistaken for no other affection. From Bright' s disease, by the absence of dropsy, and of tube casts in the urine ; the amount of albumin in the urine is never so great or constant in diabetes mellitus as in Bright’s disease. From Diabetes insipidus, by the absence of sugar in the blood and urine, and the larger quantity of urine voided in polyuria. Simple glycosuria differs from diabetic glycosuria in that the amount of sugar in the urine is not constant — at one time being present, at another absent — the amount of urine voided is never in excess of health ; simple glycosuria is a disease of the aged ; diabetic glycosuria 208 PRACTICE OF MEDICINE. usually appears under fifty years. Simple glycosuria often results from the inhalation of chloroform, the use of chloral, in the insane, from excitement, or as one of the results of injuries to the head. Prognosis. Most unfavorable as regards a cure, it being fairly questionable if complete recovery has ever occurred in a typical case. Still, decided amelioration may take place in the symptoms, and the progress of the malady be greatly retarded. The younger the patient the more rapid the fatal termination. Treatment. Impress upon patients the importance of a strictly regulated diet. Prohibit or restrict the consumption of such articles as contain sugar or starch , especially ordinary bread or flour, sugar, honey, potatoes, peas, beans, rice, arrowroot, cracked wheat, oat- meal, turnips, beets, corn and carrots, prunes, grapes, figs, bananas, pears, apples, and liquors of all kinds whether distilled or fermented. The main diet should be of animal food, including meat, poultry, game and fish. A moderate amount of fluids should be allowed, and in a majority of cases milk will prove beneficial, although, theoretically, contra- indicated. Tea, coffee and cocoa, without sugar, may be allowed in moderation, glycerin or saccharin being used as a substitute for the sugar. Regulated exercise is of importance. The patient should wear flannel, and have two or three warm baths every week, or an occa- sional Turkish bath. Therapeutical Treatment. It is difficult to estimate justly the action of any drug in this disease, for, as is so well known, a proper modi- fication of the diet will alone produce the most marked improvement. Opium exercises an influence over the excretion of sugar, but the effect is not maintained in all cases. Pavy strongly urges the use of codeina in doses of gr. ^-iij, three times a day. The use of mor- phina hydrochloras , gr. j daily, or pulvis opii , gr. iij-v daily, is a favorite prescription. Prof. DaCosta suggests the use of ergota, which has decreased the urinary discharge and the quantity of sugar in a number of cases. Prof. Bartholow has met with an apparent cure by ammonii carbonas. Uranii niiras, gr. iij, three times daily, will often markedly reduce the urine and sugar, and sodii salicylas, gr. xv, three times daily, will markedly control the formation of sugar. Liquor, bromini arsenitis, n\,iij-v, three times a day, often gives good results. Dickinson remarks that “ strychnina is, of all remedies, the most ACUTE GENERAL DISEASES. 209 constantly useful.” Potassii bromidum , 3j» during the twenty-four hours, is strongly urged. The following remedies are recommended by different observers, to wit: ftepsinum , liquor potassii arsenitis , iodurn , potassii iodidum , aciduni lacticum, glycerinum , quinina , and tinctura cannabis indices . The evidence in favor of the majority of these drugs is far from satisfactory. For diabetic coma, alkalies are particularly indicated. Sodium carbonas subcutaneously, or by intravenous injection, watching closely the effect on pulse and heart, as recommended by Stabelman. Use also inhalations of oxygen, and diuretics and fluids to promote elimination of toxic products. Symptomatic treatment is mostly called for. For emaciation and anaemia, ferrum and oleum morrhuce ; for sleeplessness and restless- ness, morphina, potassii bromidum , chloral, or hyoscince hydrobromas. For boils and carbuncles, calcii sulphidum. Duchenne suggests the following solution for the excessive thirst of diabetic patients : — R . Potassii phosphat., two parts Aquae, . seventy-five parts. Sig. — One teaspoonful twice or thrice daily in wine or hop tea. The dyspepsia and lung symptoms must be managed on general principles. The constant galvanic current has been productive of good results. A change of scene and air is beneficial. Surgical operations should on no account be undertaken on diabetic patients. DIABETES INSIPIDUS. Synonyms. Polyuria ; polydipsia. Definition. An affection characterized by the habitual discharge of a very large quantity of pale, watery urine, free from albumin and sugar. Causes. Occasionally hereditary, or diabetes mellitus may have existed in the parent ; more common in children or young adults ; men are more liable than women; injuries and diseases of the ner- vous system ; exposure to cold ; drinking freely of cold water ; fatigue ; prolonged debility ; malaria ; syphilis. The probable immediate cause of the excessive flow of urine con- sists in dilatation of the renal vessels, the result of paralysis of their 210 PRACTICE OF MEDICINE. muscular coat, caused by derangement of innervation, as the con- dition can be induced experimentally by irritating a spot in the fourth ventricle, or by section of portions of the sympathetic nerve. Symptoms. The affection is characterized by great thiist, with an increased flow of pale, watery, slightly acid urine, the amount varying from one to five or six gallons in the twenty-four hours. The specific gravity ranges from i .001-1.007. Sugar and albumin are absent. Urea and the other solids are increased. The appetite is voracious, the bowels are obstinately constipated, and the skin is dry and harsh. The large flow of urine is usually preceded by various nervous phenomena, as nervousness , irritability , inability to concentrate the mind , vivid imagination , a failure of memory , and headache. Unless the affection is soon arrested great loss of flesh and strength result. Diagnosis. It differs from diabetes mellitus by the absence of grape sugar in the urine. From paroxysmal diuresis , by the absence of the increased urine permanently. From interstitial nephritis , by the greater amount of urinary dis- charge and the absence of albumin, oedema, and casts. Prognosis. Rather unfavorable as to a radical cure, unless caused by syphilis. Death rarely is due to the diabetes, but to some inter- current malady that the patient has been unable to withstand, on account of the weakness produced by the diabetes. Treatment. If due to syphilis, potassii iodidum and hydrargyrum are of real benefit. Prof. DaCosta has had success with ergota in the form of the fluid extract or the aqueous extract. Pilocarpus has been used with success. Prof. Bartholow recommends galvanism in cases not cured by potassii iodidum, placing “one electrode to the neck below the occiput, the other to the hypochondriac region in turn.” Valerian, potassii bromidum, and sodii salicylas have been used. The author has effected a cure in three cases, where other remedies had failed, by the use, internally, of — R . Strychninae sulphatis, g r - Acid, hydrochlor. dil., Tt\,x Aquae laurocerasi, f 3 ij- M. Well diluted. The obstinate constipation is best overcome by pilulce catharticce composites , one at bedtime. ACUTE GENERAL DISEASES. 211 LITFLEMIA. Synonyms. Lithiasis ; uric acid diathesis ; half gout. Definition. A condition in which the fluids of the body are satu- rated with nitrogenized waste, in the form of lithic or uric acid ; char- acterized by marked dyspepsia, various nervous phenomena, muscu- lar and articular pains, bronchial catarrh, all or any of these associ- ated with scanty, high-colored, acid urine. Causes. High living, with little exercise ; imperfect digestion of nitrogenized food ; impaired elimination of uric acid. Pathology. Not yet clearly determined. The non-elimination of certain products which have a deleterious influence upon the nervous system. That uric acid does exist in the blood is now gen- erally accepted. Symptoms. Those of dyspepsia associated with irregular bowels , scanty, high-colored, acid urine , sp. gr. 1.024-1.028, containing neither sugar nor albumin, but showing an increased proportion of urates. Also depressed spirits , impaired memory , loss of mterest in occupa- tion , sleepless nights , attacks of vertigo , neuralgic pains in the head, and a constant dread of apoplexy or cerebral disease. Also pains in the joints , neuralgic in character. If the condition be allowed to continue, the following organic changes may result, to wit : fatty heart ; fibroid kidney ; enlarged liver, or changes in the cerebral vessels. Diagnosis. From gout, by the absence of acute paroxysms and resulting changes in the joints. Prognosis. If properly recognized and treated, complete recovery will result, although it is a disorder of long duration. If not properly treated, develops some one of the organic diseases mentioned. Treatment. Regular diet, using fresh meat once daily, poultry, game (plainly cooked), fresh fish, oysters, occasionally eggs, lettuce, spinach, celery, cold slaw and tomatoes ; avoid all kinds of starchy and saccharine foods, also all stimulants, tea and coffee, using milk, skimmed milk, or milk and cream. Act freely on all the secretions, particularly the liver and kidneys. Systematic exercise . Avoid tonics, bromides, chloral and opium. Long course of alkaline waters, particularly the lithia waters. Good results follow lithii citras, gr. xx, t. d., sodii phosphas, gr. xxx, ter die, or acidum benzoicum , gr. x, t. d., 212 PRACTICE OF MEDICINE. all well diluted with water. One of the very best drugs is acidum nitri- cum dilutum , gtt. x, in half a glass of water, four times a day, with the occasional use of pilulce rhei composite at bedtime. Strontium has acted nicely in several cases. R . Strontii bromidi purse, % iss Glycerini, f ij Infus. gentianse, vj. M. Sig. — f 3 i j before meals, well diluted CHOLERA. Synonyms. Epidemic cholera ; Asiatic cholera ; malignant cholera ; spasmodic cholera. Definition. An acute, specific, infectious disease, epidemic in the majority of, although endemic in other, localities ; characterized by the transudation of serum into the stomach and intestinal canal, and violent purging of a peculiar, rice-water-like fluid, the persistent vomiting of a similar material, severe muscular cramps, and a condi- tion of prostration, followed by collapse and death, or of a reaction from the collapse and the development of the typhoid state ( cholera typhoid'). Causes. A specific poison , the “ comma bacillus” of Koch. Cholera is but feebly contagious , in the usual acceptation of that word, but it is unquestionably infectious. The evidence seem s co n elusive that the cholera stoo Is are the main, if not the only, channel of infection, and that the great cause of the pro- pagation of cholera is the contamination, with the cholera stools, of the water used for drinking purposes. Milk may also be the vehicle by which it spreads. It is claimed that the bacillus is inert in the intes- tinal canal unless the individual is in the “ receptive state — ” that is a condition of intestinal catarrh, such as results from eating unripe fruit, beer and spirit drinking, and indigestible food. It is also determined that the bacilli are destroyed by acids, and that if the stomach be normal, cholera will not result. “With pure water, pure air, pure soil and pure habits, cholera need not be feared.” (Hart.) Little, if any, danger exists from being in the presence of the affected, although the emanations from the cholera excreta in the at- mosphere may generate the disease if swallowed or inhaled. The dead bodies of cholera subjects apparently possess slight infective ACUTE GENERAL DISEASES. 213 property, “ the bacteria of decomposition ” probably destroying the cholera germs. One attack does not afford protection against another. Th q. period of incubation is short, under a week, usually. Pathological Anatomy. This is, as yet, far from satisfactory. The morbid appearances in the majority of cases of death from chol- era may be thus summarized. The temperature generally rises after death, the body remaining warm for a considerable time. Rigor mortis rapidly ensues, the muscular contractions being often so pow- erful as to displace and distort the limbs. The skin is mottled and the body greatly shrunken. The blood is darker in color, thick, viscid, feebly coagulable, and slightly acid. The arteries are quite empty of blood; the veins, on the other hand, are distended. The organs are, as a rule, pale and shrunken. The stomach and intestinal mucous membranes are congested, and present evidence of extravasation and ecchymoses, or are bleached and pale. The stomach and intestines usually contain a quantity of whey-like material, having an alkaline reaction, as well as quantities of cast-off epithelium and the peculiar bacillus. It is thought by many that the stripping-off of the epithelium is a post-mortem phenomenon. The Peyer’s solitary and Brunner’s glands are usually enlarged and prominent, and occasionally evidences of ulceration are apparent in the solitary glands, and sections placed under the microscope show the “ comma bacillus.” The villi of the mucous membrane, as well as the epithelium of the small intestines, are stripped off, leaving the basement membrane, for the most part, exposed. The liver is more or less advanced in fatty degeneration, presenting a somewhat mot- tled, yellowish discoloration. The kidneys are congested, the epi- thelium of the tubules granular and detached from the basement membrane, blocking up the tubes. Prof. Bartholow observed, in all of his autopsies, “ considerable hypersemia and dilatation of the ves- sels of the medulla oblongata. The constancy of this lesion would seem to indicate a relationship between congestion of the medulla and the cramps.” Symptoms. In accordance with the law of epidemic infectious diseases, the onset, course and character of the symptoms vary in different cases and at different periods in the same epidemic. The disease may either set in suddenly in a patient previously in good health, or it may follow an attack of rather severe and persistent 214 PRACTICE OF MEDICINE. diarrhoea, with pain , nausea , vomiting and depression. Such cases are termed Cholerine, the stools of which are infectious. In a typical case there are three stages : first, diarrhoea ; second, prostration ; third, collapse, or, in favorable cases, reaction. First Stage. Begins with chilliness, excessive thirst, coated tongue, unpleasant taste in the mouth, slight abdominal pain, and three or four copious, watery, yet faecal stools during the day, and a decided feeling of weakness, the stools rapidly becoming whey-like, easily voided, but with force and only slight pain. Second Stage. The stools rapidly increase in number, are voided with a rushing force, and consist of many quarts of grayish, or whitish, rice -water-like fluid, accompanied with forcible vomiting, first of the contents of the stomach, mixed with more or less bilious matter, afterward of the peculiar rice-water-like material ; thirst becomes most intense, increasing or diminishing with the variations in the number of the vomiting and stools ; severe muscular cramps soon follow, most severe in the calves, although occurring in all parts of the body. Third Stage. The stools, vomiting and cramps continue. The appearance of the patient becomes frightful; the eyes are sunken and surrounded by blackened rings, the nose pinched and pointed, the cheeks hollow, and the lips blue (facies cholerica) ; the surface cold and moistened with a sticky perspiration ; the skin of the hands and fingers has the sodden appearance of the “ washerwoman who has washed all day,” and if picked up in folds, the fold but slowly disappears. The temperature rapidly falls, the pulse becomes small and compressible, barely perceptible at the wrist, and the heart beats are scarcely recognizable. The voice is weak, husky and sepulchral (vox cholerica), the tongue is like ice. the breath is cold and icy, the urine markedly diminished and albuminous. The mind\s not cloudy, but most patients are apathetic and indifferent to their danger. This, the algid stage of cholera, or cholera asphyxia , usually terminates in death in from three to twelve, twenty- four or forty-eight hours, but reaction may be established. Stage of Reaction. The temperature of the body rises, the pulse gradually becomes fuller and stronger, the countenance becomes brighter, the stools less frequent and more faecal, the vomiting de- creases, the thirst lessens, the urine increases in amount, but con- tinues albuminous, the patient entering a slow convalescence, or ACUTE GENERAL DISEASES. 215 typhoid symptoms develop, the so-called cholera typhoid , which pro- longs the recovery for several weeks. Convalescence is often prolonged and complicated by the develop- ment of severe bed sores, boils, bronchitis, pneumonia or parotitis. Sequelae. Suppuration of the parotid gland ; painful tetanic con- traction of the flexor muscles of the limbs ; abscesses or ulcers of the limbs ; profuse sweats ; roseola, erythema, urticaria, and rarely vesi- cular eruptions. Diagnosis. The epidemic character, and rapid spreading, and great mortality of the affection prevents its being mistaken for any other disease, although isolated cases are often confounded with cholerine or with cholera morbus, the points of distinction being few, unless the “comma bacillus” only be found in the stools of true cholera. Prognosis. Very unfavorable, the mortality rangingfrom twenty to eighty per cent. The last epidemic in this country was much milder than former ones. The prognosis is controlled by the general condition of the patient, the age, habits, and the development of the algid stage ; the prognosis being more favorable in those cases which develop gradually than in those in which it reaches its acme at a single bound ; the very young or very old, those addicted to the various excesses and surrounded by unfavorable hygienic conditions, are more apt to perish than are others. Treatment. The success depends, to a great extent, upon its prompt and early treatment, for experience amply attests that the arrest of the disease in the diarrhceal stage is comparatively easy, and that in the stage of collapse its cure by any means whatever is altogether an exceptional occurrence ; therefore, during the preval- ence of cholera the mildest cases of diarrhoea ought to receive prompt treatment, for many cases have their beginning as a mild diarrhoea. It must not be overlooked that intelligent nursing and regimen are equally as important as medical treatment. The patient should be put to bed at once, and all food withheld for a time at least. Small pellets of ice may be allowed instead of water. “ Of all the remedies proposed for the arrest of the diarrhoea, not one has done so much good as sulphuric acid. It is usual, and gen- erally best, to combine some opium with it (R. Acid, sulphuric, aromat. f£v, tinct. opii deodorat. f3iij. M., S. Ten to twenty drops every hour or two in sufficient water).” ( Bartholow .) 216 PRACTICE OF MEDICINE. Large doses of bismuth should be of value in this early stage, but opium is particularly indicated, preferably in the form of morphia hypodermically. During the epidemics of 1892-93, good results were reported from the internal use of hydrogen peroxide , f^ ij, with aqua destillata , f^ viij, in cupful doses every two hours. Salol zxvdLplumbi acetas are of value for the early diarrhoea. Ziemssen says : “ Calomel has the first place of all drugs which have been recommended in the prodromal stage. Begin with two or three doses of gr. vij, followed with small doses — gr. ^ — every two hours.” It is now generally admitted that as the first symptoms of cholera are those of intestinal catarrh, direct medication ought to be of the greatest service. This is done by enteroclysis or irrigation of the canal, with large amounts, from one to three gallons twice daily, of hot soaped water, hot four per cent, solutions of hydrogen peroxide, or weak solutions of tannin, or hot one per cent, solutions of common salt. The enteroclysis is accomplished by means of a soft rubber tube, one metre in length and of suitable size to be introduced into the rectum, in front of the promontory of the sacrum, into and up through the sigmoid flexure and into the descending colon. This tube which is connected with a reservoir should not be too small nor too large, in order to facilitate its introduction through the folds of the sigmoid portion of the lower bowel. In fact, the greatest difficulty to be encountered, is to successfully pass the tube in front of the promontory of the sacrum, and enter it into the sigmoid flexure. The tube should be of proper firmness to prevent it from bending or buckling upon itself when the end (which in all cases should be rounded) comes in contact with the obstructing folds of the intestine. For the distressing vomiting, lavage of stomach with H 2 0 2 , f^ij (medicinal) to two or three pints of hot water, or iced champagne , cocaine , or acidum hydrocyanicum may sometimes give relief. Locally , either continue the mustard application to the abdomen or the constant use of rubber bags filled with boiling water. For the cramps , hot water in bottles, hot irons or bricks applied over painful parts, or an ointment of chloroform or chloral, chloro- form or ether inhalations, or the use of the following hypodermic solution, strongly recommended by Prof. Bartholow (R. Chloral, ^iij , ACUTE GENERAL DISEASES. 217 morphinae sulph., gr. iv, aq. laurocerasi, f^j. M. Sig. — F ifteen to thirty minims each injection.) For the collapse, heat to the surface and the free use of stimulants , or spiritus frumenti or spiritus vini gallici , hypodermically, also the hot bath, also hypodermatoclysis and the intravenous injection of saline fluids and hypodermic injections of strychnines sulphas., gr. ^ . Heat is of the greatest value in all stages of cholera, both ex- ternally as very hot baths (hot air or hot water), and hot rectal injec- tions. If reaction occur, treat indications as they arise, and use tonics, such as ferrum , quinina and arsenicum. All the discharges from the patient should be thoroughly disin- fected as soon as voided, and the stools and vomited material buried. TRICHINOSIS. Synonyms. Trichinae ; Trichina spiralis ; “ flesh-worm disease.” Definition. A typhoid condition, the result of the entrance of a parasite — the Trichina spiralis — into the intestinal canal, and their subsequent migration into the muscular structure : characterized by severe gastro-intestinal irritation, severe muscular soreness, and a low typhoid condition. Cause. The Trichina spiralis are introduced into the human body by eating the infected hog’s flesh, either raw or but imperfectly cooked. Description. The parasite is found in two forms, to wit : intes- tinal trichina , which is sexually mature, and muscle trichina , which is sexually immature. The intestinal trichina is a small, hair-like worm, the male meas- uring yg- of an inch, and the female l /s of an inch in length ; the head is smaller than the rest of the body ; the tail of the male has a bi-lobed prominence, between the divisions of which the anal opening is placed, and from which a single spiculum can be protruded ; the female has a blunt, rounded tail, the reproductive outlet being situated toward the anterior part of the body ; the ova are very small, containing embryos being produced viviparously at the rate of at least one hundred each week after the entrance of the female into the intestinal canal. 18 218 PRACTICE OF MEDICINE. The 7nuscle trichina develops its sexual apparatus after it has entered the intestinal canal of the host. The viable embryos discharged from the female are in a state ot motion, and at once migrate from the intestines to the muscular structure of the individual, and here set up inflammatory action, they becoming surrounded by a capsule or shell in which they are coiled. After a time, in the muscle, the trichina undergoes a further change ; lime salts being deposited in and about the capsule and in the para- site itself, when minute specks of lime are seen distributed throughout the muscular structure. The development of the parasite from the period of impregnation up to the time of sexual maturity is, under favorable conditions, less than three weeks. Within two days from the ingestion of the infected pork occurs the maturation of the muscle larvae ; in six days more the birth of embryos occur, and in about two weeks the migrating progeny have arrived at their habitat , the muscular structure. Symptoms. These depend upon the number of parasites in the infected food. According to Dr. Sutton, of Indiana, a piece of pork the size of a cubic inch contained eighty thousand trichinae. There are three stages described, to wit : the intestinal , the migration , and the encapsulation. Intestinal stage , a gastro-intestinal inflammation, with nausea , vom- iting , and watery diarrhoea , the severity depending upon the number of the parasites ingested. Migration stage , a typhoid-like fever , rapid , feeble pulse , profuse sweats, intense thirst , dry tongue and lips, and red, swollen face, with soreness and tenderness of the muscular structure, increased by any muscular act. As a rule the mind is clear but decidedly apathetic. Encapsulation Stage. If the number of parasites ingested have been few, recovery may occur in this stage, but if the number have been large, the gastro-enteritis, fever and muscular phenomena are severe, the patient is in a critical condition, between twenty and fifty per cent, succumbing. Diagnosis. Unless the physician has some intimation of the cause, cases are readily mistaken for either ordinary ileo-colitis or typhoid fever. Prognosis. Depends upon the number of trichinae in the pork eaten. Mortality between twenty and fifty per cent. ACUTE GENERAL DISEASES. 219 Treatment. The preventive treatment consists in eating no pork that has not been so prepared as to kill any trichinae that might exist. If the parasites have been recently taken, within the first four or five days, emetics and purgatives to remove them from the stomach and intestinal canal are indicated. After thorough action from these, at- tempts may be made to destroy such of the parasites as have escaped the action of the emetic or purgative. For this purpose much is said in favor of glycerini , one part, aquce , two parts ; or a trial can be made of acidum carbolicum and tinct. iodi , as suggested by Prof. Bar- tholow. Quinina gave the best results in the cases seen by Dr. Sutton. After migration has begun, the powers of life should be sustained by nourishing food, stimulants and tonics, as “there are no drugs which have any influence upon the embryos in their migration through the muscles.” (Osier.) DISEASES OFTHE RESPIRATORY SYSTEM. PHYSICAL DIAGNOSIS. Physical Diagnosis is the art of discriminating disease* by means of the eye, the ear and the touch. The signs thus ascertained are connected with changes or altera- tions in the form, density, or condition of the structures within, and are known as physical signs. “ Physical signs are , then , the exponents of physical conditions , and of nothing more." (Da Costa.) The methods employed in the physical exploration of the chest, are: I, Inspection; II, Palpation; III, Mensuration; IV, Percussion; V, Auscultation; VI, Succussion. Percussion and auscultation , dealing with sounds, are of the great- est value clinically. For the purposes of physical exploration, the chest is mapped off into regions or divisions, as follows : — ANTERIORLY. First : — Supra-clavicular , Lying above the upper edge of the clavicle, usually about an inch in extent. 220 PRACTICE OF MEDICINE. Second: — Clavicular , Corresponding to the inner two-thirds of the clavicle. Third : — Infra-clavicular , From the clavicle to the lower border of the third rib. Fourth : — Mammary, Between the third and sixth ribs. Fifth : — Infra-mammary, Downward from the sixth rib. LATERALLY. First : — Axillary, That portion above the sixth rib. Second : — Infra-axillary , That portion below the sixth rib. POSTERIORLY. First : — Supra- scapular, That portion above the scapula. Second : — Scapular, That portion covered by the scapula. Third : — Inter-scapular, That portion between the scapulae. Fourth:— Infra-scapular, That portion below the angle of the scapula. INSPECTION. Inspection signifies “the act of looking.” Views of the chest should be taken from the sides and behind as well as from the front ; for which purpose a good light should be obtained, and the patient be placed in as easy and comfortable a position as is possible. Inspection reveals the form, size, color and movements of the chest, as well as the condition of the superficial parts. In health the sides of the chest are for the most part symmetrical in form, size, color and movements, both sides rising equally during the act of inspiration, and falling equally during the act of expira- tion. During the act of inspiration the -intercostal spaces in the lower two-thirds of the chest become more hollow, as also do the supra-clavicular fossae. Inspiration is almost entirely the result of muscular action ; expira- tion, on the other hand, is chiefly due to the elasticity of the lungs and chest walls, aided somewhat in forced respiration by muscular action. The movement of inspiration by inspection is of longer duration than that of expiration, and the pause between the acts but momentary. The respiratory movement is visible over the whole thorax, although in males and in children it is most distinct at the lower portion ( in- ferior costal breathing), while in the female it is most distinct at the upper portion of the chest ( superior costal breathing). DISEASES OF THE RESPIRATORY SYSTEM. 221 PALPATION. By palpation is meant the application of the palmar surfaces of the hands and fingers to the chest, by which means we appreciate impressions which are capable of being conveyed by the sense of touch. The objects of palpation are: — . First : — To give more accurate information regarding what is revealed by inspection. Second : — To locate spots of soreness, the density and condition of tumors, if any be present, the state of the chest walls, the frequency of the breathing, and the action of the heart. Third: — To determine the existence and character of the various kinds of fremitus (vibrations). By fremitus is understood certain tactile impressions or vibrations conveyed to the surface of the chest, which are classed and produced as follows : — First : — Vocal fremitus , produced by the act of speaking or crying. Second: — Tussive fremitus, produced by the act of coughing; of value especially when the voice is’ very weak. Third : — Bronchial fremitus , produced by the passage of air through mucus, blood, or pus, in the bronchial tubes, during the act of respiration. Fourth : — Friction fremitus , produced by the rubbing together of the roughened surfaces of the pleura. When the normal chest vibrates lightly, it is termed the normal vocal fremitus. The vocal fremitus is more distinct upon the right side toward the apex. If the lung be consolidated (denser), the vibration is greater and more easily distinguished, — the vocal freinitusis increased. In feeble persons, or when any cause interferes with the trans- mission of the vibrations, the vocal fremitus is diminished or absent. MENSURATION. Mensuration, or measurement of the chest, is of little practical importance, and hence seldom performed. The only measurement likely to be required is the circular or circumferential , in different 222 PRACTICE OF MEDICINE. parts of the chest, which is performed with either an ordinary gradu- ated tape measure or a double tape measure, made by uniting two tapes in such a manner that they start in opposite directions from the same point at the mid-spinal line. The tapes drawn around each side until they meet at the mid-sternal line , on a line immediately above the nipple, or on the level of the sixth rib near its attachment to the cartilage — the sixth costo-sternal joint — the patient first being directed to effect a complete expiration, the number of inches noted, and then to take a deep inspiration, the increase in inches noted, the difference between the two giving a rough estimate of the capacity of the lungs. In right-handed persons the right side is usually one-half to three- fourths of an inch larger than the left ; if larger than this it is usually the result of some abnormal condition. In well-developed men the chest measures at the upper part about thirty-three to thirty-five inches during expiration, and is increased fully three inches upon inspiration. PERCUSSION. Percussion, or “ The act of striking,” to ascertain the composi- tion of structures, affords signs and information of great value in diagnosis. There are two methods employed, immediate and mediate. Immediate , or direct percussion, is performed by striking the thorax directly with the points of the fingers or the palmar surface of the hand. This method of percussion has been generally abandoned, as it does not enable the physician to distinguish, with sufficient correct- ness, between the various shades of difference in the pitch or quality of percussion sounds. Mediate , or indirect percussion, may be practiced in three different ways, to wit : — First: — With the finger of one hand interposed between the body percussed and the percussing finger. Second: — With the finger acting as a pleximeter and the percussion hammer. Third : — With the percussion hammer and the pleximeter. The first of these modes affords the most correct and ready infor- mation regarding the resistance of the parts percussed. The skillful DISEASES OF THE RESPIRATORY SYSTEM. 223 use of the fingers is more difficult to acquire than that of the plexi- meter and hammer ; but if the examiner has acquired sufficient skill in its performance, an absolutely accurate result may be obtained. “ He who is skilled in digital percussion will be able to percuss equally well with the hammer, the inverse of which does not always hold good.” In addition to being proficient in the technical modus ope- randi , it is necessary to possess a sensitive ear, educated to distin- guish between the various shades of the sounds. When the fingers are employed, it is a matter of choice whether one or more fingers are used as the pleximeter. Usually the last phalanx of the first or second fingers of the left hand are used, the other fingers being raised from the chest , so as not to interfere with the sound vibrations ; they should be applied firmly and evenly to the surface, thus preventing the slipping of the soft parts, and also to determine the resistance of the chest walls when the blow is given.’ The rounded ends of the first and second fingers of the right hand are used as a hammer, striking the pleximeter fingers in such a manner that the nails shall not touch the skin of the underlying fingers. The force employed varies in different regions, but usually, for the chest, should be only of moderate degree. Forcible percussion is of use only when he sound of deep-seated organs is desired. The stroke should be made perpendicularly to the surface and not slanting, as is too often done. The whole movement should proceed only from the wrist-joint , and ought not to be too rapid or unequal, or of great force, the fingers being rapidly withdrawn, so as not to interfere with the vibrations. The objects of percussion are to elicit certain sounds , and the amount of resistance or elasticity of the organs percussed. The main sounds elicited by percussion are the dull , clear and tympanitic . Familiarity with the intensity , character and pitch of each of these sounds is essential. When percussing the healthy chest, the sound obtained is termed the normal pulmonary resonance. It is of variable intensity , depend- ing upon the force of the stroke employed and the amount of adipose and muscular tissues covering the thorax, and the tension of the chest walls. There is no exact standard of the normal pulmonary or vesicular resonance, but if the two sides of the chest are compared, the normal standard of each person is obtained. 224 PRACTICE OF MEDICINE. The character is termed pulmonary or clear , as characteristic of the healthy chest wall. The pitch is always relatively low. The sounds elicited by percussing a healthy chest are not, however, alike over all its parts. Anteriorly , the portion of lung above the clavicle yields a sound which becomes somewhat tympanitic , as the trachea is ap- proached. Over the clavicle the sound is clear and pulmonary at the centre of the bone, but at the scapular extremity it is duller, and towards the sternum it becomes somewhat tympanitic. At the infra- clavicular region the resonance is clear and distinct, but little resistance being offered to the percussing finger, and the sound elicited may be taken as the type of the pulmonary resonance. In this region, however, a slight disparity exists between the two sides; on the right side the sound is less clear, shorter and of a higher pitch than on the left side. In the mammary region of the right side the resonance of the lung is not so clear, the sound being modified by the size of the mamma and the upper border of the liver. On the left side the heart deadens the sound from the fourth to the sixth rib, and in a transverse direc- tion, from the sternum to the left nipple. This dull sound in the left mammary region is lessened in extent during full inspiration, and in emphysema, when the lung more completely covers the heart. In the infra-mammary region on the right side the percussion note is dull , except during the act of complete inspiration, when the liver is displaced downward by the inflated lung. In the left infra-mam- mary region the sound consists of a mixture of the dull sound of the heart and spleen and of the clear sound of the lung, together with the tympanitic sound of the stomach. Over the upper part of the sternum — above the third rib — the sound is slightly tympanitic. Below the third rib, over the sternum, the sound is dull, due to the presence of the heart and liver. Th z position exercises some influence on the results of percussion. More accurate results are obtained when the patient is standing or sitting than when recumbent. While the front of the chest is per- cussed, the arms should hang loosely by the sides ; the hands may be clasped across the top of the head during the percussion of the axillary region ; during the examination of the back the head must be bent forward and the arms tightly crossed in front. DISEASES OF THE RESPIRATORY SYSTEM. 225 On the posterior surface of the chest the sound also varies according to the part percussed. Over the scapula the sound is duller than between these bones or below their inferior angles. Over the infra-scapular region a clear sound is obtained as far as the lower border of the tenth rib on the right side, where the dullness of the liver begins. On the left side, below the angle of the scapula, the percussion sound is tympanitic if the intestines are distended, or it may be slightly dull if the spleen be enlarged. In the axillary region the sound is clear and distinct on each side. In the infra-axillary region of the right side the sound is duller , owing to the presence of the liver ; at the corresponding situation on the left side, the sound is clear or tympanitic , from the distention of the stomach, and at the ninth or tenth rib of the left axillary region dullness and the sense of resistance mark the location of the spleen. The sound obtained by percussion of the unhealthy or abnormal chest are as follows : — First : — Hyper-resonance or an increase of the normal pulmonary resonance is due to the relative increase in the proportion of air to the solid tissues of the lung, providing the tension of the chest walls be not altered, occurring in emphysema of the lungs, atrophy of the lungs, or consolidation of the opposite lung. Second : — Dullness or an absence of resonance, due to the relative increase of solid tissues in proportion to the amount of air, as seen in the different stages of phthisis, in pneumonia, pleural effusion and hydrothorax. The pitch is increased or heightened in proportion to the diminution of the amount of the air and the increase of the solids. If there be entire want of resonance, the percussion note is said to be flat ; if there is a slight decrease in the resonance of the part the note is said to be impaired. The sense of resistance is greater, the more marked the consolida- tion of the lungs and the greater the tension of the chest walls. Third: — Tympanitic , or the drum-like percussion note, is a non- vesicular sound having the character elicited by percussing over the normal intestines ; wherever heard it indicates the presence of air in conditions similar to that of the intestines, to wit : inclosed in walls which are yielding, but neither tense nor very thick. 19 226 PRACTICE OF MEDICINE. When elicited over the chest it may be due to the transmitted sound of the distended stomach or colon. It is obtained over the chest in pneumothorax, in moderate pleural effusions above the level of the liquid, over the seat of cavities in the pulmonary tissues, and in oedema of the lungs. The tympanitic percussion note differs from the normal pulmonary resonance in being more ringing in character and of a higher pitch. The amphoric or metallic sound is in reality a concentrated tym- panitic sound of high pitch, and denotes a large cavity with firm, elastic walls. The cracked-pot or cracked-metal sound is another variety of the tympanitic sound. The condition most commonly producing this sound is a cavity in the lung tissue, communicating with a bronchial tube. It requires for its development a strong, quick blow of the percussing finger, with the patient’s mouth open. RESPIRATORY PERCUSSION. The percussion sound will vary greatly with the respiratory move- ments. If a full inspiration be taken and percussion performed, then a full expiration taken and percussion performed, and then the chest percussed during the normal respiration, slight changes in the char- acter and pitch of the note are obtained, which otherwise would escape detection. Prof. DaCosta has designated this method, respira- tory percussion. AUSCULTATORY PERCUSSION. This method consists in listening with a stethoscope applied to the thorax, to the sounds elicited by percussion. “It is a serviceable means of determining with accuracy the boundaries of various organs, as those of the lungs or heart, or of the liver or spleen, and yields particularly exact results when carried out with the double stetho- scope.” AUSCULTATION. Auscultation, or listening to the sounds produced within the chest during the act of respiration, coughing, or speaking, furnishes the most reliable means of studying the condition of the lungs, and is, therefore, the most valuable method of discriminating between the various conditions which may affect the lungs. DISEASES OF THE RESPIRATORY SYSTEM. 227 Auscultation is either immediate or mediate. It is immediate when the ear is applied directly to the chest, which may be either denuded or thinly covered. It is mediate when the sounds are conducted to the ear by means of a tubular instrument, termed a stethoscope. For ordinary purposes, immediate , or direct auscultation is suffi- cient, but when it is desirable to analyze circumscribed sounds, as in diseases of the heart, or where the patient objects to this method, on the score of delicacy, or the auscultator objects, on account of the uncleanliness of the person examined, the stethoscope is to be pre- ferred. Moreover there are certain parts of the chest which can only be explored satisfactorily by the aid of a stethoscope, and again this instrument has the additional advantage of intensifying the sound. In auscultation, the following rules, formulated by Prof. DaCosta, should be observed : — “ i. Place yourself and your patient in a position which is the least constrained and permits of the most accurate application of the ear or stethoscope to the surface. Above all, avoid stooping, or having the head too low.” “ 2. Let the chest be bare, or what is better, covered only with a towel or a thin shirt.” “ 3. If a stethoscope be employed, apply closely to the surface, but abstain from pressing with it. This may be obviated by steadying the instrument, immediately above its expanded extremity, between the thumb and the index finger.” “4. Examine repeatedly the different portions of the chest, and compare them with one another while the patient is breathing quietly. Making him cough, or draw a full breath, is, at times, of service ; especially the former, when he does not know how to breathe.” SOUNDS IN HEALTH. If the ear be applied over the larynx or trachea of a healthy per- son, a sound is heard with both the act of inspiration and expiration. Its intensity is variable , its pitch high , and its quality tubular (to wit : a current of air passing through a tube — the larynx or trachea). The duration of the sound during inspiration being somewhat longer than during expiration. A short pause follows the act of expiration. This sound is termed the normal laryngeal respiration , and is 228 PRACTICE OF MEDICINE. identical in character, duration and pitch with an important morbid sound, termed bronchial respiration. The sound heard by placing the ear over the lung tissue is differ- ent ; it is produced in the very finest bronchial tubes and air cells by their expansion and contraction, and is termed the normal vesicular 7nurmur. The inspiratory portion of the sound is of variable intensity , its pitch is low , its quality soft and breezy , designated vesicular ; its duration is during the entire act of inspiration. The expiratory portion of the sound is not always perceptible ; it is of feeble intensity , very low pitch, its character soft and blowing , and its duration much less than the act of inspiration. It is to be remembered, however, that the vesicular murmur will be found to vary in the different regions on the same side, and in corre- sponding regions on the two sides of the chest. These variations within the range of health are especially important, and should be memorized. Infra-clavicular Region. — The vesicular murmur in this region on either side is much more distinct than over any other part of the chest. On the left side the inspiratory sound is of greater intensity, ot lower pitch, and more distinctly vesicular in quality than that heard upon the right side. On the right side the expiratory sound is nearly or quite the same in length as the inspiratory sound, and is higher in pitch and more tubular in quality than the expiratory sound upon the left side. Supra-scapular Region. — Owing to the small number of air vesicles and the large number of bronchial tubes, and their nearness to the surface, the respiratory murmur has an intense, high-pitched, tubular and expiratory quality. Scapular Region. — Compared with the infra-clavicular region, the respiratory murmur heard over the scapulae on either side is more feeble, and the vesicular quality less marked. Interscapular Region. — The murmur in this region differs from the normal laryngeal breathing only in intensity and duration. Infrascapular Region. — The murmur in this region very closely resembles that heard in the left infra-clavicular region. Mammary and Infra-mammary Regions . — The murmur in these regions differs from that heard in the infra-clavicular region, in being of less intensity. DISEASES OF THE RESPIRATORY SYSTEM. 229 Axillary and Infra-axillary Regions. — The respiratory sound in the axillary regions is as intense as in any portion of the chest. In the infra-axillary regions the intensity is less and the pitch lower. VOICE IN HEALTH. If the ear be applied over the larynx or trachea of a healthy per- son, and he be directed to count “ twenty-one, twenty-two, twenty- three,” in a uniform tone and with moderate force, there is perceived a strong resonance, with a sensation of concussion or shock, and a sense of vibration, thrill or fremitus, the voice seeming to be concen- trated and near the ear. Often the articulated words are distinctly transmitted (laryngophony). The sounds thus heard are termed the normal laryngeal resonance. If the ear or stethoscope be applied over the third rib anteriorly, on either side of the chest of a healthy person, and he be directed to count “ twenty-one, twenty-two, twenty-three,” in a uniform tone, with moderate force, a confused, distant hum is perceived, of variable intensity, accompanied with more or less vibration, thrill or fremitus, most distinct in adults, but notably weaker in women than in men. This sound is termed the normal vocal resonance. If the ear or stethoscope be applied over the third rib anteriorly, of a healthy person, and he be directed to whisper , in a uniform man- ner, the words, “ twenty-one, twenty-two, twenty-three,” there is heard a sound corresponding closely in character to the sound of expiration over the same region during the act of forced respiration ; or, in other words, a feeble, low-pitched, blowing sound. This sound is termed the normal bronchial whisper , and is produced by the air in the bronchial tubes during the act of expiration. SOUNDS IN DISEASE. The vesicular murmur may undergo, in disease, changes in its in- tensity , its rhythm , and in its character. The intensity of the respiratory murmur may be : — 1. Exaggerated or increased. 2. Diminished or feeble. 3. Absent or suppressed. Exaggerated respiration differs from the normal vesicular respiration only in an increase in the intensity of the respiratory sounds. When general over one lung, it will usually indicate de- 230 PRACTICE OF MEDICINE. ficient action of other parts. In this manner an effusion compressing the lung, one-sided deposits, obstruction of the bronchial tubes by secretion, or inflammation of the lung structure, necessitate a supple- mentary respiration in a healthy portion of the same lung or the lung upon the opposite side. From its resemblance to the loud, strong, quick respiration of young children, it has been ^termed puerile res- piration. Exaggerated respiration is, therefore, to be regarded as indirect evidence of disease in some portion of the pulmonary tissue. Diminished respiration, called also senile respiration, as being characteristic of old age, is characterized by diminished intensity and duration of the sound. In the large majority of instances the inspi- ration suffers the greatest, the expiratory sound not diminishing in the same proportion. In asthma, emphysema, diseases of the larynx and bronchial tubes, pleuritic pain, rheumatism or paralysis of the chest walls, or in thickening of the pleural membrane, we observe super- ficial or diminished respiration. When one side of the chest is partially filled with fluid, we may hear a deep-seated, but feeble breath sound. Absent or suppressed respiration occurs whenever the action of the lung is suspended ; this may be from external pressure, as when the lung is compressed by the presence of fluid or air in the pleural cavity, or when complete obstruction of the bronchial tubes prevents the air from either entering or escaping from the lungs. The rhythm of the respiratory murmur may be 1 . Interrupted or jerky. 2. The interval between inspiration and expiration prolonged. 3. Expiration prolonged. In health the inspiratory and expiratory sounds are even and con- tinuous, with a short interval between each act ; this may be altered in disease, and both sounds, especially the inspiratory, have an interrupted or jerky character, termed “cog-wheel respiration.” This jerky breathing 1 is noted in some spasmodic affections of the air tubes, in hysteria, the earliest stages of pleurisy, pleurodynia, and the early stages of pulmonary phthisis. It is most frequently associated with phthisis, due probably to the adhering to the walls of the finer bronchial tubes of tough mucus, which obstructs the free entrance and exit of the air ; it is usually most notable under the clavicles. DISEASES OF THE RESPIRATORY SYSTEM. 231 The interval between inspiration and expiration may be prolonged, instead of these two sounds closely succeeding one another. When this occurs the inspiratory sound may be shortened, or the expiratory sound may be delayed in its commencement. If the inspiratory sound is shortened, it is the result of consolidation of the lungs ; if the expiratory sound is delayed, it is the result of lessened elasticity of the lung structure, and is most commonly asso- ciated with emphysema. Prolonged expiration denotes that the air is obstructed in its exit from the lungs. It may be the result of diminished elasticity, the result of emphysema, or from the deposit of tubercles, which impair the contractile power of the lungs. If the former, it is asso- ciated with clearness on percussion ; if the latter, however, with impaired resonance on percussion. When prolonged expiration is detected at the apex of the lung, and is associated with impairment of the normal pulmonary resonance, it is for the most part the result of a tubercular deposit. The quality of the respiratory murmur may be 1. Harsh , termed vesiculo-bronchial respiratio 7 i. 2. Bronchial. 3. Cavernous. 4. Amphoric. Harsh respiration, or, as it is termed by Prof. DaCosta, vesiculo- bronchial respiration, is that variety in which both the inspiratory and expiratory sounds have lost their natural softness. It generally indi- cates more or less consolidation of lung tissue. In normal vesicular respiration the sounds produced by the air expanding the air cells and finer bronchial tubes obscures the sound produced by the passage of air through the larger bronchial tubes, the healthy lung being an imperfect conductor of sound, so that as soon as any portion of the lung becomes consolidated the vesicular element of the respiratory sound is diminished, the bronchial element becoming prominent. Harsh respiration is, then, a union of the vesicular and bronchial sounds, being a vesicular sound mixed with some of the qualities of a bronchial sound, the expiration being prolonged and tubular in character. It is present when the bronchial mucous membrane is swollen, as in the earlier stages of bronchitis, also in the earlier stages of phthisis and pneumonia. Bronchial respiration is characterized by an entire absence of 232 PRACTICE OF MEDICINE. all the vesicular quality. Inspiration is of high pitch and tubular in character; expiration still higher in pitch , of greater intensity, pro- longed and tubular in quality ; the two sodnds being separated by a brief interval. The bronchial respiration encountered in disease closely resembles that heard in health over the larynx or trachea. Whenever bronchial respiration is present where, in health, the normal vesicular murmur should be heard, it indicates consolidation of the lung structure. Cavernous respiration is a variety of the bronchial respiration, at least so far as the quality of the sound is concerned. It is essen- tially a blowing sound, yet not always heard during both the act of inspiration and expiration, being often only perceptible in the one, and in the other mixed with gurgling sounds. Its pitch is lower than that of ordinary bronchial respiration, and its character is hollow. For its production there must be a cavity of considerable size in the lung substance, not filled with fluid, near the surface of the chest walls, communicating with a bronchial tube. It is met with most commonly in the last stages of pulmonary consumption, although hollow spaces of any kind, from abscess or dilatation of the bronchial tubes, occasion it. Amphoric respiration is a blowing respiration, having a musi- cal or metallic quality. It is a variety of bronchial respiration pro- duced in a large cavity with firm walls, permitting the reflection of the sound. An imitation of this sound, though only an imperfect one, is produced by blowing over the mouth of an empty bottle. The amphoric character is present with both the act of inspiration and expiration. Amphoric or metallic respiration is indicative of a large cavity, not common in phthisis, but much oftener heard at the upper part of a lung compressed by fluid and air, as in pneumo-hydrothorax. RALES. Rales, or, as they are teimed, adventitious sounds , because they have no analogue in the healthy state, cannot be considered as modi- fications of the normal respiration. Grouped according to the anatomical situation in which they are produced, we have : — i . Laryngeal and tracheal rales. 233 DISEASES OF THE RESPIRATORY SYSTEM. 2. Bronchial rales. 3. Vesicular rales. 4. Cavernous rales. 5. Pleural rales. Rales may be divided into two groups, according to their character, to wit: dry and moist , and may be audible either during the act of inspiration or expiration, or during both. Dry rales, for the most part are produced by the vibration of thick fluids which the air cannot break up, and which, therefore, temporarily lessens the calibre of the bronchial tubes. When this narrowing exists in the smaller bronchial tubes the resulting sound is high-pitched or the rale is said to be sibilant or whistling ; when the narrowing exists in the larger bronchial tubes, the rale is low-pitched , more musical in character, or sonorous. Dry rales are particularly prone to be dislodged by coughing, and when they are uninfluenced by the acts of breathing or coughing, they do not depend upon the presence of secretions, but upon the narrowing of the air tubes from the pressure of tumors, or from a thickened fold of mucous membrane, or from a spasmodic contraction of the air tubes. Moist rales are those produced by the air passing through thin fluids, such as mucus, blood, serum, or pus, during the respiratory movements. When the fluid exists in the smaller bronchial tubes, the rales are termed small bubbling , mucous, or subcrepitant. When the fluid exists in the large bronchial tubes, the rales are said to be large bubbling or mucous. Moist rales are not persistent, but vary in intensity, and shift their positions as the air drives the liquid which occasions them before it, or during violent attacks of coughing, or after copious expectoration. Laryngeal and tracheal rales are those produced within the larynx and trachea, and may be either moist or dry. The moist or bubbling sounds, produced when mucus or other liquids accumulate in this part of the air tubes, frequently occur in the moribund state, and are then known as the “death rattles.” When not due to this condition they denote either insensibility to the presence of liquid, as in stupor or coma, or inability to remove liquid by the acts of ex- pectoration, as in croup or inflammation of these parts in the very feeble. The dry rales produced within the larynx or trachea are generally 234 PRACTICE OF MEDICINE. caused by spasm of the glottis, to wit : laryngismus stridulus, whoop- ing cough or croup, or from the presence of a foreign body in the part. Bronchial rales, resulting from the passage of air through the thin liquid, occasion bubbling sounds. When the liquid is present in the large-sized bronchial tubes, the rales are said to be large bubbling , or large mucous rales, occurring in acute or chronic bronchitis. When the liquid is in the smaller bronchial tubes, the resulting rale is called small bubbling , small mucous, or subcrepitant , also occurring in acute or chronic bronchitis. Bronchial rales due to the narrowing of the tube by its spasmodic contraction, or to the presence of tough, tenacious mucus, which is set in vibration by the passage of the air through the bronchial tubes, are termed dry bronchial rales. Frequently they are suggestive of cer- tain familiar sounds, such as snoring, cooing, humming, or wheezing, or they are often musical notes. When produced in the smaller bronchial tubes, they are termed sibilant , or high-pitched rales : when produced in the larger bronchial tubes, they are termed sonorous or low-pitched rales. They principally occur in the dry stage of bronchitis, or during an asthmatic paroxysm. The vesicular rale, or as it is more commonly termed, the crepitant rale, is produced within the air vesicles or at the terminal portion of the smaller bronchial tubes. It is to be distinguished from very fine bubbling sounds, or the sub- crepitant rale. “ It is a very fine sound, or rather series of very fine uniform sounds, occurring in puffs and limited to inspiration .” (Da Costa.) It resembles the noise occasioned by throwing salt on the fire, or alternately pressing and separating the thumb and finger, moistened with a solution of gum arabic, and held near the ear, or rubbing together a lock of dry hair near the ear. The crepitant rale is produced by the movement of fluid in the air cells or in the finest extremities of the bronchial tubes, or by the forcing open, during the act of inspiration, of the air cells aggluti- nated by exuded lymph. These sounds may be defined as being very fine, dry, crackling sounds, heard at the end of inspiration. They are usually present in the first stage of pneumonia, but when limited to the apices, are significant of the incipient stage of phthisis. Cavernous rales, or, as they are commonly termed, gurgling DISEASES OF THE RESPIRATORY SYSTEM. 235 rales, are produced in a pulmonary cavity of considerable size, containing a large amount of liquid communicating freely with a bronchial tube. The sound is occasioned by the agitation of the liquid within the cavity, and may be compared to the sound pro- duced by the boiling of liquid in a flask or large test-tube. The sound is sometimes high-pitched or musical, whence it has been termed “ amphoric gurgling,” but it is generally low in pitch. The rale is heard almost exclusively during the act of inspiration, and its diag- nostic importance relates to the advanced stage of phthisis. Pleural rales may be either dry or moist. Dry pleural rales, or as they are more commonly termed , friction sounds , are occasioned when the surfaces of the pleurae are covered with a glutinous substance preventing the unobstructed movements of the pleural surfaces upon each other during the respiratory acts, for in health, these movements occasion no sound whatever. The sounds are generally interrupted or irregular, occurring during the act of inspiration or expiration, or during both acts. The character of the sound is variable, being termed rubbing, grazing, rasping, grating or creaking, according to the intensity of the respiratory acts and the amount of exudation. They are distinguished by the apparent nearness of the sound of the ear, and are usually intensified by firm pressure of the stetho- scope upon the chest. When the chest is fixed, especially at the lower two-thirds, and the ear applied over the seat of the sound, it will be found to have disappeared. The sound is diagnostic of the first stage of pleurisy. Moist friction sounds are produced in the same manner as those just mentioned, the exudation being softened in character. This sound is frequently confounded with moist bronchial rales, and its discrimination is often only positive by a careful study of the symp- toms and concomitant signs present. Metallic tinkling is a sign of pneumo-hydrothorax with per- foration of the lung, and when found is usually diagnostic of this affection, although it occurs rarely in cases of phthisis with a large cavity, the physical conditions for its production being similar to those in pneumo-hydrothorax, to wit : a space of considerable size contain- ing air and liquid, the space communicating with the bronchial tubes. It consists of a series of tinkling sounds , of high pitch, silvery or metallic in tone, and is very well imitated by dropping a small marble 236 PRACTICE OF MEDICINE. into a metallic vase. It occurs irregularly, not being present with every act of breathing, and may be produced by forced, when not heard during tr.anquil breathing. Were it not for the location and the absence of concomitant signs it might be confounded with tinkling sounds sometimes produced within the stomach and transverse colon. THE VOICE IN DISEASE. The normal vocal resonance, as heard over the third rib of the chest anteriorly on either side, may have its intensity — 1. Diminished or absent. 2. Increased or exaggerated. Or its resonance may be of the character of — 3. Bronchophony . 4. Pectoriloquy. 5. AZgophony. 6. Amphoric voice. The vocal resonance may be diminished or feeble in bronchitis with free secretion, pleurisy with effusion, or in complete consolidation of the lung structure and the bronchial tubes. The vocal resonance is absent in pneumothorax and in pleurisy with effusion. Exaggerated vocal resonance differs from the normal vocal resonance in a slight increase of its density. It denotes a slight degree of solidification of lung tissue, and is chiefly of value in the diagnosis of tubercle. Bronchophony, or the voice concentrated near the ear, raised in pitch and in intensity, denotes complete consolidation of the pul- monary tissue in those parts in which the sound is abnormally present. Pectoriloquy is complete transmission of the voice to the ear, the articulated words being distinctly recognized. It has a close resemblance to the resonance heard over the larynx in health. Its presence indicates either a pulmonary cavity or more complete con- solidation — in other words, an exaggerated bronchophony. •iSUgophony is a modification of bronchophony, consisting in tremulousness of the voice, its character nasal or bleating, somewhat suggestive of the cry of a goat. When heard, it may be considered a sign of pleurisy with slight effusion, or of pleuro-pneumonia. DISEASES OF THE RESPIRATORY SYSTEM. 237 Amphoric voice, or “ the echo,” as it is sometimes called, is a musical sound, of a somewhat hollow, metallic character, like that pro- duced by blowing into an empty bottle. It is sometimes produced in large cavities within the lung, but is especially incident to pneumo- thorax. Increased bronchial whisper is a sound in which the whis- pered words are abnormally intense, and higher in pitch than the normal bronchial whisper. It has the same significance as exagger- ated vocal resonance. SUCCUSSION. The succussion or splashing sound is pathognomonic of one affection, namely, pneumo-hydrothorax. It is obtained by jerking the body of a patient with a quick, somewhat forcible movement, the ear being very near or in contact with the chest. The sound is like that produced when a small keg, partially filled with liquid, is shaken. The only liability to error is in confounding this splashing sound with that sometimes produced within the stomach ; but attention to concomitant signs and the symptoms will always protect against this error. ASSOCIATION OF THE PHYSICAL SIGNS (DA COSTA). “ As many of the signs elicited by the various methods of physical diagnosis depend on the same physical conditions, they may be studied in groups. The following will be usually found to be asso- ciated : — Auscultation Percussion. OF Respiration. Auscultation of Voice Vocal Fremitus. Physical Conditions. Clear Vesicular murmur or its modifi- cation. Normal vocal resonance. Unimpaired. Lung tissue healthy or nearly so ; at any rate, no increased density from deposits, etc. Dull Bronchial, or harsh respiration. Bronchophony. Increased. Solidification of pulmon- ary structure. Absent respi- ration. Absent voice. Diminished or absent. Effusion into pleural sac. Tympanitic. Cavernous or feeble, ac- cording to cause. Uncertain ; cavernous or diminished. Uncertain ; mostly di- minished. Increased quantity of air within the chest, due to a cavity or to overdis- tention of the air cells. Amphoric or metallic. Amphoric or metallic. Amphoric or metallic. Mostly di- minished. Large cavity with elastic walls. Cracked metal sound. Cavernous respiration. Cavernous respiration. Uncertain. Generally a cavity com- municating with a bron- chial tube. 238 PRACTICE OF MEDICINE. DISEASES OF THE NASAL PASSAGES. ACUTE NASAL CATARRH. Synonyms. Acute rhinitis ; acute coryza ; “ cold in the head.” Definition. An acute catarrhal inflammation of the mucous membrane (pituitary or Schneiderian membrane) lining the nose and the cavities communicating with it ; characterized by feverishness, feeling of fullness and discomfort in the head, and attended with dis- charges of fluid, watery, mucous, or muco-purulent in character. Pathological Anatomy. Hypercemia of the mucous mem- brane, attended with redness, swelling, and deficient secretion. This tumefaction is partly increased by an oedematous infiltration , causing a quantity of colorless, salty, and very thin liquid to flow from the nose. The secretion soon assumes the character of thick, tenacious mucus or muco-pus, due to the desquamation' of the epithelium of the nasal mucous membrane, and a copious generation of young cells, the hyperaemia and the swelling of the membrane diminishing. The respiratory portions of the nasal fossae are more markedly affected than are the olfactory. Rarely, and then in new-born infants and those affected with the eruptive fevers, the exudation in the nasal passages is of a fibrinous nature, somewhat similar to that observed in diphtheria. Causes. Atmospherical changes are the most frequent and in- fluential. Exposure of the neck to a draught of cold air, or of the feet and ankles to cold and dampness, or changing from a warm to a cold atmosphere suddenly, are among the most usual causes. Irri- tating gases and vapors, dust, certain powders, as ipecac and tobacco. The scrofulous taint and the rheumatic diathesis seem to render the mucous membrane susceptible to frequent attacks. Acute coryza is usually present in the initial stage of measles and influenza. Epidemic influence occasionally prevails on an extensive scale. The poison of syphilis or the use of the iodide of potassium not un- frequently act as exciting causes. At times the catarrh seems to spread by contagion. Symptoms. “A cold in the head” is usually preceded by a feeling of lassitude or weariness and more or less frontal headache ; DISEASES OF THE NASAL PASSAGES. 239 then occur irregular sensations in the back, followed by more or less feverishness and an uncomfortable feeling of dryness in the nares, with a strong inclination to sneeze. This is soon followed by an abundant watery and saline discharge , which is continually dripping from the nostrils, or occasions an attack of sneezing followed by blowing the nose, which relieves the congested and swollen mem- brane for a few moments. The relief is temporary, however, the fullness of the head and difficult obstructed nasal respiration rapidly returning. The anterior nares are red and inflamed , and the eyes red and suffused with tears, through partial or entire closure of the tear ducts. The discharge soon assumes a purulent character. The voice has a peculiar tone, rather nasal and muffled in character. Within a few days the swelling subsides, and secretion lessens, health being restored in about ten days fiom the beginning of the attack. When the attack has almost terminated hard crusts may form within the nostrils, either on the septum or turbinated bones, which are with difficulty expelled by blowing the nose. Complications. Irritation and swelling of the upper lip, from repeated blowing of the nose and the constant contact of the irri- tating discharge. Extension of the catarrh to the ethmoid or sphenoid cavities or frontal sinus , causing [increased and severe frontal headache ; or to the antrum of Highmore , causing tenderness over one or both cheeks. Extension to the Eustachian tube and middle ear, causing impaired hearing ; or to the pharynx or larynx , causing cough. Duration. In mild cases about one week ; severe cases continue, more or less marked, for two weeks. Prognosis. Favorable if early and proper treatment be insti- tuted ; if neglected, the catarrh tends to become chronic. In very young infants, if the catarrh is not rapidly relieved, loss of flesh and strength occur, from inability to take the breast. Treatment. Attacks the result of atmospherical causes may be aborted by the early administration of quinines szdphas , gr. x-xv, with morphines sulphas, gr. % , or the early use of pulvis ipecacuanhcs et opii, gr. v, repeated in two hours. The following errhine used at the very onset has proved successful in aborting many cases : — 240 PRACTICE OF MEDICINE. y R . Aluminis, Bismuthi bicarb., Pulv. talc, aa gr. xx Morphinse hydrochlor., gr. ij. M. et ft. chart. No. xx. Sig. — I nsufflate one powder in each nostril after clearing the nose. (Sajous.) If the attack has already developed, relief is soon afforded by iinctura belladotmce, gtt. ij, every hour until six doses are taken, after which one drop every two or three hours until the physiological actions of the drug are produced ; if much fever be present, tinctura aconitiy gtt. i-ij, may be added ; the addition of camphora is of value, in fact, camphora in full doses at the onset and locally will often abort an acute catarrh. The following combination of Dr. Sajous is often successful : — R. Ammonii chlor., T)ij Tinct. opii, TT^xxiv Sacch. alb., gj Aq. camphorae, ad fjjj. M. SiG. — One teaspoonful in water every hour or two. Attacks of acute rhinitis unaccompanied by febrile reaction are gen- erally promptly aborted by a four per cent, solution of cocaine dropped in the nostrils, repeated every half hour. With either of the above plans may be added one of the following errhines : — R. Bismuth, subnit., . ^vj Pulv. acaciae, ^ij Morphinae hydrochlor., gr. ij . M. Sig. — E very hour or two. (Ferrier.) Or — R. Pulv. cubebae, 3 j Bismuth, subnit., 5 i j Morphinae hydrochlor., gr. ,ij- M. Sig. — U sed by insufflation every two or three hours. Acute coryza occurring in infants at the breast is controlled by either one of the following errhines thrown into the nose, with a powder blower ; finely powdered saccharum album , or equal parts of finely powdered saccharum album and camphora , or Robinson’s errhine of saccharum album and camphora , each half ounce, finel y powdered, and acidum tannicum , gr. xl. DISEASES OF THE NASAL PASSAGES. 241 Attacks of nasal catarrh due to the poison of syphilis should at once be placed upon the proper constitutional treatment. Attacks of nasal catarrh associated with the eruptive or mild fevers require no special treatment. It is well to remember that attacks of nasal catarrh occurring in very young children are generally the result of hereditary syphilis, and should be treated accordingly. CHRONIC NASAL CATARRH. Synonyms. Chronic rhinitis ; chronic coryza. Definition. A chronic inflammation of the mucous membrane lining the nasal passages, with more or less alteration of structure ; characterized by a sensation of fullness in the nares, increased secretion, and a perversion of the special sense of smell and of hearing. Causes. The result of repeated attacks of the acute variety ; inhalation of irritating vapors and dust ; syphilis and scrofula. Pathological Anatomy. The mucous membrane of the nares is thickened , of a dark-red , sometimes grayish color , the superficial veins dilated and varicose, often forming polypoid enlargements. In many cases there is ulceration of the structure, with more or less loss of substance; the secretion is thick, tough, of a greenish character, and often very fetid ; large collections of dried mucus are often formed upon the turbinated bones and septum. Symptoms. A feeling of fullness in the nares , increase of the secretion , the character being thick and greenish, which, dropping posteriorly into the pharynx, causes paroxysms of “hawking,” which are more marked in the morning immediately after arising. The special sense of smell is more or less impaired, and in many cases entirely abolished ; the special sense of hearing is more or less diminished, from an extension of the inflammation to the Eustachian tubes ; the voice has a peculiar nasal intonation. An almost constant dull frontal headache , associated with a feeling of weight, showing the extension of the disease to the infundibulum and frontal sinus. Sudden changes of temperature cause acute exacerbation of these symptoms, when there is superadded difficult nasal respiration. If ulceration of the nares occur, the discharge has a fetid odor. This condition is termed ozcena. 20 242 PRACTICE OF MEDICINE. From extension of the inflammation to the nasal duct or its ob- struction, the tears flow over the malar eminence {epiphora), leading to more or less congestion of the eyes. Diagnosis. Hypertrophy of the turbinated bones and naso- pharyngeal catarrh are constantly misnamed chronic nasal catarrh. The rhinoscope readily determines the diagnosis. Prognosis. Permanent cure is seldom obtained; the disease being so decidedly chronic and obstinate, the treatment is of neces- sity protracted, and the majority of patients tire of it before a com- plete cure is effected. Treatment. If it depends upon diathetic conditions, the cause must be ascertained and treatment directed accordingly. When no diathetic cause can be determined, attention should be paid to the general health, the secretions constantly attended to, and the diet be nutritious and digestible. Cleanliness of the nasal passages is of the utmost importance, and is best effected by the posl-nasal syringe , with either simple or medicated tepid waters, or a cleansing solution, such- as Dobell’s, to wit: — R . Acidi carbolici, gr. j Sodii bicarbonat., Sodii borat., aa gr. v Glycerini, fzj A q u «> fjj- Sig. — A s a spray or with a proper syringe. Or the following combination of Dr. Sajous : — R. Sodii bicarb., Sodii bibor., Ext. pinus canad. fid., . Glycerini, . . . f 3 ij Aquam, . . . fgiv. SlG. — Apply with atomizer three or four times daily. M. M. After which decided benefit follows the use of one of the following : — R . Acidi borici, % ss Bismuth, subnit., 3 ij Morphinse hydrochlor., gr. j. M. Or— R . Pulv. sanguinarise, Acid tannici, . . Pulv. camphorse, Bismuth, subnit., 3J gr. v gij. M. Sig. — T o be used by insufflation or as a snuff \ every three or four hours. DISEASES OF THE PHARYNX. 243 Or— J&. Ammonii chloridi, Glycerini, Ext. pinus canad. fid., Aquae destil., .... ad SiG. — Five to ten drops, dropped into each nostril two or three times a day, or applied with camel’s hair brush. DISEASES OF THE PHARYNX. ACUTE CATARRHAL PHARYNGITIS. Synonyms. Catarrhal tonsillitis ; angina catarrhalis ; acute “ sore throat.” Definition. An acute catarrhal inflammation of the mucous membrane of the tonsils, uvula, soft palate, and pharynx ; character- ized by rigors, fever, painful deglutition, coughing, or constant desire to clear the throat, with a more or less decided nasal intonation of the voice. Causes. Exposure to cold and damp ; swallowing hot fluids or food ; during the prevalence of scarlatina, measles, erysipelas, influ- enza, diphtheria, or variola. Pathological Anatomy. The mucous membrane and sub- mucous tissues of the uvula, soft palate, fauces, tonsils, and pharynx are congested, red, and swollen ; the secretion is at first lessened or entirely arrested, later it is increased, but of a thick, tenacious, opaque character. The swelling is most evident at the uvula, due to the amount of relaxed sub-mucous tissue, which is especially thick and long, often resting on the root of the tongue (“the palate is down”). Frequently one or both tonsils are swollen to such an extent that the fauces are completely occluded, and the condition is mistaken for the graver phlegmonous tonsillitis. In severe attacks of catarrhal angina, white or grayish-white mem- branous masses form in small, irregular, roundish spots on the red- dened mucous membrane of the tonsils, soft palate, and pharynx, causing the affection to be frequently mistaken for diphtheria. Symptoms. The onset is usually sudden, with rigors , fever , thirst, headache, loss of appetite, coated tongue, bad taste, foul 244 PRACTICE OF MEDICINE. breath, dryness in the throat, painful deglutition , and constant desire to clear the throat , due to the increased length of the uvula ; as the inflammation proceeds the secretions are increased, the fluid often filling the mouth and also causing a constant desire to swallow, each act being associated with acute pains. Not infrequently earache adds to the patient’s distress, from extension of the “ catarrh” to the Eus- tachian tubes and tympanum. In severe attacks of catarrhal pharyngitis, cases which, from the intense hyperaemia, have been termed erysipelatous or erythematous pharyngitis , the muscles of the palate are infiltrated with serum, which greatly interferes with their function. Under normal conditions the contraction of the muscles of the anterior half arches of the palate prevents the return of the food and drink into the mouth ; while the con- traction of the muscles of the posterior half arches, together with the uvula, closes the passage to the nose ; if the function of these muscles be impaired, fluids would be driven through the nose or back into the mouth by the contractions of the pharynx in the act of deglutition. In all affections of the pharynx a nasal tone is pathognomonic, especially if the muscles of the half arches are interfered with. Varieties. Exanthematous Pharyngitis is the form of the affec- tion complicating the acute infectious diseases, such as scarlatina, measles, influenza, and smallpox. Erysipelatous Pharyngitis is the form complicating facial erysipelas; rarely, however, the affection begins in the pharynx, spreading to the face and other parts. Gangrenous Pharyngitis may occur with diphtheria, scarlatina, erysipelas, smallpox, and typhoid fever. The symptoms assume a typhoid (depressed) character, the termination being usually fatal. Phlegmonous Pharyngitis is the variety in which is present an accu- mulation of pus in the submucous and deeper tissues of the pharynx, constituting a retro-pharyngeal abscess. This variety of pharyngitis may follow the penetration of a sharp piece of bone or be secondary to caries of the cervical vertebrae. Fibrinous Pharyngitis , or, as it is sometimes termed, pseudo-mem- branous, is considered with croup and diphtheria, of which it consti- tutes a part. Diagnosis. On account of the great swelling of the tonsils, it may be mistaken for aqute tonsillitis ; but the mild inflammatory symptoms should prevent the error. DISEASES OF THE PHARYNX. 245 Cases with membranous deposits upon the tonsils, soft palate, and pharynx are no doubt often misnamed diphtheria ; the marked differ- ence in the cqnstitutional symptoms should prevent the error. Prognosis. Favorable, the affection terminating in three or four days by the raising of a quantity of thick, opaque mucus. Treatment. If the attack is the result of exposure to cold or damp, or a symptom of some one of the infectious diseases, the very best results follow the application of sodii bicarbonas by insufflation. Opium in some form, alone or combined with ipecac or camphora , will often abort an attack of catarrh. Salol , gr^x (reducing size of dose for children), repeated four to six times daily? is a most valuable remedy for relieving the pain in all varieties of acute anginas. If the fever be marked, advantage follows the addition of small doses of tinctura aconiti. In children no one drug can compare with small repeated doses of tinctura aconiti. Locally , cocaine painted over the inflamed parts, of the strength of a four per centum solution, or used in the form of lozenges, is a val- uable remedy. Holding small pellets of ice in the mouth is useful, as is the application of either heat or cold to the angles of the jaws. Gargles or sprays of aluminis (gr. viij-aquas f^j), ammonii chloridum (gr. xx-aquse f^j), or potassii chloras (gr. xij-aquse f^j), used at fre- quent intervals, often allays the congestion and consequent swelling. For the gangrenous variety stimulants and the local use of argenti nitras. If a retro-pharyngeal abscess develop, evacuate the pus early and give quinina and ferrum for the constitutional symptoms which may develop. In all varieties the use of pellets of ice is comforting. ACUTE TONSILLITIS. Synonyms. Amygdalitis ; quinsy ; phlegmonous pharyngitis. Definition. An acute parenchymatous inflammation of one or both tonsils, with a strong tendency toward suppuration ; character- ized by moderate fever, pain in the throat, a constant desire to relieve the throat, painful and difficult deglutition, impeded respiration, and more or less muffling of the voice. Causes. Generally attributed to exposure to cold, but, in the majority of cases, the exposure is so slight that there must be a pre- 246 PRACTICE OF MEDICINE. disposition to the affection ; for persons once affected are particularly prone to repeated attacks upon the slightest exposure. Pathological Anatomy. One or both tonsils will be seen, on inspection, to project from its bed, as a rounded, deep red body, which may even extend beyond the median line, when they may en- tirely* occlude the isthmus of the fauces ; the half arches and posterior border of the soft palate are reddened and somewhat swollen. The surface of the tonsils is often covered with small, yellowish points, which closely resemble patches of false membrane, but careful in- spection will show that they are beneath the mucous membrane, be- ing only the distended follicles of the gland. The mucous membrane of the fauces and pharynx is more or less red and swollen. Symptoms. Onset more or less sudden, with rigors , rise in tem- perature 102° to 104° Y ., full, frequent pulse , 100 to 120, headache , thirst , pain and swelling at the angle of the jaw , with a constant desire to clear the throat, difficult and painful deglutition , from the enlarged tonsils almost closing the fauces, when the respiration is more or less impeded ; the voice is more or less muffled, and attempts at phonation increase the pain. Darting pains along the Eustachian tubes are of frequent occur- rence, the patient complaining of earache and more or less deafness. If suppuration be imminent, the throat becomes more painful, the character of the pain throbbing, the febrile phenomena increase, with more or less depression, the symptoms seeming to be of great danger, when suddenly, after an effort at vomiting, or spontaneously, the ton- sillar abscess bursts, a quantity of pus escapes from the mouth, and prompt relief follows. Duration. The disease lasts from three to seven days, terminat- ing either by suppuration or the gradual resolution of the enlarged glands. Diagnosis. Tonsillitis can hardly be mistaken for any other af- fection if the fauces are inspected. Prognosis. In the majority of cases the result is favorable, it very rarely proving fatal, except in children, and only then by ob- structing the respiration, and, at the same time, so seriously interfer- ing with nutrition that the child’s strength fails. Treatment. The first indication in an attack of acute tonsillitis, is a prompt and efficient purgative and none is belter than calomel (ft . Hydrarg. chlor. mitis, gr. v ; sodii bicarbonatis gr. v, M., ft. chart., DISEASES OF THE PHARYNX. 247 followed in six or eight hours by a saline). I can confidently recom- mend sodii salicyhi £, gr. x-xv, every three hours until a drachm and a half to two drachms are administered. It should be well diluted. Salol, gr. x, every four hours, is often a valuable remedy. Should the febrile reaction be high, tinctura aconiti in small doses frequently repeated, either alone or alternating with sodii salicylas, rapidly reduces the temperature and the frequency of the pulse, and, by its local action, lessens the pain and swelling. If from any cause the internal use of aconitum be contraindicated, the tinctura aconiti may be diluted with glycerinum and painted over the affected parts. Cases not seen until two or three days after the onset are benefited by the following : — R. Tincturse ferri chlor., f ^ij \ Glycerini, ad f^ij. M. SiG. — Teaspoonful every two hours, undiluted. This palatable mixture, suggested by Dr. Bosworth, acts as a local astringent in passing over the inflamed tonsils, and should not be followed with water or food for an hour at least. Scarification , a long, sharp bistoury being used to make five or six cuts, affords great relief when the tonsils are much inflamed ; the ex- ternal use of ice over the site of the glands, and small pellets allowed to dissolve in the mouth, afford great relief. If the application of cold be objectionable, heat may be substituted in the form of warm compresses or poultices. In all cases we must also have recourse to such general therapeutic measures as are calculated to guide the morbid action to a favorable issue ; the bowels should be kept open and the skin and kidneys active ; the diet should be in the shape of gruels, as it is impossible for the patient to swallow any solid substance, and in cases where even gruels cause painful deglutition, thin oatmeal gruel can be used with advantage. When suppuration cannot be averted, hot applications should be applied to the angles of the jaws, hot gargles and the steam atomizer resorted to, medicated with opium, belladonna, benzoin, or cocaine, and as soon as fluctuation can be detected the abscess should be opened. Also during this stage administer quinince sulphas, gr. iij-v, every three or four hours. After the acute symptoms have subsided, 248 PRACTICE OF MEDICINE. assist the return of the glands to their normal condition by the topi- cal application of cupri sulphas (gr. xx-aquse f^j) or liquor ferri sub- sulpha tis (f^j-aquae f^j). DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. Synonyms. Catarrhal laryngitis ; “ sore throat.” Definition. An acute catarrhal inflammation of the mucous membrane of the larynx ; characterized by feverishness, diminished or suppressed voice, painful deglutition, and more or less difficulty of respiration. Causes. Atmospherical changes ; cold draughts of air, whether directly inspired or exposure of parts or all of the body to the same. Cold, wet feet; inhalation of irritating vapors, such as gas, smoke, or ammonia ; inhalation of dust. Prolonged efforts at public speaking or singing or the same efforts under difficulties. In children, from violent fits of crying. Pathological Anatomy. In mild cases there is a transient congestion (hyperaemia) of the mucous membrane over the entire, but more commonly circumscribed portions of the larynx, with more or less swelling and diminished secretion ; the mucous membrane soon returns to its normal condition, the secretion being slightly increased. Symptoms. The attack begins rather suddenly with a feeling of dryness , rawness , and tickling , referred to the larynx with the sensa- tion of the presence of a foreign body in the throat, and with hoarse- ness and a disposition to cough. Deglutition causes pain by the upward movement of the larynx and by the pressure of the food on the larynx as it passes along the gullet. Attempts at speaking are attended with more or less distress and the larynx is tender on pressure. Coughing , from the onset, of a noisy , harsh , hoarse , or toneless character and the act of coughing attended with a sensation of scratching in the larynx. The first day or two there is scanty expec- toration, but in a short time the secretion is increased, giving the DISEASES OF THE LARYNX. 249 cough a loose character. In the early stages the sputa may be slightly streaked with blood. Rarely a hemorrhage occurs from the mucous membrane of the larynx. The voice is at first decidedly hoarse , soon followed by complete aphonia. The respiration is but slightly, if at all, affected in adults. There may be more or less febrile reaction. In children the onset is with fever , white coated tongue , frequent , tense pulse , hot skin and flushed face , embarrassed respiration, the voice hoarse and whispering , with harsh , ringing , croupy cough and great restlessness. During the night the child is subject to suffocative attacks (laryngismus stridulus). Laryngoscopic appearances. These vary with the severity of the attack and the stage of the inspection. In mild cases , at an early period, the mucous membrane presents a bright red appearance. Severe cases present, in addition to the bright redness, the mucous membrane swollen, to such an extent at times as to conceal the vocal cords, they appearing only as slender threads of a reddish tint. At times the mucous membrane presents the appearance of erosions or ulcerations, due to a desquamation of the epithelium. Duration. Usually about one week ; if very severe, two or three weeks may elapse before the larynx returns to its former condition. Prognosis. Simple catarrhal laryngitis never terminates fatally. Treatment. Confinement to an apartment of uniform tempera- ture, the air kept moist by the vapor of water being disengaged in it, and particularly in the case of children. Locally , a hot pack should be kept constantly wrapped about the throat, and if its application is preceded by the temporary use of a weak mustard plaster, the relief afforded is more rapidly obtained. At the very beginning of an attack the feet should be placed in a hot mustard foot bath, and either a saline cathartic or mercurial purgative administered. Prompt action on the skin at the very onset will , frequently shorten the duration of a catarrh of the larynx. Use for this purpose in adults pulvis ipecacuanhce et opii (gr. iij) combined with potassii nitras (gr. iij) every three or four hours. If there be much febrile reaction, benefit follows the use of tinctura aconiti , u\J— ij , every half hour until five or six doses are taken, after which every hour or two, combined with tinctura opii , n\,j-v ; or diaphoresis may be produced by antimonii et potassii tartras , gr. every hour, or by a hypodermic injection of pilocarpince hydrochloras gr. y£. 21 250 PRACTICE OF MEDICINE. For children, several doses of the following powder a couple of hours apart, until the bowels are freely moved : — R . Hydrargyri chloridi mitis, gr. Pulvis ipecacuanha, gr. y& Sacc. lac., gr. ij. to be followed by the following : — R . Potassii citrat., Tinct. aconiti, ........ Tinct. opii camphorat., .... Syr. scillae, Syr. tolu, , ad . . Sio. — One teaspoonful every two hours. If a tendency to spasm of the glottis obtains, full doses of the bro- mides should be administered at once. Inhalations from the onset are not only soothing, but curative, in their actions. Either of the following are recommended : — R . Infusi humuli, Oj Vinegar, f^ss-j. M. SiG. — Inhale hot every hour. R. Tinct. benzoin comp., fg j- ij Aquae bull., Oj. M. SiG. — Inhale hourly. The local application of cocaine is of great benefit. Attacks of acute laryngitis occurring from efforts in public speaking or singing are wonderfully benefited by the use of acidum nitricum dilutum , rr\jj-v, every hour or two. The patient should abstain altogether from the use of the voice and from taking food or drink of an irritating character. 9 iv TT\> f^ij-iv f.^ij M. GEDEMATOUS LARYNGITIS. Synonym. (Edema of the glottis. Definition. An acute inflammation of the mucous membrane of the larynx and that about the glottis, with an infiltration of the areolar tissue by a serous, sero-purulent or purulent fluid ; characterized by obstructed or stridulous breathing and dysphonia or aphonia. Causes. The result of acute laryngitis ; abscess in or about the throat or tonsils; erysipelas of the face; scarlatina; smallpox; Bright’s disease ; syphilis of the larynx. Rare in children. DISEASES OF THE LARYNX. 251 Pathological Anatomy. Infiltration into the loose connective tissue of the ary-epiglottic folds, the glosso-epiglottic ligament, the base of the epiglottis, and the inter-arytenoid space. If the true vocal cords are inflamed, their color changes, and instead of appear- ing white, glistening and brilliant, they are dull, grayish-red or violet- red in patches. If the swelling be the result of purulent infiltration, the parts affected present a deeply congested color, with here and there spots of a yellowish hue. Serous infiltration, sufficient to cause fatal oedema, disappears with death, leaving but slight traces to account for the formidable symptoms. Symptoms. The onset is much the same as a simple catarrhal laryngitis with a gradually increasing hnpediment to the respiration. The patient experiences the sensation of a foreign body in the throat, and after a short time a difficulty of breathing , which ultimately threatens suffocation. The deglutition is rendered difficult owing to the swelling of the epiglottis ; the voice, at first muffled, gradually becomes weaker and weaker, until finally it is almost extinct ; the cough at first is dry and harsh, but as the infiltration increases it becomes stridulous and suppressed ; there is no expectoration except that after great effort to clear the throat, a little frothy mucus is raised. The difficulty of respiration, as the disease progresses, becomes greater and greater, and the paroxysms of impending suffocation more fre- quent. The inspiration is accompanied by a whistling sound, char- acteristic of the narrow condition of the glottis, the patient sits up in bed, his mouth open, gasping for breath, his eyes protruding, the whole body trembling with intense convulsive movements, and after a time a general cyanosis commences, the face assuming a bluish hue, all these symptoms continuing for a few moments, when slight relief occurs, to be again followed by another paroxysm, in one of which, if nature or art does not afford prompt relief, death occurs from asphyxia. A physical exammation of the parts may be made by gently pass- ing the finger into the throat, when the epiglottis may be felt very much thickened, and the ary-epiglottic folds may have attained such tumefaction as to convey to the finger an impression similar to that which is given by touching the tonsils. Laryngoscopic appearance. The mucous membrane has a bright red appearance. The epiglottis has the appearance of a semi-trans- 252 PRACTICE OF MEDICINE. parent roll-like body, or it is often merely erect and tense. It is this condition of the epiglottis which explains the pain and difficulty in deglutition. Rarely the vocal cords are infiltrated. Diagnosis. Any disease which gives rise to dyspnoea may simulate oedematous laryngitis, but the history of the case together with a laryngoscopic examination will generally furnish conclusive evidence as to the real nature of the malady. Prognosis. As a rule, unfavorable. If early and vigorous treat- ment be instituted, recovery is possible, but without it death is the inevitable result, the patient dying asphyxiated. Even when local measures have removed the obstruction to free respiration, the patient is very likely to perish subsequently from exhaustion, or blood poison- ing, or from pneumonia or other lung complication. The duration of infiltration of the larynx varies from a few hours to several days. Treatment. Prompt local treatment must be adopted in order to remove the laryngeal obstruction. Leeches placed over the sides of the larynx in mild cases may effect so much reduction in the oedema as to render the subsequent progress of the case free from danger. If the infiltration has already occurred and is slight in amount, scarification , guiding the instrument by the index finger of the oppo- site hand, may afford relief, or the hypodermic injection of pilocar- pince hydrochloras , gr. repeated, may lessen the swelling. Niemeyer recommends the persistent use of small pellets of ice swallowed or held far back in the mouth till dissolved, early in the attack. Trousseau recommends the inhalation or spray of a strong solution of acidum tannicum. Prof. DaCosta suggests the applica- tion, as near the seat of the disease as possible, of liquor ferri sub- sulphatis (Monsel’s solution), full or half strength. Mackenzie says the patient should be kept constantly under the influence of potassii bromidum. If these means fail, tracheotomy is indicated ; in those cases of sudden and rapid infiltration of the glottis or larynx occurring in Bright’s disease, erysipelas, scarlatina, or syphilis of the larynx, and especially the former and the latter, tracheotomy should be performed at once. In all cases of infiltration of the larynx stimulants should be boldly administered per rectum, if stomachic administration be impossible. If the infiltration be composed of pus, quinince sulphas., gr. v, every four hours, and stimulants are indicated. DISEASES OF THE LARYNX. 253 SPASMODIC LARYNGITIS. Synonyms. Spasmodic croup ; false croup ; catarrhal croup ; child crowing. Definition. A catarrhal inflammation of the mucous membrane of the larynx, associated with temporary spasmodic contraction of the glottis; characterized by paroxysmal coughing, difficulty of breathing and attacks of threatening suffocation. Causes. Atmospherical changes or “ taking cold ” ; excesses in eating and drinking; excitement; violent emotion, are all given as causes for simple croup. Pathological Anatomy. Congestion of the mucous membrane of the larynx, with slight swelling and deficient secretion, are the only changes that have thus far been noted. Symptoms. The attack occurs chiefly during the night , the child on retiring having either its usual health, or perhaps being a little feverish. After several hours of sleep the child is suddenly awakened by a paroxysm of suffocation , and a dry, harsh , ringing cough. After half an hour or an hour or two the breathing becomes easier, the cough less “ croupy,” the skin is covered with more or less perspiration, and the child falls asleep. The next day there is present cough of a loose character, the respiration being about normal. If no treatment be instituted, the same phenomena occur on the second night, the child being apparently well during the second day, the cough being less in amount ; phenomena of a similar character, but of much less severity, are present the third night, after which the dis- ease usually disappears. If the symptoms of the first paroxysm continue pronounced for two or three days, there is a strong probability that the inflammation may become fibrinous in character, or that true croup may develop. Diagnosis. The symptoms are so characteristic that it seems impossible for the affection to be mistaken for any other disease. Prognosis. Spasmodic or simple croup always terminates favor- ably. Treatment. During the paroxysm, the child should at once be placed in a hot bath and hot or cold compresses wrapped about the throat. These means should be preceded or followed by a mild emetic. The late Chas. D. Meigs always used aluminis , with or with- out syrupus ipecacuanhce ; Prof. Bartholow recommends hydrargyri 254 PRACTICE OF MEDICINE. subsulphas flavus (turpeth mineral), gr. i-iij ; Prof. DaCosta suggests the cautious use of apomorphince hydrnchloras , gr. y 1 ^, hypodermically. A favorite remedy for emesis, in Germany, when the jaws are not closed, and one that is highly successful, is tickling the fauces with the finger or a feather until vomiting is produced. Inhalations of chloroformum often at once relieve the spasms, but must never be employed by non -professional persons. Having by any of the above means broken up the spasm of the larynx a prompt cathartic should be administered, (R. Hydrargyri chloridi mitis, gr. ij, sodii bicarbonatis, gr. iij. M. et ft. chart. No. i), followed in six to eight hours if not sufficient results, with oleum ricini , after which: R . Tincturse aconiti, rr^ v iij Syr. ipecacuanhae, f^iss Tincturse opii camphorat., f 3 iij Liquor potassii citratis, ... ad f ^ iij. M. Sig. — O ne teaspoonful every hour or two. CROUPOUS LARYNGITIS. Synonyms. Membranous croup ; true croup. Definition. An acute inflammation of the mucous membrane of the larynx, attended with the exudation of a tough secretion — the false membrane — and the occurrence of spasm of the glottis ; charac- terized by febrile reaction, frequent ringing cough, dyspnoea, with loud inspiratory sound, and altered or extinct voice, showing a strong tendency toward death by asphyxia. Causes. A disease of childhood, most common in strong, vigor- ous, well-nourished males. Certain families present a strong hered- itary tendency. Most common during a humid winter. We cannot assent to the dictum of some authorities, that laryngeal diphtheria and croupous laryngitis are identical. Pathological Anatomy. Intense hypercemia of the mucous membrane of the larynx, associated with swelling, oedema and marked redness. There soon appears on the surface of the mucous mem- brane a grayish pellicle, rapidly coalescing and becoming thicker — the opaque , false membrane — which differs in extent, thickness and adhesiveness in different portions of the larynx. In all cases the false membrane is found on the vocal cords and inner surface of the epiglottis. The first exudation (membrane) softens by the serum DISEASES OF THE LARYNX. 255 which is exuded, and is then mechanically dislodged by acts of coughing or vomiting, but is followed by successive deposits upon the mucous membrane. When the false membrane is detached the mucous membrane of the larynx is found unaffected, so far as the loss of structure is con- cerned. Several successive crops of membrane may occur after the detachment, or it may entirely cease to form after the removal of the first exudation. On microscopical examination the false membrane is found to be composed of a fine network of fibrillae, holding in their interstices leucocytes of an albuminous or fibrinous nature. The false membrane may extend into the pharynx, but especially is it liable to extend into the trachea and bronchial tubes, and, as the inflammation extends downward, the character of the exudation changes from fibrinous to muco-purulent. Symptoms. The onset of “ true croup ” is either suddenly, by an attack of spasmodic croup, or gradually, as an acute catarrh of the larynx, rapidly increasing in severity, with a feeling of heat in the throat, huskiness of the voice, harsh cough, fever and thirst, the hoarse- ness soon becoming marked, and the cough having a metallic, “ croupy ” character, rapidly changing to a stridulous, husky sound ; every few minutes the child takes a sudden, deep stridulous inspiration, the voice becoming more and more husky. Difficulty of breathing now follows, the child is unable to lie down, or if, exhausted by the efforts at inspiration it is quiet for a moment, it soon starts up in fright, breathing more heavily, with a shrill, whistling inspiration. Soon, from the narrowing of the glottis, from the presence of the membrane, the expiration becomes difficult and noisy, and suffocation seems im- minent from the paroxysmal attacks of spasm of the glottis, the child tosses wildly about, tears at its throat, as if to remove some obstacle, the face becoming cyanosed, the alae of the nose working rapidly, the mouth wide open, the inspiratory efforts gasping, the body covered with a profuse sweat, and death seems imminent, when, suddenly, the spasm is relaxed, air enters the chest, the breathing becomes some- what easier, and the child, exhausted and partially stupefied, drops into a fitful sleep of a few moments’ duration. The suffocative attacks return at short intervals, or there occur decided remissions between them, considerable portions of the false membrane being expelled, allowing the child to fall into a refreshing sleep. 256 PRACTICE OF MEDICINE. In those cases which tend to a favorable termination, the appear- ance of improvement noted between the suffocative attacks is main- tained, the paroxysms of suffocation becoming less frequent, the expectoration of membrane more marked, the difficulty of breathing lessens, the cough loosening, the voice gradually returning, the fever, which has been more or less high during the attack, disappearing. If, instead of improvement, the case tends toward a fatal termina- tion, the suffocative attacks become more frequent, expectoration is absent, the voice and cough inaudible, although the efforts at speak- ing and coughing are visible, the difficulty of breathing continues, the respirations becoming more frequent and shallow, but without whist- ling and stridor, cyanosis deepens, the countenance has an indiffer- ent, drowsy and stupid look, the eyes dull and nearly closed, with symptoms of depression, the pulse rapid and weak, the surface covered with a cold, clammy sweat, the extremities cold, stupor and insensibility more marked, the child dying of carbonic acid poisoning or asphyxia. Duration. The duration of true croup is about one week, rarely continuing ten days. Diagnosis. (Edema of the glottis might be mistaken for croup until the period of the formation of the characteristic membrane. The chief points of distinction from the onset are, however, absence of fever, paroxysmal attacks of difficult respiration, followed by a complete return to the normal condition. (Edema of the glottis is rare in childhood. The following are the chief points of difference between croup and laryngeal diphtheria: — Croup. A local disease. Begins in trachea and extends up. Exudation never cutaneous. No pain in swallowing. No swelling of sub-maxillary and lymphatic glands. Cough always present and often re- duced to a mere whistle with pecu- liar metallic ring. Not traceable to bad drainage. Diphtheria. A constitutional disease. Begins at tonsils and extends down. Exudation often cutaneous. Often severe pain in swallowing. Swelling of submax illary and lymph- atic glands. Seldom much cough and then only hoarse. Often traceable to bad drainage. DISEASES OF THE LARYNX. 257 Croup. Seldom occurs in adults. Neither contagious nor infectious. A sthenic disease. Membrane does not extend to nares. No symptoms of septicaemia. No albuminuria. Neither attended with nor followed by paralysis. Death seldom caused by syncope. Death due to suffocation. Absence of a specific germ. Diphtheria. Often occurs in adults. Both contagious and infectious, both before and after death. An asthenic disease. Often extends to nares and many other parts. Septicaemia generally present. Albuminuria frequent. Paralysis not uncommon. Death from syncope common. Death frequently results from other causes. Presence of the Klebs-Loeffler bacillus. Prognosis. A very fatal disease. The danger increases in pro- portion to the age and feebleness of the child. Unfavorable symptoms are: Loud, stridulous, inspiratory and expi- ratory sounds, laborious and prolonged expiration, depression of the base of the thorax during inspiration, whispering voice or complete aphonia, congestion of the face and neck, stupor, weak, rapid and irregular pulse, cold extremities, and a cold, clammy perspiration. Favorable symptoms are : Expectoration of false membrane, de- crease of the stridulous respiration, voice changing from whispering to hoarseness, looseness of the cough, moderation of the fever, and an improvement in the general condition. Treatment. The indications for treatment are to detach and remove the false membrane , to prevent its reformation , to prevent the attacks of spasm of the glottis, and to maintain the strength . To detach and remove the membrane emetics are of the highest utility, the favorite of this class being the one first used in this disease by Dr. Fordyce Barker, consisting of hydrargyri subsulphas flavus (turpeth mineral), gr. ij, for a child of two years of age, repeat- ing the dose as often as rendered necessary by the obstructed breathing ; but the unnecessary administration of emetics should be avoided, as the strength of the patient must be maintained. To prevent the formation of the membranous exudation a num- ber of remedies have been recommended and highly lauded, but 258 PRACTICE OF MEDICINE hydrargyrum is the only one that has stood the test of experience ; it may be used as hydrargyri chloridum corrosivum, gr. 4*3— 2V > every two or three hours, or in the following formula: — R . Hydrargyri chloridi mitis, gr. Sodii bicarbonatis, gr. ij Pulvis ipecacuanhse, gr. Jg-i. M. Sig. — One powder every two hours. Prof. DaCosta has suggested either of the following combinations : R . Antimonii sulphurati, gr. % Pulv. ipecacuanhse et opii, gr. y^. M. Sig. — In powder every two hours. Or— R . Hydrargyri chloridi mitis, gr. Pulvis ipecacuanhse et opii, gr. M. Sig. — In powder every two hours. Antimonii et potassii tartras, a remedy that some years ago was popular in large doses, is again brought forward in doses of gr. ^o~£u- Quinince sulphas , gr. v, every three hours until six doses have been taken, if given before the exudation has formed, it is claimed will prevent its formation. It can be used by suppository. To prevent the paroxysms of spasm, small doses of opium in the form of pulvis ipecacuanha et opii (Dover’s powder), or full doses of the bromides , preference being given to ammonii bromidum , as suggested by Prof. Bartholow, on account of its being “ eliminated by the bronchial and faucial mucous membrane, thus acting locally.” To maintain the strength of the patient, alcoholic stimulants in full doses, nutritious but easily digested aliment , quinina in tonic doses, and ammonii carbonas, are particularly indicated. Locally , the use of all caustic or irritating applications to the fauces or larynx is emphatically contraindicated. The inhalation of the vapor of slaked, freshly burned lime is one of the most ready and efficient means for assisting in the detachment of the false membrane. The application of cold or hot compresses , according to the feelings of the patient, around the throat, have a strong tendency to prevent the recurrence of the spasms. After the formation of the membrane, great relief follows the use of the vapor inhalations and of oxygen gas, which with stimulants and liquid nour- ishment may safely carry the patient through the disease. Cases DISEASES OF THE LARYNX. 259 in which the membrane presents a tendency to slowly loosen itself, if the patient’s strength does not contraindicate it, are greatly benefited by the application of sinapis , or even small flying-blisters , to the larynx. Inhalations of oxygen have seemed useful in several cases, as has the internal use of hydrogen dioxidum. Niemeyer advises in cases showing carbonic acid poisoning from obstruction of respiration due to accumulation of membrane, the pouring from a moderate height of a few gallons of cold water over the head, nape and back of the child ; the shock produced always causes it to revive for a while, and to cough vigorously, thus expecto- rating large quantities of the membrane. Relief from the obstructed respiration is obtained and the affection often beneficially influenced by the use of “ O’Dwyer’s tubes.” If the exudation still continues, regardless of the means employed, the propriety of tracheotomy must be determined. LARYNGISMUS STRIDULUS. Synonyms. Spasm of the glottis ; pseudo-croup ; Millar’s asthma ; thymic asthma ; “ Kopp’s asthma tetany. Definition. A spasm of the muscles of the larynx innervated by the inferior or recurrent laryngeal nerves ; characterized by a sudden development of dyspnoea and the appearance of deficient oxygena- tion of the blood. MacKenzie describes it as “ a form of convulsion occurring in ill-nourished infants, characterized by spasmodic action of the abduc- tors of the vocal cords, and in severe cases by spasm of the diaphragm and intercostal muscles.” Causes. Most common in children, the result of teething, laryn- gitis, indigestion, scrofula, or other cachexiae. Attacks in adults are not uncommon. It is often hereditary. Pathological Anatomy. Death the result of spasm of the glottis is such a very rare occurrence that the changes in the larynx are illy understood. The mechanism consists in an irritation of the superior laryngeal nerve — the afferent nerve — whose function is to supply the mucous lining of the larynx with sensibility, whence is reflected through the inferior laryngeal nerve — the efferent nerve — the motor influence resulting in the spasm of the laryngeal muscles. 260 PRACTICE OF MEDICINE. Symptoms. The spasm of the laryngeal muscles is of sudden onset, and usually after nightfall. The child may have been in perfect health, to all appearances, on retiring, or it may have shown symptoms of catarrh of the upper air passages, or been suffering from gastro-intestinal or dental irritation. The child awakes suddenly, coughing m. a metallic, resonant tone — the croupy cough — and with great dyspnoea , with loud , crowing , stridulous inspirations , the result of narrowing of the larynx from spasm, with wheezy , stridulous expirations. The entrance of air is so greatly obstructed that all the accessory muscles of respiration are called into use ; the lips and finger nails become blue, the surface cold, the countenance anxious, and the inferior portion of the chest is drawn in, instead of being expanded, during inspiration. General convulsions occur at times, during a par- oxysm, also strabismus , and involuntary discharge of the faeces and the urine. The paroxysm continues from half an hour to an hour or more, to return after a few hours’ sleep, or during the following night ; the cough, during the day, having the croupy character. Diagnosis. The non-febrile and distinctly intermittent nature of the affection differentiates it from croup, and its own distinctive char- acters, from all other diseases. The view is gaining that it i£ a variety of tetany. Prognosis. Favorable. Death from suffocation during the par- oxysm may occur in very young children, but it is certainly a very rare termination. Treatment. For the paroxysm , the inhalation of a few drops of chloroformum is the most prompt method, due care being exercised, as complete anaesthesia is unnecessary. Success is reported from the prompt inhalation of amyl nitris , also from n itro-glycerinum , in small, but frequently repeated doses. The following combination is a prompt antispasmodic : — R • Potassii bromidi, 3 ij Chloral, gr. xxxij Syr. aurantii cort., f%j Aquae menth., f^j. SlG. — One teaspoonful every half hour. After the paroxysm has been suspended by the above combination, the tendency to a recurrence of the attacks is prevented by the steady DISEASES OF THE LARYNX. 261 and continued use of potassii bromidum, in moderate doses. Emetics are often useful in suspending an attack, especially if it be due to indigestion. Mackenzie advises the use of musk during the attack if the child can swallow ; and if not, then as soon as the child can take it, and continued at intervals for a day or two. His formula is as follows : — Moschi, Sacch. alb., . . . gr. ij Pulv. acacise, Syr. aurantii flor., Aquam, aa . . . . .f 3 j. M Sig. — A dose. The high price of musk prohibits its general use. Locally , the hot , alternating with the cold pack , should be constantly applied to the throat. The air of the room should be moistened by the vapor of hot water constantly disengaged in it. After the attack has passed off, the general condition of the child requires attention ; for this purpose it is well to administer a dose of hydrargyri chloridum mite , to be followed by a dose of oleum ricini or magnesii carbonas. The diet must be regulated, all farina- ceous articles being absolutely forbidden. TUBERCULOUS LARYNGITIS. Synonyms. Laryngeal phthisis ; throat consumption. Definition. An inflammation, tending to ulceration, of the tissues of the larynx, of tuberculous origin ; characterized by pain on degluti- tion, cough, weakness of voice, and progressive emaciation, asso- ciated with hectic fever. Causes. An infection of the larynx with the bacillus tuberculo- sis , either from the inspired air or by the sputum. A depressed state of the system is essential for the action of the bacilli. Pathological Anatomy. It is well to remember that all chronic inflammations of the larynx associated with pulmonary tuberculosis are not tubercular. Begins with redness of the mucous membrane, showing scattered tubercles. The tubercles show a strong tendency to cluster, then soften, leaving shallow irregular ulcers. The ulcers are covered with 262 PRACTICE OF MEDICINE. a grayish exudate. The mucous tissue round about the ulcers is thickened. The ulcers may and generally do, erode the true vocal cords, often entirely destroying them. The ulcers slowly extend in all directions, destroying the tissues attacked. The epiglottis may be entirely destroyed. Symptoms. Usually develops secondary to pulmonary symp- toms ; rarely it may occur as a primary disease to be followed with tuberculosis of the lungs. The first symptom is a change in the voice — huskiness ; this associated with symptoms of ill health is al- ways a warning to the physician. The husky voice may proceed until itjs but a painful whisper. Cough of an irritating painful char- acter associated with slight expectoration. Painful and difficult deglutition (dysphagia) is a very constant and distressing symptom. There is the remitting fever so characteristic of tuberculosis, with night sweats, loss of appetite, loss of flesh, and insomnia. Laryngoscopic examination reveals the characteristic broad, shal- low, irregular, grayish ulcers, with the thickened surrounding mucous membrane. The vocal cords show infiltration and thickening or ulceration. Diagnosis. To discriminate from non-tubercular laryngitis, ex- amine the sputum and if the specific bacilli are found the diagnosis is conclusive. Prognosis. Unfavorable. Treatment. Remember that tubercular laryngitis is not always preceded by pulmonary phthisis, but in a fair proportion of cases is a primary disease. Much can be done to make the patient comfort- able. The application of twenty, forty, or even sixty, per centum solution of acidum lacticum is a very successful remedy, Cocaince hydrochloras applied directly to the ulcers gives relief to the pain and dysphagia. Local applications of hydrogen dioxidum , argenti nitras , and menthol are of value. Curetting the ulcers and applying iodoformum in emulsion or with morphince sulphas has been prac- ticed with benefit. The general condition must be treated, the diet liquid and of a most nourishing character. DISEASES OF THE BRONCHIAL TUBES. 263 DISEASES OF THE BRONCHIAL TUBES. ACUTE BRONCHITIS. Synonyms. Bronchial catarrh ; acute bronchial catarrh ; “ cold on the chest.” Definition. An acute catarrhal inflammation of the bronchial tubes of the larger, middle and third size ; characterized by fever, sub-sternal pain, a feeling of thoracic constriction, oppression in breathing, and at first scanty, followed by more or less profuse ex- pectoration. Causes. Most frequent in childhood, especially during the period of dentition, when there exists a strong tendency to catarrh of the mucous membranes in general and of the bronchi in particular. In old age the predisposition again returns. Inhalations of irritants such as dust, smoke and air too hot or too cold. More common in cli- mates characterized by considerable moisture of the atmosphere combined with a low temperature, and especially where there are sudden and marked variations. Pathological Anatomy. HyPercemia of the mucous mem- brane of the bronchial tubes, manifested by a diffused redness , swell- ing \ oedema and diminished secretion ; this is followed by an increased secretion and overgrowth and desquamation of the epithelial cells, together with a copious generation of young cells, the expectoration then becoming of a yellowish color (muco-purulent). As a result of the hyperaemia, rupture of the capillaries of the mucous membrane frequently occurs, when the slight expectoration of the first stage is streaked with blood. In cases of bronchitis following the exanthemata, or in scrofulous patients, the bronchial glands participate in the inflammation, they becoming hyperaemic, swollen and filled with secretion, and not unfrequently the glandular elements undergo a hyperplasia, and finally the “ cheesy ” degeneration. Symptoms. The invasion is usually characterized by the occur- rence of either nasal or laryngeal catarrh, or both, the patient feeling chilly , followed by flushes of heat , the limbs , joints , and even the body , are affected with pain of an aching, contused character, and 264 PRACTICE OF MEDICINE. with a sense of fatigue and want of energy ; there may be a furred tongue, anorexia and constipation. In nervous, irritable persons, and in children, there may be slight delirium, and often in very young children, especially during the period of dentition, convulsions may usher in an attack. After a day or two of these initiatory symptoms, those characteristic of bronchial catarrh develop. Pain is experienced beneath the sternum , especially towards its upper part, of a raw , burning or tearing character, aggravated by a deep inspiration or by coughing ; the pain also radiates towards the sides, following the course of the primary bronchial tubes. Tenderness over the sternum is often experienced. Cough from the onset, at first in paroxysms of a hard, dry char- acter, changing as the disease progresses, and becoming looser, fol- lowed by free expectoration. The expectoration at first is small in quantity, almost transparent, frothy, and having a salty taste, often streaked with blood. As the disease progresses, it becomes more abundant, of a yellowish or a greenish-yellow color, and of a tena- cious consistency. There are present slight fever, hot, dry skin, frequent pulse, loss of appetite, moderate thirst and constipation. A feeling of languor and weariness, and often considerable depres- sion, quite out of proportion to the febrile state, are not infrequent. Percussion. Normal, except in those rare cases in which the bronchial glands are involved, when irregular spots of dullness can be developed. Auscultation. First Stage : The bronchial membrane being swollen and dry, the respiratory murmur is harsh or vesiculo-bronchial in character, associated with diffused sonorous and sibilant rales. Second Stage : The secretion from the bronchial mucous membrane being increased, the respiratory murmur is less harsh in character, but is associated with large and small moist or bubbling rales. Diagnosis. The points of resemblance and difference between acute bronchitis and other diseases of the chest will be pointed out when those affections are described. The association of bronchitis with other diseases must not be forgotten. Prognosis. Acute bronchitis of the larger tubes usually termi- nates in complete resolution within two weeks. In children and in the aged, the course is more protracted, and the symptoms more DISEASES OF THE BRONCHIAL TUBES. 265 severe, but recovery is the rule. Very aged and feeble persons may succumb, but it is rare. Treatment. During the invasion , quinince sulphas , gr. x, com- bined with morphince suiph., gr. l /e, will usually prevent or abort an attack of acute bronchitis. In the first stage, in adults, when the mucous membrane is swollen and dry, either of the following prescriptions will give prompt relief : — R. Antimonii et potassii tart., gr. ij Liquor, ammonii acetatis, fj^iv Spts. setheris nitrosi, f^j (Tinct. aconiti, if indicated), f 7 , ss Syr. simplicis, ad fj|vj. M. Sig. — Two teaspoonfuls every two or three hours. Or — R. Vini ipecacuanhse, f^j Liq. potassi citrat., f^fiij Liq. ammonii acetat., f Jiij. M. Sig. — Tablespoonful every two or three hours. If the cough of the dry stage be severe, or if looseness of the bowels follow the use of either of the above combinations, tinctura opii camphorata may be added with advantage. For young children, the above in proportionately reduced doses, or the following : — R. Pulv. ipecac, et opii, gr. v Pulv. scillae, gr. xij Hydrargyri chlor. mitis, gr. iv Sacch. lact gr. x. M. Ft. chart. No. xij. SlG. — One every two hours. Locally : Hot mustard foot bath, and sinapis or terebinthina stupes over the chest, the patient being confined to an apartment in which the air is moistened by the vapor of hot water. Second Stage : The secretion of the bronchial mucous membrane being copious, stimulating expectorants are indicated such as ammon ii chloridum, scilla , ammonii carbonas, ox potassii carbonas. A reliable combination is : — R . Ammonii chloridi, 3 iss Scillae aceti f 3 ij Misturse glycyrrhizse comp., . . . ad . . . f^iij. M. Sig. — Dessertspoonful every three hours. 22 266 PRACTICE OF MEDICINE. Attacks showing a tendency to linger are greatly benefited by the following : — R . Terpini hydrat., gr. xlviij Glycerini, q. s. sol. Syr. lactucarii, ad f£ ij. M. Sig. — T easpoonful every three hours. During the attack, attention must be given to the secretions and to the diet of the patient. CAPILLARY BRONCHITIS. Synonyms. Broncho-pneumonia (?) ; “suffocative catarrh.” Definition. An acute catarrhal inflammation of the mucous membrane of the terminal bronchial tubes, or bronchioles ; charac- terized by fever, impeded and increased respiration, impeded circula- tion, slight cough and scanty expectoration, and symptoms of non- aeration of the blood. Causes. Most common in childhood, following exposure to cold or sudden changes of temperature ; occurs also in the aged, and also complicates measles, whooping cough, or any of the debilitating dis- eases. There may be a special germ. Pathological Anatomy. Hyfiercemia , redness and swelling of the lining membrane of the bronchioles, with the exudation of a tough, tenacious secretion. In those cases in which the air cells are not involved in the inflam- matory changes, the air passes, during the act of inspiration, through the secretion blocking the smaller tubes, but is prevented from escaping during the act of expiration, the secretion in the smaller tubes acting as a valve ; the result is distention of numerous vesicles, producing a circumscribed or diffused functional emphysema. If the secretion produces complete closure of any of the smaller tubes, the air previously drawn into the vesicles will be absorbed, causing collapse (atelectasis). If the inflammation extends to the alveoli of the lungs, it produces the condition known as broncho-pneumonia , a frequent complication in children and feeble elderly people ; it is most commonly lobular in character, whence the term “ lobular pneumonia." Symptoms. Usually preceded by more or less ordinary bron- chitis, followed by rise of temperature , 102-103° F., increased pulse, DISEASES OF THE BRONCHIAL TUBES. 267 difficult and increased respiration , numbering forty, fifty or sixty in the minute, with paroxysms in which the dyspnoea is markedly aggra- vated, when cyanosis rapidly develops ; the tongue is coated, bowels costive, appetite impaired, and there is restlessness and headache. The circulation through the lungs is impeded by the dyspnoea, the pulse becomes feeble and flickering, and there results general con- gestion of the venous system, the countenance becomes livid t the lips and nails blue , the surface cold , and often covered with a clammy perspiration , the mind dull , and in children stupor and convulsions rapidly supervene, the result of the non-aeration of the blood. The cough is slight, but of a suppressed character, the expectoration scanty , the patient usually swallowing the sputum. When cyanosis occurs, the cough may almost entirely cease ; expectoration also ceases, death soon following, from apnoea and depression. Percussion. Normal , except over those portions of the lungs (a bilateral disease) which are in a condition of collapse , when dullness rapidly develops and may as rapidly disappear, changing to other portions of the lung — shifting dullness. Auscultation. First stage , a feeble, but high pitched, respira- tory murmur, becomes less distinct and harsh as the disease progresses. The rales in the first stage are fine whistling, sibilant, changing in the second stage to fine bubbling or subcrepitant rales. The respira- tory murmur is absent over the dull area. Diagnosis. There is one point characteristic of capillary bron- chitis — it is a general or bilateral disease. Capillary bronchitis is often mistaken for true catarrhal pneumonia, the points of distinction between which will be pointed out when discussing the latter affection. Prognosis. In children, on account of their inability to expec- torate, which tends to rapid collapse of the lungs, and in the aged, the prognosis is most grave. In the strong and vigorous, recovery follows prompt and energetic treatment. Treatment. From the very onset of the attack the treatment must be supporting, with the addition of such measures as seem to possess a controlling influence over the catarrhal process. The patient must be confined to bed, well covered and the tem- perature of the room varying between 75 0 and 8o°, the air moistened with steam. In the first stage dry cups , mild sinapis applications or terebinthina stupes should be applied to the chest, after which it should be covered with an oil-silk jacket or a cotton jacket. 268 PRACTICE OF MEDICINE. The diet must be of the most nutritious character, the great aim being to sustain the powers of life until the catarrhal process has passed through its different stages, hence milk, eggs, chicken, mutton and beef broths, with the free use of stimulants, commenced early and in amounts large enough to overcome the signs of depression which are present early in the attack. Unless the fever be high, 102° F., and continues, it need not be treated, but if it continues at that point or higher, a few doses of aceianilidum , gr. ij-iv, in brandy or whiskey may be used. If the urine be scanty, use spiritus aetheris nitrosi. If suffocation be imminent, the cautious use of emetics may be indi- cated ; the most suitable are ipecacuanha and hydrargyri subsulphas fiavus. Do not repeat emesis so often as to produce exhaustion. For the catarrhal process two remedies are of inestimable value; one is potassii iodidum , gr. j-ij, for a child every hour or two, and gr. v-x for an adult, its action being to liquefy the tenacious secretion and modify the inflammatory action ; the other is ammonii carbonas , gr. j-ij, for a child every hour or two, and gr. v-x for an adult. The two combined, but for the taste, make a valuable prescription : — R . Potassii iodidi, gr. ij-v Ammonii carbonat., gr. iij-v Syr. glycyrrh., f 3 ss Syr. tolu, f 3 ss. M. Sig.— Every two or three hours. Excellent results have been obtained in the children’s wards of the Philadelphia Hospital from the careful inhalation of oxygen. Prof. H. C. Wood, in desperate cases of suffocative catarrh,- advises the alternate use of the hot and cold douche conjointly with stimulating remedies. FIBRINOUS BRONCHITIS. Synonyms. Membranous bronchitis ; plastic bronchitis ; diph- theritic bronchitis ; croupous bronchitis. Definition. An acute inflammation of the mucous membrane of the larger and middle-sized bronchial tubes, attended with an exudation, forming a membraniform layer, which is closely adherent to the mucous surface ; characterized by febrile reaction, cough, diffi- cult breathing, scanty expectoration, followed by the expulsion of the false membrane in the form of patches or casts. DISEASES OF THE BRONCHIAL TUBES. 269 Causes. Unknown ; associated with membranous laryngitis from extension downward ; asthma ; emphysema ; phthisis ; frequently result of exposure to cold or damp, in those of feeble health or in tuberculous (?) constitutions. Pathological Anatomy. Hypercemia of the mucous mem- brane of the bronchial tubes, associated with swelling and cedema , during which the surface is covered with a whitish or grayish-white, firmly adherent, membranous deposit , cemented together by a coagu- lable exudation, and prolonged by rootlets from its under surface into the bronchial follicles, which sooner or later is loosened and detached by suppurative process and is expectorated after a violent fit of coughing or vomiting. When expectorated, the false membrane , as it has been termed, has either the form of patches or is thrown off en- tire from the bronchial tube, and may be found to consist of casts representing more or less of the bronchial subdivisions, and present- ing an appearance not unlike “ boiled macaroni.” On microscopical examination , the detached membrane presents fibrillse which characterize fibrin or lymph in other situations, and if placed in a solution of acetic acid, it becomes greatly swollen, while ordinary mucus contracts and becomes more dense if added to the same solution. Symptoms. There are no symptoms or signs by means of which this variety of bronchitis can be distinguished from ordinary catarrhal bronchitis, prior to the expectoration of the false membrane. Expectoration is preceded and accompanied by violent paroxysms of coughing , and after more or less of the membrane has been raised a muco-purulent expectoration, streaked with blood, may be present for several days. Duration. The inflammation may be either acute t sub-acute , or chronic , expectoration of patches or strips of the membrane being repeated at intervals of days, weeks, months, or even years. Prognosis. In adults, favorable, if not associated with other grave affections, such as phthisis, pneumonia, or emphysema. In young children it may cause obstruction to the respiration, and not unfrequently proves fatal. Treatment. As the character of the inflammation can seldom be determined until the membrane or portions of it have been expec- torated, the treatment is at first the same as in cases of ordinary acute bronchitis. 'I 270 PRACTICE OF MEDICINE. As soon, however, as the character of the inflammation can be de- termined, active emesis is the most effective means of removing the obstruction caused by the false membrane, the best agents of this class being either hydrargyri subsulphas Jlavus , ipecacuanha , or zinci sulphas , to be repeated as indicated. Inhalations of solutions of ammonii chloridum , pix liquida , euca- lyptol , or simply the vapor of water, and especially of lime water , are highly serviceable. To prevent the formation of membrane, Prof. Bartholow strongly urges the use of ammonii iodidum and ammonii carbonas combined, in small doses, every hour or two. In a case treated by the author after this method, excellent results followed. Potassii iodidum is also useful. In cases showing a tendency to become chronic, good results will follow the application of flying blisters to the chest and the internal administration of arsenicum and some preparation of pix liquida. CHRONIC BRONCHITIS. Synonyms. Chronic bronchial catarrh ; winter cough ; second- ary bronchitis. In the aged, senile bronchitis. Definition. A chronic inflammation of the mucous membrane of the larger and middle-sized bronchial tubes ; characterized by cough and more or less profuse expectoration, plus, in many cases, the symptoms of emphyseina of the lungs, which is a frequent complica- tion. Chronic bronchitis may be either primary or secondary. Causes. Primary , exposure to wet or cold, or the repeated inha- lation of dust, vapors, or other irritants. Secondary , gout, rheuma- tism, syphilis, cardiac, renal, or pulmonary diseases, or alcoholism.- 2 ^ Varieties. I. Mucous catarrh , associatecfwith moderate expecto- ration. II. Bronchorrhcea, profuse expectoration. III. Dry catarrh, scanty expectoration. IV. Fetid bronchitis. V. Bronchiectasis, or dilatation of the bronchi. Pathological Anatomy. The mucous membrane of the bron- chial tube is discolored, being of a more or less dull red, often of a deeply venous hue, mingled with a grayish or brownish color. These changes may be either in patches or extensively diffused. The ves- sels of the mucous membrane are dilated. The mucous membrane DISEASES OF THE BRONCHIAL TUBES. 271 is thickened, resulting in the reduction in the calibre of the tube and a roughening of its internal surface. The submucous tissue becomes infiltrated, contracted, and indurated. The elastic and muscular coats of the tubes become hyper- trophied, lose their elasticity, and the cartilages become the seat of calcareous deposits. As the result of the loss of elasticity and muscular tone of the tubes they become irregularly dilated, “ bronchial dilatation .” The dilata- tions may be uniform in character, resembling somewhat the fingers of a glove, or they may be sacculated or globular , forming actual cavities in the bronchial structure. In the mucous variety the secretion consists of young cells and mucous corpuscles, having a yellowish color ; in the dry variety , the “ catarrhe sec” of Lsennec, or “dry bronchial irritation,” the secre- tion is scanty, tough, semi-transparent, and occurs in defined globular masses ; in bronchorrhcea , which is usually associated with bronchial dilatation, the secretion is abundant, greenish-yellow in color, and often fetid. The majority of cases of chronic bronchitis have associated chronic gastric catarrh. Symptoms. The most characteristic symptoms of chronic bron- chitis are the cough and expectoration . The cough occurs at all hours, but is more severe at night and early in the morning. The cough is not always present. It disappears almost altogether for a time, and then reappears, continuing thus .for years. Coated tongue, disagree- able taste, loss of appetite, impaired digestion, with eructations of gases, are present in many cases, due to the chronic gastric catarrh. Unless associated with other diseases, the general health suffers but little, if at all, constitutional symptoms being present only during acute exacerbations. Mucous catarrh , or, from its occurring most commonly during the winter months, “ winter cough,” is characterized by paroxysms of cough, more or less violent, followed by the expectoration of a yellow- ish mucus. Dry catarrh is characterized by a harsh cough, a feeling of soreness or rawness under the sternum, and the expectoration of small globu- lar masses ; this variety occurs with emphysema, gout, rheumatism, and asthma. Bronchorrhcea, which is associated with bronchial dilatation, and 272 PRACTICE OF MEDICINE. most common in the elderly, is characterized by paroxysms of severe coughing, followed by the copious expectoration of greenish-yellow, often fetid, mucus ; the amount expectorated often amounts to four or five pints in the twenty-four hours. Fetid bronchitis , often associated with bronchial' dilatation, has an excessively fetid odor of the breath and expectoration. The decom- position of the secretion may cause gangrene of the bronchial mucous membrane, and even of the lung structure. Percussion. Unless complicated with other affections, normal; if bronchial dilatation occur, there are diffused spots of the tympanitic or amphoric percussion sound, the physical condition being a circum- scribed cavity containing air and communicating with a bronchial tube. Auscultation. Harsh or vesiculo -bronchial respiration, asso- ciated with more or less profuse, sonorous, sibilant, and large and small bubbling rales ; in bronchial dilatation , in addition to the harsh respiration, is found broncho-cavernous breathing , with large and small gurgling rales. If emphysema complicate chronic bronchitis, the physical signs are somewhat modified, and will be pointed out when discussing that affection. Diagnosis. Make it a rule to always examine the urine in case of cough, and particularly in case of chronic bronchitis, as this latter disease is one of the most common complications of Bright’s disease. Incipient phthisis is often confounded with chronic bronchitis. The diagnosis is not always easy. The physical signs of chronic bron- chitis are more or less diffused through both lungs, and not, as a rule, associated with failure of the general health ; while in phthisis, from the onset, there is failing health, with a concentration of the physical signs to the apices. The discovery of the bacillus determines the diagnosis. Prognosis. If unassociated with disease of the lungs, heart or kidneys, chronic bronchitis is never dangerous to life, although the symptoms are present, more or less, continually, and aggravated upon the least exposure. Rarely is a cure recorded. If associated with phthisis, emphysema, disease of the heart or of the kidneys, the prognosis is governed by those affections. In turn, it is to be remembered that chronic bronchial catarrh may lead to emphysema of the lungs, asthma, or to cardiac dilatation. DISEASES OF THE BRONCHIAL TUBES. 273 Treatment. Cases of chronic bronchitis, of whatever variety, should observe the following general rules : i. Attention to the gen- eral health. 2 . The clothing; wearing flannel the year round, or, what is better, silk under-clothing, taking care that the opposite ex- treme of too much clothing be not practiced. The medical treatment is guided by the cause , character , and severity of the disease. If secondary to other affections, in the majority of cases remedies directed to the bronchial mucous membrane are contra-indicated . If the result of the rheumatic or gouty diathesis, in addition to the remedies directed to the disease itself, should be combined change to a warm climate, if possible, and a more or less protracted course oM l^cftassii iodidum , or lithii citras, or a residence at one of the alkaline springs. If associated with alcoholism or chronic gastric catarrh, the follow- ing is a valuable combination: [R. Ammonii chloridi, 3iij ; tinct. nucis vomicae, f^ij ; infus. gentianae comp, ad., q. s., f^iv. M. et Sig. Dessertspoonful in water before meals.] For mucous catarrh, with acute exacerbations : — R . Ammonii chloridi, Glycerini, Codeinae sulph., Vini picis liq., Syr. prun. virg., SlG. — Tablespoonful every three or four hours. • 3ij . f J iss • gr. % . fgiss. M. Dry catarrh is greatly benefited by — R . Potassii iodidi, Elix. cinchonae, Vini picis liq., ad . . . Three times a day. ■ gr. v-x . T1\XX M. Or— R . Morphinae sulphatis Ammonii chloridi, Glycerini, Vini picis liq., . . . . ad . . . gr. j 7 * iij W fjvj. M. Sig. — D essertspoonful every four hours. For bronchorrhoea , copaiba , gtt. v-x every three hours, or spls. terebinthince , gtt. v, every four hours, or acidum carbolic um, gr. ss. 23 274 PRACTICE OF MEDICINE. four times a day, or terebenum , rr\,v> or terpini hydras , gr. iij, in pill or capsule three or four times daily, and at the same time using ol. morrhuce and arsenicum , or, if these means fail, inhalations of alumen , acidum gallicum , or acidum tannicum. If the expectoration be fetid , “fetid bronchitis,” Prof. Da Costa recommends the internal use of acidum carbolicum , gtt. j every third hour, with inhalations of acidum carbolicum (gr. v, aqua , fSjj) two or three times a day. If, after prolonged treatment, cure or great amelioration does not occur, then a change of climate is called for. Usually a warm climate is the most suitable, but sometimes a dry, bracing climate does better. Locally , irritation with tinclura iodi, or flying blisters, repeated once or twice weekly, is of advantage. ASTHMA. Synonyms. Bronchial asthma ; spasmodic asthma. Definition. A paroxysmal, spasmodic contraction of the mus- cular layer surrounding the smaller bronchial tubes, and perhaps associated with a tonic spasm of the diaphragm and more or less bronchial catarrh ; characterized by spasmodic attacks of distress- ing expiratory dyspnoea, continuing several hours, days, or weeks. Causes. A true neurosis of the respiratory apparatus. The result of peripheral or local disturbances in the nervous system. Chiefly hereditary. A family history of asthma, chorea, or epilepsy. It sometimes is of reflex origin, starting from diseases of the nasal mucous membrane, explaining the attacks due to the inhalation of various substances, as ipecac, turpentine, or irritating dusts. Climate. Some attacks may be due to a peculiar and characteristic disease of the bronchial mucous membrane — an “asthmatic bronchiolitis.” Asthma is more common in men than in women ; in childhood and young adults than those of middle life and old age ; in the well-to-do and wealthy than in the poor. Symptoms. The onset of a first attack of asthma is abrupt and sudden , the succeeding attacks being preceded by prodromes , which the individual rapidly learns to appreciate, to wit : coryza, bronchial irritation , thoracic constriction , marked dyspepsia , or the scanty pas- sage of pale, limpid urine, the “hysterical urine.” DISEASES OF THE BRONCHIAL TUBES. 275 The paroxysm begins, in the majority of instances, in the early morning hours or during the afternoon , with a feeling of anguish and constriction in the chest and an intense desire for air. The breathing is accompanied with loud wheezing , the face is flushed , at . times even cyanosed , and bathed in perspiration, the eyes staring, the eyeballs protrude, and the muscles of the neck become prominent as they aid in the effort for air. The dyspnoea soon becomes so severe that the inspiration is but a gasp, the lips are pallid, cyanosis deepens, and the patient feels as if death were impending. Owing to the tonic contraction of the smaller bronchi the air drawn into the alveoli escapes imperfectly, resulting in the expiratory dyspnoea, the emphy- sematous chest, and the lowered position of the diaphragm. After some minutes or hours the respiration becomes easier, the air in the lungs changes, the cyanosis disappears, and gradually the paroxysm ceases, the patient feeling exhausted and the chest fatigued. During the paroxysm there is a short, dry cough, becoming looser as the attack subsides. The sputum of asthma is unique. Early in the paroxysm it is raised with difficulty, and is in the form of rounded gelatinous masses (“perles” of Laennec). If these pellets be care- fully examined they will be found to consist of moulds of the smaller bronchi, and, under the microscope, show Leyden’s crystals and Curschmann's spirals. After a day or two the sputum becomes muco-purulent, and the spirals and crystals are absent. The duration of an attack varies from one to many hours, or even days. Instead of single paroxysms, slight remissions may occur at intervals of one, two, or three hours, to be followed by exacerbations lasting from four to six hours, continuing for a week or two, prevent- ing the patient lying down or taking food. Percussion. During the paroxysm, hyper-resonance over both lungs, termed vesiculo-tympanitic , the “band-box tone” of Bam- berger, due to the retained air in the alveoli. Auscultation. First stage feeble or absent vesicular murmur, with prolonged expiration associated with loud wheezing, whistling, sibilant and sonorous rales ; as the paroxysm subsides, the vesicular breathing becomes more apparent and is associated with moist rales. Prognosis. In itself asthma is not fatal to life ; but if the parox- ysms are frequently repeated there results either emphysema , cardiac dilatation with subsequent dropsy, or even cerebral hemorrhage. 276 PRACTICE OF MEDICINE. Attacks of asthma frequently occur as a complication in emphy- sema, chronic bronchitis, valvular diseases of the heart, or Bright’s disease. Treatment. There are two indications, to wit : the relief of the paroxysm, and to prevent its recurrence. To relieve the paroxysm, no medication is so effective as the hypo- dermic injection of morphince sulphas , gr. ]/e to combined with atropince sulphas , gr. y^. Chloral , gr. x, repeated, where no heart complication exists, is often effective ; drinking strong, hot, black coffee is often serviceable. Caffeince citrat ., gr. iij hypodermically, is often valuable. Page strongly recommends sodii nitris. (R. Pulv. sodii nitritis, gr. xxiv ; aquae f^j. M. Sig. Teaspoonful at once, re- peated in half hour once or twice if necessary.) Chloroformum , cether , or amyl nitris inhalations have been recommended ; also nauseant expectorants , lobelia , ipecac , scilla, or ext. grindelice fid . gtt. xx, repeated every two or three hours. Dr. Pepper speaks highly of the following for the paroxysm : — R. Ammonii bromidi, 5jij Bij Ammonii chloridi., Tinct. lobelise, . . Spts. aetheris comp., Syr. acaciae q. s., . SiG. — Dessertspoonful in water every hour or two. M. Another remedy that at times is successful is syrupus acidi hy- driodici , tAxv-xxx, every three or four hours. Inhalations of the fumes of belladonna , stramonium , nitre-paper , chloro forum, ethyl bromidum, or the use of various pastilles or cigar- ettes, are of immense benefit in many cases. A twenty per cent, solution of menthol as an inhalation has been successful in some cases. Inhalations of oxygen have given excellent results in a num- ber of cases. Paroxysms of asthma are said to be relieved by rectal injections of sulphureted hydrogen after the manner suggested by Bergeon, of Paris. If an attack is impending it may often be aborted by drinking freely of strong black coffee, or by full doses of the bromides. To prevent the recurrence of the paroxysms, the general health must be cared for, and any suspected causes corrected. In all cases DISEASES OF THE BRONCHIAL TUBES. 277 a thorough examination of the nasal mucous membrane should be made and any diseased condition found removed. If chronic bron- chitis be present it should be persistently treated. Two remedies long continued frequently give good results, potassii iodidum in doses ranging from five to fifteen grains, and arsenicum in small doses. Additional aids are systematic exercise short of fatigue, bathing, regulated diet, and, when possible, a change of climate. HAY ASTHMA. Synonyms. Hay fever ; autumnal catarrh ; rose fever ; rose cold. Definition. An acute, specific, catarrhal inflammation of the upper air passages, extending to the bronchial tubes, associated with spasmodic contraction of their muscular layer occurring at a par- ticular season of the year ; characterized by coryza, croupy or wheezy cough, and difficult respiration. Causes. A predisposition, often hereditary, of the nervous system seems to be a strong etiological factor. Persons in whom the predisposition exists have attacks excited by the inhalation of the pollen of grasses, rye, corn, wheat, or roses. Pathological Anatomy. Hypertrophy of the inferior and middle turbinated bones ; a peculiar hyperaesthesia of the mucous membrane covering the inferior and middle turbinated bones, the middle meatus, the floor of the nose and that part of the septum below the limit of the olfactory membrane are frequently associated with the disease. Symptoms. Begins by irritation of the eyes, severe coryza , with sneezing , a clear, watery, nasal discharge , and congested Eustachian tubes, rapidly extending to the larynx and bronchial tubes , when occur a hoarse , croupy, and wheezing cough , and difficulty of breath- ing . The dyspnoea occurs in paroxysms, which are often as severe as those occurring during a regular asthmatic attack. There is mild de- pression of the nervous system in nearly all attacks. The paroxysms remit after a few days, returning again for several days or weeks, and again remitting, the bronchial catarrh persisting for a month or more. The constitutional symptoms are mild, unless complications occur. 278 PRACTICE OF MEDICINE. Complications. The affection may extend to the finer bronchial tubes (capillary bronchitis) ; congestion or oedema of the lungs and pneumonia are not infrequent. Duration. Unless a change of climate is resorted to, paroxysms of hay fever continue more or less severe for six, eight, or ten weeks of the year, each year the paroxysms growing more severe. Prognosis. The affection never proves fatal in itself, but one or more of the following sequelce may result, to wit : asthma, chronic bronchitis, or loss of the special sense of hearing or of smelling. Treatment. No specific, unless the hypertrophy of the turbin- ated bones be a constant phenomenon, when their removal by the galvano-cautery would at once produce a cure. An attack of hay asthma is often prevented by a change of climate during the season of the year when the attacks are most common, to wit : the early autumn. Any of the following locations may be selected — White Mountains, Catskills, Adirondacks, Rocky Moun- tains, or a sea voyage. Attacks are sometimes aborted and always relieved by the applica- tion to the nares of tablets of cocaince hydrochloras, gr. l /e, or a four or six per centum solution, every few hours. On several occasions pulvis ipecacuanha et opii t gr. v, ter die, has aborted a suspected attack, as has the following pill : — R. Atropinoe sulph., gr. ^ Morphinse sulph., gr. \ Strychninse sulph., gr. ^ Quininse muriat., gr. x Sodii arseniat., g r - M. et ft. pil. no. xxx. StG. — One every hour until dryness, then two or three hours apart. Success has followed the use of quinina , gr. v three times a day, beginning one month before the expected paroxysm. Bartholow “ has seen several cases benefited greatly ” by a solution of quinina applied to the nares, as suggested by Helmholtz, “ but to achieve success the application must be thorough and timely.” The following applied thoroughly to the nostrils has a high repute : — R. Menthol,. Cerat. simpl., jfij Ol. amygd. dulcis, fg iss Zinci. oxidi purae, 3 j. Acid, carbolici, £ss. M. Sig. — A pply every few hours. DISEASES OF THE BRONCHIAL TUBES. 279 A long course of arsenicum in minute doses sometimes removes the susceptibility to the disease. WHOOPING COUGH. Synonyms. Whooping cough ; pertussis. Definition. A convulsive, paroxysmal cough, consisting of a number of forcible expirations, followed by a series of deep, loud, sonorous inspirations (the whoop), repeated several times during each paroxysm, and associated with catarrh of the bronchial tubes. Causes. Chiefly a disease of childhood, one attack generally removing the susceptibility; contagious; the result of an unknown poison, perhaps atmospheric, affecting the nervous system. Pathology. The changes, if any, occurring in the nervous sys- tem are unknown. It is said that “ irritation of the internal branch of the superior laryngeal nerve produces relaxation of the diaphragm, spasm of the glottis, and a convulsive expiration, the series of phe- nomena present in a paroxysm of asthma.” Hvpercemia oi the mucous membrane of the nares, pharynx, larynx, and bronchial tubes, with diminished secretion , followed by an in- creased secretion of a transparent mucus, afterward becoming puru- lent, the mucous membrane pale and anaemic. Symptoms. Divided into three stages, to wit : catarrhal , spas- modic, and terminal. Catarrhal stage originates as an ordinary naso-larvngo-bronchial catarrh, with a loose cough. Duration one or two weeks. Spasmodic stage : The cough becomes paroxysmal, consisting of a succession of short, rapid, expiratory efforts, the face becoming red, the eyes swollen and protruding, the body bending forward, and when these expiratory efforts have exhausted the breath, they are followed by a deep, loud, crowing inspiration — the whoop : each paroxysm being composed of three such spells, the last one followed by the expectoration of a small amount of tough, viscid mucus. The attacks of cough may be so severe as. to cause vomiting, and if the vomiting occur shortly after food has been taken, the nutrition of the patient will suffer. Profuse epistaxis is not infrequent. Duration about four weeks. Terminal stage : The paroxysms recur at longer intervals, are of shorter duration and less intensity, the catarrhal symptoms being 280 PRACTICE OF MEDICINE. more marked, the expectoration freer. Duration one or two weeks, often followed by the “ cough of habit.” Complications. Congestion of the lungs, capillary bronchitis, pneumonia and emphysema, or, rarely - , convulsions, hydrocephalus, or apoplexy. Diagnosis. During the catarrhal stage whooping cough cannot be distinguished from a common cold, but on the advent of the characteristic whoop the diagnosis is determined. Prognosis. Depends upon the age and strength of the patient, the severity of the paroxysms, and the presence or absence of com- plications. Ordinary cases, favorable. Moderately severe attacks during infancy are followed by cerebral symptoms, while attacks occurring in adults are followed by chest symptoms. Treatment. No specific. A self-limited disease. Remedies will not cure the disease, but often lessen the duration of or modify the severity of the symptoms. Prof. Da Costa prefers quinince sulphas , in full doses, or chloral in good-sized doses, often advantageously combined with the bromides , and the use of a spray of sodii bromidum (gr. xx, and aquae, f^j), to which may be added extraclum belladonnce fluidum , n^ij. A remedy of great utility is ammonii bromidum. Excellent results have followed the use of acetanilidum , gr. j-iij, every three or four hours, according to the age, or phenacetin , gr. j-ij, four times daily. Either of these drugs seem to act better if given with an expectorant. Terpini hydras gr. i-ij-v, is sometimes valuable. Belladonna may be added to any of the remedies named, with advantage. The use of cocaine lozenges modifies the paroxysms in some cases. Dr. Keating reports “remarkable improvement in four cases of whooping cough by the use, four or six times daily, of a spray com- posed of” — R . Ammonii bromid., Potassibromid., aa gj Tinct. belladonna, f gj Glycerini, f%) Aquae rosae q. s. ad f Jiv. The diet of the patient must be regulated, the clothing to be warm but not too heavy, and the patient kept in the open air as long as pos- sible. DISEASES OF THE BRONCHIAL TUBES. 281 EMPHYSEMA. Synonym. Vesicular emphysema. Definition. Dilatation of, or increase in the size and capacity of the air vesicles, characterized by enlargement or distention of the lungs, difficulty of breathing, especially on exertion, and associated sooner or later with dilatation of the heart. Causes. The predisposing cause of emphysema is a hereditary nutritive derangement of the lung structure, often associated with a rigid enlargement of the thorax. The exciting cause is the result either of a too forcible and long continued inspiration — the theory of inspiration — or the excessive mechanical distention of the vesicular walls by forced expiration — the theory of expiration. But for either of these theories to be operative the lung structure must be congenitally weak, for if violent respiratory efforts alone were the essential factor , the disease would be much more frequent. What is known as vicarious emphysema is a distention of the air cells of the healthy portion of the lung, some other part being the seat of consolidation. I?iterlobular emphysema is the presence of air in the spaces between the lobules of the lungs underneath the pulmonary pleura. Pathological Anatomy. The situation of vesicular emphy- sema is, in the majority of cases, the superior portions of the chest, and is more marked on the left side than on the right. An emphysematous lung feels remarkably soft to the touch, and upon cutting, a dull, creaking sound is barely perceptible. It is of a pale red color, the vesicular walls are thinner and slighter, the vesicles are greatly enlarged, sometimes to the size of a pea or bean, and have an irregular shape, and traversing most of these large cysts (dilated vesicles) a few delicate bands, the remains of the lacerated inter- alveolar septa, are visible. With the destruction of the septa many of the capillaries are destroyed, whereby the emphysematous tissue is remarkably bloodless and dry. In consequence of the destruction of so many of the capillaries, the obstruction to the pulmonary circulation becomes so great that the pulmonary artery and right cavities of the heart are greatly dis- tended ; finally, the muscular tissue of the heart undergoes granular, followed by fatty degeneration. The distention of the veins results 282 PRACTICE OF MEDICINE. in a general venous stasis, to wit: nutmeg liver, congested kidneys, and gastro-intestinal catarrh. Symptoms. The disease is often not suspected until it is well developed. The chief symptoms of vesicular emphysema are diffi- culty of breathing (dyspnoea), greatly aggravated on exertion, more or less cough , the result of an attending bronchitis , and the various symptoms resulting from dilatation of the heart , particularly cyanosis without marked distress. The discomfort of the patient is often in- creased by paroxysms of asthma. Inspection. The shoulders are rounded, the intercostal spaces widened, the vertical diameter elongated, with circumscribed promi- nences between the clavicles and nipples, often increased by the act of coughing — the peculiar “barrel-shaped” chest, characteristic of this disease. The character of the respiratory movements is marked, there being but slight movement observed on forcible respiration, the chest hav- ing the constant appearance of a full inspiration. Palpation. The vocal fremitus is diminished, and the cardiac impulse depressed and nearer to the sternum. Percussion. The resonance is increased (hyper-resonant) over all the emphysematous portions, and if the whole lung be involved, extends to the seventh or eighth rib anteriorly and to the twelfth rib posteriorly. The hepatic dullness may not begin until the inferior margin of the ribs is reached ; the cardiac dullness is lessened, on account of the emphysematous lung nearly covering the heart. Auscultation. The vesicular murmur is weakened , and in pro- nounced cases almost absent. If bronchitis be present, the inspira- tory sound may be rough or sibilant in character, but its duration is always shortened. Expiration is always prolonged, and if bronchitis be present, may be associated with more or less pronounced moist or bubbling rales. The first sound of the heart is lessened in intensity and duration, the second sound being sharply accentuated. Diagnosis. Bronchitis is distinguished from emphysema by the absence of dyspnoea, hyper-resonance of the chest, changes in its shape, size and movements, and the disturbance of the circula- tion. Spasmodic asthma by the paroxysmal character of the affection, emphysema being a permanent malady, with attacks of asthma. DISEASES OF THE BRONCHIAL TUBES. 283 Cardiac diseases due to other causes than emphysema do not have the characteristic physical signs of that affection. Prognosis. Vesicular emphysema is essentially a chronic dis- ease. In itself it rarely proves fatal, but if aggravated, from any cause, or if associated with frequent or prolonged asthmatic paroxysms the cardiac changes are hastened, general dropsy supervenes, death occurring from exhaustion, or, more commonly, as the result of inter- current attacks of pneumonia. Treatment. It being impossible to restore the altered lung struc- ture, the indications for treatment are to relieve the symptoms and to endeavor to prevent its further progress. For the relief of the asthmatic paroxysms, morphince sulphas com- bined with atropince sulphas may be used hypodermically, or ext. qtiebracho fid., f^ss-j, every hour until relief, or large doses of potas- sii bromidum , frequently repeated, or inhalations of oxygen. For attacks of bronchial catarrh use: — R . Ammonii chloridi, g ij Spts. frumenti, fgiv Glycerini, f%j Syr. prun. virg., ad f^iv. M. SlG. — Half-tablespoonful every few hours, well diluted. To prevent the progress of the affection , remove the bronchial catarrh, relieve the difficulty of breathing, and strengthen the cardiac action, no one combination seems comparable with the following : — R . Potassii iodidi, gr. v Strychnin® sulph., § r * to Liq. potassii arsenit., lTLv Aq. laurocerasi, fgj. M. SlG. — Four times a day, well diluted. But of all means hitherto proposed for the relief of emphysema, nothing has approached the inhalation of compressed air , by means of the apparatus of Waldenberg. For attacks of cyanosis a free venesection often saves life. The dropsy arising from failure of the heart to compensate for the circulatory derangement in the lungs, may be relieved for a time by the use of digitalis , or, if this fails, scilla, combined with hydragogue cathartics. 284 PRACTICE OF MEDICINE. HEMOPTYSIS. Synonyms. Bronchial hemorrhage ; broncho-pulmonary hemor- rhage ; bronchorrhagia. Definition. The expectoration of pure or unmixed blood, usually of a bright red color, following the act of coughing. Causes. In the majority of cases, the result of tubercular deposi- tion in the walls of the minute bronchial arteries ; excessive cardiac action ; bronchial congestion ; excessive bodily exertion, straining, lifting or running; a symptom of hcemophilia (“ bleeder’s disease ”). Pathological Anatomy. Haemoptysis rarely causes death in itself, so that few opportunities for observing post-mortem appear- ances are obtained, and when they do occur, the location of the hemorrhage is seldom found. The air passages are more or less filled with clotted blood, the mucous membrane is swollen, and of a dark-red color, rarely, pale and bloodless. The air-cells contain blood clots, or are distended with air, the bronchi being filled with clots, preventing its escape. Unless the clots are rapidly removed by expectoration or absorption, a secondary inflammation develops around about them. Symptoms. “Spitting of blood” occurs suddenly; rarely, it is preceded by epistaxis, cardiac palpitation, and some difficulty of breathing. It begins with a sensation of warmth under the sternum, tickling in the throat, a sweetish taste in the mouth, which, upon attempting to remove by the act of coughing, a warm , saltish, bright red, frothy liquid gushes from the mouth and nose. The quantity of blood raised varies from an ounce to a pint. The appearance of the blood depresses the individual, he becoming pale, tremulous, often faint- ing. The attack may subside within half an hour to several hours, re- turning for several days, in the meantime the expectoration being either bloody or streaked with blood. A slight febrile reaction, with chest pains, supervenes upon the hemorrhage, the result of the inflammation at the site of the bleeding, which soon subsides, except where blood clots develop a secondary pneumonia, which may undergo the cheesy metamorphosis. Auscultation. Coarse, bubbling rales are heard in circumscribed portions of the chest. DISEASES OF THE BRONCHIAL TUBES. 285 Diagnosis. From epis taxis, or hemorrhage from the posterior nares, it is distinguished by the absence of air bubbles and an inspec- tion of the fauces and the nasal cavities. Hcematemesis , of hemorrhage from the stomach, differs from haemoptysis in the blood being vomited instead of expectorated, of a dark color , clotted, mixed with the acid contents of the stomach, fol- lowed with black, tar-like stools, and the absence of rales in the chest. Exceptions to the above occur when the blood from the lungs is first swallowed and afterwards raised by vomiting, or when the hemor- rhage in the stomach is caused by the erosion of a large artery, the result of ulcer of the stomach ; in these cases, however, the raising of blood is preceded by epigastric pain and the blood is not frothy. Prognosis. Haemoptysis in itself rarely terminates fatally, al- though causing much depression ; the patient rapidly recovers, unless secondary pneumonia results. In nine cases out of ten it is the diag- nostic sign of phthisis. Treatment. Perfect rest in bed, the head and shoulders elevated, and perfect quiet, the diet to be bland, the drinks' cool, the patient slowly swallowing small particles of ice. An ice bag over the chest, if it does not cause chilliness, is valuable. Common salt, slowly dis- solved in the mouth, is a popular remedy, and if of no real benefit, serves to occupy the attention of the patient and friends until medical advice is obtained. The hypodermic injection of atropince sulphas , gr. ^y, will usually at once control a hemorrhage. It may be repeated pro re nata. The hypodermic injection of ergotin, gr. x-xxx, or the internal administration of extractum ergotce fluidum , 3ss-j are valuable, or : — R. Acid, gallic., gr. xv Acid, sulph. dil., TT^x Aquae cinnamomi f^iv. M. SlG. — Repeated every fifteen or twenty minutes. Or tinctura matico, f^j, or extractum hamamelis fid., rr^xx-f^j, alumen, gr. xx, or acidum gallicum, gr. v-x, frequently repeated. If the hemorrhage causes great nervous excitement, or depression, 7norphina, either hypodermically or internally, to quiet the patient, is indicated. Inhalations , by means of the steam atomizer, of either Mouse l' s 286 PRACTICE OF MEDICINE. solution or tinctura ferri chlotidum , are recommended when the above means fail. Prof. Da Costa recommends, for frequent small hemorrhages, con- tinuing day after day, cvpri sulphas , gr. ( T ^), ext. opii, (gr. ff), p. r. n. DISEASES OF THE LUNGS. CONGESTION OF THE LUNGS. Synonyms. Pulmonary engorgement ; hypostatic congestion. Definition. An increase in, or abnormal fullness of, the capil- laries of the air cells ; active congestion when the result of an accel- erated circulation ; passive congestion when caused by an impeded outflow from the capillaries. Causes. Active. Increased cardiac action ; over-exertion; alco- holic excesses ; mental excitement ; inhalation of cold or hot air. Passive. Obstruction to the return circulation. Dilated heart ; valvular diseases ; low fevers (hypostatic congestion) ; Bright’s dis- eases. Pathology. The hyperaemic lung has a bloated, dark-red appearance ; its vessels are distended to the uttermost, the tissues succulent and relaxed, blood flowing freely over the cut surface; a bloody, frothy liquid is present in the bronchi, and the alveolar walls are so much swollen that the condensed lung shows scarcely any indication of its cellular structure, resembling the tissue of the spleen ( spienification ). Symptoms. Active. Rapidly developing thoracic distress and difficulty of breathing , flushed face, strong, full pulse, throbbing caro- tids, cardiac palpitation and congested eyes, with a short, dry cough, followed by scanty, frothy expectoration, slightly streaked with blood. Passive. Developed slowly, with difficulty of breathing, blueness of the surface, almost continuous hacking cough, followed by scanty, blood-streaked expectoration. Percussion. The resonance of the lungs slightly diminished, the quality of the sound being somewhat tympanitic. DISEASES OF THE LUNGS. 287 Auscultation. The vesicular murmur is diminished and accom- panied with sub- crepitant rales. Duration. Active. Usually from three to five days, terminating either by resolution, hemorrhage, or, rarely, pneumonia. The onset may be so severe and overwhelming that death rapidly supervenes. Passive. Developed slowly, and subject to great variations, de- pending upon the cause. Diagnosis. Active congestion of the lungs cannot be distinguished from the stage of engorgement of a true pneumonia. Prognosis. An acute congestion of the lungs may prove fatal within a few hours, but under prompt treatment it generally terminates favorably. The passive form is controlled entirely by the cause. Treatment. Active. In the strong and vigorous wet cups to the chest, or, if the symptoms are pronounced, a general venesection. Internally , tinctura aconiti , gtt. j-ij every half hour or hour, as indi- cated, with free catharsis with saline purgatives. Passive. Dry or wet cups over the chest, hydragogue cathartics , and the internal administration of digitalis ; if much depression of the vital powers, stimulants such as spiritus vini gallici and spiritus ammonia aromaticus , are indicated. CEDEMA OF THE LUNGS. Synonym. Pulmonary oedema. Definition. An exudation of serum into the pulmonary interstitial tissue and the alveoli of the lungs ; characterized by dyspnoea, cough, and a frothy, blood-streaked expectoration. Causes. Pulmonary oedema is the result of stasis, occurring when the outflow of venous blood in the lung meets an obstacle that cannot be overcome by the right ventricle, as in cardiac diseases, in which the left ventricle fails. Bright’s disease ; alcoholic excesses, causing cardiac depression. Sequelae to other lung inflammations. Pathological Anatomy. The lung tissue is swollen, and does not collapse when the chest is open. The elasticity of the tissue has disappeared, and it pits upon pressure. If following congestion of the lungs, the color is red ; if a symptom of a general dropsy, its color is pale. On cutting into the oedematous spots an enormous quantity of 288 PRACTICE OF MEDICINE. albuminous fluid, sometimes clear, at other times of a red color, mixed more or less with blood, flows over the cut surface. The liquid is filled with bubbles, is frothy, from being copiously mixed with air, providing the air cells have not been entirely filled with serum, thereby exclud- ing the air. Symptoms. The pre-eminent symptom is dyspnoea, the breath- ing being hurried , labored and rattling , all the accessory muscles of respiration being called into action. The sense of oppression and anxiety is extreme. There is also a constant , harassing , short cough , and the expectoration is a blood-streaked , frothy mucus. The action of the heart may be tumultuous or feeble. The face is at first flushed, but as the left ventricle fails or if the effusion into the air cells be sufficient to prevent the entrance of air, symptoms of cyanosis rapidly supervene, the pulse becoming feeble , the surface cold , the breathing shallow and hurried, the cough suppressed, stupor replacing the rest- lessness, soon deepening into coma. Percussion. If no other lung disease, the percussion note is but slightly, if at all, impaired. Auscultation. The vesicular murmur is lost by the diffused sub- crepitant and bubbling rales. Diagnosis. Acute Pneumonia in the earlier stages is the only condition likely to be confounded with oedema of the lungs, but as the two diseases progress, the picture of pulmonary oedema is so characteristic that it cannot be mistaken. Prognosis. Grave, and particularly if occurring in pneumonia, cardiac, or Bright’s disease. In the majority of instances it is a ter- minal symptom coming on in all forms of acute and chronic diseases. Treatment. As a rule, remedies are useless. The indication is to hold up the left heart, and this is best done with hypodermic injec- tions of strychnince sulphas , gr. repeated every half hour, caffeince citras, gr. iij-v, sparteince sulphas, gr. j-ij, every hour or two, or digi- talinum, gr. repeated every hour or two. One or more of these drugs may be advantageously combined. Atropince sulphas, gr. and ergota in some form are valuable remedies. Occasionally relief follows a free venesection or the application of wet cups. Al- coholic stimulants are often invaluble. The above means may be aided by counter-irritation to the chest, hot mustard foot-baths , active saline purgatives, and diuretics . DISEASES OF THE LUNGS. 289 CROUPOUS PNEUMONIA. Synonyms. Lobar pneumonia; pneumonitis; fibrinous pneu- monia; pleuro-pneumonia ; lung fever; winter fever. Definition. An acute, infectious, croupous inflammation, involv- ing the vesicular structure of the lungs, rendering the alveoli imper- vious to air ; characterized by a severe chill, headache, fever, thoracic pain, dyspnoea, cough, rusty sputum, and great prostration. Causes. Croupous pneumonia is an infective disease caused by the diplococcus pneumonia of Fraenkel, “ which has its seat of elec- tion in, and produces its chief effects on the lung.” All ages liable. Males more frequently affected than females. One attack predisposes to another. Debilitating causes render individuals more susceptible. Alcoholism is one of the most frequent predispos- ing factors. It is most frequent in winter, at times occurring epidemi- cally , the result of atmospheric conditions ; exposure to draughts and cold. Gout, rheumatism, diabetes, and Bright’s disease. Pathological Anatomy. The most frequent seat of croupous pneumonia is the lower right lobe ; the next most frequent seat is the lower left lobe ; the next, the upper right lobe, although in children and the aged this lobe is affected equally as often as the right lower lobe. The changes are, I. Hypercemia (engorgement) ; II. Exudation (red hepatization) ; III. Resolution (gray hepatization) ; or it may un- dergo purulent transformation or the development of abscesses (yellow hepatization). I. Stage of hypercemia or engorgement consists in the vessels of the alveoli being distended to their utmost, encroaching upon the cavity of the air vesicle ; the lung has a reddish-browm color, is heavier, sinking somewhat lower in water than a normal lung, and having a slight exudation upon the vesicular surface. The same changes are perceived in the adjacent bronchioles. II. Stage of exudation, consists in the exudation of a viscid, fibrin- ous fluid, admixed with white and red corpuscles and blood, which rapidly coagulate, firmly enclosing the corpuscles and completely filling the alveoli. When the exudation and coagulation are com- pleted, the lung is red, sinks at once when placed in water, and its elasticity is destroyed. When cut into, the color, density and granu- lar appearance so closely resemble the cut surface of a section of the liver, that Laennec termed it red hepatization . 24 290 PRACTICE OF MEDICINE. A thin section shows under the microscope, as a rule, the lancet- shaped diplococcus of Fraenkel^ as well as staphylococci and strep- tococci. III. Resolution , or gray hepatization, follows the above condition in the majority of cases, the coagulated albuminous exudation under- going liquefaction and absorption, the cellular element undergoing a fatty degeneration, the greater part being absorbed, the remainder expelled during acts of expectoration, the alveoli returning to their normal condition, both as to capacity, function and elasticity. If resolution be retarded and portions of the coagulated exudation undergo purulent transformation , changing from a yellowish to a greenish-yellow color (yellow hepatization), pus cells are rapidly formed, the part becoming a granular, fatty mass. The portions of the lung not undergoing this purulent transformation retain the red- dish color with intermixed yellowish patches, the lung structure proper remaining intact. The purulent contents may be ejected in part, the remainder undergoing fatty degeneration and finally absorption. Abscess of the lung may result from the lung structure becoming involved in the purulent disintegration. Abscesses may be solitary or in great numbers, which by disintegration of intervening structure form one 'or more large abcesses ; these abscesses either terminate fatally, or open into the pleural cavity, causing empyema and exhaus- tion, or open into the bronchi and are expectorated, or an interstitial pneumonia is developed and the abscess encapsulated in a firm cica- tricial tissue. Gangrene of the lungs may result from blocking up of the bronchial or pulmonary arteries by coagula, during any stage of the disease. The uninflamed portions of the lungs are hyperaemic and their functional activity is increased. Death sometimes results from a general oedema of the unaffected lung, such cases being often erroneously termed “ double pneu- monia.” If inflammation of the pleura be associated with a pneumonia, the so-called pleuro-pneumonia, the changes in the pulmonary pleura are characteristic. “An uneven, thin, downy-looking layer of plastic exudation covers its surface. This plastic layer may conceal the liver-brown color of the pneumonic lung. As the third stage is reached, the opposing surfaces of the pleura may become agglutinated. The pleuritic changes follow very closely those which occur within DISEASES OF THE LUNGS. 291 the lung. The cells in the pleuritic exudation are mainly pus. The pleuritic membrane is opaque, congested and ecchymotic. It may become so thick as to give a dull note on percussion, after resolution is reached.” Duration of Stages : stage of congestion , from one to three days ; stage of exudation , from three to seven days ; stage of resolution , from one to three weeks. In severe cases or in the very young, the aged or the depressed, the stage of red hepatization may be fully developed within forty-eight hours. Symptoms. Begins with a severe and usually protracted chill (in children often convulsions, adults vomiting), followed by a rapid rise of temperature , 103-104° F., a strong, full, but rapid pulse, soon showing evidences of embarrassed cardiac action from obstructed respiratory circulation, either a dull or sharp pain near the nipple, aggravated by pressure, breathing or coughing, shortness of breath, the inspiration short and superficial, the expiration accompanied with a moan or grunt, the number of respirations increasing to 40, 50 or more per minute, causing interrupted speech, the ratio between pulse and respiration may be 1 to 2 or more ; cough, first short, ringing and harsh, soon followed by a scanty, frothy, mucus, soon becoming semi- transparent, viscid and tenacious, about the second day changing to the familiar rusty sputum, becoming more copious and of a yellow color as the disease advances ; rarely cases occur with bloody or blood-streaked sputum during the continuance of the fever. There are present headache, sleeplessness, rarely delirium, save in drunkards, epistaxis, flushed coimtenance, and especially over the malar bones is a well-defined mahogany blush ; gastric disturbances and scanty, high-colored urine, with diminished chlorides, and often albuminuria. From the very onset of the disease the prostration is of the most serious character. The above symptoms continue more or less marked until either the fifth, seventh, ninth , ox eleventh day, when a crisis occurs, and within twenty-four hours convalescence is established, recovery rapidly fol- lowing. Typhoid pneumonia is a term applied to those cases which are accompanied by signs of extreme prostration, delirium, tremor, very high temperature and profuse and prolonged exudation. They may also terminate by a crisis. 292 PRACTICE OF MEDICINE. Bilious pneumonia occurs in cases accompanied by congestion of the liver , the result of venous stasis from pulmonary obstruction or from an accompanying acute catarrhal jaundice. In malarial dis- tricts pneumonia and malaria are often associated, when jaundice more or less pronounced occurs. Such cases are termed malarial or intermittent pneumonia. Alcoholic , or pneumonia of the intemperate, has one very char- acteristic symptom, to wit, early delirium. In pneumonia generally the mind is clear when all the conditions are unfavorable. Pneumonia of the intemperate may begin with symptoms closely resembling an attack of delirium tremens , cough, expectoration,, and pain being very slight, or even absent. If purulent infiltration follow the stage of red hepatization, instead of the crisis, symptoms of exhaustion occur, with profuse purulent ex- pectoration, high temperature, severe sweats, the tongue brown and dry, sordes collecting on the teeth, low delirium, feeble pulse, rapid, rattling breathing, the recovery slow and convalescence tedious. Pneumonia in the aged or the insane may be latent, coming on without chill or pain and with only a slight fever; the cough and expectoration are slight, physical sighs ill-defined and changeable, and the constitutional symptoms out of all proportion to the amount of lung involved. Inspection. First stage , deficient movement of the affected side, due to the pain. Second Stage, the healthy side, rises normally, the affected side lag- . ging behind. If both lower lobes are impervious to air, the diaphragm cannot descend and the epigastrium does not project during inspira- tion, the breathing being conducted by the upper part of the chest (superior costal respiration). Palpation. First stage, the vocal fremitus more distinct than normal. Second stage, the vocal fremitus is markedly exaggerated except in those rare instances of occlusion of the bronchi by secretion. The cardiac impulse is felt in the normal position. Percussion. First stage , the percussion note is slightly unpaired, indeed, at times having a hollow or tympanitic quality. Second stage, dullness over the affected parts, with an increased sense of resistance. Auscultation. First stage , over affected part, feeble vesicular DISEASES OF THE LUNGS. 293 murmur , associated with the true vesicular or crepitant (crackling) rale, most distinct during inspiration. Second stage , harsh, high-pitched bronchial respiration , at times resembling a to and fro metallic sound, except in those rare instances in which the bronchi are more or less filled with secretion. Bronchophony , or distinctly transmitted voice, at times pectoriloquy, or distinct transmission of articulated sounds, is present. Third stage, breathing changing from bronchial to vesiculo bron- chial, the crepitant (crepitatio redux) rale returning, and if resolution proceed, the breath sounds are associated with large and small moist and bubbling rales. “ The morbid phenomena, physical signs and symptoms of the malady correspond usually in this matter.” — (Da Costa). I. Stage of 1 engorgement Crepitant rale; slight per- Cough; beginning dyspnoea and beginning exuda- cussion dullness. and rapidly developed fever tion. heat. II. Stage of solidification Percussion dullness ; bron- Rusty-colored sputum ; dysp- of lung-tissue (red*- chial respiration; bron- noea ; cough ; high fever with hepatization). chophony. marked evening exaceiba- tions and morning remis- sions. III. Stage of softenipg (gray The same physical signs as Chills; prostration, etc.; hepatization). in the second stage unless purulent or brownish spu- large abscesses have turn; generally high tempera- formed. ture. Terminations. Asthenic gases recoverwithin two weeks. When purulent infiltration supervenes, the disease pursues a tedious course of several weeks’ duration, with a low exhaustive fever. If death occur during the first or second stages it is usually the result of a collateral oedema of the uninflamed lung, ox cardiac failure and impaired nerve force. If abscesses occur, there are exhausting sweats, frequent cough, with a large amount of yellowish-gray, at times blood-streaked, expectoration. Gangrene of the lungs is a rare termination ; it is associated with symptoms of collapse, the expectoration of a blackish, fetid sputum,, and the physical signs of a pulmonary cavity. Diagnosis. (Edema of the lungs may be confounded with the first stage of pneumonia, but the subsequent history, its presence on 294 PRACTICE OF MEDICINE. both sides, and the waterish expectoration and absence of chill and pain and the physical signs of pneumonia soon determine the diagnosis. Pleurisy is oftener confounded with pneumonia than any other dis- ease, the points of distinction between which will be pointed out when discussing that affection. Complications. Acute pleuritis is a frequent complication of croupous pneumonia, occurring as often as from ten to twenty-five per cent, of cases. The more acute localized pain, the greater em- barrassment of respiration, and the usual physical signs of effusion are the evidences of a pleuro-pneumonia. Capillary bronchitis is a rare but dangerous complication. Pericarditis , rheumatism and gout are rare complications. Prognosis. Depends upon the extent of the inflammation, the dangerous features of croupous pneumonia being cardiac failure, the result of a myocarditis or of embarrassed respiratory circulation, and the rapid tissue waste associated with extreme fever, 105°, resulting in impaired nerve force ; double pneumonia has a very grave prognosis, but it is not nearly so frequent as was at one time supposed. The co- existence of pleuritis adds to the gravity of the prognosis, although not as fatal as generally supposed. Pneumonia of drunkards almost in- variably terminates fatally. Typhoid pneumonia, pneumonia of the aged and in the insane, the so-called bilious pneumonia, purulent infil- tration, abscesses of the lungs and gangrene, all give a grave prognosis. Treatment. If pneumonia be regarded as a constitutional malady with a local lesion, then the consolidated lung no more calls for treatment than does the intestinal ulcer of typhoid fever, but the general condition of the patient is to govern in the management of the case and not the local changes going on in the thorax. A simple pneumonia attacking persons previously in good health requires no more active treatment than any of the so-called self-limited diseases, provided only that the extent of the disease be moderate, and there be no complication. The much-discussed question of venesection is now a settled prob- lem in the affection ; if we bleed it is “ not because of pneumonia , but in spite of p 7 ieumoniaP Called to a case in the first stage of the disease, or early in the second stage, who has been vigorous and otherwise healthy, with a high temperature, 105° or more, with fre- quent pulse, one hundred and twenty, beats or more, or a slow, full DISEASES OF THE LUNGS. 295 pulse showing cardiac oppression, flushed surface and marked dysp- noea, a copious bleeding is indicated, and the same may be said when symptoms of collateral oedema threaten ; this is bleeding for symp- toms and not for the disease per se. There is no remedy which can in any way exert a favorable influ- ence upon the pneumonic process. Many cases recover without any, and many cases in spite of treatment. At the onset if venesection is not indicated, relief of the pain may follow the use of dry cups. If the tongue be coated and the gastro- intestinal canal deranged, a calomel purge is indicated. (R. Hydrar- gyri chloridi mitis, gr. ij, sodii bicarb., gr. iv, pulv. ipecac, gr. j. M. et ft. chart. No. iv. Sig. — O ne every two hours, followed in four hours after last powder by mild saline.) Action on the skin and kidneys by refrigerant mixtures, or small doses of Dover’s powder and potassii nitras is valuable. The admin- istration of such arterial sedatives as aconitum, veratrum viride and antimony is questionable. An exception may be made in the case of pneumonia of children, where the use of small, frequently repeated doses of tmctura aconiti in the early stage is useful. Poultices are of slight value, but the use of home-made mustard plasters, weakened with flour, is useful in all stages. If the heart be weak from the onset, either of the following are valuable : digitalis , caffeina , sftartein , or strychnina. Quinines sulphas , gr. ij-v, every three or four hours is always of use. Second Stage. It is at this period of a severe attack of acute pneu- monia that two prominent indications for treatment arise, — heart- insufficiency and high temperature. To sustain the heart is one of the most important indications in the treatment of an acute pneumonia, for experience shows that cardiac failure is responsible for a large number of deaths in this affection. Strychnines sulphas , gr. repeated every few hours by mouth or the hypodermic method, or caffeines citras. gr. ij-v, every four hours, or tinctura strophanthus , gtt. v-x, every three hours, are valuable car- diac tonics in pneumonia. Alcoholic stimulants judiciously employed are most efficient means for preventing or overcoming the cardiac failure. The amount can only be determined by a careful study of each case, as a few ounces in the twenty-four hours may answer in one case, while another case may require eight or ten ounces. It is well to 296 PRACTICE OF MEDICINE. begin with small doses, increasing or decreasing as its effects are good or bad. The indicator of the heart's condition is the pulse. In the aged, the feeble, or in those accustomed to the use of alcohol, stimulation is indicated from the onset. Other indications would be a frequent, feeble, irregular or intermitting pulse ; a dicrotic pulse ; delirium, muscular tremor and subsultus ; immediately following crisis, and the period of collapse. To reduce the temperature is also an important indication. If the fever is under 103° F., cool sponging with alcohol and water, or water alone, is usually sufficient. If the temperature is above 103° F., antifebrin , gr. v, should be used every three hours until a reduction occurs. Strychnina or caffeina may be added to each dose. Phena- cetin or acetanilidum are also valuable, and considered less depressing. The use of the cold pack or of cold baths for reducing the temper- ature in acute pneumonia has not met with the approval of practical clinicians. Dr. Mays strongly advocates the use of ice bags to the chest in pneumonia. He says: “Very often it is found that the application of the ice to an affected spot is immediately followed by a marked lowering of the temperature, and improvement in the physical signs in the part.” The diet must be of the most nutritious but easily digestible character, and given at periods of every three hours. Strong black coffee throughout the disease is valuable. Third Stage. The treatment is a continuation of that of the second stage, gradually reducing the antipyretics as the fever declines, and adding one of the preparations of ferrum. Convalescence. Nutritious diet, quinince sulphas in tonic doses, ferrwn , together with a good blood-making wine or a good prepara- tion of malt. If the consolidation shows a disposition to linger, blisters may be used. Many cases are favorably influenced by an expectorant from the onset of the disease. The following is valuable : (R . Ammonii chloridi, gr. v-x ; strychnine sulph., gr. \ aquae chloroform., f 3 j— ij . M. Sig. — E very three hours). The various symptoms other than those particularly mentioned are to be met, as they arise, by their proper remedies. For typhoid pneumonia, purulent infiltration, abscess of the lungs, DISEASES OF THE LUNGS. 297 or pneumonia in drunkards, the weak or the aged, quinina , ferrum , nutritious diet and bold stimulation , and the free use of ammonii carbonas or spiritus ammonia aromaticus , are the indications. The so-called antiseptic treatment of acute pneumonia is still under trial, and no definite opinion can be expressed concerning it. CATARRHAL PNEUMONIA. Synonyms. Broncho-pneumonia ; lobular pneumonia ; capillary bronchitis (?). Definition. An acute catarrhal inflammation of the bronchioles and alveoli of the lungs, characterized by fever, cough, dyspnoea, copious expectoration and great depression. Causes. From an extension of a bronchial catarrh downward; following the eruptive fevers, especially measles ; complicating whoop- ing cough. Persons of the rickety or scrofulous diathesis, in whom there is a greater irritability of the epithelial elements, are particularly predisposed to this form of pneumonia on slight exposure; emphy- sema ; diseases of the heart ; most frequently seen in childhood and' old age. Bacteriological investigations seem to indicate that secondary broncho-pneumonia is due to more than one germ. Pathological Anatomy. Hypercemia of the mucous membrane of the bronchi, extending to the connective tissue of the bronchioles and accompanying arterioles and to the alveoli, with swelling and succulence of these tissues, accompanied by an abnormal secretion and an immense production of young cells from the proliferation of the bronchial and alveolar epithelium, admixed with a yellowish, creamy, mucoid material, which blocks up the bronchioles and air cells. The affected parts first have a reddish-gray, soon changing to a yellowish-gray color, due to the rapid metamorphosis of the newly developed cells. If the fatty change be completed, absorption takes place, and the consolidation is removed ; if it remain incomplete the cells atrophy, the little mass becoming caseous, and the disease passes into a chronic state. The bronchial tubes also participate in the disease, the walls be- come thickened, from a hyperplasia of the connective tissue ( peri- bronchitis ), and their calibre is often dilated. 25 298 PRACTICE OF MEDICINE. Symptoms. Catarrhal pneumonia begins as a catarrhal bron- chitis. It may be either acute, sub acute or chronic in its course. Acute variety : Its onset is announced by a gradual rise of tem- perature to io2°-io3° F., the febrile phenomena assuming a typical remittent character, with rapid, laborious and shallow breathing, as shown by the widely dilated nares and violent action of all the acces- sory muscles, while the insufficient distention of the lungs is shown by the great recession of the lower part of the chest walls and sinking in of the intercostal spaces. The inspiration is short and imperfect, the expiration noisy and prolonged ; th z pulse is frequent , 100-120 or more, and somewhat compressible ; the cough , which, during the bronchitis, was loose, now becomes short, hacking, dry and painful, soon followed by more or less copious muco-purulent expectoration ; the appetite is impaired, bowels somewhat loose, urine scanty, high- colored, and the surface frequently covered with a more or less pro- fuse perspiration . The sub-acute and chronic varieties have the same general symp- toms, but the duration is longer and the exhaustion greater. The progress of catarrhal pneumonia is sometimes, although not often, a very acute one. The disease may prove fatal in a few days, especially if it attack feeble children ; in such the countenance becomes pale and livid, the lips bluish, the eyes dull, and a rest- lessness giving place to apathy, and a continually augmented som- nolence. Resolution, when it occurs, is by lysis, several weeks elapsing before complete recovery. Percussion. Dullness, scattered in patches, over both lungs, the intervening healthy lung often giving a more or less hollow or tym- panitic note. Auscultation. Vesiculo-bronchial breathing, changing to moist bronchial breathing, associated with small bubbling (sub-crepitant) rales. As the disease progresses toward resolution, the rales become larger (large bubbling) and more copious. If pneumonic phthisis result, physical signs indicative of that condition are soon evident. Sequelae. Attacks of catarrhal pneumonia complicated with atelectasis, or collapse of the lobules, when recovery occurs, are fol- lowed by emphysema of the lungs. If the catarrhal products which fill the alveoli and bronchioles and intervening connective tissue do not rapidly undergo complete fatty DISEASES OF THE LUNGS. 299 metamorphosis and consequent absorption, pneumonic phthisis re- sults. Diagnosis. Ordinary bronchial catarrh differs from catarrhal pneumonia by the absence of dyspnoea, fever, and dullness on per- cussion, and the presence of the large bubbling rales, and also by the subsequent history of the two affections. Croupous pneumonia is a unilateral disease ; catarrhal pneumonia is bilateral and diffused over both lungs ; the former a self-limited disease, the latter having no fixed duration. Acute tuberculosis at its onset is characterized by the presence of a capillary bronchitis, a differentiation being possible only by a study of the clinical history and course of the two maladies and the presence or absence of the tubercular bacilli. CEdema of the lungs is a bilateral disease associated with a short, dry cough, and dyspnoea, but lacks the previous catarrhal history and high temperature of catarrhal pneumonia. Prognosis. Fully one-half of the cases of true catarrhal pneu- monia terminate fatally. The prognosis must be guarded in scrofu- lous or rachitic subjects, or those enfeebled by other diseases, for unless prompt resolution, can be effected, it will terminate fatally early, or develop pneumonic phthisis. Have seen cases continuing up and down for eight and ten months, and finally make a good recovery. Treatment. Confinement to bed is paramount, although the position of the patient is to be frequently changed. The diet must be of the most nutritious character, administered at frequent intervals ; milk, eggs, chicken, beef, mutton and oyster broths are the most suitable articles. The steady use of brandy or whiskey throughout the attack is of importance, regulating the amount by the age of the patient and the severity of the attack. Locally a weak mustard plaster followed with a cotton batting jacket is valuable. Poultices of little use. The febrile symptoms and early cough are often modified by the following mixture : (R. Potassii citratis, 3yj ; spts. aetheris nitrosi, f£iv ; tinct. opii camphorat., fgiv ; liquor potassii citratis, ad f^vj. M. Sig. Dessertspoonful every three hours). Early in attack, in children with high temperature, tinciura aconiti , in small frequently repeated doses. If the fever persists a combination of phenaceiin or antifebrin , camphor , and digitalis is useful. The ice bags or poultice are as strongly urged for broncho- 300 PRACTICE OF MEDICINE. pneumonia as for croupous pneumonia, and in sthenic cases should be given a trial. For the catarrhal process, the air of the apartment should be main- tained at an even temperature and moistened by disengaging the vapor of water in it. The following combination is of great utility in nearly all cases, regulating the dose in accordance with the age of the patient : — R . Ammonii carbonat., gr. v Ammonii iodidi gr. v-x Mucil. acacise, q. s. Syr. glycyrrh., f 3 j-ij Syr. prun. virg., q. s. ad f^ij-iv SlG. — Every three hours. A much pleasanter way of administering the ammonia salts is in capsules, each containing about two and one half grains of each salt with an aromatic oil. Terpinum hydras acts remarkably well in many lingering cases. For convalescence , nutritious food, ferri iodidum , quinince sulphas , and oleum morrhuce. Locally : repeated application of mustard poultices or turpentine stupes followed by cotton jacket. If the inflammatory processes tend to become chronic, scattering blisters should be used. PULMONARY TUBERCULOSIS. Synonyms. Phthisis pulmonalis ; phthisis ; consumption ; pneu- monic phthisis ; tubercular phthisis. Definition. An infective disease, caused by the bacillus tubercu- losis , the lesions of which are characterized by nodular bodies called tubercles or diffused infiltrations of tuberculous tissue which undergo caseation or sclerosis and may finally ulcerate, or in some situations calcify. (Osier.) Clinical Varieties. I. Acute miliary tuberculosis; II. Pneu- monic phthisis ; III. Tubercular phthisis ; IV. Fibroid phthisis. Cause. It is now generally accepted that all varieties of pulmon- ary consumption are due to the active presence of the bacillus tuber- culosis, discovered by Koch in 1881. The lung tissues must be in a receptive state as the bacilli may be present in the respiratory tract without the development of the disease. DISEASES OF THE LUNGS. 301 Any condition that lowers the tone of the general system, renders the tissues susceptible to the changes produced by the tubercle bacilli. These will be enumerated in speaking of the clinical varieties of the disease. ACUTE MILIARY TUBERCULOSIS. Synonyms. Acute phthisis ; galloping consumption. Definition. An acute infective febrile affection, due to the rapid eruption in various parts of the body, but especially in the lungs, of miliary tubercles ; characterized by high fever, rapid pulse, hurried respiration, pains in chest, cough, profuse expectoration and rapid prostration. Causes. In the majority of cases it is the result of an auto-infec- tion, arising from either an active or latent tuberculous focus. Cases develop in which no cause can be assigned. Often follows measles, whooping-cough, variola, and influenza. Most common between puberty and middle life. “ That the gray granulation is deposited throughout the body under the influence of certain conditions of irritation, it is necessary that a peculiar vulnerability of the constitution exist, in other words, that it be of the scrofulous type.” Clinical Forms. General or typhoid, pulmonary and cerebral. The cerebral will be described in the section on nervous diseases. Pathological Anatomy. Pulmonary form. “ The gray granu- lation or miliary tubercle consists of a fine reticulation of fibres, with a mass of epithelioid cells and granules, and often having a giant cell for its centre.” The deposit is generally over both lungs and the bronchial tubes, and is followed by hyperaemia, increase of secretion, having a viscid and adhesive character, and the destruction of all the tissue with which it comes in contact. Deposits also take place in the brain, pleurae, intestines, peritoneum and kidneys. General or Typhoid. — Symptoms. Gradual progressive weak- ness, with loss of appetite, dry, clean tongue, costive bowels, flushed cheeks, fever, irregular in type, and rapid, feeble pulse. Rarely the temperature reaches 103° F., to 104° F., associated with a mild delirium. The respirations are increased with slight or no cough, and 302 PRACTICE OF MEDICINE. little or no expectoration. As the symptoms continue the prostration increases, cyanosis develops, the patient growing stupid, gradually deepening into coma and death. Diagnosis. There are none or so slight local conditions, the symptoms pointing to an acute general infection, that the disease is apt to be mistaken for typhoid fever. The points of difference are the absence of the typical typhoid temperature record, the characteristic eruption, and the diarrhoea. Prognosis. Recovery is the rarest termination. Treatment. Expectant and symptomatic. Pulmonary Form. — Symptoms. The onset is usually sudden, with a chill or chilliness , followed by fever , io2°-io4° F., rapid , dicrotic pulse , 120-140, cough , with scanty, glairy sputum, increased respiration , 30-50 per minute, pain in the chest, hot skin, dry tongue, deranged digestion and great prostration, the severity of the symp- toms rapidly increasing, with evidences of cyanosis, the sputum becoming more abundant and often rusty in color, with more or less frequent attacks of hcemoptysis, soon followed by headache, vertigo, sleeplessness, often delirium, coma and death. If deposits have occurred in the meninges or the intestines, symp- toms of these affections are superadded. Percussion. The percussion resonance is normal until consider- able deposits have occurred, when it is either slightly impaired or even slightly tympanitic. With the development of cavities the am- phoric percussion note is present. Auscultation. Vesiculo-bronchial breathing, associated with large and small, moist or bubbling rales , soon followed by bronchial and broncho-cavernous breathing, with large and small, moist and circumscribed gurgling rales. Duration. Acute phthisis usually terminates fatally in from four to twelve weeks. Rarely of several months’ duration. Diagnosis. Commonly mistaken for typhoid fever with lung complications, an error that is readily made unless a close study of the history, symptoms, physical signs, and sputum be made. Treatment. There are no means of retarding the progress of this malady. Loomis says: “ Morphia in small doses — one-twentieth of a grain hypodermically every six or eight hours — has, in my hands, been more satisfactory in staying the progress of the disease, prolong- ing life, and keeping the patient comfortable, than any other plan.” DISEASES OF THE LUNGS. 303 Dr. McCall Anderson claims that subcutaneous injections of atropina check the exhausting sweats ; and that quinina, digitalis and opium reduce the temperature, and if they fail, ice cloths to the abdomen will accomplish the desired result. The various symptoms should be met as they occur, the patient at the same time being supplied with large quantities of stimulants. PNEUMONIC PHTHISIS. Synonyms. Chronic catarrhal pneumonia; catarrhal phthisis; caseous pneumonia ; caseous phthisis. Definition. A form of pulmonary consumption characterized by the destruction of the pulmonary tissue resulting from the action of the bacilli, causing the caseation or cheesy degeneration of inflam- matory products in the lungs, and the subsequent softening and destruction of the caseous matter, with greater or less destruction of the pulmonary tissue ; characterized by hectic fever, cough, shortness of breath, purulent expectoration, and more or less rapid prostration . Causes. The predisposing factor in the etiology of pneumonic phthisis is a strumous or scrofulous diathesis, or a condition of low- ered health, the result of various unfavorable hygienic influences. The exciting causes are : the irritation produced by the presence of the bacillus tuberculosis and a catarrhal pneumonia in any portion of the lung, but especially at the apex ; inflammation occurring about a blood clot; inhalation of irritant particles occurring in certain occu- pations, to wit: weavers, grinders, miners, hatters, millers, cigar makers, and the like. Many cases of pneumonic phthisis can be traced to an attack of influenza a year or so before. Pathological Anatomy. When a pneumonia terminates in resolution the inflammatory products are absorbed by first undergoing a fatty metamorphosis. If the fatty metamorphosis be incomplete, the cells are atrophied and undergo the caseous degeneration , which con- sists in the absorption of the watery parts, the fatty degeneration of the cellular elements, and the granular disintegration of the fibrin- ous material, so that ultimately a soft, solid mass is produced, yellow- ish in color, having the appearance of cheese. The destructive changes are thus described byNiemeyer: “Cells, the products of inflammation, accumulate in the alveoli and minute bronchi crowd upon each other, becoming densely packed, and thus 304 PRACTICE OF MEDICINE. by their mutual pressure they bring about their own decay, as well as that of the lung textures, by interfering with their nutrition, the alve- olar walls being also themselves damaged by the inflammatory pro- cess.” The position of the catarrhal pneumonia resulting in the above changes is usually at the apex, but it may occur at any portion of the lungs, or a whole lung becomes infiltrated, and undergoes the cheesy degeneration (phthisis florida). Symptoms. Pneumonic phthisis occurs in three forms, the chronic , the sub-acute , and the acute. Chronic form: The origin is rather insidious, the individual being susceptible to “colds,” or “catarrhs,” on the slightest exposure; gradually a persistent cough , with the expectoration of muco-pus, is established, each severe cold being accompanied with chill , fever , pain in the chest, and either slight hemorrhage or blood-streaked sputa. Finally, the catarrhal symptoms become persistent, with morning chills , evening fevers , and rather profuse night sweats , dis- tressing cough, profuse muco-purulent sputa, containing the bacilli, great weakness and exhaustion, loss of appetite and feeble digestion, the symptoms growing persistently worse, death occurring from exhaustion after one or two years’ duration. Sub-acute variety. History of an acute attack of pneumonia of one or two weeks’ duration, followed by a decided improvement, but not complete recovery. After a lapse of some weeks or months, symp- toms of pulmonary softening begin, destroying the lung structure and forming cavities, accompanied by chills , fever , ?iight sweats , emaci- ation, cough , muco-purulent and blood-streaked expectoration contain- ing the bacilli, the patient dying from exhaustion within a year. Acute variety , the so-called phthisis florida , runs a rapid course, beginning either as a croupous or catarrhal pneumonia, involving the whole of one or part of both lungs, associated with rapid loss of flesh and strength, high but variable tejnperature , io3°-io 5° F., with remissions, profuse night sweats , shortness of breath , severe cough, profuse , purulent and blood-streaked sputa containing the bacilli, loss of appetite , and feeble digestion, the patient succumbing in a few weeks or, months, from exhaustion. A decided remission in the local and general symptoms of the acute variety may occur, the disease afterward pursuing a more chronic course. DISEASES OF THE LUNGS. 305 Inspection. Shows deficient respiratory movements of the dis- eased portion of the lungs. Palpation. Increased vocal fremitus over the consolidated lung tissue and cavities. Percussion. The percussion note varies from a slight impair- ment of the normal note to dulness , and when cavities are formed, associated with scattered points of the tympanitic or hollow note. If the cavities communicate with a bronchial tube the cracked-pot or cracked-metal sound is elicited. If the cavities are filled with pus the percussion note is dull. If the pus be expelled, the tympanic or cracked-pot sound returns. Auscultation. The vesicular murmur is unimpaired in those parts free from disease : it is feeble or indistinct if many bronchioles are obstructed ; and is harsh or blowing if the bronchioles are nar- rowed. The inspiratory sound will be jerking , and the expiratory sound prolonged and blowing when the lung has lost its elasticity. Associated with the impaired vesicular murmur is a fine , dry, crack- ling sound (crepitation), appearing at the end of inspiration. If bron- chitis be associated, large and small moist or bubbling rales are also heard during respiration. When cavities form, either bronchial or broncho -cavernous respira- tion is heard, associated with more or less distinct gurgling rales. If the cavity be free from pus and have rather firm walls, the breath- ing is more amphoric in character. Diagnosis. Catarrhal bronchitis has many points of resemblance to pneumonic phthisis. The subsequent course of the latter, with the high temperature, prostration, emaciation, sputa containing bacilli, and physical signs will prevent error. Acute fibrinous and catarrhal pneumonia, often after a course of two or three weeks, show the bacilli and yet are not recognized as tuberculosis. It is a safe rule of practice to suspect tuberculosis and examine daily for the bacilli, in all cases of pneumonia that show the least tendency to linger, and particularly where there are chills and a remittent temperature record. Prognosis. Acute variety, the phthisis florida, usually terminates fatally within a few months. The sub-acute and chronic varieties may, under judicious treatment and favorable hygienic conditions, be arrested, the caseous matter partly expectorated and partly absorbed, leaving more or less loss of 306 PRACTICE OF MEDICINE. structure, cicatricial tissue supplying its place, which after a time con- tracts, causing more or less retraction of the chest walls. Cases not properly treated, either from carelessness or poverty, succumb after a year or two. TUBERCULAR PHTHISIS. Synonyms. Tuberculosis; consumption; incipient phthisis; chronic phthisis ; chronic ulcerative phthisis. Definition. A chronic pulmonary disease caused by the bacillus tuberculosis, resulting in the deposition of tubercle in the lung structure, which in turn undergoes ulceration and softening which results in a septic infection, characterized by progressive failure of health, fever, cough, dyspnoea, emaciation and exhaustion. Causes. Hereditary and acquired susceptibility to the influence of the bacillus tuberculosis. It is questionable if an individual is born with pulmonary tuberculosis, or makes his advent with tissues that are a congenial soil for the growth and ravages of this wide-spread germ. Amongst the acquired causes are syphilis, alcoholism, chronic nephritis, certain occupations, and living in damp, overcrowded, dark and illy ventilated locations. Debility following an attack of influenza, predisposes to the deposition of tubercle. Pathological Anatomy. Tubercle is a grayish-white, translu- cent and semi-solid granulation, about the size of a millet seed, most commonly deposited in the walls of the bronchioles, exciting a low form of inflammation, the result of its own death. The masses of tubercle soon undergo softening (cheesy transformation) ; the lung structure is secondarily affected, undergoes softening, which results in more or less destruction of the tissue, whence cavities are formed. The inflammation may extend to the small arteries, causing hemor- rhage. The deposit of tubercle is generally at one of the apices, and “ once present in an apex, the disease usually extends in time to the opposite upper lobe ; but not, as a rule, until the apex of the lower lobe of the lung first affected has been attacked. Lesions of the base may be primary, though this is rare.” Depositions may also occur in the brain, intestines and liver. The pleura is usually the seat of a chronic inflammation (dry pleurisy, tubercular), resulting in the obliteration of the pleural cavity. DISEASES OF THE LUNGS. 307 Symptoms. The symptoms correspond closely to the stages of deposition, of softening, septic infection, and of the formation of cavi- ties. The development Is insidious, with increasing dyspepsia and ancemia, the loss of appetite, distress after meals, and feeling of weakness, often misleading the patient and physician for some time until the occurrence of an irritable heart , a slight, dry, hacking cough, referred to the throat or stomach, scanty, glairy expectoratio?i, gradual loss of weight, impaired muscular strength, pallid appearance, and a more or less copious hcemoptysis. Pam, sharp in character, below the clavicles, is often present. These symptoms are characteristic of the develop- ment of the disease. The beginning of softening is announced by increased cough, freer expectoration, showing under the microscope the bacilli, dyspnoea in- creased on exertion, morning chills, evening fever, night sweats — the so-called hectic fever, diarrhoea, increased emaciation and weakness , the patient, however, continuing very hopeful. With the formation of the cavities , the cough is more aggravated, with profuse and purulent expectoration, at times containing yellow striae, the amount depending upon the number and size of the cavi- ties ; haemoptysis is not common at this stage ; th e pulse rapid and weak, increased hectic , burning of the soles and palms, copious night sweats, greater debility and emaciation, with oedema of the feet and ankles, denoting failure of the circulation, death soon following from asthenia, the mind clear and hopeful to the end. Inspection. First stage, often shows slight depressions in the supra-clavicular, and at times in the infra-clavicular regions. Palpation. Second stage , the vocal fremitus is slightly increased. Percussion. First stage , slight impairment of the normal per- cussion resonance can sometimes be elicited. Second stage, the resonance is impaired , and may be even dull. Third stage, dulness with circumscribed spots of ‘the amphoric , or tympanitic or cracked-pot sound. Auscultation. First stage, inspiratio?i jerky , expiration pro- longed, the pitch higher than normal, the inspiration associated with crackling rales. Second stage, vesico-bronchial breathing, associated with sub-crepi- tant and large and moist or bubblmg rales. Third stage, bronchial , broncho-cavernous and cavernous respira- 308 PRACTICE OF MEDICINE tion , associated with large and small moist or bubbling, and localized gurgling rales. Bronchophony in its various degrees is associated with the second and third stages of tuberculosis. Complications. Tubercular diseases of the brain, larynx, pleura, intestines and peritoneum ; perineal abscess leading to fistula, endo- carditis and myocarditis. Diagnosis. The early diagnosis of tubercular phthisis rests mainly on the history, together with the symptoms and physical signs. In the first stage it is often mistaken for dyspepsia, ansemia, malarial fever, or disease of the heart ; if the bacilli can be found in the sputum the diagnosis is settled. Prognosis. In the main unfavorable, although under proper treat- ment, change of climate and like favorable conditions, life may be pro- longed for years. FIBROID PHTHISIS. Synonyms. Chronic interstitial pneumonia ; cirrhosis of the lungs ; Corrigan’s disease. Definition. A hyperplasia (thickening) of the pulmonary con- nective tissue, resulting in atrdphy and degeneration of the vesicular structure, associated with bronchial inflammation ; characterized by cough, profuse expectoration containing the bacillus tuberculosis, fever, emaciation, and ultimately death by asthenia. Causes. Hereditary predisposition ; inhalation of irritants and associated with certain occupations, such as stone-cutters, grinders, etc. Following lobar pneumonia; chronic bronchitis; alcoholism; syphilis ; chronic nephritis. Pathological Anatomy. Thickening of the bronchial mucous membrane and dilatation of the air tubes ; hyperplasia of the pul- monary connective tissue, resulting in the compression and conse- quent destruction of the vesicular structure, which is assisted by the contraction of the newly formed tissues. Sooner or later catarrhal pneumonia results, the product undergoing the cheesy degeneration, cavities being formed, and as a result of the long-continued suppu- ration, tubercular depositions occur, hastening the destruction of the lung tissue. Prof. Da Costa has reported a number of cases of “ grinders’ phthisis,” in whose sputum was found the “ bacillus tuberculosis,” and in whose family history there were no traces of consumption. Symptoms. The course is chronic, beginning as a bronchial DISEASES OF THE LUNGS. 309 catarrh , worse in winter, better in summer, when, after several years, the cough becomes more continuous , the expectoration freer and muco-purulent, containing the bacillus tuberculosis in large numbers, hectic fever develops, night sweats , dyspnoea , and rapid emaciation , soon followed by oedema of the feet and ankles, the result of failing circulation, death occurring by asthenia. Inspection. Depression of the chest walls. Percussion. Impaired resonance, followed by dulness, with ir- regular spots of amphoric or tympanitic percussion note over the points of depression. Auscultation. First stage , vesiculo -bronchial, or harsh respira- tion associated with large and small, moist or bubbling rales, followed by bronchial, broncho-cavernous , and cavernous respiration, with cir- cumscribed gurgling rales. Diagnosis. Beginning as a bronchial catarrh, slowly progressing, with the remission of the symptoms during the summer months, finally becoming progressively worse, the discovery of the bacilli in the sputum, with the formation of cavities, and symptoms of asthenia, are the chief points in the diagnosis. Prognosis. The duration of fibroid phthisis is most protracted, six to twelve years being the average duration ; death, however, is the inevitable termination. Prof. Da Costa has records of one hundred deaths from “ grinders’ consumption ” whose average life was twelve years. TREATMENT OF PULMONARY TUBERCULOSIS. Can pulmonary tuberculosis be prevented ? To a very great extent, yes, as in a large proportion of cases the infection of the system is the result of contagion or the ingestion of food containing the germ. The afflicted are not following the precepts of the Golden Rule, through ignorance of the laws of public hygiene. The medical pro- fession is responsible for the lack of knowledge of the laity as to the dangers of consumptive patients. It is now known that tuber- culosis is very common in the cattle, whose flesh forms such a large part of our food. Were it not for the protection given by cooking, the history of this disease would be a sadder one than it is. But the milk is not often cooked. May not the great increase in tubercu- losis be caused by the use of cow’s milk ? The bacilli once found in the sputum, can the unfortunate host be cured ? 310 PRACTICE OF MEDICINE. While I have never seen a case of incipient phthisis cured, in the broad acceptation of the term, I have repeatedly seen life prolonged for a number of years, and the deposition of tubercle long delayed by a change of climate early in the history of the case, warm cloth- ing, life and exercise in the open air short of fatigue, and systematic bathing and a nutritious plan of dieting. If the diet is arranged in accordance with the appetite, the latter will gradually increase, but should it not, it may be stimulated by such bitters as strychnines sulphas , nucis vomiccs , ignatia amara, Colombo , ox gentian. The symptoms are to be met as they arise, and drugs are not to be used simply because the patient has the physical signs of beginning tubercle. For the general debility and malaise that accompanies the early stages of this malady, any one, or a combination of the follow- ing drugs, exercising care that they in no way interfere with the appetite : Guaiacol , gtts. iij-v, for adult, and gtts. ij-iij, for child, four times daily, in either sweetened water, milk, or meat broth, or wine ; ol. morrhuce , ferri iodidum , hypophosphites , elixir quinince , ferri et strychnines , or a combination of arsenicum and digitalis. (R. Acidi arseniosi, gr. j; digitalini (Merck’s), gr. j. M. et ft. pil. No. xxx. Sig. — One after meals.) In the pneumonic variety an attempt should always be made to remove the caseous matter by absorption and expectoration. The following prescriptions will sometimes prove successful : — R . Ammon, carb, gr. v Ammon, iodidi, gr. v-x Aq. chloroformi, fsjij Syr. prun. virg., f^ij. M. Every five hours, diluted, alternating with R . Liq. potassii arsenitis, rt^v Mass, ferri carb., gr. v Vini xerici, f^j Aquae dest., q. s. ad f^ss. M. In the tubercular variety the early dyspeptic symptoms are wonder- fully relieved by the following : — R. Pepsini cryst., gr*. ij Acid, hydrochlorici dil. , 1A XV Glycerini . rr^xx Succi limonis, rr^xv Aquae auranti flor., .... ad f£ij. M. SlG. — With meals. DISEASES OF THE LUNGS. 311 It is in this variety of consumption that every means should be employed to improve the general health. Benefit may often follow from the long-continued moderate use of alcoholic stimulants, the amount being only such as will increase the appetite and improve the digestion. If rise of temperature, flushed face, or dyspeptic symptoms occur, discontinue the rum at once. For the fibroid variety, to prevent the hyperplasia of the connec- tive tissue, hydrargyri corrosivum chloridum, potassii iodidum , or aurii et sodii chloridum , are recommended. Oleum morrhuce is of benefit. For the gastric symptoms , which are often so severe as to seriously interefere with assimilation, either bismuth , gr. xx before meals, or salol, gr. j-ij, or arsenicum. (R. Liquor, potassii arsenitis, rr^xxx, tincturae nucis vomicae, f^j, aquae chloroformi, ad f^ij. M. Sig.— Teaspoonful before meals.) For the fever , unfortunately, but little can be accomplished with drugs. If, however, it exceeds ioi° F., an attempt should be made to reduce it. The “ Niemeyer pill ” is usually recommended, its formula being — U . Quininse sulph., gr. j Pulv. digitalis., • • * gr. ss Pulv. opii, gr. % Pulv. ipecac, gr. M. From a very considerable experience with this “ famous ” pill, I can recall few cases in which it has proven of the least benefit. The following is much more effectual : — R . Quininoe sulpli., gr. x Quininae muriat., gr. x Pulv. opii et ipecac., gr. iij. M. Ft. capsul. No. ij. SiG. — One capsule five hours, and the other three hours before the de- cided rise of temperature. In a few instances the temperature has been favorably influenced by antifebrin gr. v, in tablets at one, three, and five o’clock each afternoon, or acetanilidum , gr. v, at the same hours. If sweating occur, add to each five-grain tablet agaricin gr. Many patients prefer cool sponging, adding alcohol, vinegar, or bay-rum to the water, and there is no doubt but that sponging will promptly reduce the temperature, two or three degrees. 312 PRACTICE OF MEDICINE. For the cough either of the following are of use : — R. Codeinae sulphat., gr. Acidi hydrocyanici dil., n\jj Syr. tolu, fg j. M. Sig. — S everal times a day. Or— R . Ammonii chloridi, g iij Spts. frumenti, f^iv Glycerini, . . f % iv Tincturce opii camphorat., f^iv Aquae chloroformi, f^j Syr. prun. virg., ad fg vj. M. Sig. — Dessertspoonful every four or five hours, with water. If diarrhoea develop, bismuth , gr. xx-xxx every three or four hours, with rest in bed and mustard to the abdomen, or R . Cupri sulphat, gr. jss ; ext. nucis vom., gr. iij ; pulv. opii, gr. vj. M. et ft. pil. No. xij. Sig. — One every three or four hours ; or, R . Liquor, potassii arsenitis, rr^xxx; tincturae opii deodorat., f- 5 jss; liquor pepsini, ad f^ij. M. Sig. — Teaspoonful at meal time. For night sweats , atropince sulphas ., gr. at bedtime, or agari- cine , gr. ^“tS' at bedtime, adding small dose of morphina if it cause loose stools. Camphoric acid, gr. xx-xxx, about two hours before the expected sweat ; the time of administration is important, as the drug is rapidly eliminated. It has the additional advantage of causing no ill or disagreeable effect. It is best given dry on tongue. It is claimed that sulphonal, gr. vij-x, at bedtime, controls the night sweats and also produces a quiet, refreshing sleep. For hcemoptysis no one remedy is comparable with atropince sulphas, gr. -2gQ~TiJo~6 1 o> hypodermically repeated pro re nata. Beginning in December, 1890, a large number of cases of incipient tuberculosis were treated in the wards of the Philadelphia Hospital with Koch’s tuberculin. The treatment was negative in every case. In the fall of 1892 ten cases of early tuberculosis were placed under treatment with Kleb’s tuberculocidin. Its action is different from Koch’s tuberculin in that it never excites the febrile reaction of the latter. The results are thus far encouraging, as there is a lull in the symptoms in each case. Creosoium and guaiacol have not proven their specific properties. The diet must be of the most nutritious and easily digestible DISEASES OF THE PLEURA. 313 character. If oleum morrhuce or petrolatum can be assimilated, either should be used for a long time. The hygiene of the patient is of the utmost importance, and as it is a struggle for life, no means should be left untried to gain the victory. DISEASES OF THE PLEURA. PLEURISY. Synonyms. Pleuritis; “ stitch in the side.” Definition. A fibrinous inflammation of the pleura, either acute , subacute or chronic in character, occurring either idiopathically or secondarily ; characterized by a sharp pain in the side, a dry cough, dyspnoea, and fever. It may be limited to a part, or may involve the whole of one or both pleural membranes. Causes. Idiopathic pleuritis is said to be due to cold and expo- sure, to injuries of the chest walls, or the result of muscular exertion. Tuberculosis is the cause of a few acute pleurisies. Secondary pleuritis occurs during an attack o'f pneumonia, pericardi- tis, rheumatism, variola, scarlatina, measles, Bright’s disease, or puer- peral fever. Chronic pleurisy follows an acute attack, or is the result of tuber- culosis, Bright’s disease, or alcoholism. Pathological Anatomy. The course pursued by an inflam- mation of a serous membrane is hypercetnia followed by exudation of lymph , the effusion of fluids its absorption, and the adhesion of the membranes. The first or dry stage of pleurisy is a hyperremia or diffused, irreg- ular redness of the membrane, with little specks of exudation. The second stage is characterized by the copious exudation of lymph, more or less completely covering the membrane, giving it a dull, cloudy, or shaggy appearance. If the inflammation ceases at this point, it is termed dry pleurisy. The third , or stage of effusion, is characterized by the pouring out of a semi-fibrinous liquid ; more or less completely filling and distending the pleural cavity, and floating in the fluid are fibrinous flocculi, blood, and epithelial cells. 26 3 J 4 PRACTICE OF MEDICINE. Absorption of the fluid and more or less of the exudative lymph soon occurs, the unabsorbed portion becoming organized, forming adhesions which obliterate the pleural cavity. The effusion, if on the right side, pushes the heart further to the left ; if on the left side, the heart is displaced to the right, the impulse often being seen to the right of the sternum. The lungs are also compressed and displaced upward and against the spinal column, and, on removal of the fluid, expand again, except in cases of chronic pleurisy, when the functional activity of the pulmonary structure is more or less permanently impaired. Chronic pleurisy results when the fluid is not absorbed or when it is effused into the cavity in a slow and insidious manner. The mem- brane is irregularly thickened, with firm adhesions, fluid being found in the meshes ; depressions of the thoracic walls also occur. The fluid may be serum, pus {empyema), or pus and blood. Open- ings may form, through which there is a permanent discharge, either externally (fistulous empyema) or into the bronchi, or, rarely, into the bowels Symptoms. Acute variety : Begins with a chill , followed by a sharp lancinating pain (stitch) near the nipple or in the axilla, aggra- vated by coughing and breathing, associated with slight tenderness on pressure. The respirations are rapid and shallow, 30-35 per minute, a short, dry, hacking cough , moderate fever , compressible pulse, 90- 120. With the effusion of liquid the dyspnoea becomes aggravated, the cough more distressing, the cardiac action embarrassed, the coun- tenance wearing an anxious expression, the patient usually lying on the affected side. With the absorption of the fluid the symptoms gradually ameliorate, convalescence being more or less rapid. Subacute variety : Begins insidiously after cold, exposure, and fatigue in those enfeebled. Patients usually complain of a sense of weariness , shortness of breath, aggravated on exertion, evening^^r, followed by night sweats, short, harassing cough, none or very scanty sputum; the pulse is small, feeble, but frequent, 100-1 20 beats per minute. The characteristic pain in the side is usually wanting. Chronic variety, irregular chills, fever, night sweats, dyspnoea, palpitation, embarrassed circulation, with more or less prostration. Inspection. First stage, deficient movement of the affected side, on account of the pain induced by full breathing. Second stage, bulging or fullness of the affected side, with oblitera- DISEASES OF THE PLEURA. 315 tion of the intercostal spaces and displacement of the cardiac im- pulse. Palpation. Second stage , vocal fremitus feeble or absent over the site of the effusion, exaggerated above the site of the fluid. Rarely , fluctuation may be obtained. Percussion. First stage , may be slightly impaired. Second stage, dulness or even flatness over the site of the effusion ; tympa7iitic percussion note above the fluid. Auscultation. First stage, feeble vesicular murmur over th^ affected side, the patient breathing superficially, to prevent the pain ; a friction sound, slight and grating or creaking, becoming louder as the exudation of lymph increases, limited usually to the angle of the scapula of the affected side, rarely heard over the entire side, accom- panies the respiratory movements. Second stage, feeble or absent vesicular murmur on the affected side, depending upon partial or complete compression of the lungs by the fluid. Above the fluid puerile breathing, and just at the upper margin of the fluid a friction sound may be heard. The vocal resonance is diminished or absent over the site of the fluid and markedly increased above, cegophony being present at the upper margin of the fluid. With the absorption of the fluid the vesicular murmur gradually returns, associated with a moist friction sound. Diagnosis. Acute pneumonia is often mistaken for the effusion stage of pleurisy. The points of distinction are, in pneumonia there is the pronounced chill, high fever, and characteristic sputa, bronchial breathing, exaggerated vocal fremitus and resonance, and no displace- ment of the heart, the reverse occuring in pleurisy. Enlargement of the liver may be mistaken for pleurisy with effusion, the chief poinj of distinction being that, in enlargement of the liver, the superior line of dulness is depressed upon full inspiration, while in pleurisy with effusion inspiration does not modify the location of the dulness. Prognosis. Idiopathic pleurisy usually terminates in recovery within three weeks. Pleurisy the result of constitutional causes has its prognosis modified by the condition with which it is associated. Empyema, unless the result of a diathesis, terminates favorably. Double pleurisy is unfavorable . The etiological factor of tuberculosis 316 PRACTICE OF MEDICINE. must always be borne in mind in making a prognosis in pleurisy, whether acute or chronic. Treatment. At the onset, in plethoric patients, wet cups over the affected side ; if great dyspnoea, severe pain and high arterial tension, even venesection, and in anaemic or weak persons, dry cups , follow- ing the use of either the wet or dry cups with poultices or turpentine stupes. The severe pain is promptly relieved by the hypodermic in- jection of morphince sulphas , over its site, repeated as indicated, or the frequent use of small doses of pulvis ipecacuanhce et opii. In the very early stages of pleurisy the disease may be cut short by sodii salicylas, gr. xv-xx, well diluted, every three or four hours. In the stage of effusion excellent results follow the use of the salicylates. Salol, gr. x every three or four hours, is sometimes useful early in the disease. After effusion has begun extracium pilocarpi Jluidum, gtt. xx, every two or three hours, or in drachm doses every other day for a week or two, after which twice weekly ; or — R . Potassii acetat., gr. xxx Infus. digitalis, f^ij. M. Every three or four hours. Bowditch, of Boston, for years has advocated early aspiration in pleural effusion. If after three or four days no impression is made on the effusion by drugs, aspiration should be employed and table- spoonful doses of liquor ferri et ammonii acetatis ( Basham's mixture') administered every four hours, and an early morning dose of mag- nesii sulphas, ^ss-j. The effusion of pleuritis is rapidly removed by the method of treat- ment suggested by Prof. Matthew Hay, of Scotland, consisting in the use of a concentrated solution of saline cathartics: “ Order the patient to take nothing after the evening meal, and then, an hour or so before breakfast, the salt is given dissolved in as little water as possible. Usual dose from 3iv-vj to ^j-ij magnesii sulphatis to an ounce or two of water, no fluids to be used after the dose ; this usually produces from four to eight watery stools, without pain or discomfort, and also acts as a diuretic.” The essence of the “Hay method” consists in getting the concen- trated solution into the intestines at a time when the fluid contents are scanty. DISEASES OF THE PLEURA. 317 If the effusion is uninfluenced by the above named means, use potassii iodidum , gr. xv, every four hours, well diluted, with flying blisters over the affected side, or unguentum hydrargyri in the arm- pits, groins, and over the site of the effusion. In double pleuritic effusion , evacuate the fluid at once with the aspi- rator •, and use the potassium and digitalis mixture mentioned above. Chronic pleurisy : if the effusion be still serous, it is often absorbed by the internal use of potassii iodidum, alternating with “ Basham' s mixture ," and blisters, the secretions being watched. If, however, the liquid is pus {empyema), the aspirator should be used at once, the patient placed upon “ Basham s mixture," stimulants and quinina. Usually, however, within a very few days after aspiration, another accumulation of pus will have taken place. Should this occur, the purulent pleurisy should then be treated as an abscess, an incision being made between the fifth and sixth ribs, the pus evacuated, a drainage tube introduced, and an antiseptic dressing applied. If the tendency to pus secretion still remains, the pleural cavity must be washed out with an antiseptic solution, the constitutional treatment being continued. HYDROTHORAX. Synonym. Dropsy of the pleura. Definition. The effusion of fluid into the pleural cavities (bilat- eral), the result of a general dropsy from renal or cardiac disease. Pathological Anatomy. More or less clear serous fluid in both pleural sacs, compressing the lung. No signs of inflammation are present. Symptoms. Following dropsy of the abdomen occurs dyspnoea, with signs of deficient blood aSration, both lungs being compressed. Palpation. Absent vocal fremitus over the site of the fluid. Percussion. Dulness over the site of the fluid. Auscultation. Absent vesicular murmur over the site of the fluid. Diagnosis. Easily determined by association of the symptoms with a genera] dropsy. Prognosis. Controlled by the cause producing the general dropsy. Treatment. Depending upon the condition causing the dropsy. Dry cups over the chest afford relief. If the symptoms of non-aera- 318 PRACTICE OF MEDICINE. tion of the blood are severe, the fluid should be at once evacuated with the aspirator. PNEUMOTHORAX. Synonyms. Air in the pleural cavity ; hydropneumothorax. Definition. The accumulation of air in the pleural cavities, with the consequent development of inflammation of the membranes ; characterized by sharp pain, followed by rapidly developing dyspnoea and cough. Causes. Generally the result of tubercular phthisis, causing per- foration of the pleura. Perforation may take place from the pleura into the lung, in connection with empyema or abscess of the chest walls. Direct perforation from without, by laceration of a fractured rib oy severe contusion. Pathological Anatomy. The gas in the pleural cavity consists of oxygen, carbon anhydride, and nitrogen in variable proportions. It may fill the pleural sac completely, compressing the lung, or is sometimes limited by adhesions. The gas tends to excite inflamma- tion, the resulting effusion being either serous or purulent. Symptoms. Symptoms of pneumothorax, the result of perfora- tion, are sudden or sharp pain in the side, intense dyspnoea , attended with symptoms of collapse , coldness of the surface, and cold sweats. The above symptoms, in many instances, follow a severe or violent paroxysm of coughing. In severe cases there is never a moment’s cessation of the acute pain and distressing dyspnoea, causing orthop- noea from the onset until death. Inspection. Enlargement of the affected side, the intercostal spaces being widened and effaced or even bulged out so that the surface of the chest is smooth. Respiratory movements of the affected side are diminished or absent. Percussion. Immediately after the rupture the percussion note is hyper-resonant, or even tympanitic or amphoric in quality. If the amount of air in the pleural cavity becomes extreme, there is dulness on percussion, associated with a feeling of great resistance or density. When effusion of blood occurs, dulness is observed over the lower part of the chest, hyper-resonant or tympanitic percussion note over the upper portions of the chest, these sounds changing as the patient changes position. Auscultation. The normal vesicular murmur may be diminished DISEASES OF THE CIRCULATORY SYSTEM. 319 or absent. The typical amphoric respiratory sound is heard when the fistula is open, usually associated with a metallic echo. Metallic tinkling , or the bell sound, is sometimes distinctly pro- duced by breathing, coughing or speaking, after the development of inflammation of the pleura. The vocal resonance may be diminished or absent, or, rarely, it may be exaggerated, with a distinct metallic echo. After the development of inflammation in the pleura, suddenly shaking the patient gives rise to a splashing sensation , the succussion sound, if both air and fluid are present in the pleural cavity. Prognosis. When occurring as the result of tuberculosis, the prognosis is extremely unfavorable ; rarely, the fistulous opening being enclosed by inflammatory action ; the case then becomes one of chronic pleurisy. Treatment. At once a hypodermic injection of morphince sulphas , which relieves the severe pain and somewhat modifies the distressing dyspnoea, followed by the evacuation of the fluid and air with the aspirator. If the fistulous opening be closed by inflammatory action, the case resolves itself into one of chronic pleurisy, the treatment indicated for that affection plus the treatment of tuberculosis, being the indication. DISEASES OF THE CIRCULATORY SYSTEM. The methods employed in making a physical examination of the heart are : I. Inspection. II. Palpation. III. Percussion. IV. Aus- cultation. Inspection indicates the exact point of the cardiac impulse , and the presence or absence of any abnormal pulsations or any change in the form of the prcecordium. Normally the impulse is visible only in the fifth interspace , midway between the left nipple and the left border of the sternum, its area covering about one square inch, most distinct in the thin, while often barely seen in the very fleshy ; often displaced downward by full in- spiration and elevated by complete expiration. 320 PRACTICE OF MEDICINE. Disease may alter the position and area of the impulse. The position of the impulse is moved to the right by left pleuritic effusions ; downward by cardiac hypertrophy or pulmonary emphy- sema ; upward by a pericardial effusion. The area of the impulse is changed and enlarged by pericardial adhesions, cardiac dilatation, or hypertrophy. Palpation confirms the observations of inspection, and also deter- mines the force, frequency and regularity of the cardiac impulse. The force of the impulse is diminished by cardiac dilatation, fatty and fibroid degenerations of the heart, emphysema, pericardial effu- sion, and adynamic diseases. The impulse is increased by cardiac hypertrophy, during the first stage of endocarditis and pericarditis, functional cardiac disturbances and sthenic inflammations. Percussion will determine the boundaries of the superficial and deep cardiac space, the so-called prcecordium. It is essential that the upper, lower, and two lateral boundaries of the pericardial region be memorized, to wit : superior boundary , the upper edge of the third rib ; the lower boundary is a horizontal line passing through the fifth intercostal space ; the left lateral boundary is about or a little within a vertical line passing through the nipple, the line a mammalis ; and the right lateral bowidary is an imaginary vertical line situated one- half an inch to the right of the sternum. These boundaries vary somewhat in health/but are sufficiently accurate for all practical purposes. The superficial cardiac space represents that portion of the heart uncovered with lung ; it is triangular in form, its apex being the junc- tion of the lower border of the left third rib with the sternum, its area not exceeding two inches in any direction. The superficial space is increased by cardiac hypertrophy, dilata- tion or pericardial effusion. Diminished at the end of full inspiration or by emphysema. The deep cardiac space represents that portion of the heart covered by lung, and extends from the upper border of the third rib to the lower edge of the fifth interspace, and from half an inch to the right of the sternum to near the left nipple. It is increased by hypertrophy or dilatation of the heart, left pleuritic effusion, and apparently increased by consolidation of the anterior border of the investing lung. DISEASES OF THE CIRCULATORY SYSTEM. 321 Auscultation indicates the character of the normal cardiac sounds, and the point at which they are heard with greatest intensity, and should be thoroughly familiarized if abnormal sounds are to be fully appreciated. The ear or stethoscope applied to the prsecordium distinguishes in health, two sounds, separated by a momentary silence — the short pause, and the second sound followed by an interval of silence---^ t0 which may be added with advantage atropince sulphas , gr. hypodermically, or nitro-glycerm , gr. j-oo ~ts~wu> every three or four or five hours. In many cases the use of gr. of this powerful drug, three or four times a day tor a long time, lessens not only the frequency but the severity of the paroxysms. Chlorodyne , rr\, x-xv, repeated, often answers well. Chloroformmn has proven prompt, efficient, and harm- less administered as suggested by Balfour, viz. : “ a half drachm is poured upon a sponge at the bottom of a wide-mouthed bottle, from which the patient may breathe ad libitum .” Dr. William Evans recommends sparteince sulphas , gr. ^ t. i. d. t between attacks to pro- long the interval and lessen the severity of the paroxysms. ARTERIOSCLEROSIS. Synonyms. Atheroma ; anterio-capillary fibrosis (Gull and Sutton) ; endarteritis chronica deformans (Virchow). Definition. An overgrowth of the connective tissue of the arteries followed with calcareous deposits. The changes may extend to the capillaries and veins. As a result of the impairment of the arterial circulation occur fibroid degenerations in other organs, resulting in loss of elasticity in the walls of the vessels, increase of arterial ten- DISEASES OF THE CIRCULATORY SYSTEM. 359 sion, narrowing of the calibre of smaller arteries, and impairment of the nutrition of the organs supplied. Causes. Old age, alcoholism, syphilis, lead-poisoning, diabetes, malaria, rheumatism. Heredity is a predisposing factor in some cases. Chronic nephritis. More common in men than in women. Pathological Anatomy, The atheromatous changes are most frequent in the aorta. Other arteries affected are the coronary, the radial, ulnar, brachial, iliac, femoral, and the arteries of the brain. The internal surface of the affected vessel is irregularly thickened with either gelatinous and translucent, or dense and fibrous or calcareous, deposits or products. If the calcification is extensive, the vessel is changed into a hard, stiff tube. Often the surface of the thickening or deposit is destroyed, presenting the so-called “ Athero- matous ulcers,” which may be covered with masses of thrombus. The above changes are the result of inflammatory change in the intima of the affected vessel. This appears three or four times as thick as normal, due to the swelling of its elements, the new growth of connective tissue, and the deposit of round cells. Fatty degenera- tion of the inflammatory products results. The result of the changes in the arteries is a loss of their elasticity, thus hindering the propulsion of the blood current and raising the arterial tension, leading to hypertrophy of the left ventricle. The changes finally affecting the coronary arteries lead to changes in the myocardium. If the intima of the smaller vessels be involved the blood supply to the organs supplied is lessened, resulting in disturb- ance of their nutrition. Symptoms. Not always apparent. The symptoms vary with the arteries involved and the organs whose blood supply is lessened or cut off. Cardiac hypertrophy from the increased resistance to the arterial circulation. The peripheral arteries involved in the atheromatous changes can be determined by palpation, they having a hard, bony feeling, much like a whip-cord. Attacks of vertigo, pseudo-apoplectic attacks, or spells of uncon- sciousness in the aged or those having superficial hardened arteries are generally due to changes in the cerebral vessels. Evidences of myo- carditis and angina pectoris point to atheroma of the aorta and cor- 360 PRACTICE OF MEDICINE. onary arteries. Gangrene of the extremities in the old — senile gan- grene — point to atheroma or thrombi, the result of the fibrosis. Palpation. Hard, superficial arteries, those at the wrist feeling like a string of beads, pulsating. The cardiac impulse is forcible in the early stages. Percussion. Increased prsecordial dulness, particularly over left ventricle. Auscultation. In the early stages the first sound of the heart is prolonged, the second sound accentuated over the aortic cartilage. As the heart dilates and the walls become diseased, the sound be- comes feeble and often irregular and intermittent. Diagnosis. Only determined by a close study of the various symptoms and sequels. Prognosis. Incurable. Treatment. Entirely symptomatic. No remedy can remove the fibroid changes. ANEURISM OF THE AORTA. Varieties. I. Aneurism of Jhe arch of the aorta. II. Aneurism of the thoracic aorta. III. Aneurism of the abdominal aorta. The arch of the aorta is divided by Gray into three parts, the ascending, the transverse, and the descending. The ascending portion is two inches in length, arising from the left ventricle, on a level with the lower border of the left third costal cartilage, behind the left edge of the sternum. It ascends obliquely upward to the right to the upper border of the right second costal- sternal articulation. The transverse portion commences at the upper border of the right second sternal articulation, and, arching to the left and forward, passes in front of the trachea and oesophagus to the left of the third dorsal vertebra. The descending portion extends down- ward to the left side of the fourth dorsal vertebra. The thoracic aorta extends from the left lower border of the fourth dorsal vertebra, and ends in front of the body of the twelfth dorsal vertebra, at the aortic opening in the diaphragm. The abdominal aorta begins at the aortic opening in the diaphragm, descends a little to the left side of the vertebral column, and termi- nates over the body of the fourth lumbar vertebra, where it divides into the two common iliac arteries. DISEASES OF THE CIRCULATORY SYSTEM. 361 Definition. A circumscribed dilatation of some portion of the aorta, the result of disease of the vessel wall weakening its resistance to the blood pressure. Causes. Those causing arterio-sclerosis are the chief causes. Exertion is an exciting cause. Aneurisms occur in early middle life rather than in old age, when the force of the heart has decreased. More common in men than in women. Pathological Anatomy. All aneurisms may be divided into two classes, dissecting and circumscribed. Dissecting Aneurism — false aneurism — is the result of fatty changes in the internal and middle coats of the artery. The shape may be sacculated, fusiform, or cylindrical. A disease of the aged. Cir- cumscribed Aneurism may be true or false, depending on the rupture of the walls or not. It is a disease of middle life or under. Most frequent in men, usually a true dilatation. Syphilis is a most frequent cause. ANEURISM OF THE ARCH. Symptoms. The onset is usually gradual, with evidences of arterio-sclerosis and failing health. Pain , either paroxysmal or constant, is a constant symptom, with increasing dyspnoea. The difficulty in breathing may be constant with exacerbations, or it may be remittent. Rarely dysphagia occurs. A slight cough from pressure on the laryngeal nerve with more or less alterations in the voice may be present. The pupils are dilated or contracted or are irregular, in some cases due to pressure on the sympathetic nerve. There is a gradual loss of flesh, disorders of the circulation, and a careworn expression of the face. Inspection. Negative until the appearance of a pulsating tumor. Palpation. A pulsation over the tumor expansive in character (Corrigan’s Sign). If the aneurism is situated at the transverse portion of the arch, the left pulse and the left carotid are smaller and weaker than those on the right side. Tracheal tugging is a diagnostic sign (Page). “ Place the patient in the erect position with his mouth closed and chin elevated to the fullest extent. Then, on grasping the cricoid cartilage between the fingers and thumb and making gentle traction up- ward, the pulsations of dilated aorta or aneurism, if any exist, will be distinctly felt, in most cases transmitted through the trachea to the hand.” 30 362 PRACTICE OF MEDICINE. Percussion. Dulness, the extent depending on the size of the tumor. Dulness, other than cardiac, across the sternum is diagnostic of a mediastinal tumor. Auscultation. Over the tumor a murmur or bruit is usually- heard, synchronous with the first sound of the heart. It is louder than the systole, lower in pitch, and of a blowing character. Diagnosis. If the tumor can be seen or felt, the diagnosis is made, its location being determined by a study of the physical signs. ANEURISM OF THE THORACIC AORTA. Symptoms. The most constant symptom is deep-seated thoracic pain, constant or paroxysmal. Dysphagia is a frequent condition. There is seldom dyspnoea, and alteration of voice and pupils does not occur. Physical Signs are usually wanting, and the diagnosis is rarely made during life. ANEURISM OF THE ABDOMINAL AORTA. Symptoms. The chief and most constant symptom is pain at a circumscribed spot in the abdomen, or diffused. Other symptoms depend upon the location of the aneurism, as they are the result of pressure. There is a gradual loss of health. Inspection. Usually negative unless the aneurism reach an enormous size. Palpation. A pulsating tumor in the abdomen to the left of median line. The pulsation is synchronous with the first sound of the heart, and is expansile (Corrigan’s sign) in character. Percussion. Dulness may be elicited if the tumor is large and the abdomen emaciated. Auscultation. Rarely a murmur or bruit is heard, systolic in time. Diagnosis. Abdominal aneurism and pulsating abdominal aorta may be mistaken for each other. The point of difference is in the aneurism the presence of the tumor with an expansile pulsation, while in pulsating abdominal aorta the beating is like a pulsating cord, an up-and-down movement, not expansile. The condition of the patient is also important ; aneurism in males, at middle life, with changes in the vessels ; abdominal pulsation occurring in nervous women or effeminate men. DISEASES OF THE NERVOUS SYSTEM. 363 Tumors located over the abdominal aorta may give rise to an ap- parent pulsation, causing them to be mistaken for an aneurism. The rule is in all cases of abdominal pulsation to place the patient in the knee-chest position ; if the tumor is aneurismal, the expansile pulsation continues ; if not an aneurism but a cancer, impacted fasces, or other tumor, the pulsation at once ceases. Prognosis of Aortic Aneurisms. Unfavorable. The duration of life after the development of the aneurism is from one to four years. Treatment. A persistent effort should always be made to pro- mote clotting in the sac and the contraction of the tumor. The so-called Tufnell’s method is the most successful for this pur- pose, its aim being to diminish the force and rapidity of the circula- tion, and, if possible, to increase the fibrinous deposit. Its essential element is absolute rest of mind and body and a restricted diet ; the patient is kept absolutely in bed day and night, for at least three months, and placed on the following diet : Breakfast — two ounces of bread with butter and two ounces of milk ; dinner — two or three ounces of bread, same amount of meat, and two to four ounces ot milk or claret wine ; supper — two ounces of bread with butter and two ounces of milk. At the same time potassii iodidum is administered in increasing doses to the physiological limit. Galvano-puncture is said to do good in some cases ; two needles inserted into the aneurism are connected with the poles of a galvanic battery, and a weak current is passed through the tumor. The various symptoms are to be met with their appropriate reme- dies, always having in mind the condition of the arterial wall allowing the rupture and dilatation. DISEASES OF THE NERVOUS SYSTEM. The diseases of the nervous system will be described under the following named headings : — I. Diseases of the cerebral membranes. II. Diseases of the cerebrum. III. Diseases of the spinal cord. IV. Diseases of the nerves. V. General or nutritional diseases. VI. Mental diseases. 364 PRACTICE OF MEDICINF. DISEASES OF THE CEREBRAL MEM- BRANES. PACHYMENINGITIS. Synonyms. Meningitis ; haematoma of the dura mater. Definition. Inflammation of the dura mater ; when the external layer is primarily involved it is termed pachymeningitis externa ; when the internal layer is primarily involved it is termed pachymen- ingitis interna . Causes. Pachymeningitis externa is a surgical malady, excited by fractures, penetrating wounds, and other injuries of the skull. Pachymeningitis interna is due to blows upon the head without injury to the skull. A predisposition may be created by chronic al- coholism, scurvy, Bright’s disease, and syphilis. Chronic internal otitis and suppurative inflammation of the orbit may cause it, also in- flammation in the venous sinuses the result of a thrombus undergoing suppurative changes. Pathological Anatomy. Pachymeningitis interna. Hyper- aemia of the membrane, followed by an exudation which develops into a membranous new formation, containing a great number of vessels of considerable size but having very thin walls. Hemor- rages from these new vessels are of frequent occurrence, which in- crease the size and thickness of the neo-membrane. The usual position of the neo-membrane or new formation is on the upper surface of the hemispheres, extending downward toward the occipital lobe. The changes in the adjacent portion of the brain are dependent on the size and thickness of the neo-membrane. Bartholow observed a case in which the “cyst” was half an inch in thickness at its thickest part, and it depressed the hemisphere corres- pondingly, the convolutions being flattened, the sulci almost obliter- ated, and the ventricle lessened one-half in size. In Pachymeningitis syphilitica, the pathological lesion is in the form of gummatous tumors or masses which may degenerate and become either cheesy masses or be converted into a purulent-looking fluid. In old age the dura mater becomes thick, cartilaginous, and of a dull white color. The sheaths of the arteries are also thickened. DISEASES OF THE CEREBRAL MEMBRANES. 365 Symptoms. Very obscure ; principally those of cerebral pres- sure. Cases of persistent headache , vertigo , photophobia, anorexia, insomnia, gradual impairment of intellect and locomotion, followed by delirium, and convulsions and coma , or by apoplectic attacks and paralysis ; in the aged, or those in whom some one of the causes of the affection are present, an inflammation of the dura mater may be suspected. Circumscribed painful oedema behind the ear and less fulness of the jugular of the corresponding side, the phlegmasia alba dolens en miniature of Griesinger, are indicative of thrombosis in the transverse sinus, as was first shown by Virchow. Diagnosis. Always problematical, as the symptoms are masked and so obscure that a positive diagnosis is impossible. Prognosis. Most unfavorable for either forms, although the course of the malady is usually slow. Surgical treatment in traumatic cases offers some hope. Treatment. Pachymeningitis externa is to be treated surgically. Trephining is indicated in some cases. It is claimed that benefit has followed a thorough course of potassii iodidum. In the great majority of cases, however, all that can be done is to treat symp- toms. ACUTE MENINGITIS. Synonyms. Acute Leptomeningitis ; cerebral fever ; arachnitis. Definition. An acute exudative inflammation of the cerebral pia mater and arachnoid membranes, usually limited to the convexity of the cerebrum ; characterized by fever, vomiting, headache, delirium, and followed by symptoms of general collapse. Causes. During the course of the acute infectious diseases; ery- sipelas ; associated with or a sequela of influenza. Cerebral overwork ; prolonged wakefulness; acute alcoholism; exposure to the sun; disease of the internal ear ; secondary to diseases of serous mem- branes. Most frequent in early adult life and in young children, and in males rather than females. “The micro-organisms found in meningitis are the pneumococcus, streptococcus pyogenes, intracellular diplococcus, the pneumo-bacil- lus, and a bacillus resembling that of typhoid fever.’’ (Dana.) Pathological Anatomy. The inflammatory changes may be limited either to the convexity or to the base of the brain , but more frequently both portions are involved. 366 PRACTICE OF MEDICINE. Intense hypercemia of both membranes, followed by a purulent and fibrinous exudation. The ventricles may be filled with fluid, com- pressing and flattening the convolutions. In 25 post-mortem examinations at the Philadelphia Hospital a meningo-encephalitis was present in 14. Symptoms. Vary according to the stages : — Prodromes ; headache , vertigo , cerebral vomiting , more or less feverishness , continuing from a few hours to one or two days, when occurs the Stage of Invasion ; onset sudden, with chill, high fever , io3°-io4° pulse 1 00- 1 20, face flushed , with congested eyes , headache , most intense and continuous, ringing in the ears, photophobia , vertigo , the nausea aggravated, projectile vomiting , with delirium. Stage of Excitation ; general sensibility of the body increased, sensitiveness to light, and acuteness of hearing, delirium furious, often resembling mania, continual jerking of the limbs, oscillations of the eyeballs — nystagmus — twitching of the muscles of the face, followed by powerful contractions of the flexor muscles, even to the extent of opisthotonos, and in children convulsions. Duration, from one day to a week or two. The finger drawn across the surface leaves a red line, the tache cerebrale. Stage of Depression or Collapse ; the patient gradually becomes more quiet, the delirium subsiding, as well as the muscular agitation ; somnolence develops, passing into coma , at times temporary conscious- ness, coma soon following again ; pulse irregular and slow, fever less ; various palsies , to wit : strabismus, ptosis, pupils uninfluenced by light, mouth drawn to one side, urine and faeces involuntarily dis- charged. Death following, either by convulsions or by deepening coma with cyanosis. Diagnosis. The characteristic symptoms indicating the existence of acute meningitis are headache , vomiting , fever and delirium , all developing rather rapidly. The headache is most persistent, the vomiting not due to gastric trouble. The absence of any one of the four characteristic symptoms named above does not prove the absence of meningitis, nor does the combination of delirium and fever alone determine the presence of meningeal disease. Cerebro-spinal fever closely resembles acute meningitis, the points of distinction between which are the first named occur- DISEASES OF THE CEREBRAL MEMBRANES. 367 ring epidemically, associated with marked spinal symptoms and an eruption. Meningitis and abscess of the brain are apt to be mistaken for each other, the differential diagnosis being pointed out in that disease. The cerebral symptoms of rheumatism are differentiated from idio- pathic meningitis by the association of the joint trouble. Cerebral symptoms of typhoid and typhus fever have a close resem- blance to idiopathic meningitis, and are only determined by a study of the clinical history. In acute urcemia the face is turgid, cedematous, with puffiness of the eyelids ; in meningitis the face is pale and no oedema ; uraemia has decided albuminuria ; it is slight or absent in meningitis ; meningitis has chills followed by fever ; uraemia has irregular temperature record rapidly rising to 104° F.-106 0 F., and dropping to 99 0 F., to as rapidly rise again, and usually associated with convulsions. In deliriwn tremens the delirium is a busy one, the patient imagin- ing persons and animals around him, and is wild in his gestures and utterances ; the temperature is normal or subnormal, the skin wet and clammy. In meningitis the delirium is mild but incoherent, the sur- face is hot and dry, and there is severe vomiting and headache. Prognosis. Not very favorable. If recognized early and treated, a fair number of recoveries occur, but it usually leaves the patient subject to attacks of epilepsy or with a persistent headache, and more or less mental impairment. Treatment. Must be prompt and energetic from the onset. At once, active purgation by oleum tiglii. gtt. ij, glycerinum , n\,v, dropped on the tongue ; and if the urinary secretion be scanty, dry cups or digitalis poultices over the kidneys. In vigorous subjects a copious venesection ox leeches applied behind the ears, to the temples, or the nuchal region, followed by the appli- cation of cold to the head ; that it may be thoroughly applied, the head should be shaven. Control the active circulation by aconitum in full doses, frequently repeated, combined with potassii bromidum , gr. xx-xl, or use extrac- tum ergotce Jluidum , f^ss-j every few hours. The cerebral circulation may be markedly influenced by compression of the carotids. The apartment should be cool, the air pure, the patient’s head elevated. The diet should be nutritious but easy of assimilation. 368 PRACTICE OF MEDICINE. The secretions must be carefully watched, the catheter being fre- quently used during the stage of collapse. For the vomiting use chloral , gr. iij-v, per mouth, diluted with aquae menthae f^ss, repeated in half hour and p. r. n., or by enema in doses of gr. x-xv. The most refractory vomiting, of whatever cause, will yield to a few doses of this drug. If the case show a disposition to linger, small doses of hydrargyri chloridum mite or potassii iodidum are of benefit. Third stage : Free stimulation , nutritious food, ferri iodidwn and flying blisters. TUBERCULAR MENINGITIS. Synonyms. Basilar meningitis ; acute hydrocephalus. Definition. An inflammation of the leptomeninges (soft mem- branes), more particularly the basal pia mater, attended with or due to the deposit of gray miliary tubercle; characterized by gradual decline of the bodily and mental powers. Causes. Usually a secondary affection, a sequel to tubercular disease of some other organ. Most frequently occurs in children between two and six years of age, although numerous cases are reported occurring between twenty and thirty years ; scrofulous diathesis; inherited diathesis. The “gelatinous children of album- inous parents,” as the phrase goes, possess a special susceptibility to tubercular meningitis. Pathological Anatomy. The deposition of tubercle usually occurs at the base of the brain. Depositions of grayish-white granules, of a translucent, somewhat gelatinous appearance — rniliary tubercle, are distributed along the vessels of the pia mater, resulting in inflammation and the exudation of lymph, with the consequent thickening and opacity of the mem- branes. The cerebral tissue is not usually involved, although on section the lines indicative of blood vessels are very much increased in number. The ventricles are distended by a clear, or milky, or even bloody serum. Tubercular deposits occur in the lungs, intestines, and, at times, in other organs. The presence of the tubercles alone may give rise to no symptoms until the exudative products of the resultant inflammation develop. DISEASES OF THE CEREBRAL MEMBRANES. 369 Symptoms. The advent is either gradual and insidious, or with convulsions, in which cases the after progress is rapid. Prodromes : the child grows irritable, with loss of appetite, loss of flesh, swollen abdomen, constipation alternating with diarrhoea, irreg- ular attacks of feverishness, with attacks of grinding its teeth during sleep, or sleeplessness. Headache occurs, as shown by the child, even when at play, suddenly stopping and resting its head on its hand or on the floor. Duration of this stage is from one week to a month or two. Stage of excitation : the onset is rather sudden, with obstinate vomiting , severe headache , convulsions , fever , io 2 °-io 3 ° in the even- ing, falling to 99 0 in the morning, pulse soft and compressible, with irregular rhythm. On drawing the finger nail lightly over the surface a red line results, “the cerebral stain ” of Trousseau. The symp- toms grow progressively worse with exaltation of the special and general senses ; the least pinch or even touch causing exquisite pain ; spasmodic movements of the muscles , with contraction and rigidity , at times opisthotonos. Duration of this stage is about two weeks. Stage of depression ; the result of the pressure of the exudation ; the pulse slow and compressible, with irregular rhythm ; temperature de- pressed ; tendency to somnolence alternating with quiet delirium » mental stupor, continual movement of the fingers, as in picking up objects ; convulsions from time to time, strabismus, oscillation of the eyeballs, followed by intervals of wakefulness, when the headache is excruciating, causing the peculiar, unearthly shrill cry or shriek, “ the hydrocephalic cry,” associated with contraction of the muscles of the face, as if suffering were experienced ; finally collapse , occurring with the “ Cheyne-Stokes ” respiration, the coma deepening, followed by death, convulsions often ending the scene. Duration, from a day or two to two weeks. Diagnosis. Acute meningitis and tubercular meningitis have closely analogous symptoms during the stage of excitation, but the history and clinical course of the two maladies determine the diag- nosis. Prognosis. Unfavorable. Usual duration, three or four weeks after fully developed prodromes. If ushered in by convulsions the duration is shorter. Treatment. Most unsatisfactory. No means of retarding the 3i 370 PRACTICE OF MEDICINE. disease. Treat symptoms as they develop. Blisters, leeches, active purgation, pustulating ointments, potassii iodiduvi and hydrargyrum , are all useless. If the hereditary tendency be marked, nutritious food, olewn mor- rhuce , ferri iodidum and quinina may somewhat delay the develop- ment of the affection. DISEASES OF THE CEREBRUM. CONGESTION OF THE BRAIN. Synonyms. Cerebral hyperaemia ; cerebral congestion. Definition. An abnormal fulness of the vessels (capillaries) of the brain ; active , when arterial fulness ; passive , when venous ful- ness ; characterized by headache, vertigo, disorders of the special senses, and if the hyperaemia be decided, convulsions. Causes. Active. Increased cardiac action, the result of hyper- trophy of the left ventricle ; general plethora; excesses in eating and drinking ; acute alcoholism ; sunstroke ; prolonged mental labor ; diminished amount of arterial blood in other parts, the result of the compression of the abdominal aorta ; ligation of a large artery, and the suppression of an habitual bleeding hemorrhoid are examples. Passive. Dilatation of the right heart ; pressure upon the veins returning the cerebral blood. While congestion of the brain is not so common as was once sup- posed, the view that it cannot occur is disproven by the results follow- ing the inhalation of a full dose of amyl nitris. The relief of head symptoms after a free epistaxis and the distress resulting if it does not occur is another instance. Pathological Anatomy. The post-mortem appearances are, overloading of the venous sinuses and of the meningeal vessels, in- cluding the finer branches ; the pia mater appears vascular and opaque ; the gray matter of the convolutions unduly red ; the convo- lutions may be compressed and the ventricles contracted, with the displacement of a corresponding amount of cerebro-spinal fluid. Long continued or repeated congestions lead, to enlargement and DISEASES OF THE CEREBRUM. 371 tortuosity of all the vessels, a moist and slimy condition (oedema) of the cerebral substance, and an increase in the sub-arachnoid fluid. Symptoms. “Rush of blood to the head ” may be gradual or sudden in its onset, the symptoms aggravated by the recumbent position. Headache , with paroxysmal neuralgic darts, disorders of vision and hearing , buzzing in the ears and sparks before the eyes, contracted pupils, vertigo , blunted intellect , inability to concentrate the mind, irritable tejnper and Curious hallucinations. The face is red , the eyes congested , and the carotids pulsating. The sleep is dis- turbed by dreams and jer kings of the limbs. If the attack be sudden (apoplectiform), sudden unconsciousness with musciilar relaxation occur. Cerebral hyperaemia in children often presents alarming symptoms, such as great restlessness, insomnia , night terrors , gnashing of the teeth during sleep, vomiting, contraction of pupils followed by general convulsions. Any or all of these symptoms may continue more or less marked from an hour or two to a day, the child enjoying its usual health, after a sound sleep, save some fatigue. Prognosis. Mild cases terminate favorably in a few hours to a day or two, but show a strong tendency to recur. Severe cases (apo- plectiform) may terminate in health, but usually foretell cerebral hemorrhage. The passive form is controlled by the lesions giving rise to it. Treatment. Active form. Remove the cause if possible. Elevate the head and apply cold, either cold cloths or the ice cap, at the same time warmth to the feet. Leeches to the mastoid, or cups to the neck, or in the apoplectiform variety venesection, to diminish the intercranial blood pressure ; compression of the carotids, or l : gatures about the thighs, have been recommended. An active purgation is indicated, either by oleum tiglii, or magnesii sulphas, by the mouth. The following enema is often valuable : (R . Magnesii sulphatis, ^ij ; glycerini, f J j ; aquae bul., f^iv. M., and ad- minister per rectum with little force ) In mild cases the application of an ice cap to the head, sin apis to the nucha, and potassii bromidum, gr. xxx-xl, repeated, and the enema mentioned, control the symptoms. Extractum ergotce pluidum is strongly recommended, but its value seems to be overestimated. In severe cases, with forcible overacting heart, to the above means must be added tinctura veratri viridis or tinctura aconiti. Passive form. Becomes a part of the treatment producing the stasis. 372 PRACTICE OF MEDICINE. CEREBRAL ANAEMIA. Definition. An abnormal decrease in the quantity of blood in the cerebral vessels ; general, when the diminished supply includes all the vessels ; partial , when the diminished supply is limited in area ; char- acterized by pallor, headache, vertigo, some loss of power, and, rarely, convulsions. Causes. Partial cerebral anaemia results from obstruction of a vessel, from embolism or thrombosis. General cerebral anaemia results from hemorrhages, wasting diseases, during convalescence from severe attacks of fevers, sudden shock, feeble cardiac action and general anaemia. Pathological Anatomy. The blood in the brain is contained in arteries, capillaries, and veins. The functional condition of the brain depends on the quantity and quality of the blood circulating in the cerebral capillaries. Any decrease in the normal quantity or impairment in the quality produces the symptoms of cerebral anaemia. The brain is pale and milky in color, and on transverse section there are no bloody points; the ventricles and perivascular lymph spaces are well filled with fluid. In partial anaemia the local conditions differ somewhat from the above. Symptoms. General : headache, relieved by the recumbent position ; vertigo, aggravated by exertion ; general pallor and anae- mia, with attacks of fainting ; when the general cerebral anaemia is sudden and decided, convulsions occur. Partial ancemia ; sudden loss of power, of limited muscular area, gradually returning to the normal condition. Prognosis. Favorable in all cases save those the result of severe and repeated hemorrhages. Treatment. Regulated nourishment, with stimulants. A certain number of hours daily in the recumbent position is of advantage. When a tendency to attacks of swooning exists, stimulants or even the cautious inhalation of amyl nitris are indicated. To improve the quantity or quality of the blood — R. Tinct. ferri chlor., rr^xv Acid, phosph. dil., rt\,v Liq. arsenici chloridi, TT^iij Syr. limonis, ff\,xx Syr. zingiberis, q. s. ad . gij. Sig. — E very six hours, well diluted. M. DISEASES OF THE CEREBRUM. 373 Or — R. Strychninse sulph., gr. j Quininse sulph., gr. xlviij Acid, hydrochloric! dil. f% ij Tinct. gentian, comp., f ^ iij Tinct. card, comp., q. s. ad . f vj. M. SlG. — Teaspoonful in water after meals. CEREBRAL HEMORRHAGE. Synonym. Apoplexy ; “ a stroke.” Definition. The sudden rupture of a cerebral vessel and escape of blood into the cerebral tissue, causing pressure and more or less destruction of the brain substance ; characterized by sudden uncon- sciousness, irregular, noisy respiration and complete muscular relaxa- tion. Causes. Rare under forty years of age, The principal cause is disease of the vessels — the development of miliary aneurisms, or a chronic endarteritis with an associated cardiac hypertrophy ; heredi- tary tendency ; Bright’s disease ; syphilis ; alcoholic and dietary ex- cesses; gout. More frequent in the spring and autumn. Pathological Anatomy. The most common locations of cere- bral hemorrhage are the internal capsule , corpus striatum and thala- mus opticus ; less common the anterior and middle cerebral lobes and the cerebellum ; next in frequency the pons and medulla oblongata ; and rarely on the convexity of the brain, termed meningeal hemorrhage. When the hemorrhage is large, the blood may break into the ven- tricles and pass by the iter from the third to the fourth ventricle. A recent clot is dark in color, and in consistency a soft, grumous mass, composed of coagulated blood and brain substance in varying proportions, at whose centre is the opening into the ruptured vessel. The ^/excites inflammation around it, resulting in its being encysted, by the development of new connective tissue from the neuroglia, and then gradually absorbed, leaving a cicatrix ; or the brain tissue around the clot softens and degenerates — localized softening. Symptoms. The attack may occur suddenly as an apoplectic shock or stroke or slowly with prodromes or “ warnings.” Prodromes. Headache, vertigo, transient deafness or blindness, sensations of numbness of the extremities, with local palsies, together with the constant dread of an attack. 374 PRACTICE OF MEDICINE The attack begins with vomiting , followed by either partial or com- plete insensibility ; respiration slow, irregular and noiy ; during the inspiration the paralyzed cheek is drawn in, and puffed out in expira- tion ; pulse slow and full ; pupils uninfluenced by light, the face flushed, the eyes congested and the carotids throbbing ; the tempera- ture declines below the norm, a degree or two, but rises within twenty- four hours to ioo° F.-101 0 F. In fatal cases the temperature may rapidly rise to 107° F.-108 0 F. The muscular system is profoundly relaxed, and the reflex move- ments are abolished. The head and eyes deviate , in many cases, toward the affected side in the brain or from the paralyzed side. Rarely convulsions occur. Ingravescent apoplexy begins as a mild stroke with a rapid return of consciousness and power, except, perhaps, of speech. Headache is present with some one or more local symptoms and in a few hours to a few days consciousness gradually becomes impaired, the loss of power again occurs, the coma deepens, the patient dying comatose. If the unconsciousness continues longer than twenty-four hours, death is the usual termination, preceded by pale face, irregular and rapid pulse and respiration, and rise of temperature. Reaction obtains in from a half to three hours, consciousness re- turning, reflex excitability reviving, associated with headache, con- fusion of mind, and more or less paralysis of motion and sensibility of one side of the body, termed — hemiplegia. The electro-excitability of the paralyzed parts is preserved. Recovery may be delayed by inflammatory symptoms, the tem- perature rising to ioi°-io4° F., with tonic contractions {early rigidity) of the paralyzed muscles and severe neuralgic pains. Localization of the lesion of a cerebral hemorrhage is of great practical importance. Capsular hemorrhage y the most frequent, causes loss of conscious- ness, of sudden or rapid onset, hemiplegia, involving face, arm, and leg, with motor aphasia if the hemiplegia be on the right side. There is also a unilateral loss of reflex action, conjugate deviation of the eyes from the paralyzed side and unilateral defective movement with flaccidity of the limbs. Cortical hemorrhage , localized unilateral paralysis of the face, the arm, or the leg, with local convulsions or convulsions that have a local beginning, or profound unconsciousness. DISEASES OF THE CEREBRUM. 375 Centrum ovale hejnorrhages resemble the cortical with the local convulsions. Crus-cerebri hemorrhage , loss of consciousness with hemiplegia in- volving the lower half of the face and the limbs, with paralysis of the third nerve on the opposite side, or the side of the lesion. The uni- lateral third nerve symptoms are ptosis, external strabismus, dilatation of the pupil, and loss of accommodation for near objects. The paraly- sis is termed “ crossed ” or “ alternate ” hemiplegia. Pons hemorrhage causes either general convulsions or irregular con- vulsions in the legs, bilateral motor paralysis, bilateral anaesthesia, either contracted or dilated pupils, embarrassed respiration, repeated non-gastric vomiting and high temperature. If the hemorrhage is large, death is sudden or within a few hours, and even if small the prognosis is unfavorable. Ventricular hemorrhages are generally of the ingravescent variety and are characterized by a second apoplectic seizure soon after the first, with extension of the hemiplegic symptoms or a relaxation of the muscles from one side to both sides of the body. Cerebellar hemorrhage varies so greatly in the symptoms that a positive diagnosis can seldom be made. Meningeal or dural hemorrhage , usually due to a trauma. Two varieties : I. Infantile meningeal hemorrhage , occurring during labor. II. Extra-dural he7norrhage the result of direct injury to the head. The infantile variety presents symptoms of irritation and compres- sion of the cortex such as convulsions, general or unilateral, rigidity, opisthotonos, and either hemiplegia or diplegia. The extra-dural variety is almost always the result of fracture or trauma of the skull, resulting in an extravasation of blood between the dura and the skull from the middle meningeal artery ; the hem- orrhage may be on one or both sides. The symptoms may develop at once or after some days, and are those of pressure, hemiplegia, partial or complete, convulsions, impaired or absent reflexes, dila- tation with loss of reaction of pupil of opposite side, stupor gradually deepening into coma and death. Sequelse. Paralysis of the muscles of the face, tongue, body and extremities of one side, opposite to the location of the hemorrhage, termed unilateral paralysis or right or left hemiplegia. Paralysis of both sides of the body, due to simultaneous hemorrhage on both sides, termed bilateral hemiplegia , or diplegia. PRACTICE OF MEDICINE. 376 Paralysis of one side of the face and the extremities of the opposite side, due to hemorrhage into the pons Varolii , termed alternating or crossed paralysis. Occasionally tonic contractions occur in muscles long paralyzed, termed late rigidity , and is evidence of a secondary degeneration of the nerve fibres. Choreic movements in paralyzed muscles are termed post-hemi- plegic chorea , due, according to Charcot, to changes in the motor centres. The mental powers are always more or less permanently impaired, the patient irritable and emotional, and the same holds good concern- ing the memory. Diagnosis. The diagnosis of the apoplectic seizure is often one of the most difficult questions in medicine, and yet of the greatest importance as the treatment hinges on it. The diagnosis of the sequelae is comparatively easy. I?isensibility from drink differs from apoplexy in the following points, to wit : insensibility is not so complete, no drawing in and puffing out of one cheek with respiration, the pulse frequent instead of slow, the pupils influenced by light ; upon raising both legs no difference is apparent on allowing them to drop ; the eyes and head are not turned to one side, and lastly, the condition is ameliorated on the inhalation of ammonia. I have satisfactorily used Dr. von Wedekind’s test for temulence, to wit: “By simply pressing on the supraorbital notches with a steadily increasing force you may, with certainty of success, bring an unconscious alcoholic to his senses, and thus differentiate between alcoholic and other comas.” Opium poisoning differs from apoplexy by the gradual approach of the coma, and that the patient can be momentarily aroused, and also by the absence of the heavy stertor of apoplexy. Urcemia causes a coma that closely resembles apoplexy. A history of Bright’s disease at once clears up the case ; again, uraemic coma is generally preceded by convulsions, a rapid rise of temperature as shown by the thermometer, often 104° F. to 106° F., while to the hand the surface appears but little, if at all, above the normal ; the pulse is usually weak with irregular force, the respirations averaging twenty- five to thirty per minute, the face having a glossy appearance. Cerebral embolism cannot always be differentiated from apoplexy. We may suspect cerebral plugging, if the patient be young ; if he be DISEASES OF THE CEREBRUM. 377 laboring under acute or chronic cardiac valvular trouble ; if, within brief periods, several incomplete attacks have occurred before a com- plete comatose condition obtains ; or, if hemiplegia results with pass- ing or slight unconsciousness ; or, if the phenomena are sooner or later followed by cerebral softening, as embolism and thrombosis are the most common causes of softening. Syncope or a fainting-fit is of sudden onset, but being due to a failure of the circulation, the pulse is feeble, the face pale, the respi- ration quiet, and the duration of unconsciousness short, all the very opposite of an apoplectic attack. Prognosis. If the patient survive the immediate effects of a cerebral hemorrhage, he is always in danger of a new attack, since the causes of the original attack still remain. Another attack or two is the usual course, a fatal termination ultimately occur- ring. The hemiplegia is uncertain ; a partial recovery may occur within a few months, or it may continue for years. Treatment. If there are prodromal indications, the most prompt means of reducing the intra-cranial blood pressure is by venesection , followed by a brisk purgative ; if the patient be weak, however, leeches to the mastoid, and potassii bromidum , gr. xl-lx, or extraction ergotce fluidion , f^ss-j, may be substituted. For the attack , loosen clothing, elevate the head, remove constric- tions, place in a cool room, have perfect quiet, placing the patient sufficiently on his side, with the face somewhat downward, for the tongue and palate and secretions to fall forward instead of backward into the pharynx, and at once venesection , cold to head , a mustard foot bath , and oleum tiglii, gtt. j-iij, with glycerinum , gtt. xv, placed on back of tongue ; if the pulse be full and strong, when conscious- ness is regained, either tinctura veratri viridis or tinctura aconiti is indicated. If during the attack the face be pallid and the pulse irregular , and the patient is prostrated by the shock , stimulants and digitalis are in- dicated, with, perhaps, leeches to the mastoid and an enema of tere- binthina. For the secondary fever, either tinctura aconiti or tinctura veratri viridis ; for the headache and delirium, camphorce bromidum. For promoting the absorption of the clot, keep the secretions active, 378 PRACTICE OF MEDICINE. a good diet and a course of potassii iodidum or hydrargyri chloridum corrosivum , alternated with — R . Liq. potassii arsenit gr. v Syr. calcii lacto-phosph f^ij. Three times a day. After two or three months a weak galvanic current applied directly to the brain, by placing an electrode on each mastoid process, pro- motes absorption. For the paralyzed muscles , the faradic current applied by placing one electrode over or near the nerve innervating the muscle and the other over its belly, acts as a tonic, preventing wasting ; it is assisted by hypodermic injections of strychnince sulphas , gr. ^ three times a week. CEREBRAL THROMBOSIS AND EMBOLISM. Synonyms. Partial cerebral anaemia; occlusion of cerebral vessels ; cerebral apoplexy (?). Definition. The occlusion of a cerebral vessel, from the forma- tion of a thrombus , or the presence of an embolus , thus causing ancemia of some portion of the brain ; characterized by the gradual — when the result of thrombosis, and the sudden, when due to embolism — devel- opment of headache, vertigo, disorders of intelligence, with more or less complete insensibility and paralysis. Causes. Thrombosis , or the formation of a clot in the vessel — an ante-mortem coagulation — is almost always the result of chronic endarteritis, as seen in the aged, together with a slowing and weaken- ing of the blood current. Chronic alcoholism and syphilis are the usual causes when occurring in young adults. Emboli , in the great majority of instances, result from an endocar- ditis — cardiac emboli ; small particles of the exudation being carried into the circulation and deposited in the brain. Emboli may also be derived from aortic aneurism, or syphiloma of the great vessels. Pathological Anatomy. The cerebral arteries may be ob- structed by emboli or thrombi ; the cerebral veins and sinuses by thrombi only. The changes in the cerebral tissue are those of anaemia of the part or parts supplied by the occluded vessels. The subsequent changes depend upon the anatomy of the vessels. If the obstructed DISEASES OF THE CEREBRUM. 379 artery has anastomoses, the collateral circulation is soon established and the brain tissue assumes its normal condition. If, on the other hand, the occluded vessel be one of “ Cohnheim’s terminal arteries ” — arteries without anastomoses — the blood in the whole extent of the occluded vessel coagulates, thus preventing the backward flow of blood from the surrounding capillaries and so obstructing collateral circulation, whence the anaemic tissue dies or undergoes necrobiosis , followed by yellowish-white softening ; or, if the vessel beyond the seat of the occlusion remains pervious, blood flows back through the capillaries from the nearest artery or vein ; the parts that a short time before were bloodless now become deeply engorged, the suc- ceeding changes in the vessels permitting diapedesis of the red blood globules ; the tissues which are undergoing disintegration are colored by the red globules, causing the appearances entitled “ red softening,” which after some weeks becomes “ yellow softening,” finally changing to “white softening,” when there is a milky, or rather creamy, fluid mixed with masses or particles of broken-down nerve elements. The vessel most commonly occluded is the left middle cerebral artery , which sends branches to the second and third frontal convo- lutions, the anterior and superior portions of the three temporal convolutions, the island of Reil, the parietal convolutions, part of the external and all of the internal capsule, the lenticular nucleus, and most of the corpus striatum, — the motor centres. Symptoms. Two distinct modes of onset; gradual, when the result of thrombosis ; sudden or apoplectic, when due to embolism. Cerebral thrombosis. Most common in the aged. Persistent head- ache and vertigo , at one time severe and at another mild. Next, alterations in the patient’s character ; irritable , morose and despondent , with periods of absent-mindedness, disorders of vision, and impairment of memory, speech becoming hesitating and mumbling. Impaired locomotion, the result of the vertigo, and of muscular weakness and trembling, followed sooner or later by hemiplegia, which may be preceded by sudden insensibility or occur gradually, the symptoms slowly proceeding to senile dementia and death from exhaustion ; or rarely, the symptoms are not so grave, and partial or complete recovery occurs after the hemiplegia, from establishment of the “collateral circulation.” Cerebral embolism. The symptoms are sudden, but either mild or grave in character. 380 PRACTICE OF MEDICINE. Mild variety ; sudden and severe vertigo, confusion of mind, mus- cular twite-kings, usually one-sided, and vomiting, followed by hemi- plegia, most frequently of the right side, the intellect clear but hesi- tating. After some weeks or months the paralysis usually disappears and recovery is complete. Grave or apoplectic variety . Sudden headache, vertigo, flushing ox pallor of the face, or the patient may utter a sharp cry, fall to the ground with sudden unconsciousness and complete muscular relaxa- tion, followed by death, or a gradual return of consciousness with hemiplegia, which is generally right-sided, with aphasia, remaining for several weeks or months, or is persistent, the mind remaining normal or enfeebled and the emotional nature highly excitable and th treason and judgment clouded, continuing thus for years, or gradually developing into dementia, exhaustion and death. The following are some of the symptoms of “ localization ’’ if par- ticular vessels are blocked : Vertebral artery, the left most frequently, results in acute bulbar paralysis from involvement of the nuclei in the medulla, associated or not with hemiplegia. Basilar artery causes diplegia with bulbar symptoms. There is rapid rise of temperature. Death follows within a day or two, or sud- denly, if respiratory centres involved. Middle cerebral artery is the most frequent seat of embolic or thrombotic occlusions. The symptoms depend upon the exact branch involved : if plugged before the central arteries are given off, the internal capsule is deprived of its blood supply and permanent hemiplegia may follow : if the blocking is in the central branches the hemiplegia involves the arm and face, and if the left side aphasia occurs. The individual branches passing to the third frontal (aphasia), the ascending parietal (hemiplegia, particularly hand), supra-marginal and angular gyri (word blindness), and the temporal gyri (word deaf- ness), may be plugged. Duration. Thrombosis, essentially an affection of the elderly, has a chronic course. Months or years may be occupied with the various symptoms until the phenomena of senile dementia develop. Embolism is of sudden onset, and may be followed by a rapid recovery. Diagnosis. Thrombosis is associated with changes in the vessels, the arcus senilis and other evidences of senile degeneration. DISEASES OF THE CERERRUM. 381 Embolism may be mistaken for cerebral apoplexy, and while a positive differentiation cannot always be made, the chief point to be considered is the presence of cardiac murmurs. Prognosis. Thrombosis is a permanent and progressive condition in the majority of instances. Recovery is a rare termination. Embolism may be followed by a perfect recovery. Usually, how- ever, some evidences of the plugging remain permanently. Death may be the result within a day or two, from the plugging of a large vessel, the patient never emerging from the coma. In other cases the patient arouses from the coma, the hemiplegia with aphasia persisting, and the case pursues the usual course of localized cerebral softening. Treatment. The indication in the early stage of embolism and thrombosis is the reestablishment of the circulation within the district deprived of blood-supply, in order to prevent the changes incident to defective nutrition ; this is accomplished by means to strengthen the heart’s action, tonics, perfect rest for some time after the attack, a plain but nutritious diet, and attention to the various excreta. Prof. Bartholow “ has had remarkable results from the following plan of treatment in thrombosis Ammonii carbonas , gr. x, with ammonii iodidum , gr. v, three times a day, continued for several months, “the object being dual — to increase the action of the heart and arteries and to effect a solution of thrombi forming by main- taining the alkalinity of the blood.’’ In the aged, presenting indications of degeneration, much benefit results from the use of — R. Liquor, potassii arsenitis, rqjij-v Syr. calcii lacto-phosphat., fgj-ij. M. SiG. — After meals. It may be combined with oleum morrhuce with decided advantage. For embolism , the immediate and persistent use of the following may dissolve the plug: — R . Ammonii carbonat., gr. v Liquor, ammonii acetatis, fgj. M. SiG. — Three or four times daily. “ In a month or two a very light galvanic current (from two cups) may be passed through the brain in both directions” (Bartholow). 382 PRACTICE OF MEDICINE. CEREBRAL ABSCESS. Synonyms. Acute encephalitis ; suppurative encephalitis. Definition. An acute suppurative inflammation of the brain structure, either localized or diffused, primary or secondary ; charac- terized by impairment of intellect, sensation and motion. Causes. Primary cerebral abscess is exceedingly rare. Pyaemia ; glanders ; embolus from ulcerative endocarditis. Secondary cerebral abscesses result from injuries to the cerebral tissues, to wit: apoplexy, embolism, thrombosis, and injuries to the cranial bones. Chronic ear disease ; chronic suppuration in some other portion of the body. Pathological Anatomy. Abscess of the brain affects the left side more frequently than the right. They are usually encysted or enclosed in a limiting membrane. Abscess of the brain may be single or multiple, varying in size from an almond to an egg. It occupies a limited and well-defined region of the cerebral tissue, to wit : either corpora striata, optic thalami, gray matter of the cortex, the cerebellum, or the white matter of the hemispheres. “ The initial stage at the site of the abscess is hyperaemia. Minute extravasations take place (capillary hemorrhages), giving to the in- flamed area a dark, reddish color, whence the term red softening. Migration of white corpuscles, diapedesis of some red corpuscles and exudation of serum holding albumin and fibre in solution, occur simultaneously. The brain tissue, being soft and easily broken up, is rapidly dissociated and its elements disintegrated, and in a short time a soft, pultaceous, red mass results, which more and more assumes a purulent character, becoming first reddish-yellow, then yellow or greenish-yellow, ultimately almost white. The injury caused by an abscess is not limited to the portion of the brain inflamed, but the neighboring territory is in the condition of collateral hyperaemia and oedema ” (Bartholow). Symptoms. A concise description of the symptoms of abscess of the brain is very difficult, on account of the wide variations depend- ent on its location, and also the difficulty of isolating it from the affec- tions to which it is secondary. The onset varies according to the cause, although all cases are asso- ciated with headache, irritative fever, vomiting, persistent and spread- DISEASES OF THE CEREBRUM. 383 ing paralysis, convulsions, optic neuritis, mental apathy, delirium, and coma. If following apoplexy, thrombosis, or emboli, there occurs fever and delirium, the paralysis remaining and spreading with spasmodic contractions of the affected muscles. Occasionally cases run a chronic course, the onset rather insidious ; dull, persistent headache, changed disposition, peevish, irritable, un- reliable, with decline of moral sensibility ; easily fatigued by mental work ; inability to stand exertion ; memory impaired; vertigo; dys- pepsia, soon followed by slight palsies, which progressively increase, becoming general, with involuntary discharges, death following from exhaustion. Of the focal symptoms, hemiplegia, of incomplete character, occurs in about one-half of all cases of abscess of the brain. A very con- stant symptom of diagnostic value, when hemiplegia is very marked, is exaggerated knee-jerk with pronounced ankle clonus. Diagnosis. A positive diagnosis is only possible by a close study of the causes and the clinical history, as the symptoms at times indi- cate meningitis and again cerebral tumor. Purulent meningitis may follow trauma to the brain or chronic ear disease, making the diagnosis impossible. The chief points of dis- tinction are, the subacute or chronic course of abscess (rarely an acute course), slight involvement of cranial nerves, hemiplegia, and the presence of an active, persistent, unilateral ankle clonus and exaggerated knee jerk on paralyzed side. Prognosis. The usual termination is in death. The course de- pends upon the character and extent of the injury, varying from a few days to several months. Treatment. Surgical treatment has been attended with marked success in some cases of abscess of the brain, the withdrawal of the pus being followed by recovery. For traumatic abscess the operation of trephining is indicated. Symptomatic treatment for relief of the various symptoms as they arise. INTRA CRANIAL TUMORS. Synonym. Cerebral tumors. Definition. Tumor of the brain is either a growth in the cere- bral tissue, on the meninges, or in the vessels ; characterized by symptoms of pressure upon the brain structure. 384 PRACTICE OF MEDICINE. Causes. Injuries to the head ; syphilis; changes in the vessels ; tubercle and cancer ; heredity. Pathological Anatomy. The size of tumors vary, and may become as large as an orange before they will give rise to symptoms. Tumors of the brain are of various kinds, to wit : vascular tumors — aneurisms ; parasitic tumors — cysticercus ; diathetic tumors — tu- bercle or syphilis ; accidental tumors — glioma. Whatever the character of the growth, it produces irritation of the surrounding parts, and by pressure, destruction of the tissues, or it interferes with the arterial or venous flow. Symptoms. Those common to tumors in general are, headache , persistent and increasing in intensity, defects of vision , even blind- ness, due to an optic neuritis, a very constant symptom ; defects of hearing , taste and of speech, the result of paresis of the vocal cords ; vertigo , associated with nausea and vomiting ; convulsions, epilepti- form in character, usually limited to one side of the body, occurring at regular intervals, or confined to the eyeballs (nystagmus), or one limb, with no loss of consciousness ; palsies , beginning first as strabismus, ptosis and dilatation of the pupil, of the facial muscles, paraplegia and general hemiplegia ; defects of sensibility, to wit : sensations of numbness, and coldness in the limbs and body. Occasionally distur- bances of equilibrium manifested by a tendency to go backward or turn to the right or left ; intellectual faculties well preserved until late in the affection, when the memory becomes impaired or lost for cer- tain articles, and finally a gradually advancing imbecility. Diagnosis. Rarely can a positive diagnosis be made. The fol- lowing points will aid : long-continued, persistent headache, without appreciable cause, epileptiform convulsions, unilateral, without loss of consciousness, difficulty of vision, hearing and speech, associated with nausea and vomiting, and local and general palsies. The location of the tumor may be determined by the more or less pronounced character of certain symptoms. The diagnosis of the character of the growth can only be deter- mined by a close study of the history. According to Herter, “ the indications that suggest that the tumor is a syphilitic growth are as follows : ” Syphilitic history, symp- toms of irritative disease of cortex rather than destructive evidences of rapid growth at the onset followed by a period of slow progress or stationary symptoms, gradual improvement under anti-syphilitic DISEASES OF THE CEREBRUM. 385 treatment, development between twenty and forty-five years of age. Indications suggesting tubercular growth are : family history of or tuberculosis in some other organ of the patient, rapid development of symptoms, indications of the growth in the cerebellum or in the pons, early appearance of the symptoms, especially before the tenth year, and history of injury to head. Indications suggesting sarcoma or cancer are : the presence of a sarcoma elsewhere and rapidly failing health, with cerebral tumor symptoms in patient over fifty years. Indications suggesting glioma : sudden loss of consciousness with exacerbation of all symptoms in the clinical history of cerebral tumor, cortex irritative symptoms as in syphiloma, developing under fifty years of age, and the absence of all evidences of tubercle, syphilis, sarcoma, and cancer. The focal symptoms of intracranial tumors are so important in diag- nosis that the following summary is given of symptoms caused by brain tumors : — Prefrontal region. Mental impairment, pressure in central region, causing aphasia, Jacksonian epilepsy, and disturbances of smell. Central region . Motor aphasia, monoplegia, partial anaesthesia, Jacksonian epilepsy. Posterior parietal region. Word-blindness, homonymous hemi- anopsia, disturbed muscular sense. Corfus callosum. Progressive hemiplegia. Crus cerebri. Crossed paralyses of oculo-motor nerve and limbs. Corpora quadrigemina. Oculo-motor paralyses, reeling gait, possi- bly blindness and deafness. Pons and medulla. Crossed paralyses of face and limbs, or tongue and limbs. Other lesions in cranial nerves. Cerebellum. Marked cerebellar ataxia, vomiting, convulsions, coma. Base, anterior fossa. Mental enfeeblement, and disturbances of smell and vision, exophthalmos. Base , middle fossa. Impairment of vision ; hemiplegia ; oculo- motor disturbances. Base, posterior fossa. Trigeminal neuralgia ; neuro-paralytic oph- thalmia; paralyses of the face and tongue; impaired hearing; crossed paralyses. 32 386 PRACTICE OF MEDICINE. Diagnosis between cerebral Tumor and Abscess. Both may have any or all of the following symptoms: headache, vomiting, double optic neuritis, and mental failure. Tumor has in addition, marked focal symptoms, monoplegia, hemiplegia, paralysis of cranial nerves and marked optic neuritis; the absence of these favor abscess, or if hemiplegia the ankle clonus and knee-jerk is exaggerated. Fever and rigors point to abscess. The causes of abscess are very clear, those of tumor often uncertain. Prognosis. Unless of syphilitic origin, unfavorable ; but it is to be borne in mind that all syphilitic tumors of the brain do not have a favorable termination. Treatment. Unsatisfactory. Mostly symptomatic. As benefit occasionally follows the use of potassii iodidum , gr. xx, three times a day, or ext. ergotce fid., f^ss-j, three times a day, continued until their physiological effects are produced, these remedies should be used in all cases, discontinuing them if no benefit follow. The surgical treatment of tumors of the brain was given a great impetus from the report of the case operated upon in the practice of Hughes-Bennet. The surgical treatment is promising for the future. APHASIA. Definition. The inability to use spoken language or give vocal utterance to ideas. Amnesic aphasia, or loss of the memory of words by which ideas are expressed. Ataxic aphasia , the inability to combine the different parts of the vocal apparatus for vocal expression, although the memory of words still remains, so that the afflicted person can write his ideas intelli- gently. Agraphia, the inability to recognize and make the signs by which ideas are communicated in written language. Amnesic agraphia, the inability to combine the muscular apparatus — “writers’ cramp.” Paraphasia, the mental state in which the wrong words are used to express the idea. Paragraphia, the state in which wrong or meaningless written signs are used to express the idea. Pathological Anatomy. The distinction between aphasia and aphonia must be clearly determined. DISEASES OF THE CEREBRUM. 387 Aphasia is not the result of any' one specific lesion, but occurs during the course of several, to wit : occlusion of certain cerebral vessels ; cerebral hemorrhage ; cerebral abscess or softening ; men- ingitis ; tumors ; mental or moral causes ; hysteria. It is now almost definitely determined that lesions of the left middle cerebral artery, island of Reil, third frontal convolution, and parts of the corpus striatum, are associated in the production of aphasia. The lesions are usually upon the left side of the brain, the aphasia being associated with right hemiplegia. Symptoms. The degree to which articulate language is impaired varies, from the loss of a few words to complete inability to commu- nicate ideas. The intellect does not suffer in proportion to the loss of words ; for, showing the individual an article, while he may mis- call it, if you call it by name he will recognize it. This inability to convey thoughts is a source of great mental suffering, in some lead- ing to a suicidal tendency. A strange clinical fact is the strong tendency to profanity shown by aphasic patients. Diagnosis. Aphonia , or loss of voice, should not be confounded with aphasia, or the inability to remember words. Paralysis of the tongue , or inability to move this organ, thereby interfering with articulate language, should not be confounded with aphasia, which, as a rule, is not associated with paralysis of the tongue. Prognosis. Controlled entirely by the cause. If the result of congestion of the brain or a syphilitic tumor, the prognosis is favor- able. If associated with hemiplegia the clot may undergo absorp- tion, and recovery follow. If associated with softening of the brain, however, the disease grows progressively worse. Treatment. Depends upon the cause, which must be energet- ically treated, as the aphasia pursues a course parallel to the associated malady. Cases not associated with cerebral softening have regained the memory of words by a course of carefully conducted speech lessons. Cases of aphasia of sudden occurrence are strongly diagnostic of injury due to a spicula of bone if a history of a head wound, or from the pressure of a clot, and the operation of trephining may be of benefit. 388 PRACTICE OF MEDICINE. VERTIGO. Synonym. Dizziness. Definition. Vertigo or dizziness is a subjective state, in which the individual affected, or the objects about him, seem to be in rapid motion, either of a rotary, circular, or a to-and-fro character. Causes. The etiology of an attack of vertigo depends upon the particular variety. Ocular vertigo results from the paresis of one or more of the ocular muscles, eye-strain or astigmatism. Aural or Auditory vertigo, or Meniere's disease, results from disease of the semicircular canals and cochlea. Meniere’s disease properly so-called, is a sudden severe vertigo, the result of either a hemorrhage or a serous or purulent exudation into the semicircular canals. Gastric vertigo is the most common variety, and results from either stomachic or intestinal dyspepsia, disordered hepatic function or con- stipation. “ The mechanism of the vertigo is complex. There are two factors ; one consists in the toxic effect of the imperfectly oxidized materials which accumulate in the blood ; the other is reflex. An impression made on the end organs of the pneumogastric in the stomach is reflected over the sympathetic ganglia ” (Bartholow). Nervous vertigo is associated with migraine, sick or nervous head- ache, and is also caused by physical or nervous excesses, also by the immoderate use of tea, coffee, alcohol and tobacco. It is also a result of many of the organic diseases of the brain. Senile vertigo is the result of the disordered cerebral circulation resulting from changes in the heart and vessels. Symptoms. In all varieties of vertigo, the symptom of a sensa- tion of objects moving around the patient , or the patient moving around objects which remain stationary, is present in some degree. The attack of giddiness comes on suddenly, with an indistinctness of vision and slight confusion of the thoughts. The patient may fall unless he grasps something to steady himself. Nausea and vomiting and cardiac palpitation with tinnitus aurium are often associated with the vertiginous sensations. There is no loss of consciousness. In the ocular vertigo the attack is usually the result of reading, writing, sewing, or other close application of the eyes, the ordinary symptoms of vertigo being preceded by headache, nausea, specks before the eyes, and pain in the eyeballs. DISEASES OF THE CEREBRUM. 389 In Meniere's disease the vertigo is associated with serious tinnitus aurium and the vertiginous sensations are of various forms, such as a see-saw movement, a gyratory motion, right or left; a vertical whirl, or a sensation of rising and falling like unto the swell of the ocean. The symptoms are of long duration, becoming marked in paroxysms. The attack of aggravated vertigo is so sudden and overwhelming at times that the person is’ suddenly thrown to the ground as if struck with a blow, associated with nausea and vomiting. As the condition continues the character of the individual changes, becoming morose, irritable and suspicious. Not all cases of Meniere’s disease become permanent, but it may occur in isolated attacks, the interval being free from all sensations. Gastric vertigo is by far the most frequent variety. Persons subject to vertigo of this kind live in constant dread of cerebral disease, which frequently results in true melancholia. The vertiginous sensations usually occur during the course of well- marked and long-standing stomach and intestinal disorders, such as pain or oppression after meals, nausea, pyrosis, heartburn, frequent eructations and constipation or rarely diarrhoea. The abdomen is often distended with flatus. Great pain in the nucha is a very frequent occurrence. The attack may be associated with either hypersemia or anaemia of the brain. The symptoms are not constant, but recur at intervals, sometimes remote, at others very close on each other. In nervous vertigo the vertiginous symptoms are usually associated with more or less irritability of temper, restlessness and insomnia. The onset is sudden, after some one of the etiological factors. In megrim there is headache, nausea and vomiting. This form of vertigo often precedes or replaces the epileptic convulsion, it also often pre- cedes softening of the brain. In senile vertigo the vertiginous symptoms are the result of anaemia of the brain. The attacks are developed by any exertion, often by merely assuming the erect posture. There is a swimming sensation in the head, darkness falls on the eyes with a sensation of chilliness and prostration. Diagnosis. The diagnosis of the various forms of vertigo can only be determined after a close study of the history and course of the attack. The existence of organic cerebral disease must always be kept in mind in solving any case. Prognosis. This will be influenced by the variety of the vertigo. 390 PRACTICE OF MEDICINE. The prognosis is favorable in ocular and gastric vertigo. Unless the result of organic disease the prognosis is good in nervous vertigo. In auricular vertigo the prognosis is fair, but in genuine Meniere’s disease the prognosis is unfavorable, as it also is in senile vertigo. Treatment. For ocular vertigo, rest for the eyes and properly adjusted glasses. For cases of Meniere’s disease rest in the recumbent position and the use of full doses of quinina , grs. x to xv, daily for a long period, as suggested by Charcot. For gastric vertigo a careful regulation of the diet. At the begin- ning of the treatment it is often of great advantage to place the patient on an exclusively milk diet, gradually widening the variety as improvement occurs. In these cases a course of arsenicum is often serviceable. If the digestion be torpid, the use of tinctura nucis vomiccE is indicated. If the bowels are constipated, benefit is obtained from extractum cascarce sagradce Jiuidum. (R. Ext. cas- carae sagr. fid., fgj ; glycerini, f^j ; tinct. card, comp., f^ss ; aquae menthae, f^ss. M. et Sig. One teaspoonful three times daily.) For nervous vertigo the removal of the exciting cause and the use of such remedies as ferrum , quinina and strychnina , either alone or variously combined. For senile vertigo, a highly nutritious but easily digested diet, the use of a good spiritus frumenti and a course of hydrargyri chloridum corrosivum or arsenicum with tinctura nucis vomicce. In all varieties of vertigo the habits of the patient must be most abstemious, excluding tobacco, tea, coffee, highly seasoned foods, malt liquors, and alcohol unless particularly indicated. MIGRAINE. Synonyms. Megrim ; hemicrania ; sick headache ; bilious headache ; blind headache. Definition. A unilateral paroxysmal pain in the head, periodical, accompanied with nausea, often vomiting, intolerance of light and sound and incapability of mental exertion, the brain for the time being temporarily prostrated and disturbed. Causes. In the majority of patients the nervous predisposition to migraine is inherited, but whether inherited or acquired, it com- monly develops before the age of thirty. DISEASES OF THE CEREBRUM. 391 Among the many exciting causes are disturbances of digestion, irritation of the ovaries or womb, worry, exacting mental labor, sex- ual excesses and insufficient sleep, and eye strain. The causes of many attacks, however, are wrapped in mystery. Symptoms. Attacks of migraine occur in irregular paroxysms, the intervals between being free from pain or nervous disturbance. For a day or two preceding the paroxysm, it will be ascertained, on close questioning, that there was a feeling of fatigue without apparent cause, heaviness over the eyes, with some flatulency and indigestion. The attack proper is ushered in by chilliness, nausea , often vomiting, yawning and general muscular soreness, with intolerance of light, and noises in the ears and incapability for mental exertion and pain of a sharp , shooting character of great intensity and persistency localized most frequently in either the frontal, temporal or occipital regions of the left side ; at the same time there is tenderness over the whole side of the head. Rarely the pain is felt on the right side and still more rarely on both sides at the same time. The nausea and other diges- tive symptoms may follow the onset of the pain instead of preceding it. There is more or less disturbance of the circulation, temperature and secretions of the affected parts. At times there is marked con- traction of the vessels, when the face is pale, the eyes shrunken and the pupils dilated ; again, the vessels may be dilated, when the face is flushed, the conjunctivae injected and the pupils contracted. Motion, sound and light aggravate the acute suffering. The attack may continue with more or less intensity fora few hours to two or three days, the average duration being twenty-four hours. Diagnosis. The symptoms are so characteristic that an error seems impossible. It may, however, be confounded with anaemic headache, hyperaemic headache, dyspeptic or bilious headache and neuralgic or rheumatic headache. The pains of organic brain disease must be excluded. Prognosis. While few cases of true migraine are permanently cured, the affection is free from danger to life. In a fair number of cases the susceptibility to attacks declines as the person advances in years, it being rarely seen after fifty years. “ Cases of migraine of the ophthalmic variety appear to be not rarely followed by general paralysis of the insane” (Herter). 392 PRACTICE OF MEDICINE. Treatment. To abort an attack of migraine or dispel a paroxysm after its onset, any one or two of four remedies are almost infallible — one is a hypodermic injection of morphines sulphas , gr. with atro- pines sulphas , gr. t ^q, or anlipyrine , gr. xx, repeated in an hour or two ; or phenacetin gr. x, repeated in an hour or two. In many attacks exiraclum cannabis indices fiuidum, gtt. ij-iij, every half hour or hour for a number of doses, is curative. A combination for attacks associated with contraction of the vessels is — &. Potassii bromid., . gr. xxx Morphinse sulph., g r - X vel Codeinse sulph., gr. j vel Tr. opii deodorat., TT^xxx Aquae menth. p., ad f^ss. M. Sig. — R epeated p. r. n. The local use of menthol pencils eases the pain. In the intervals between the paroxysms, measures to improve the general system should be used, and to overcome as far as possible any of the etiological factors in its production. For this purpose ex - tractum cannabis indices, gr. X> three times daily for several months, is highly recommended. “ If the disposition to the malady is inherited, the prophylaxis is very important, and should include diet, exercise, clothing, and the avoidance of all those conditions which tend to develop an abnormal excitability of the nervous system. The best results have been ob- tained from galvanization of the superior ganglia of the sympathetic ; the positive pole over the ganglion and the negative on the epigas- trium in the tetanic (contraction of vessels) form ; and the poles re- versed in the paralytic (dilatation of vessels) form.” Bartholow. ALCOHOLISM. Varieties. Acute alcoholism ; chronic alcoholism. Synonyms. Acute variety, temulentia ; mania-a-potu. Chronic variety, delirium tremens ; dipsomania or oinomania. It would hardly be correct to consider these terms interchangeable ; they are rather names applied to various conditions due to acute or chronic alcoholic poisoning. DISEASES OF THE CEREBRUM. 393 Definition. Alcoholism is the term used to designate the physi- cal and mental phenomena induced by the abuse of alcohol. Temulentia , meaning drunkenness ; mania-a-potu is an acute men- tal derangement, occurring in those of strong neurotic tendencies ; delirium tremens is an attack of delirium associated with tremors in persons with the numerous changes resulting from chronic alcoholism. Delirium tremens results in alcoholics suffering from some form of nephritis, preventing the elimination of some poison developed from the ingested alcohol. Dipsomania or oinomania , an alcoholic insanity in which an individual at longer or shorter intervals has paroxysms of alcoholic desires, between which he neither wishes nor craves alcohol. Causes. Predisposing causes are influences arising from unfavor- able moral, social and personal conditions. Heredity. Exciting causes are the immoderate use of alcoholic beverages, of which there are three groups : r, spirits, or distilled liquors ; 2, wines, or fermented liquors, and 3, malt liquors. Pathological Anatomy. Acute alcoholism. The brain is the seat of an active hyperasmia ; the mucous membrane of the stomach and duodenum is markedly injected and covered with a ropy mucus slightly tinged with blood, and the gastric juice is altered in quality and quantity. The kidneys are also the seat of an active hyperaemia. Chronic alcoholism . In this condition of the economy there are no organs or tissues which do not present morbid changes. The gastro-intestinal mucous membrane presents the changes of chronic catarrhal inflammation ; the liver, the first organ to receive the poison after the stomach, presents the changes of congestion, cirrhosis or fatty degeneration ; the kidneys show chronic congestion and often the changes incident to chronic interstitial nephritis. The post-mortem re- sults found in twenty-five cases of delirium tremens dying in the Phila- delphia Hospital, were fourteen with the changes of interstitial nephritis, eight with chronic parenchymatous nephritis, and three with fatty kidney ; all showed chronic gastric catarrh and changes in the myo- cardium and the arteries of the heart, brain and the aorta. The mus- cular structure of the heart may undergo fatty degeneration and the vessels the senile changes of the aged. The brain structure presents the changes of sclerosis in various stages, and there may be chronic meningitis and pachymeningitis with haematoma. The nerves are 33 394 PRACTICE OF MEDICINE. altered, atrophied and hardened, and the neuroglia, vessels and ganglion cells of the spinal cord show similar changes. Symptoms. Acute alcoholism , resulting from the use of a large quantity of alcoholic fluid, occurs with symptoms of mild intoxica- tion, to drunkenness passing to acute delirium and acute coma. The condition begins with a period of exhilaration , passing to semi- delirium and ending in an acute coma , when the breathing is ster- torous , the face bloated and congested, the lips swollen and purplish , the pupils contracted, the pulse feeble and slow, the skin cold and clammy, the temperature depressed and frequently control of sphincters lost. An individual so affected is said to be “ dead drunk." The cases of ordinary drunkenness do not often pass beyond the stage of exhilaration ending in a mild coma or sleep. Mania-a-potu, or acute alcoholic delirium, is the direct result of alcoholic excess in those engaged in a sudden debauch, or who have drunk alcoholic beverages very “hard” for a comparatively short period. The individuals grow more and more excitable, lose all desire for food, are unable to sleep, become the prey of horrible hallucinations — “the horrors” — finally terminating in mania which resembles delirium tremens in all save the tremor, which is absent. Chronic Alcoholism. The condition to which this term has been given is truly a disease. It is the result of the continued use of alco- holic beverages until one or more of the morbid organic changes have occurred. These persons are markedly dyspeptic, with coated tongue, fetid breath and early morning vomiting, straining or retch- ing, attended with much distress. There is a gradually developing muscular tremor, progressing to the ataxic gait, and insomnia. The face may either become pallid, flabby and bloated, with an imbecile expression, or swollen, rough and dusky, with great bladders under the eyes, with yellow injected conjunctive. There is headache, vertigo, and attacks of hallucinations ; the memory grows weaker, the judgment less accurate, the moral sense blunted and the will power weak and erratic. These and many other symptoms add to the distress of the individual, which he attempts to overcome by the use of more and more of the poison. Delirium Tremens. In the majority of instances delirium results from a prolonged debauch, in an old drinker. It begins by an in- creased tremor, insomnia, irritable, excitable manner, followed by the characteristic hallucinatious and illusions, during which snakes and DISEASES OF THE CEREBRUM. 395 all forms of repulsive reptiles are seen, causing the most intense hor- ror and abject fear. There also occur illusions of smell and hearing. This marked excitement is followed by great depression, the skin is cold and clammy, the pulse feeble, the muscular system weak, the mind in a condition of coma-vigil, and a febrile condition, typhoid in character, develops. Urcemic symptoms soon develop, the tempera- ture suddenly bounding to 103° F. to 104° F., or 105° F. with albumin and casts. The ordinary duration of an attack of delirium tremens is about two weeks in those recovering, although death may occur at any time from cardiac failure, uraemia, or alcoholic pneumonia. Con- valescence dates from the beginning of refreshing sleep, the patient awakening with a clear mind and desire for food. Should the deli- rium subside, but the patient continue to mutter and pick at the bed-clothing, the tongue become dry and cracked and the regurgita- tion of dark brownish and bilious matter occur, the condition is critical and an early fatal termination may be expected. Dipsomania or oinomania is the inherited or acquired mental con- dition which craves the drinking of intoxicating liquors. This is a true mental disease. It manifests itself in periodical attacks of exces- sive indulgence in alcoholic drinking, or this symptom of this sad disease may be replaced by other irresistible desires of an impulsive kind, such as lead to the commission and repetition of various crimes, the gratification of other depraved appetites, robbery, or even homi- cide. Imbecility and dementia frequently result. The paroxysms at first occur at long intervals, but gradually the intervals become shorter and shorter until the individual entirely sur- renders himself to alcoholic and other excesses. Diagnosis. Profound drunkenness or alcoholic coma may and often is confounded with apoplectic and uraemic coma. Von Wede- kind suggests the following method for diagnosing drunkenness ; “ By simply pressing on the supraorbital notches with a steadily increasing force you may, with certainty of success, bring an un- conscious alcoholic to his senses, and thus differentiate between alco- holic and other comas.” The symptoms of chronic alcoholism often bear a close resem- blance to the following maladies : general paralysis, disseminated sclerosis, paralysis agitans, locomotor ataxia, cerebral and spinal softening, epilepsy, dementia chronica, and nervous dyspepsia. 396 PRACTICE OF MEDICINE. In individuals whose habits are secret the question of diagnosis is attended with considerable difficulty. Anstie lays much stress upon the importance of the following four points, diagnostic of chronic alcoholism ; insomnia, morning vomiting , muscular tremor and cause- less mental restlessness. Prognosis. In acute alcoholism the prognosis is good if the patient is manageable. In chronic alcoholism the organic changes, the direct result of the alcoholic habit tend to shorten life by the production of fatty heart, Bright’s disease, insanity, impotence, epilepsy, melancholia and organic brain diseases. The danger in delirium tremens is heart failure or deepening coma. The association of chronic nephritis with delirium tremens, perhaps its cause, must always be taken into account in determining a prognosis. Acute lobar pneumonia is a very fatal complication of all forms of alcoholism. Treatment. In deciding upon a plan of medication in any ot the varieties of alcoholism the condition of the kidneys, heart and vessels must be considered. The treatment of a case of drunken- ness requires no consideration, as the rapid elimination of thealcohol soon occurs if its ingestion be stopped. Liquor ammonii acetatis in large, frequently repeated doses, assists the elimination of the poison. For mania-a-potu the immediate and complete withholding of alco- holic beverages is essential for its successful treatment. If the stom- ach will tolerate food, and usually it will, milk, diluted with liquor calcis, or Seltzer water, or hot beef tea strongly seasoned with capsi- cum, should be frequently administered, together with such cerebral sedatives as potassii bromidum, chloral, per mouth or rectum, or the hypodermic use of morphines sulphas ., gr. y 3, with either hyoscin hydrobromas , gr. y^, or atrophies sulphas., gr. y^. If the attack be associated with symptoms of cardiac depression, brisk frictions, artificial warmth, stimulating enemata and hypodermic injections of strychnines sulphas, gr. repeated, or caffeines citras, gr. iij repeated, or digitalis , are indicated. “ If chloral be inadmissible by reason of weakness of the circulation, paraldehyde maybe substituted, in doses of from half a drachm to one drachm, repeated at intervals of from one to two hours until quietude is produced” (J. C. Wilson). Act on bowels and kidneys in all cases. For the collapse following a lethal dose of alcohol, the stomach should be immediately emptied by emetics or the stomach tube or DISEASES OF THE CEREBRUM. 397 pump and the organ washed out with warm water or coffee, the patient placed in the recumbent position and surrounded with artificial warmth, hot frictions to the lower extremities, the use of artificial respiration or the use of faradism to the thorax, inhalations of am- monia , hypodermic injections of digitalis , strophanthus or atropina. “The flagging heart may be stimulated by occasionally tapping the praecordia with a hot spoon — Corrigan’s hammer ” (J. C. Wilson). An attack of acute alcoholism or mania-a-potu may often be aborted with trional , gr. xxx, repeated in two hours, or chloralamid, gr. xxx-xl, repeated. Chronic Alcoholism. — The combine of symptoms termed chronic alcoholism, are the direct result of the continuous action of a single toxic principle, and no success of even a temporary kind can be expected unless the poison be withdrawn. The rapidity with which this can be accomplished is a question for the skill, judgment and experience of the physician to determine ; the chief obstacle to its success will be found moral rather than physical. Next to the disuse of alcohol is the question of diet. Much progress will be made as the appetite and digestion improve, and so great attention should be given to it. The general health will also be benefited by fresh air, exercise, mental occupation and cold or tepid sponging and an occa- sional hot bath at bedtime. For the combination of symptoms of spirit craving, morning vomiting, muscular tremor, mental restless- ness and insomnia, no drug is comparable with strychnines nitras, either hypodermically twice daily or, what is preferable, per the stomach to secure its local action on the mucous membrane. If the insomnia be persistent, in spite of the foregoing treatment, the tempo- rary use may be made of such remedies as chloral , morphina, par- aldehyde, or extractum lupulin ethereal (gr. j-iij), or trional , gr. xxx, repeated. In many cases it is desirable, for its mental effect, if no other, to administer what the patient terms a substitute for his alcoholic beverages. The following is a good combination for that purpose : — R. Tincturae nucis vomicae, fS; ss Tincture capsici, f 25 j Ex. lupulini fid., f J iij Inf. gent, co., • f^ iss. M. SiG. — Dessertspoonful three or four times daily well diluted. For the anaemia, loss of strength, and mental debility, benefit may follow the use of syrupus hypophosphitis cum strychnines. 398 PRACTICE OF MEDICINE. Delirium Tremens. — The patient should be isolated, have a skil- ful, sensible nurse, the quantity of alcohol entirely withdrawn or greatly reduced, supplied with easily digested nutritious diet, and remedies used to combat the excited nervous system. For this latter purpose no one combination is comparable with hypodermic injec- tions of morphines sulphas , gr. with atropines sulphas , gr. or hyoscin hydrobromas , (gr. x ^o). repeated p. r. n. ; or trional , chlo- ralamid or paraldehyde ; chloral in the following combination also acts well if the stomach be not too irritable : — R. Chloral, ^ss Tr. capsici, f % ss Aquae menth. p., f^vss. M. Sig. — T ablespoonful every two hours until sleep, alternated with a cup of hot beef tea to which has been added a bolus of capsicum , gr. xx. Care is necessary that a condition of coma be not produced by the remedies mentioned. For depression and cardiac weakness the internal use of any one of the following drugs is serviceable : Strychnines sulphas , caffeines citras , spiritus chloroformi , ammonii carbonas , tinctura strophan- thus, or digitalis. Dipsomania. — The management of these cases is much the same as has already been mentioned for chronic alcoholism, although the strychnina treatment should be given the preference. Strict attention must be given to the skin, bowels and kidneys. If the heart be not depressed, the cautious use of hot air bath or hypo- dermic injections of pilocarpines hydrochloras , gr. repeated at the onset of the mania. HEAT STROKE. Synonyms. Insolation; sun-stroke; thermic fever; coup-de- soliel ; heat exhaustion. Definition. A depression of the vital powers, the result of exposure to excessive heat. The condition manifests itself as acute meningitis (rare), heat exhaustion (common), and as true sun-stroke. Causes. Exposure to the influence of excessive heat, either to the direct rays of the sun or artificial heat in confined quarters, or diffused atmospheric heat without proper ventilation. Among the predisposing causes, which act by lessening the power of the system to resist the heat, are great bodily fatigue, overcrowd- ing and intemperance. DISEASES OF THE CEREBRUM. 399 Pathological Anatomy. The action of the heat upon the system is so sudden, and the malady so rapid in its course, that structural changes have not developed. The left ventricle is firmly contracted (Wood). The right heart and vessels are gorged with dark fluid blood. All the tissues and organs of the body are in a state of great venous congestion. The blood is dark, thin, and either but feebly alkaline or decidedly acid, and its power of co- agulability is destroyed. The post-mortem rigidity is early and marked. Symptoms. Depending upon the variety. Acute Meningitis , the result of exposure to heat is similar to that due to other causes. Heat-exhaustion develops with a rapid feeling of weakness and prostration , the surface cool , the face pale, the voice weak , the pulse rapid and feeble , the respirations increased , the vision growing dim and indistinct , noises develop in the ears, the individual, overcome, becoming partially or completely unconscious. In some cases the attack of prostration is sudden, the person failing unconscious, with perhaps convulsions or tremors, and shrunken features. Sun-stroke. The symptoms, developing suddenly, with or without prodromata, are, insensibility , with or without delirium , or convulsions , or paralysis, the surface flushed and hot, the conjunctives injected, the breathing either rapid and shallow or labored and stertorous, the pulse quick and either bounding or weak, and the temperature in the axilla ranging from 105°, to 108°, to no°, with suppression of all glandular action. Death occurring, the result of asphyxia, or from a slow failure of respiration and cardiac action. Diagnosis. It is of great importance, therapeutically, to distin- guish at once between attacks of sunstroke and heat-exhaustion. Cases of sunstroke are to be differentiated from cerebral hemor- rhage and alcoholic insensibility, for which purpose the clinical thermometer is indispensable. Prognosis. Attacks of heat-exhaustion, if properly and promptly treated, favorable. The prognosis of sunstroke or heat-fever is unfavorable in the majority of cases, death resulting in from half an hour to several hours. Unfavorable indications are, increased tem- perature, cardiac failure, convulsions, absent reflexes, followed by complete muscular relaxation. Favorable indications are, decline in surface heat and axillary or 400 PRACTICE OF MEDICINE. rectal temperature, stronger pulse, increased depth of respirations, restored reflexes, and return of consciousness. Treatment. Cases of heat-exhaustion are successfully treated by placing the patient in the recumbent position, with the head low, and the use of stimulants. If able to swallow, administer at once spiritus vini gallici, J ss-j, with tinctura opiideodorata, ir^xx-xxx, to be repeated p. r. n.; if he be unable to swallow, the remedies may be thrown into the rectum, or spiritus fru?nenti, strychnince sulphas, and tinctura digitalis can be used hypodermically. As convalescence occurs tonic doses of quinince sulphas and strychnince sulphas should be prescribed. For sunstroke, the indications for treatment are the very opposite. The patient is in imminent danger from the extraordinary temperature, and measures to reduce it must at once be instituted. Of these none give such excellent results as rubbing with ice, or the cold bath or cold Pack, and cold effusions , cold enemata, and the hypodermic use of qui- nince sulphas, or antipyrin. The tendency to subsequent rise of tem- perature is met by wrapping the patient in a wet sheet, or the repetition of the hypodermics mentioned if consciousness has not been regained, when they can be given by the mouth. If convulsions and restless- ness occur, the hypodermic use of morphince sulphas, gr. X - X> c au- tiously repeated, is successful. If symptoms of depression occur, the stomachic, rectal or hypodermic administration of stimulants is indi- cated, and strychnince sulphas, gr. repeated half hourly by the hypodermic method. For convalescence, use quinince sulphas, strychnince sulphas or ferrum. ACUTE HYDROCEPHALUS. Synonyms. Acquired hydrocephalus ; serous apoplexy. Definition. Strictly speaking, hydrocephalus signifies water in the brain ; but it is here restricted to the presence of a serous fluid in the arachnoid spaces, in the pia mater, in the ventricles, and in the brain substance (oedema); characterized by the more or less sudden develop- ment of cerebral excitation, followed by depression and usually death. Causes. Most common between the ages of one and five, although it may occur at any age. “The predominance of the ner- vous system in the bodily conformation ” is a strong predisposing cause. Among the exciting causes are unfavorable, hygienic condi tions, dentition, eruptive fevers, blows on the head, mechanical causes DISEASES OF THE CEREBRUM. 401 preventing the return of the blood from the venae Galeni and the right sinus, compression of the jugular vein, diseases of the right heart, and Bright’s disease. Pathological Anatomy. The effusion may be limited to the ventricles, although there is usually considerable distention of the subarachnoid spaces and oedema of the pia mater and neighboring portions of the brain, whence results more or less softening, especially around the ventricles. The choroid plexus ishyperaemic and may be the seat of minute extravasations. Symptoms. There are three varieties of acute hydrocephalus with characteristic symptoms, to wit : comatose , convulsive and the ordinary . Comatose variety , known also as “serous apoplexy,” begins abruptly with the phenomena of apoplexy, the result of the sudden effusion. The pressure is usually so great on the medulla oblongata that it ceases to functionate, death resulting in a few hours, rarely last- ing several days. Convulsive variety , the result of Bright’s disease or a general dropsy, is ushered in with headache, nausea and vomiting, followed in a day or two with convulsions , passing into coma, which usually terminates fatally, although rarely a remission may precede death for a day or two. Ordinary variety , the most common in children, begins with fever- ishness, headache, vertigo, photophobia, restlessness, nocturnal deli- rium, insomnia, twitching and spasmodic contractions of the muscles and great hyperaesthesia of the skin. Such symptoms continue for several days, when convulsions occur, followed by death, or a con- tinuance of the symptoms, followed by rigidity, stupor and death. Prognosis. Unfavorable. Treatment. An attempt may be made to remove the fluid by diuretics and full doses of potassii iodidum. CONGENITAL HYDROCEPHALUS. Synonym. Chronic hydrocephalus (?). Definition. An excessive accumulation of the cerebro-spinal fluid — a cerebral dropsy — in the ventricles — internal hydrocephalus , or in the meshes of the pia mater — external hydrocephalus , or in both — mixed hydrocephalus ; characterized by enlargement of the head and more or less pronounced nervous phenomena. 402 PRACTICE OF MEDICINE. A disease of infants, or very young children. Causes. Imperfect or arrested development of the brain or its membranes. Occurs in the offspring of tubercular, scrofulous or syphilitic parents. Inflammatory changes in the ventricles and ependyma. Pathological Anatomy. Enlargement of the head is the chief external pathological condition, although there is no constant ratio between the size of the head and the amount of fluid, the quantity varying from an ounce to a pint or more. The liquid is transparent, of a straw color, containing a small amount of albumin and chloride of sodium. If the quantity of fluid be small the ventricles are simply distended, if the amount be large the optic thalami and corpus striatum are depressed and flattened, the roof of the ventricles thinned and the foramen of Monro is greatly enlarged. The enlargement of the head may occur before birth and impede or prevent natural delivery, or the head may be normal at birth and increase afterward. As enlargement progresses the bones are so thinned as to be translucent, the fonta- nelles and sutures are widened, the lateral portions of the cranium project, the forehead bulges out over the eyes, and the orbital plates are depressed, forcing the eyes outward and downward, producing a variety of exophthalmos ; the head has an irregular, triangular shape, the base of the triangle being the top of the head. The scalp being stretched by the pressure within, becomes tense and thin, and but scantily covered with hair, the veins which ramify in it are unusually prominent and large, and the entire head is elastic on pressure, from the amount of liquid beneath. Hilton, in Rest and Pain , says, “ In almost every case of internal hydrocephalus which I have examined after death I found that this cerebro-spinal opening (between the fourth ventricle and the spinal canal) was so completely closed that no cerebro-spinal fluid could escape from the interior of the brain ; and, as the fluid was being constantly secreted, it necessarily accumulated there, and the occlu- sion formed, to my mind, the essential pathological element of internal hydrocephalus.” Symptoms. The increased size of the head, with the emaciated condition of the child, who seemingly eats well, is what first attracts the attention. The head appears too heavy, the eyes are prominent and have a downward direction, the face is devoid of expression, old DISEASES OF THE SPINAL CORD. 403 and wrinkled, the voice feeble ; the mental development is not in keeping with the age. When the period for standing or walking arrives the power is found wanting. The further history is but a con- tinuation and exaggeration of this, until convulsions occur, which sooner or later terminate fatally. The course of congenital hydrocephalus is usually slow but pro- gressively worse. The majority terminate within the first year ; cases are recorded, however, of ten and fifteen years’ duration. Diagnosis. In rachitis the volume of the head is increased, due, in part, at least, to a deposit of calcareous matter on the exterior of the cranial bones. Rachitis may be mistaken for hydrocephalus in cases in which the amount of liquid is small. The differential diag- nosis is based on the shape of the head, round in rachitis, square or triangular or with prominences in hydrocephalus ; with the persistent downward direction of the eyes and the elasticity of the head on pressure. Prognosis. Unfavorable. Arrest of progress and even cures have been reported. Spontaneous cures are reported following the accidental discharge of the fluid. But such reports are exceptional. Treatment. The use of the finest aspirator needle to evacuate the fluid is fully justifiable. The proper situation for the puncture is the coronal suture, about an inch or an inch and a half from the anterior fontanelle. Firm but gentle compression of the cranium with adhesive strips should be made during the escape of the fluid and afterward. A few ounces of fluid only should be withdrawn at a time. The internal use of potassii iodidum is recommended. All measures which tend to promote the constructive metamorphosis are to be used. DISEASES OF THE SPINAL CORD. SPINAL HYPEREMIA. Synonyms. Spinal congestion ; plethora spinalis. Definition. An abnormal fulness of the vessels of the meninges and cord; active when an arterial hyperaemia; passive when a venous 404 PRACTICE OF MEDICINE. hyperaemia; characterized by pain in the back, with more or less pronounced disorders of sensation and locomotion. Causes. Cold and exposure ; arrested menses ; arrest of habitual hemorrhoidal discharge ; malaria; protracted erect posture; injuries to the back ; certain spinal poisons, as strychnina, picrotoxinum, and alcoholic excesses. Pathological Anatomy. Active. The post-mortem appear- ances are congestion of the meninges and cord, the same vessels supplying both, with numerous points of extravasation, due to the rupture of capillary vessels. The spinal fluid is increased in amount. Passive. A general bluish discoloration, owing to the abnormal fulness of the large anastomosing vessels ; the spinal fluid somewhat increased. Symptoms. Active. Dull pain in the dorsal or lumbar region, shooting into the hips and thighs, persistent and increased by pres- sure ; tenderness on motion ; tingling sensations in the limbs and feet, and sometimes in the hands and arms ; a feeling of constriction about the abdomen is often present, with rigidity of the abdominal muscles. Increased reflexes , with disorders of motility, and when the patient is in the recumbent position Jerking of the limbs. On attempt- ing to walk it is accomplished with difficulty, from an incomplete loss of power. If the upper part of the cord be affected, dyspnoea • and palpitation occur. There often occur painful priapism and frequent nocturnal emissions. The above symptoms may be followed by a more or less pro- nounced temporary depression, the sensation diminished and the lower limbs benumbed and heavy, the movements weak. The electro-contractility is preserved, and in many cases even in- creased or exaggerated. Duration. From a few hours to several days ; if longer, myelitis may result. Diagnosis. Ancemia causes more or less spinal irritability and tenderness ; but the history, pallor and general weakness, unasso- ciated with defects of motility or sensibility, will prevent error. Spinal meningeal hemorrhage is more sudden in its onset, its violence and its range of symptoms. Myelitis and spi?ial meningitis have symptoms in common with DISEASES OF THE SPINAL CORD. 405 spinal congestion, which will be pointed out when discussing those affections. Prognosis. Favorable, recovery occurring in three or four days. If the symptoms show a tendency to linger, myelitis, more or less pronounced, will ensue. Treatment. Rest, but avoid lying on the back ; cups or leeches along the spine, followed either by the iced or the hot douche, or hot sponges, with active purgation, to diminish the blood pressure. If the result of suddenly arrested perspiration , pilocarpus and a hot air bath. If following suddenly arrested menses, aconitum. If associ- ated with an active circulation, potassii bromidum , or extr actum gel- semii fluidum, rr^v, every four hours, or extractum ergotce fluidum , fgss-j, repeated p. r. n.; and in all cases active purgation. For the passive form, treating the cause, ergota , digitalis , tonics and purgatives. PACHYMENINGITIS SPINALIS. Synonyms. Pachymeningitis spinalis interna ; hypertrophic pachymeningitis ; pseudo-membranous pachymeningitis. Definition. An inflammation of the inner surface of the spinal dura mater ; characterized by violent pains in the head, neck, shoul- ders and arms, followed by contractures and paralyses of the upper extremities. Causes. Exposure to cold and damp ; alcoholism ; syphilis ; gout; injuries. Pathological Anatomy. Hypertrophic pachymeningitis is characterized by an exudation upon the inner surface of the dura mater, which gradually solidifies into a layer of compact connective tissue, which presses upon the spinal cord and nerves, producing a myelitis and an atrophic neuritis, resulting in muscular atrophy. The most frequent seat of this form of the affection is the cervical region, as first demonstrated by Charcot, whence the term cervical hypertrophic pachymeningitis. In the pseudo-membranous form a membranous exudation also occurs, in which large numbers of blood vessels develop and rupture, the hemorrhagic extravasation forming a cyst — haematoma — which causes pressure on the cord and nerves. Symptoms. The onset is slow and gradual, with irregular chills 406 PRACTICE OF MEDICINE. and feverishness , violent pains and stiffness in the head, neck, shoul- ders and arms, continuous but subject to exacerbations, and associated with a painful constriction of the upper thorax. Numbness and prick- ling occur in the arms, more marked in one than the other. Rarely nausea and vomiting occur. These symptoms may continue off and on for several months, the muscles of the painful parts atrophying , followed by spasmodic contraction, particularly of the hands and wrists, followed later by paralysis. The paralytic stage develops gradually, with weakness in the arms, associated with contractures and rigidity. The pain continues with anaesthesia, hyperaethesia and trophic changes. Later paraplegia with rigidity, exaggerated reflexes and spinal epilepsy, develop. The development of tuberculosis and nephritis during the progress of chronic cerebral and spinal diseases, which are the immediate cause of death, is a clinical observation. The electro-contractility is lost . Prognosis. If early recognized and promptly treated, the hyper- trophic form may be improved. Generally, however, the prognosis is unfavorable. Treatment. Rest; nutritious diet; oleum morrhuce and the hypophosphites ; large doses of potassii iodidum , and repeated but systematic counter-irritation. Symptomatic remedies for the pain and spasms are indicated. SPINAL MENINGITIS. Synonym. Leptomeningitis spinalis. Definition. Inflammation of the arachnoid and pia mater mem- branes of the spinal cord, either acute, subacute or chronic ; charac- terized by pain in the back, rigidity of the muscles, disorders of motility and sensibility. It may be acute or chronic. Causes. The disease is rare and is always due to an infection from tubercle, syphilis, typhoid fever or septicaemia, or the result of a traumatism. Pathological Anatomy. Acute. Hyperaemia of the mem- branes, with swelling of the tissues, the result of serous infiltration, followed by purulent and fibrinous exudations. The roots of the spinal nerves are covered with exudation, and are swollen and soft. The cord proper is more or less congested and oedematous. Chronic. Adhesion of the membranes, with more or less accu- DISEASES OF THE SPINAL CORD. 407 mulation of fluid, resulting in atrophic degeneration of the cord from pressure. If the disease is secondary to tubercle, these granulations are seen distributed over the pia, arachnoid, and inner surface of the dura. Symptoms. There are two stages, the first, the stage of irritation , the second, the stage of paralysis of motion and sensation, with atrophy. Although an inflammatory affection, yet its onset is usually subacute, the febrile reaction being moderate, with intense boring pain in the back, aggravated by motion, rigidity of the spine and a sense of constriction around the body , — “ the girdle.” Spasmodic con- tractions of the muscles enervated by the nerves originating at the seat of the lesion, with inability to straighten the limbs. If the lower part of the spinal membranes are the seat, there occur retention of urine and constipation ; if upper part, dysphagia , dyspnoea and feeble heart. The muscular contractions are excited or increased by motion, but uninfluenced by pressure. Reflex movements are not abolished. The rigidity and spasmodic contraction of the muscles are followed by paralysis, more or less complete, death following from paralysis of the muscles of respiration. If the inflammation extend to the medulla, the above symptoms are associated with disorders of speech, vomiting and delirium. Electro-contractility lessened or absent, both as to motility and sen- sibility, in the affected parts. Chronic forin succeeds to the acute or originates spontaneously, and presents the same form and order of symptoms — excitation or irritation, and depression or paralysis. Diagnosis. The points of importance are, deep, boring pain in the back, aggravated by motion but not by pressure, with spasmodic contraction of the muscles, followed by paralysis. Myelitis slight or absence of pain with earlier and more complete paralysis. Tetanus may be confounded with spinal meningitis. The points of distinction are : in the former occur early trismus with rhythmical spasms excited by irritation of the skin, whereas irritation of the skin does not in spinal meningitis produce muscular contractions, but movement of the limbs does do so ; progressively increasing, and not associated with fever ; usually a clear history of an injury. Prognosis. Generally unfavorable. Death is either sudden, from 408 PRACTICE OF MEDICINE. paralysis of respiration and of the heart, or gradually, the result of exhaustion. Critical discharges, such as profuse perspiration, urinary flow or epistaxis occur, and are followed by rapid recovery. Cases recovering may have more or less pronounced partial or complete paralysis. Treatment. Rest in bed, upon the side or face. Cups ox leeches along the spine, followed by ice , the hot douche , hot sponges or mus- tard. Active purgation. If the result of syphilis, full doses of potassii iodidum , (gr. x-xl), combined with hydrargyri chloridum corrosivum , (gr. For the paralytic stage, quininee sulphas , gr. iij, with ex tr actum bella- donna alcoholic, gr. J, three times a day, is sometimes useful. For paralysis, the galvanic current to the spine and nerve trunks, and the faradic current to the affected muscles, with the deep injec- tion of strychnina and the use of massage. ACUTE MYELITIS. Synonyms. Acute or general diffuse myelitis; transverse mye- litis ; softening of the cord. Definition. An inflammation affecting the substance of the spinal cord, which may be limited to the gray or white matter, and involve the whole or isolated portions of the cord. When the gray matter alone is inflamed, it is termed central myelitis ; when the white mat- ter and the meninges , it is termed cortical myelitis ; it may be ascend- ing, descending or transverse in its extension. The disease is charac- terized by more or less sudden and complete loss of motion and sensation. Causes. Following spinal meningitis; exposure to cold and damp ; injuries to the vertebrae ; prolonged functional activity of the cord ; typhus fever ; rheumatism ; syphilis ; puerperal fever, or during the course of the exanthemata ; arsenical or mercurial poisoning. Pathological Anatomy. Intense hyperaemia of the substance of the cord, with extravasations, giving the tissues a reddish-brown or chocolate tint, and also serous transudations, resulting in softening of the structure of the cord, the color changing to yellow and white, the nerve elements undergoing fatty degeneration, presenting the appear- ance and consistency of cream. The membranes also undergo more or less change. DISEASES OF THE SPINAL CORD. 409 Symptoms. The severity of the symptoms depends upon the extent and location of the inflammation. The onset is usually sudden, with a chill, fever, 103° frequent pulse , with alterations in sensibility and motility, to wit : pain in the back, aggravated by touch and by heat and cold, with sensations of formi- cation, (“pins and needles”), the limb feeling as if asleep, or else complete ancesthesia , associated with severe neuralgic pains. The distinction between ancesthesia , insensibility to touch, and analgesia, insensibility to pain, must be clearly determined. A sensation of constriction around the body and limbs, as if encircled by a tight cord, “the girdle pains;” rapidly developing paraplegia, complete in a few hours, with involuntary discharges. The reflex functions are usually abolished, as seen by attempting to cause move- ment of the limbs by tickling the feet or by striking the patella tendon ; rarely are they diminished, very rarely exaggerated. The temperature of the affected limbs is lowered three or four degrees. Sloughs and bedsores and muscular atrophy result if the anterior cornua — the trophic centres — are affected. The above symptoms of loss of motion and sensibility with rectal and vesical paralysis, are associated with more or less pronounced vomit- ing, hepatic disorders, irregularity of the heart, dyspnoea, dysphagia, apncea and painful priapisms. The urine is markedly alkaline in reaction, finally developing cystitis. Among the late manifestations are shooting pains and spasmodic twitchings or contractions of one or all of the muscles of the paralyzed parts. The electro-contractility is abolished in the paralyzed parts. Diagnosis. Acute spinal meningitis is distinguished from acute myelitis by severe pains, increased by pressure, with muscular con- tractions increased by motion, followed by paralysis much less pro- found than the paraplegia of myelitis ; in spinal meningitis there exists cutaneous and muscular hyperaethesia, which is absent in myelitis. Congestion of the spinal cord is characterized by the mild character and short duration of all the symptoms. Hemorrhage in the spinal canal is abrupt, with irritative symp- toms, slight paralysis, preserved reflexes and electro- contractility. The principal diagnostic points of acute myelitis are the “girdle” around the limbs or body, rapid and complete paraplegia, loss of sen- 34 410 PRACTICE OF MEDICINE. sation, lowered temperature in the affected parts, early and persistent sloughing (bedsores) and alkaline urine or cystitis. Hysterical paraplegia shows no trophic changes, no altered reflexes, slight atrophy, irregular anaesthesia and the presence of the stigmata of hysteria. LithcEmic parcesthesia , tingling and numbness of fingers and toes, might lead to error if the cerebral symptoms of lithaemia are over- looked. The diagnosis of the location of the lesion is made by a study of the height of the anaesthesia, the skin reflexes and the distribution and extent of the paralysis, which are shown in the following table from Dana, based on that originally devised by Starr and modified by Mills and Dana. LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL CORD. Segment. Muscles. Reflex and Centres. Sensation. First cervical. Rectus laterales. Rectus capitis. Anticus and posticus. Sterno-hyoid. Sterno-thyroid. Second and Sterno-mastoid. Hypochondrium (?). Back of head to vertex third cervi- Trapezius. Sudden inspiration and neck. (Occipi- cal. Scalem and neck. Omo-hyoid. Diaphragm. produced by sudden pressure beneath the lower border of ribs. talis major, occipi- talis minor, auricu- laris magnus, super- ficialis colli, and su- praclavicular.) Fourth cervi- Diaphragm. Pupillary (fourth cervi- Neck. cal. Deltoid. Biceps. Coraco-brachialis. Supinator longus. Rhomboid. Supra- and infra-spi- natus. cal to second dorsal). Dilatation of the pu- pil produced by irri- tation of neck. Shoulder, anterior sur- face. Outer arm. (Supracla- vicular, circumflex, external musculo-cu- taneous, cutaneous.) Fifth cervi- Deltoid. Scapular (fifth cervical Back of shoulder and cal. Biceps. Coraco-brach ialis . Brachialis anticus. Supinator longus. Supinator brevis. Deep muscles of shoul- der-blade. Rhomboid. Teres minor. Pectoral is (clavicular part). Serratus magnus. to first dorsal). Irri- tation of skin over the scapula produces con- traction of scapular muscles. Supinator longus . Tap- ping the tendon of the supinator longus pro- duces flexion of fore- arm. arm. Outer side of arm and forearm to the wrist. (Supraclavicular, cir- cumflex, external cu- taneous, internal cu- taneous, posterior spinal branches.) DISEASES OF THE SPINAL CORD. 411 LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL COR D. — Continued. Segment. Muscles. Reflex and Centres. Sensation. Sixth cervi- Deltoid. Triceps (fifth to sixth Outer side and front of cal. Biceps. Brachialis anticus. Subscapular. Pectoral is (clavicular part). Serratus magnus. Triceps. Pronators. Rhomboid. Latissimus dorsi. cervical). Tapping elbow tendoft pro- duces extension of forearm. Posterior wrist (sixth to eighth cervical). Tapping tendons causes extension of hand. forearm. Back of hand, radial dis- tribution. (Chiefly external cu- taneous, internal cuta- neous, radial.) Seventh cer- Triceps (long head). Anterior wrist (seventh Radial distribution in the vical. Extensors of wrist and fingers. Pronators of wrist. Flexors of wrist. Subscapular. Pectoralis (costal part). Serratus magnus. Latissimus dorsi. Teres major. to eighth cervical). Tapping anterior ten- dons causes flexion of wrist. Palmar (seventh cervi- cal to first dorsal). Stroking palm causes closure of fingers. hand. Median distribution in the palm, thumb, in- dex, and one-half mid- dle finger. (External cutaneous, internal cutaneous, ra- dial, median, posterior spinal branches.) Eighth cervi- cal. Triceps (long head). Flexors of wrist and fingers. Intrinsic hand muscles. Ulnar area of hand, back and palm, inner border of forearm. (In- ternal cutaneous, ul- nar.) First dorsal. Extensors of thumb. Intrinsic hand muscles. Thenar and hypothenar muscles. Chiefly inner side ot forearm and arm to near the axilla. (Chiefly internal cu- taneous and nerve of Wrisberg or lesser in- ternal cutaneous.) Second dor- sal. Inner side of arm near and in axilla. (Inter- costo-humeral.) Second to Muscles of back and ab- Epigastric (fourth to Skin of chest and abdo- twelfth dor- domen. seventh dorsal). Tick- men, in bands running sal. Erectores spinae. ling mammary region causes retraction of the epigastrium. Abdominal (seventh to eleventh dorsal). Stroking side of abdo- men causes retraction of belly. Vasomotor centres. Second dorsal to second lumbar. around and downward, corresponding to spi- nal nerves. Upper gluteal region. (Intercostals and dor- sal posterior nerves.) First lumbar. None. Cremasteric (first to third lumbar). Strok- ing inner thigh causes retraction of scrotum. Skin over groin and front of scrotum. (Ilio-hy- pogastric, ilio-ingui- nal.) Second lum- bar. Vastus internus. Patellar. Striking pa- tellar tendon causes extension of leg. Outer side and upper front of thigh. Lum- bar region. (Genito- crural, external cuta- neous.) 412 PRACTICE OF MEDICINE. LOCALIZATION OF THE FUNCTIONS OF THE SEGMENTS OF THE SPINAL CORD. — Continued. Segment. Muscles. Reflex and Centres. Sensation. Third lumbar. F ourth lum- bar. Fifth lumbar. Sartorius ; adductors of thigh. Flexors of thigh. Extensors of knee. Abductors of thigh. Outward rotators. Flexors of knee. Flexors of ankle. Peronei. Extensors of toes. Gluteal (fourth to fifth lumbar). Stroking buttock causes dimp- ling in fold of buttock. Achilles tendon. Over- extension causes rapid flexion of ankle, called ankle clonus. First and second sa- cral. Calf muscles. Glutei. Peronei. Extensors of ankle. Small muscles of foot. Plantar (fifth lumbar to second sacral). Tickling sole of foot causes flexion of toes and retraction of leg. Front and outer side ot thigh. Inner side of leg and foot. Inner side of thigh, leg, and foot. (Internal cutaneous, long saphe- nous, obturator.) Back of thigh and outer side of leg and ankle ; sole ; dorsum of foot. (External popliteal, ex- ternal saphenous, mus- culo-cutaneous, plan- tar.) Back of buttock and thigh, side of leg and ankle; sole; dorsum of foot. Third, fourth, and fifth sa- cral. Perineal. Muscles of bladder, rec- tum , and external genitals. Genital centre. Vesical centre. Anal centre. Circumanal region, anus, rectum, penis, urethra, vagina, perineum. (Small sciatic, pudic, inferior hemorrhoidal, inferior pudendal.) Prognosis. Varies according to the location of the lesion and completeness of the symptoms. If the paralysis is of the ascending variety , death occurs within a few days, from paralysis of the muscles of respiration. If the trophic centres are affected, there occur bedsores, intense pyelo-nephritis and cystitis and changes in the joints; death from exhaustion, in several weeks. Central myelitis , or inflammation of the gray matter , is rapid in its progress, death occurring in a week or two. The morbid process may be arrested and the general health restored, but some spinal symptoms will persist. Treatment. Absolute rest is essential to even secure a palliation of the symptoms. Locally , considerable relief follows the use of hot-water bags or sponges dipped in hot water and applied along the spine every few hours. The remedies most strongly recommended are : digitalis , strychnina DISEASES OF THE SPINAL CORD. 413 ergota , belladojma , bromides , cimicifitga and quinina, although I have never observed a cure with any plan of medication, after the disease was fairly established, save those due to syphilis, by large doses of potassii iodidum. Gray reports having administered 700 grains daily before improvement began. INFANTILE SPINAL PARALYSIS. Synonyms. Myelitis of the anterior horns ; poliomyelitis ante- rior acuta ; essential paralysis of children ; atrophic paralysis of chil- dren. Definition. A rapidly developed inflammation of the anterior horns of the gray matter of the cord, occurring suddenly in children, at times in adults — acute spinal paralysis of adults ; — characterized by mild fever, muscular tremors and twitchings, and paralysis of groups of muscles. Causes. Essentially a disease of early life — the second month to the third or fourth year. The fact of its having occurred in adults must be borne in mind. Cold and damp ; dentition (?) ; injuries to the spine ; developed during convalescence from the acute exanthe- mata. Pathological Anatomy. The early changes are : medullary hyperaemia, vascular exudation and inflammatory softening, although the naked eye may not recognize any changes. Microscopical exam- ination reveals inflammatory softening of the anterior horns of the gray matter. Among other constant lesions are atrophic degenera- tion of the multipolar ganglion cells and of the anterior nerve roots. The changes noted as occurring in the cord are usually limited to the dorso-lumbar and cervical enlargements. As a direct result of the changes in the trophic centres and the nerve degeneration of the muscular fibres supplied, there ensue changes in the bones and joints, leading to great deformities. Symptoms. The onset of the affection varies ; it may be acute, sub-acute or chronic; it is usually sudden, with an attack of mild fever of a remittent type, of a few days’ duration, on recovery from which it is noticed that the child is paralyzed. Rarely the paralysis may be preceded by convulsions. The paralysis may affect both arms and both legs, the legs alone, or only one of the four extremities; it may, but very rarely, be a 414 PRACTICE OF MEDICINE. hemiplegia. As a rule, however, the leg suffers more frequently than the arm : in paralysis of the leg the muscles below the knee suffer more severely than those above. The bladder and rectum are not affected, or if so, only temporarily, nor can anaesthesia or numb- ness be detected. The temperature of the paralyzed limb is low and the appearance cyanosed. After a few days there is a slight im- provement in the paralyzed parts, although the muscles show a rapid wasting, which is progressive until all muscular tissue is gone. The reflex movements are impaired or abolished. The electro- contractility by the faradic current is abolished in the paralyzed parts. With the galvanic or constant current the “ reactions of degenera- tion ” are developed. To fully understand the meaning of this term a knowledge of the normal electrical reactions is necessary. The normal formulae for the production of muscular contraction in the physiological state are as follows, the strength of the current being barely capable of causing fair contractions : — First. The most effective contractions are produced by the cathode ( negative ) pole on closing the circuit, Second. The second most effective are produced by the anode ( pos- itive ) pole on closing the circuit. Third. The next most effective is by the anode pole on opening the circuit. Fourth. Cathode pole contractions on opening circuit are rarely seen in the physiological state. The “ reactions of degeneration ” are shown by any reversal of the regular formulae, to wit : if the anodal closure shows stronger contrac- tions than cathodal closure ; still greater degeneration is shown if anodal openmg contractions are stronger than either of the above ; and most complete degeneration is shown by the complete reversal of the normal formulae as shown by distinct cathodal opening contractions. Sequelse. Amongst the deformities resulting from the paralysis are the different forms of talipes. Talipes equinus, the result of paralysis of the antero-external mus- cular group of the leg. Equino-varus, the result of paralysis of the antero-external muscu- lar group of the leg, together with the adductors of the foot. Talipes calcaneus, the result of paralysis of the muscles of the calf of the leg. DISEASES OF THE SPINAL CORD. 415 Talipes cavus — “ pes cavus ” — characterized by the hollowing of the sole of the foot, with prominence of the instep, the result of paralysis of the calf muscles with contraction of the long flexor of the toe or the long peroneus — the foot flexors. Diagnosis. The recognition of acute poliomyelitis is not always possible at the onset or during its early days, as localized paralyses are difficult of detection in children, but immobility of one leg or arm in children with febrile symptoms or following convulsions is always an indication of poliomyelitis. After the initial stage has passed, the presence of paralysis, wasting, presence of R. D. (reactions of degen- eration), loss of reflexes and the absence of anaesthesia, render the diagnosis very easy. Hemiplegia from acute cerebral affections in children can be dis- tinguished from infantile paralysis by the disorders of intelligence and the special senses, and the perseverance of the normal electro-con- tractility. Paralysis of myelitis occurs in older persons, and is associated with disturbances of the genito-urinary organs and bedsores. Pseudo-muscular hypertrophy, with paralysis, begins gradually, becoming progressively worse with increase in the size of the limbs. Prognosis. More or less paralysis with muscular wasting always results, although there is no doubt that the extent can be greatly lessened by early recognition and treatment. Treatment. The diagnosis during the initial fever is impossible, so that its treatment -is symptomatic. On the appearance of the paralysis , complete rest , hot spinal douche , mild galvanism , and internally, quinina , belladonna , ergota , and potassii iodidum. With the improvement that follows the above measures, use inter- nally, tinctura nucis vomicce , rr\J— iij t. d., or hypodermic injections of sirychnince sulphas , gr. "tfu twice a week, and faradism to the paralyzed muscles. CHRONIC PROGRESSIVE BULBAR PARALYSIS. Synonyms. Glosso-labio-laryngeal paralysis ; bulbar paralysis. Definition. A chronic degenerative affection of certain nuclei of the medulla oblongata ; characterized by a slowly progressive bilateral paralysis of the tongue, lips, palate, pharynx and larynx, with atrophy of the tongue and lips. 416 PRACTICE OF MEDICINE. Causes. Obscure. Rare before the fortieth year. Among many others may be named cold, rheumatism, gout, syphilis and injuries about the neck. Pathological Anatomy. “ Degenerative atrophy of the gray nuclei in the floor of the fourth ventricle ; with atrophy and gray dis- coloration of the nerve roots from the medulla, especially of the facial and hypoglossal nerves.” “Atrophy and disappearance of the motor ganglion cells is always to be noted. It may be the sole lesion.” “ The nerves going to the muscles exhibit sclerosis of the neuri- lemma, and the degenerative atrophy is found in the nerve roots coming from the bulb.” Symptoms. The disease begins insidiously. There is first noticed some difficulty in articulation , from want of precision in movements of the tongue, particularly in the use of the lingual con- sonants, /, n , r, and /, which increases until that organ is completely paralyzed. The paralysis gradually invades the soft palate and pharyngeal muscles, causing difficulty in deglutition, of the orbicularis oris preventing closure of the lips, of the laryngeal muscles interfering with articulation. With the increasing loss of power in the tongue and lips is also a gradual atrophy of these muscles. When the disease is fully developed the condition of the patient is most pitiable, indeed ; articulation is impaired or impossible, deglutition interfered with, the lips remaining apart allowing the saliva to dribble from the mouth, and liquids to return through the nose if attempts are made to swal- low them. As the malady progresses, the pneumogastric nucleus be- comes involved, resulting in loss of voice, difficulty of respiration and cardiac irregularity. The general health gradually suffers from insufficient nutrition and imperfect respiration, although the mind is clear until the end. The “ reactions of degeneration ” are present. Besides the chronic bulbar paralysis, there are two acute forms which give the same symptoms as the chronic cases, only they develop suddenly , one, the result of hemorrhage into the medulla , which at the onset has vertigo, vomiting, loss of power in the limbs and slight sen- sory disturbances, all of which disappear, leaving the glosso-labio- laryngeal paralysis ; the second form comes suddenly, with fever, vomiting and loss of power in the limbs soon disappearing, leaving the characteristic bulbar symptoms; this variety is inflammatory and closely allied to acute poliomyelitis. Diagnosis. It can hardly be confounded with any other malady. DISEASES OF THE SPINAL CORD. 417 Prognosis. Unfavorable. The duration is from one to five years. Treatment. Entirely symptomatic. “ Galvanism is the most promising remedy. Stabile applications, the electrodes on the mas- toid processes, and in the opposite direction, galvanization of the sym- pathetic, and applications to the lips, tongue and fauces, should be persistently used” (Bartholow). PROGRESSIVE MUSCULAR ATROPHY. Synonyms. Wasting palsy ; chronic spinal muscular atrophy ; chronic poliomyelitis ; amyotrophic lateral sclerosis. Definition. A slowly, gradual progressive wasting and atrophy of certain groups of muscles, with symptoms varying in accordance with the variations in the pathological anatomy. Causes. Most frequent in males between twenty-five and fifty years of age, and in many instances is hereditary. A predisposing cause seems to exist in those who habitually use one set of muscles (muscular strain). Exposure to cold and damp ; lead ; syphilis ; inju- ries to the spinal column. Following such acute diseases as diphtheria, measles, acute rheumatism, typhoid and typhus fevers. Pathological Anatomy. Two theories as to the origin of the pathological changes are held : one that the initial lesion is in the cord (Charcot), the other in the muscular interstitial connective tissue (Friedreich). The morbid alterations are of two groups — spinal and muscular. The spinal changes consist in the atrophy and degeneration of the anterior columns, wasting and disappearance of the multipolar gan- glion-cells of the anterior horns, with hyperplasia of the neuroglia ; rarely the hyperplasia extends to the lateral columns, (amyotrophic lateral sclerosis) ; also wasting, atrophy and degeneration of the an- terior nerve roots. The muscular changes consist of a progressive wasting of the mus- cular tissue, with increase of the interstitial connective tissue. “ The final result is, that the muscle is converted into a mere fibrous band with numerous fat-cells, the development of this latter material taking place outside of the muscular elements and in the newly-formed con- nective tissue ” (Bartholow). Symptoms. The invasion is gradual, the disease having been 35 418 PRACTICE OF MEDICINE. in progress some weeks or months before the patient is aware of its existence. Wasting begins usually in the hand , the first dorsal interosseus being the first to be attacked, then the muscles of the thenar and hy- pothenar eminence , then the deltoid, and so on from muscular group to group. Often, however, the extension is very erratic in its course, jumping from one group to another at some distance. In the immense majority of cases the disease is permanently lim- ited to one or a few groups of muscles in the upper, or more rarely in the lower extremities. The only muscles not yet known to be attacked are those of mastication and those that move the eye-ball (Roberts). Fibrillary contraction is an early symptom, continuing more or less marked so long as any muscular fibres remain. It consists of wave-like movements of the muscles, excited automatically, by draughts of air or percussion. Co-incident with the wasting is loss of power, disorders of sensation, coolness of the surface, and pallor of the surface. The natural roundness and contour of the body and limbs are changed, the bones standing out in unaccustomed distinctness, giving the individual the appearance of a skeleton clothed in skin. The hand is frequently the seat of a very singular deformity — the “ claw- shaped ” hand. The electro-contractility is preserved so long as muscular fibres remain. Diagnosis. When wasting palsy is fully developed its diagnosis is a simple matter. In its early stages a doubt may exist, but atten- tion to the history, symptoms and progress will determine the ques- tion. Syringo-myelia often begins with muscular atrophy as a marked symptom, and may be confounded with wasting palsy, the chief points of distinction between which , are, the loss of power of perceiving heat, or, often, to distinguish between heat and cold, and the appear- ance of trophic changes, such as a dusky or purplish hue of the hands, with a uniform thickness resembling myxoedema, the development of blebs and ulcers, and changes in the nails. Arthropathies are sometimes met with. Prognosis. Very unfavorable, although the danger to life is often very remote. The disease may be arrested and remain stationary for years. DISEASES OF THE SPINAL CORD. 419 Treatment. Internal medication seems to have no effect on the malady, although if mineral poisoning be suspected , potassii iodidum should be used, and if syphilis be suspected a course of potassii iodi- dum , and hydrargyrum , should be administered. Arsenicum, strych- niiicB sulphas , and oleum morrhuce , with a generous diet, are amongst the remedies indicated. If the disease is the result of overworking any set of muscles, these must be allowed a rest. “ The most effective remedy in wasting palsy is, undoubtedly, gal- vanism. Numerous observations attest its value when applied locally to the affected muscles” (Roberts). I have seen improvement from the faradic current to the affected muscles, the strength being simply sufficient to produce contractions. Massage is a valuable adjuvant to the electrical treatment, as are hot sponging and rubbing along the spine. Prof. Bartholow “has apparently effected great improvement in a case, confined as yet to the left upper extremity, by the injection of glycerin solution into the wasting muscles.” SPINAL SCLEROSES. Synonym. Duchenne’s disease. Definition. A myelitis; an increase in the connective tissue of the spinal cord, with atrophy of the nerve structure proper. Varieties. I. Lateral sclerosis ; II. Posterior sclerosis , or loco- motor ataxia ; III. Ataxic paraplegia ; IV. Cerebro-spinal sclerosis. Causes. Generally a hereditary neuropathic diathesis ; syphilis ; alcoholism ; mineral poisons ; shocks or injuries to the cord; exposure to cold and wet ; mostly occurring between the ages of thirty-five and fifty-five ; males more liable than females. It is said that railroad enginemen and firemen as well as conductors and other trainmen, suffer from this and other spinal diseases by reason of the continual concussion of railway travel. The freedom from the disease in the negro has been noted by Mitchell. Pathological Anatomy. The changes in the cord are gradual in their development and follow a longitudinal instead of a transverse direction. The form, consistency and color of the cord are altered, it being atrophied, indurated and of a grayish color. 420 PRACTICE OF MEDICINE. The changes are hyperplasia of the connective tissue, with granular degeneration, atrophy and disappearance of the proper nerve ele- ments. The nerve roots undergo the same fibroid change. The joints undergo remarkable atrophic degeneration — the arthropathies or Charcot joints, consisting of an osseous hyperplasia, the joint enlarg- ing to an enormous extent. PRIMARY LATERAL SCLEROSIS. Synonyms. Antero-lateral sclerosis ; spasmodic tabes dorsalis (Charcot) ; spastic spinal paralysis (Erb). Definition. A degeneration of the lateral columns of the cord ; characterized by paraplegia, contractures of the muscles, with exag- gerated reflexes. Pathogeny. The exact morbid condition is still a subject of dis- cussion. The site of the lesion is the lateral white columns, in some cases extending to the anterior horn, and involving the whole length of the cord. The changes consist in an interstitial hyperplasia of the connective tissue, and an atrophy of the nerve elements. Symptoms. The onset of the disease is very gradual, with in- creasing feeling of heaviness and weakness in the limbs, progressing to a complete paraplegia . There is also jerking and twitching with cramps and stiffness of the muscles of the paretic limbs. The spasms of the legs gradually increase in extent as the power lessens, until at last the legs, whenever extended, pass into a condition of strong extensor spasm, rigidly fixing them to the pelvis, so that the patient lies rigid, if one leg is lifted from the couch by the observer, the other leg is moved also. The spasm may be such that the knee cannot be passively flexed by any force that can be applied to it until the spasm has become less. When flexed the limb is comparatively supple : but if it is then extended, the spasm instantly returns, making the limb rigid, and often completing the extension, just as the blade of a knife opens out under the influence of its spring, “clasp-knife rigid- ity.” Occasionally there occur brief flexor spasms, drawing the legs up. The knee-jerk is greatly exaggerated, and there can also be devel- oped rectus-clonus and ankle-clonus. The spastic gait is characteristic, termed by Hammond “ the wad- dle ; ” the legs drag behind and are moved forward as a rigid whole, DISEASES OF THE SPINAL CORD. 421 the toes catching against the ground, the patient showing a tendency to fall forward. Sensation is unaffected. As the morbid process extends upward the superior extremities suffer in the same manner as those of the lower. Electro-contractility early impaired and gradually declining until abolished. Diagnosis. The gradual development of weakness in the legs, excess of myotatic irritability and spasms with developing spastic gait render the diagnosis clear. If the symptoms develop suddenly or acutely, the morbid condition is not of the degenerative variety. Prognosis. Complete recovery rare. If the condition is early recognized its progress may be held in check for a long time. Treatment. Rest of the first importance. Every means to pro- mote the general health. If the result of lues or mineral poisons, increasing doses of potassii iodidum , or aurii et sodii chloridum. Argenti 7 iitras , or oxidum, often retards the hyperplasia of connective tissue. Benefit may sometimes follow the use of a weak galvanic current , but as a rule electricity is disappointing in central diseases. LOCOMOTOR ATAXIA. Synonyms. Posterior spinal sclerosis ; tabes dorsalis. Definition. A chronic degeneration of the posterior columns oi the spinal cord and the posterior nerve roots, characterized by loss of co-ordination, neuralgic pains in the limbs, loss of sensation and re- flexes, and visceral and trophic changes. Pathogeny. “A progressive destructive process which has a selective influence on certain tracts in the posterior columns with their roots and ganglia and to a less extent on the peripheral nerves, particularly the optic. The nerve fibres of the cord are first involved. Their destruction is not a simple wasting, but is accompanied with evidence of irritation such as swelling of axis cylinders and, secon- darily, proliferation of connective tissue and slight congestion” (Dana). Symptoms. Locomotor ataxia may be divided into three periods : i, disturbances of sensation; 2, loss of coordinating power; 3 paralysis. The onset of the disease is gradual, by sharp, darting, electric-like 422 PRACTICE OF MEDICINE. pains in the lower limbs, with disorders of the gastro-intestinal and genito urinary tracts. Associated with the pains is a loss of sensation in the feet, the patient being unable to distinguish between hard and soft substances in walking, and, if the upper portion of the spinal cord be affected, is unable to coordinate the muscles of the fingers suffi- ciently to button his clothing. A sensation of formication over the surface, especially over the lower limbs, and about the waist, the knee and the ankle, is present ; there is nearly always a feeling of constriction about the trunk — the girdle. Loss of coordination or ataxia, the subject being unable to walk upon a straight line with his eyes closed, and with difficulty if his eyes are opened. Inability to preserve the erect position with the feet close together, the body swaying widely and the patient falling on standing with closed eyes, — Romberg’s symptom, and as the malady progresses he throws his feet and legs in the most grotesque manner. Although the patient is unable to coordinate the muscles, their power is not lost, for, on being supported, he can kick or strike with his usual force. The sight is early impaired, due to atrophy of the optic nerve, either double vision or inability to distinguish between different colors. Very early there is loss of pupil reflex to light, the reaction to accommo- dation being present — Argyll-Robertson symptom. As the disease progresses the sensation becomes more and more blunted and pain is slowly felt, in cases it being several minutes until the sticking of a pin is appreciated. A characteristic sign of the disease is the aboli- tion of the patellar tendon-reflex — Westphal’s symptom, as well as other reflexes in the lower limbs. Loss of the sensation of tempera- ture also occurs. The electro-contractility is decreased in the affected limb. General emaciation is marked. Either early or late in the disease occur disturbances in micturition and. loss of sexual power and often desire. There also occur in a fair number of cases, painless swelling and disintegration of various joints, particularly the knee and elbow — the tabetic arthropathies , or Charcot joint. At any period of the disease peculiar crises , or neuralgic attacks occur : if griping pains in stomach with vomiting — gastric crises ; if renal pain or colic with disturbed urinary flow, nephralgic crises ; if pain in bladder, vesical crises ; if pain in rectum with hemorrhoids, rectal crises ; if severe paroxysm of coughing, bronchial crises ; if DISEASES OF THE SPINAL CORD. 423 constriction of throat with dyspnoea, laryngeal crises ; if cardiac pain and tachycardia, cardiac crises. Paralysis finally ends the suffering of the patient. There is gener- ally an entire absence of cerebral phenomena. Diagnosis. There are three pathognomonic symptoms of loco- motor ataxia whose presence render the diagnosis positive, they are Westphal’s symptom — absence of patellar reflex, Romberg’s symp- tom — swaying of body and inability to maintain erect position with closed eyes, and the Argyll-Robertson symptom — loss of pupil reflex to light but reaction to accommodation retained. Another important point is the history of syphilis five to twenty years before. Chronic myelitis is characterized by paralysis, and the course of the affections are otherwise so different that an error should not occur. Disease of the cerebellum presents symptoms of disordered coordi- nation, but they are the result of vertigo, and associated with headache, nausea and vomiting and neuralgic pains and eye symptoms absent. Paraplegia is a true paralysis, while sclerosis is not. Neuralgic pain is not a symptom of paraplegia. Multiple neuritis gives loss of power with pain but does not present the three pathognomonic symptoms mentioned above. Prognosis. Unfavorable. Few if any recoveries are recorded, although rarely the progress has been retarded for a long time. There are some claims of recoveries of locomotor ataxia in the early stage, but that a cure of a genuine case, extending to the second stage, is ever effected, seems very questionable. Treatment. In the management of locomotor ataxia, rest , as near absolute as possible, is of the first importance, — it will be all the more effective if it be in bed, for a period of several months. Following the suggestion of Erb, use may be made of cold along the spine , in the shape of cold sponging, cold spinal pack or short application of the cold douche to the spine. The galvanic continuous current along the spinal column is warmly advocated, with faradism to the wasting muscles. Potassii iodidum , or hydrargyri chloridum corrosivum , in full doses, or aurii et sodii chloridum, gr. three times a day, often remarkably retard the progress of the affection. The best results are obtained, however, from argenti nitras, gr. or oxidum , gr. fz, three times a day, withholding it at intervals of a few weeks, to prevent discolor- ation of the skin (argyria). 424 PRACTICE OF MEDICINE. Temporary success at least, seems to have followed, in some cases of locomotor ataxia in the second stage, from the “ suspension treat- ment" as recommended by Charcot. The treatment consists of the suspension of the patient during a period varying from one to four minutes, by means of the Sayre apparatus for applying the plaster jacket in spinal deformities. The severe and sharp pains require treatment, at first giving prefer- ence to any of the substitutes of opium, but finally opium itself will have to be resorted to ; the actual cautery applied to the back once a month is said to relieve the pains. The diet should be of a nutritious, easily-assimilated character. Nutrition can also be promoted by the use of oleum morrhuce , and, syrupus calcii lacto-phosphatis. ATAXIC PARAPLEGIA. Synonyms. Combined lateral and posterior sclerosis ; antero- lateral sclerosis. Definition. A chronic degeneration of the lateral pyramidal tracts and of the posterior columns of the spinal cord ; characterized by gradual developing paraplegia, with ataxia, and spasms of the limbs. Causes. The causes are not so well determined as in other vari- eties of spinal sclerosis. Pathogeny. A sclerosis of the lateral and posterior columns of the spinal cord. It is to be noted that the posterior columns show the morbid changes higher up than in locomotor ataxia — the dorsal rather than the lumbar regions, and that the root-zone of the postero- external column is much less involved. Nor do the lateral tracts show the same degree of involvement as in spastic paraplegia. Symptoms. The onset is slow and gradual, with loss of power in the lower extremities. The muscles involved are particularly the flexors of the thigh and knee. One leg may be weaker than the other. There is also ataxia , the patient being unsteady when stand- ing with feet together and he tends to fall if the eyes are at the same time closed. Spasms of the lower extremity gradually develop and finally become as marked as in spastic paraplegia. The knee- jerk reflex is increased, quick and extensive, and rectus and ankle clonus can be developed. The sexual power is early lost. Inconti- DISEASES OF THE SPINAL CORD. 425 nence of urine is frequent. Sensation is unimpaired and neuralgic pains are absent, as are eye symptoms. Diagnosis. The conditions ataxic paraplegia is most liable to be mistaken for, are locomotor ataxia and spastic paraplegia. The presence of knee-jerk and loss of power in lower extremities are of value in discriminating from locomotor ataxia. Spastic paraplegia is not associated with ataxia, indeed ataxic paraplegia is spastic para- plegia^/^ inco-ordination. Prognosis. As a rule unfavorable. Treatment. The same plan of treatment may be tried as recom- mended for lateral or posterior sclerosis. CEREBRO-SPINAL SCLEROSIS. Synonyms. Multiple sclerosis of the brain and cord ; cerebral sclerosis ; spinal sclerosis ; disseminated sclerosis (Charcot). Definition. A degenerative disease of the brain and spinal cord ; characterized by pains in the back, disorders of sensation, loss of co- ordination, tremor on motion, scanning speech, and some mental impairment. Pathogeny. The disease consists of the development of patches of grayish, translucent, tough nodules, varying in size from a minute microscopical object up to the size of a walnut, varying in number and widely distributed in the white matter of the hemispheres, ven- tricles, optic thalamus, corpus striatum, peduncles, pons and cere- bellum, while in the cord they are found in both the white and gray matter and in the columns. The deposits are also found in the nerve roots and nerve trunks. The nodules are composed of the neuroglia, much altered, and a newly-formed connective tissue. The result of the growth of the nodules is pressure upon the nerve structure, ending in its degeneration. Symptoms. Charcot divides this disseminated sclerosis into three varieties, depending upon the site of the marked changes, as the brain, the cord or a combination of the two. The latter variety is the more common. Rarely, the malady is ushered in with apoplectiform symptoms, but generally the onset is insidious, with pains more or less severe in the limbs and back , which are attributed by the patient to rheumatism. Also a feeling of formication, itching and burning in the limbs. Loss 426 PRACTICE OF MEDICINE. of co-ordination of the hands in writing, or the feet in walking, or a jerky co-ordination, followed after a time by paresis , more or less general, with conlracttire of the muscles. Voluntary movements of the paretic limbs develop a tremor — the shaking tremor — which sub- sides when the limbs are at rest — intention tremor, with shaking of head. An early and frequent condition is nystagmus. The loss of co-ordination, with tremor and with contractures of the muscles of the legs, has given rise to the “ waddle,” or “ hop ” gait when walk- ing. There are also present headache , vertigo , mental impairment with an unnatural contentment of the feelings and with the surround- ings, a scanning or slurring speech , disorders of vision and hearing , sexual disturbances , vesical disorders , gastric and other crises, and often the development of bed-sores. Knee-jerk and muscular reflexes are exaggerated. The disease is progressive, the symptoms developing as the various nerve tracts are invaded. Duration. Ranges from a year to twenty years, an average being five or ten years. Diagnosis. Paralysis agitans may be mistaken for disseminated sclerosis. The chief points in the diagnosis are the presence in par- alysis agitans of the fine tremor continually without shaking of the head, with a peculiar flexion and rigidity of the hand, while in cerebro- spinal sclerosis the tremor is produced only on movement of the muscle, and is associated with shaking of the head. Paralysis agitans, a disease of middle life, sclerosis under forty years. Changes in the voice, speech and vision are present in cerebro-spinal sclerosis, but absent in paralysis agitans. Tumor of the pons or crus is accompanied with wild, jerky inco- ordination closely resembling disseminated sclerosis, but tumor also has headache, optic neuritis, local spasm and local paralysis. General paralysis of the insane and disseminated sclerosis are frequently confounded, as are locomotor ataxia, and primary lateral sclerosis. Prognosis. Unfavorable. The disease slowly but steadily pro- gresses, chronic nephritis or tuberculosis, frequently developing and causing death. Treatment. There is no drug having the power to cure sclerosis. Syphilis has been the cause of the vast majority, if not all the cases observed by the writer, and potassii iodidum , in large doses, or the DISEASES OF THE NERVES. 427 following, has seemed in a few instances to hold the disease in check for a time : — R . Hydrargyri chloridi corros., gr. j Liq. arsenici chloridi, f% j Inf. gentian, ad f ^ iij. M. SlG. — Teaspoonful three times daily, in water. DISEASES OF THE NERVES. SIMPLE NEURITIS. Definition. An inflammation of the nerve trunks ; character- ized by pain and paresis of the parts supplied by the affected nerve trunk. Causes. Wounds and injuries or compression of nerves; cold and damp ; syphilis (?), lead. Pathological Anatomy. Hyperaemia, followed by exudation into the nerve sheath and connective tissue, “which becomes softened and ultimately breaks down into a diffluent mass.” Migration of white corpuscles takes place into the neurilemma. Recovery may occur before destruction of the nerve elements is produced, absorp- tion of the exudation occurring. “ It is important to note that when inflammation occurs in a nerve it may extend from the point first diseased upward ( neuritis ascendens ), or downward ( neuritis descen- dens)." Symptoms. The onset may be accompanied with febrile reac- tion. The most decided symptom is pain along the course of the nerve trunk and its peripheral distribution, of a burning , tingling , tearing , inte?ise character, increased by pressure or motion. If the affected nerve be a mixed one — sensory and motor — spasmodic con- tractions and muscular cramps occur, followed by impaired motion, terminating in paresis of the muscles innervated by the affected trunk. If the inflammation proceed to destruction of the nerve trunk, wast- ing and degeneration of the muscular tissue ensues. Various trophic 428 PRACTICE OF MEDICINE. changes also occur, such as cutaneous eruptions, and clubbing of the nails. The electro-contraciility is impaired or lost. Diagnosis. Myalgia or muscular pain is not associated with paralysis, nor does the pain follow the course of a nerve trunk. Neuralgia has the pain, but as a rule, not the tenderness of neuritis. Prognosis. Generally favorable, with proper treatment. Treatment. Repeated blistering along the course of the nerve, with full doses of potassii iodidum , are usually successful. Sodii sali- cylas, phenacetin , and antifebrin , are each of utility. As the more acute symptoms subside, the use of galvanism or a feeble, slowly interrupted faradic current, restores the disordered function of nerve and muscle. MULTIPLE NEURITIS. Synonyms. Polyneuritis; peripheral neuritis; disseminated neuritis ; degenerative neuritis ; pseudo-tabes ; alcoholic paralysis ; beri-beri (Brazil and India) ; kakke (Japan). Definition. A parenchymatous inflammation of a number of symmetrical nerves, simultaneously or in rapid succession ; character- ized by pain, numbness, loss of power, or ataxia, with muscular atrophy. Mental symptoms are often associated. Causes. Alcoholism ; syphilis ; malaria ; lead, arsenic or silver ; following diphtheria, typhoid fever, and rheumatism. Beri-beri and kakke are epidemic varieties of multiple neuritis and the result of a special poison. The probability is that the various causes named develop in the blood a poison, having a particular susceptibility or “ selective action ” for nerve fibres. Pathological Anatomy. The affection is generally bilateral and symmetrical. An important characteristic is its peripheral dis- tribution, the inflammation being most intense at the extremities of the nerves, lessening progressively toward the centre, usually termina- ting before the nerve roots are reached. The inflammatory process affects the nerve-fibres primarily and the sheath and connective tissue secondarily — a parenchymatous inflammation. The affected mus- cles are paler and smaller than normal, the fibres reduced in size and undergoing granular changes. Symptoms. All plans yet suggested for classifying the varieties DISEASES OF THE NERVES. 429 of multiple neuritis are imperfect. The onset may be sudden, even overwhelming, causing rapid death, but is usually sub-acute or chronic in its course, the symptoms being wide-spread in proportion to the acuteness, intensity and cause of the malady. The symptoms may be described under three forms — a motor , a sensory and an ataxic form. The motor form shows motor weakness, chiefly involving the flex- ors of the ankles, the extensors of the toes, and the extensors of the wrist and fingers in the forearms. Inflammation of the anterior tibial or peroneal nerve in the leg, and the radial branch of the musculo- spiral in the arm, resulting in the double “ wrist-drop ” and “ foot- drop ” so characteristic of this disease. Any nerves of the body may be affected, the symptoms varying with the particular nerves. The sensory form shows fains , tenderness , tingling and numbness with loss of cutaneous sensibility. The ataxic form shows inco-ordination with or without sensory disturbances, but with loss of the muscular sense. The forms may all be associated, in greater or less extent, in any one case. Muscular atrophy begins early and progresses with the disease. The knee-jerk is feeble or absent. The electro-contractility is feeble or lost. In alcoholic cases, there may be delirium, mania and delusions, associated with tremors. Trophic changes may occur in the nails, hair and skin. The characteristic glossy condition of the skin with some oedema, is due to involvement of the vaso-motor nerves. Rafely the vagus, optic and laryngeal nerves are involved. The disease may be ushered in with fever, ioi° F.-103 0 F., rapid, feeble pulse, headache, nausea, vomiting with delirium or confusion. The alcoholic variety affects chiefly all the limbs ; the malarial, the legs ; diphtheria, the pharyngeal and motors of the eye ; rheumatic, the face, and lead, the arms. * Diagnosis. In no disease is an early diagnosis so important from a therapeutical standpoint. Early treatment may prevent months of suffering and idleness. Since the symptoms of this widespread affection have been properly separated from diseases of the spinal cord, with which they were formerly always associated, the diagnosis is very readily determined. 430 PRACTICE OF MEDICINE. Prognosis. As a rule favorable if early and proper treatment be instituted. Treatment. Rest is of the greatest importance ; the more thor- oughly this is carried out the better will be the results. Removal of the cause is an important indication. Warmth to the affected parts by hot baths, and keeping the parts wrapped in cotton- wool. There is no specific drug for polyneuritis. For alcoholic cases, use strychnines sulphas ; for malarial cases, quinines sulphas ; for diphthe- ritic cases, linctura ferri chloridi ; for rheumatic cases, sodii salicylas, salol, or phenacetin ; for syphilitic cases hydrargyrum or potassii iodidum , and in all varieties tonics with a generous nutritious diet. Pain should be relieved with either antifebrin , or morphines sul- phas, by the hypodermic method. As convalescence begins, moder- ate exercise and mild galvanism. NEURALGIA. Definition. A disease of the nervous system, manifesting itself by sudden pain of a sharp and darting character, mostly unilateral, following the course of the sensory nerves. Varieties. I. Neuralgia of the fifth nerve ; II. Cervico-occipital neuralgia ; III. Cervico-brachial neuralgia; IV. Dorso-intercostal neuralgia; V. Lumbo -abdominal neuralgia ; VI. Sciatica. Causes. Hereditary ; anaemia ; malaria ; syphilis ; metallic poi- sons; anxiety; mental exertion; exposure to cold and damp; injuries of a nerve trunk. Pathological Anatomy. The old axiom of neuralgia being “the cry of the nerves for pure blood” is perhaps only part of the truth. The changes in the nerve trunks or centres have not as yet been determined. A fair number of cases present the changes of neuritis. NEURALGIA OF THE FIFTH NERVE. Synonyms. Tic-douloureux ; Fothergill’s disease. Symptoms. Paroxysmal pain, of a sharp, darting, stabbing character, most common at points along the course of the supra- and infra-orbital branches of the fifth nerve of the left side, attended with increased lacrymation. When of any duration, nutritive changes are observed in the nervous distribution, to wit : oedema along the course DISEASES OF THE NERVES. 431 of the nerve, gray eyebrows and convulsive twitches of the muscles, termed “ tic douloureux tenderness at the infra- and supra-orbital foramina, as well as along the course of the nerve distribution. CERVICO-OCCIPITAL NEURALGIA. Symptoms. Paroxysmal pain , of a sharp and lancinating, or deep, heavy, tensive character, along the course of the occipital nerve upon one or both sides, extending from the vertex, and on the neck as far down as the clavicle, and upward and forward to the cheek. May be associated with hypercesthesia of the skin, and with cramps in the cervical muscles, and with attacks of herpes. A sensation of cracking at the nape of the neck is an annoying symptom in many cases. CERVICO-BRACHIAL NEURALGIA. Symptoms. Paroxysmal pain , of a severe, boring, burning or tensive character, with sensations of numbness and weakness of the arm, hand, shoulder, scapula and mamma, with tenderness along the cervical plexus. (Edema of the arm and other parts along the dis- tribution of the cervical plexus occur if the neuralgia be of long dura- tion, the result of nutritive changes, the limb at times becoming pale, the skin glossy, dry and harsh. DORSO-INTERCOSTAL NEURALGIA. Symptoms. Paroxysmal pain of a sharp and lancinating char- acter, along the fifth and sixth intercostal spaces, often associated with the development of herpes, the so-called herpes zoster , or “ shingles.” Tenderness at the points where the nerves emerge from the inter- vertebral foramina at the sides of the chest and at points in front. LUMBO- ABDOMINAL NEURALGIA. Symptoms. Paroxysmal pain of a sharp and lancinating, at times heavy and dull character, following the course of the ileo-hypo- gastric nerve, ileo-inguinal and external spermatic nerve, supplying the integument of the hip, the inner side of the thigh, the scrotum and labium. SCIATICA. Definition. A neuritis. Pain following the course of the sciatic nerve. The sacral plexus is made up of the fourth and fifth lumbar and the first two pairs of sacral nerves. 432 PRACTICE OF MEDICINE. Symptoms. Sciatica usually follows an attack of lumbago, the pain becoming fixed in the sciatic nerve ; at times it is a true neuritis. The pain is sharp , tearing, shooting or lancinating in character, in- creased upon motion, shooting along the course of the nerve into the hip, inner side of the thigh, calf of the leg, ankle and heel, at one or all of these points, in paroxysms lasting from a few hours to twenty- four hours or longer. The tactile sensation in the foot and motility in the limbs are impaired, and if of long duration, wasting of the limb occurs. Diagnosis. Rheumatism , so-called, is the only condition likely to be confounded with neuralgia. The history of the attack, the character of the pain, with its local- ized spot of tenderness, should prevent such an error. Prognosis. If promptly and properly treated, unless the result of pressure of an exostosis, aneurism or other tumor, favorable. Treatment. Rest; easily assimilated but nutritious diet; re- moval of the cause, if possible. If anaemic, ferrum and arsenicum. If rheumatic, alkalies , and sodii salicylas. If syphilitic or the result of metallic poisons, potassii iodidum . If malarial, quinina. For an attack, morphina and atropina , hypodermically, affords the most prompt and ready relief. Success usually follows the use of the well-known “ Gross (Prof. S. D.) neuralgic pill : ” — R . Quininae sulphat., . Morphinae sulphat., Strychninas sulphat., Acidi arseniosi, Extracti aconiti, Ft. pil. No. i. SiG. — One every one, two or three hours. Few attacks of trigeminal neuralgia will resist the following powerful prescription : — R . Aconitinae (Duquesnel), g r - To Glycerini, Alcoholis, aa fgj Aquae menth. pip ad fgij. M. SiG. — Teaspoonful, repeated from four to eight times daily, carefully watching. g r - !J g r - 2V g r - to g r - tV gr- I- M. DISEASES OF THE NERVES. 433 Facial neuralgia is often wonderfully benefited by the internal administration of ext % gelsemii fid gtt. iij-v, every three or four hours, until its physiological effects are produced. Excellent results often follow the administration of Moussette' s pills (aconitine and quinine). For sciatica , antipyrin , gr. xx, repeated two or- three times daily, has given relief, as has phenacetin , or antifebrin. The deep injection of chloroformum , is recommended by Bartholow. A spray of chloride of methyl along the course of the nerve for a few moments, watching the skin, will relieve the distressing pain. Rarely full doses of potassii iodidum with a blister along the course of the nerve gives relief. All forms of neuralgia are more or less benefited by — R . Quininae sulph., gr*. iij Ferri reduct., . Acid, arseniosi, Aconitiae, . . g r -J In pill, every four or five hours. FACIAL PARALYSIS. Synonym. Bell’s palsy. Definition. An acute paralysis of the seventh cranial — the facial nerve, the great motor nerve of the muscles of the face — the nerve of expression. Causes. Exposure to a current of cold air against the side of the face — over the pes anserinus — is the most frequent cause. Also due to injury or disease of the middle ear. Syphilis. Symptoms. The facial nerve supplies the muscles of the face, the muscles of the external ear, also the stylo-hyoid, posterior belly of the digastric, the platysma, one muscle of the middle ear, the stapedius, and one palate muscle, the levator palati ; by means of the chorda tympani branch it controls the secretion of the parotid and submaxil- lary glands, and, possibly, the sense of taste. It also furnishes motor power to the azygos uvulae, the tensor tympani and the tensor palati muscles. The onset is usually sudden, with tingling of the lips and tongue , and upon looking into the mirror the patient is surprised by the per- fectly blank, motionless side of the face ; the corner of the mouth is depressed, the eyelids open, the face drawn toward the well side, and the patient is unable to expectorate, whistle or swallow. 36 434 PRACTICE OF MEDICINE. Any of the muscles innervated by the nerve may participate in the paresis. The electro-contractility is feeble or lost. The reflexes are abolished. Diagnosis. Paralysis of the muscles of the face occurs in hemi- plegia ; the points of differentiation are the presence of cerebral symptoms and the normal reflex excitability. Facial palsy with otorrhcea, imperfect hearing, obliquity of the uvula and loss of taste, determine its origin within the aquseductus Fallopii. It is due to peripheral neuritis if the taste be normal and the uvula straight. If other nerves are also involved the origin is central. Prognosis. Favorable. Treatment. If the result of cold and damp, diaphoresis with pilocarpus , or diuresis with potassii acetas, z >el iodidum , and blisters in front of the ear, and the use of galvanism to the affected muscles. ' . Ct/U ^ \n ' GENERAL OR NUTRITIONAL DISEASES. CHOREA. Synonyms. St. Vitus’s dance ; insanity of the muscles. Definitions. A functional (?) disorder of the nervous system ; characterized by irregular spasmodic movements of groups of muscles, with muscular weakness, more or less approaching paralysis of the affected parts. Causes. Essentially a disease of childhood ; hereditary ; reflex, from dentition, worms, masturbation or fright; probably the result of rheumatism in many cases. Pathological Anatomy. As yet there has been no constant anatomical lesion discovered, the theory of emboli having, however, many advocates. Symptoms. The onset is usually gradual, the child seemingly grimacing or jerking tl\e arm or hand, as if in imitation, followed soon by decided, irregular jactitations of the muscles of the face (histrionic GENERAL OR NUTRITIONAL DISEASES. 435 spasm), of the eyelids (blepharospasm), eyeballs (nystagmus), and the shoulder, arm and hand, finally extending to the lower extremi- ties, interfering with motility ; in severe cases, inability of self-feeding or of holding anything in the hands. The speech is often unintelligible, the tongue constantly moving in an irregular manner. The heart' s action is tumultuous and irregular, associated often with a soft, blowing, systolic murmur, most distinct at the base. The mus- cles are usually quiet during sleep, although this is not always the case. The mind is somewhat blunted, the temper irritable, the memory impaired. If the irregular muscular movements are con- fined to one side of the body, it is termed hemi-chorea. Diagnosis. Chorea was confounded with epilepsy until the points of distinction were pointed out by Sydenham. Paralysis agitans has general muscular tremor, beginning in one limb, gradually progressing, uninfluenced by treatment ; a disease of the elderly. Post-hemiplegic chorea is the choreic movement of a paralyzed limb. Prognosis. The vast majority of cases recover, but relapses are very frequent. Treatment. Remove the cause, if possible. Easily assimilated diet. Many cases improve rapidly by confinement to bed in a dark- ened room. If the muscular movements interfere with sleep, mor- phi?ia or chloral are indicated. Regulate the secretions. Arsfinir.iLm is the most reliable remedy yet introduced for the treat- ment of chorea. It should be pushed to its first physiological effects, then gradually reducing the dose until all symptoms disappear. The form of the remedy best adapted for administration in this disease is liquor hotassii a rsenitis, gtt. v, increased to gtt. x, or even gtt. xv, three times a day. Exiractum cimicifugce fluidum , tr^xx-f 3 j, t. d., is serviceable, especially in cases following a rheumatic attack. Cases resisting the arsenicum treatment may succumb to hyos- cyamine , gr. three times daily. A patient of mine, aged 16 years, who resisted all the remedies mentioned, was promptly cured by antipyrin , gr. x, four times daily. This same case in a former attack was arrested by morphines sulphas , gr. % , four times daily, but this latter remedy failed in the attack -controlled by the anti- pyrin. If anaemia be present, combine or alternate arsenicum with ferrum. Wood recommends quinina. 436 PRACTICE OF MEDICINE. EPILEPSY. Definition. A chronic disease, of which the characteristic symp- toms are a sudden loss of consciousness, attended with more or less general convulsions. Causes. Heredity ; rarely, worry, anxiety, depression, or fright. Pressure from a tumor at the periphery, or thickening of the mem- branes of the brain, causing pressure ; dyspepsia (?) ; syphilis ; uter- ine diseases. Pathological Anatomy. There are no constant anatomical lesions, as yet, associated with essential epilepsy. In “Jacksonian,” “cortical,” or “ partial epilepsy,” however, the “motor cortex” is irritated by disease and there occur tonic and clonic spasms of the same character as in general epilepsy, confined to a single arm, or an arm and half the face together, or may be the entire half of the body. These epileptiform attacks furnish precise data as to the locality of the lesion ; spasms affecting the distribution of the facial nerve point to the lower third of the central convolution ; of the arm, the middle third of central convolution ; of the lower extremity, the upper third of the central convolution. Varieties. I. Epilepsia gravior , le grand mal ; II. Epilepsia mitior , le petit mal. Symptoms. Le grand mal is preceded by a more or less pro- nounced~and curious sensation, the so-called aura epileptica. The attack proper is sudden , the subject suddenly falling , with a peculiar cry, loss of consciousness , and pallor of the face , the body assuming a position of tetanic rigidity , succeeded after a few mo- ments by more or less pronounced clonic convulsions , followed by a coma of several hours’ duration. The subject awakens with a con- fused or sheepish expression, with no knowledge of what has occurred, unless he has injured himself during the attack, either by the fall, or, what is very common, has bitten his tongue during the convulsions. Le petit mal is manifested either by attacks of vertigo , the con- sciousness being preserved, or by a passing abse?it-mindedness, either form being associated with slight convulsive phenomena, followed by slight coma or mental confusion of short duration. The mental functions are not, as a rule, injured by attacks of epi- lepsy, unless they recur very frequently. Indeed, when at wide GENERAL OR NUTRITIONAL DISEASES. 437 intervals, the subject seems relieved by them, “the sudden, excessive, and rapid discharge of gray matter of some part of the brain on the muscles,” the so-called “ electrical storm,” having cleared the cere- bral atmosphere. The great majority of epileptics suffer from chronic gastric catarrh, and have at the same time an inordinate appetite (boulimia) ; indeed an attack of gluttony may immediately precede a fit. Diagnosis. Urcemic convulsions closely resemble an epileptic attack ; but the dropsy or general oedema and albuminous urine, increased temperature, of the former should guard against error. Feigned epilepsy often misleads the most practical expert. Jacksonian epilepsy begins as a spasm of a limb or some portion of a limb, and is confined there or may gradually extend until even a general convulsion occurs. Prognosis. The vast majority of cases will not recover under treatment, but have the frequency and severity of the attacks greatly ameliorated, but sooner or later returning with their former severity. Cases the result of the various reflex causes usually recover when the cause is removed. Treatment. To avert an impending attack, inhalations of amyl nitris , gtt. iij-v, a few whiffs of chloroformum , or the hypodermic in- jection of morphina. To prevent the return of attacks, remove the cause if possible ; attention to the secretions and the internal administration of potassii bromidum , in doses sufficient to abolish the faucial reflex and produce the symptoms of bromism, have great power in diminishing the se- verity and frequency of the attacks ; better results are sometimes ob- tained by the combination of the various bromides. Cases in which the bromides are not serviceable are sometimes benefited by argenti nitras , belladonna , or cannabis indica , but such cases must be rare. Weak and anaemic subjects usually do better with strychnina in full doses than with potassii bromidum. If a history of syphilis can be obtained, the combination of potassii iodidum, and potassii bromidum, will effect a cure. Whichever of the above remedies is beneficial in any particular case, the permanency of the relief can only be maintained by the continuation of the drug for at least two years after the last attack. 438 PRACTICE OF MEDICINE. Gowers highly recommends the following in cases complicated with cardiac dilatation : — R . Potassii bromidi, gr. xx Tinct. digitalis, U^x. M. Sig. — T hree times a day, well diluted. The following is the combination used in the insane wards of the Philadelphia Hospital : — R . Sodii bromidi, Potassii bromidi, aa ^iv Liq. potassii arsenitis, f^viss Inf. gentian, comp., . . . . q. s. ad viij. M. SiG. — Tablespoonful, diluted, three times daily. Brown-Sequard’s mixture for epilepsy is as follows : — R . Potassii iodidi, 8 parts. Potassii bromidi, 8 “ Ammonii bromidi, 4 “ Potassii bicarb., 5 “ Inf. columbo, 360 “ Sig. — O ne teaspoonful before meals and three dessertspoonfuls on going to bed. The diet of the epileptic must be carefully regulated, meats, tea and coffee excluded, or used in very moderate amounts. Forbid tobacco and alcohol. Much enthusiasm is reported in the important results following tre- phining in cases of Jacksonian epilepsy. It is to be hoped success will follow this operation, but the subject is still sub judice. HYSTERIA. Definition. A nutritional disorder of the nervous system, of the nature of which it is impossible to speak definitely ; characterized by disturbances of the will, reason, imagination, and the emotions, as well as motor and sensory disturbances. Causes. A morbid condition confined almost exclusively to women. Young girls, old maids, widows, and childless married women are the most frequent subjects of the disorder. The parox- ysms frequently develop during the menstrual epoch. The meno- pause is another frequent period for its manifestation. A peculiar condition of the nervous system, either inherited or acquired, is GENERAL OR NUTRITIONAL DISEASES. 439 responsible for the phenomena of hysteria, the peculiar manifesta- tions being excited by disturbances of either the sexual, digestive, circulatory, or nervous systems. Hypochondriasis , a peculiar mental condition, characterized by inordinate attention on the part of the patient to some real or sup- posed bodily ailment or sensation, a continual introspection, as seen in males, is a condition much like the hysteria of the female. Pathogeny. Structural alterations have thus far not been de- tected in cases of hysteria ; it is thus a functional disturbance of the nervous system. It should, however, be borne in mind that hysteri- cal manifestations frequently develop during the prevalence of or- ganic diseases. Symptoms. These will be considered under the headings of the hysterical paroxysm , and the hysterical state. The Hysterical paroxysm or fit occurs nearly always in the pres- ence of others, and develops gradually with sighing , meaningless laughter , causeless moaning , ?ionsensical talking and gesticulations , or a condition of fidgets followed with a sensation of choking , dyspnoea , and a ball in the throat — the globus hystericus. These and similar symptoms precede the fit, during which the unconsciousness is only apparent , the patient being aware of what is transpiring about her. During the paroxysm the patients may struggle violently, throwing themselves about, their thumbs turned in and their hands clenched. Again, spasmodic movements occur, varying from slight twitching in the limbs to powerful general convulsive movements, and to almost tetanic spasms. The paroxysm ends by sighing, laughing, crying and yawning, and a sensation of exhaustion. During the attack it will be noted that the surface and face are normal, showing absence of respiratory embar- rassment, the breathing varying from very quiet to spluttering and gurgling sounds, the pupils not dilated, the pulse normal, the temper- ature normal, and absence of foaming at the mouth and wounding of the tongue. The Hysterical State is shown by disturbances of the nienial and sensory-motor functions respectively. It may be a permanent condi- tion or occur at intervals with greater or less severity. Mental disturbances. The patients are emotional, erratic, excita- ble, impatient, and self-important, showing marked defects of will and mental power. 440 PRACTICE OF MEDICINE. Sensory disturbances. This is either a condition of exaggerated sensibility or hyperaesthesia, as shown by the marked effects from the slightest irritation and the cutaneous tenderness along the spine, or a condition of anaesthesia as shown by the apparent absence or recog- nition of pain after severe irritation, ora perverted sensibility as shown by the feeling of tingling, numbness, and formication. Sensibility to heat or cold are often absent. There is great perversion of the special senses in many of the cases. Charcot, referring to the ovarian hyperaesthesia of hysteria, says : “ It is indicated by pain in the lower part of the abdomen, usually felt on one side, especially the left, but sometimes on both, and occu- pying the extreme limits of the hypogastric region. It may be extremely acute, the patient not tolerating the slightest touch ; but in other cases pressure is necessary to bring it out. The ovary may be felt to be tumefied and enlarged. When the condition is unilateral, it may be accompanied with hemianaesthesia, paresis, or contracture on the same side as the ovarialgia ; if it is bilateral, these phenomena also become bilateral. Pressure upon the ovary brings out certain sensations which constitute the aura hysterica , but firm and sys- tematic compression has frequently a decisive effect upon the hysterical convulsive attack, the intensity of which it can diminish, and even the cessation of which it may sometimes determine, though it has no effect upon the permanent symptoms of hys- teria.” Motor disturbances. These phenomena embrace every variety of motor disturbance, from exaggerated excitable movements to defect- ive or complete loss of power. With the paralysis that may occur, neither nutrition nor sensation are constantly impaired. Hysterical paralysis is liable to frequent and sudden changes, the loss of power often disappearing suddenly. Aphonia, from paralysis of the laryn- geal muscles, is a frequent form of paresis. Some hysterical patients refuse to even make an attempt at speech. “A curious enlargement of the abdomen is observed sometimes, constituting the so-called phantom tumor. This region presents a symmetrical prominence in front, often of large size, with a constric- tion below the margin of the thorax and above the pubes. The enlargement is quite smooth and uniform, soft, very mobile as a whole from side to side, resonant, but variable on percussion, and not pain- ful. Vaginal examination gives negative results, and under chloro- GENERAL OR NUTRITIONAL DISEASES. 441 form the prominence immediately subsides, returning again as the patient regains consciousness.” Among the numerous other symptoms that may develop in a hysterical patient are disturbances of digestion , circulation , respira- tion , and disorders of micturition and menstruation. Among other phenomena that belong to the Hysterical state are to be mentioned Hy stero- epilepsy , a condition of hysteria to which is superadded the convulsion, epileptic in form ; Catalepsy , a condition in which the will seems to be cut off from certain muscles, and in whatever position the affected member is placed, it will so remain for an indefinite time. There may or may not be unconsciousness and loss of sensation ; Trance , the individual lying as if dead, circulation and respiration having almost ceased ; Ecstasy , a condition in which the individual pretends to see visions and acts in a most ridiculous manner. Diagnosis. The hysterical state is so general in its manifestations that it is to be borne in mind in diagnosing all ailments occurring in women. The diagnosis is attended with great difficulty, however, and requires the display of all the skill of the clinician to prevent error. Prognosis. Death from either a hysterical fit or the hysterical state is the rarest of events, if it ever occur. The ultimate recovery of a hysterical patient is of frequent occurrence. Marriage has cured many cases, although it can hardly be advised by the physician. Treatment. For the hysterical fit little need be done, as a rule, unless the paroxysm is violent or prolonged, in which case ammonii valerianas , Hoffman' s anodyne , or spiritus ammonice aromaticus , may be administered. Charcot recommends the making of firm pressure over the ovarian region to check hysterical fits that are of a severe character. The management of a confirmed case of hysteria will tax the skill of the most astute physician. It is in connection with hysteria that the peculiar phenomena supposed to arise from applying different metals to the surface of the body have been noticed. Moral and hygienic measures are of the first importance in the management of an hysterical patient. The treatment by isolation of hysterical patients is strongly urged by many specialists. Dr. S. Weir Mitchell has devised a plan for bedfast hysterical patients, of massage, faradization, and forced feeding, which is successful in a number of cases. 37 442 PRACTICE OF MEDICINE. There is no fixed therapeutical treatment for hysteria, the various symptoms calling for interference as they arise. It is well, however, to avoid the use of stimulants, opiates, and chloral. NEURASTHENIA. Synonyms. Spinal irritation ; nervous prostration ; nervous ex- haustion. Definition. A debility of the nervous system, causing an inabil- ity or lessened desire to perform or attend to the various duties or occupations of the individual. Prof. Bartholow describes* it as consisting “ essentially in an exag- gerated susceptibility to bodily impressions and false reasoning thereon.” Causes. It may result from various chronic diseases ; mental worry or emotion ; overwork, as “ whenever the expenditure of nerve-force is greater than the daily income, physical bankruptcy sooner or later results ” (Jackson). Neurotic temperament ; sexual excesses ; alcohol ; tobacco. Symptoms. Nervous debility may affect any organ of the body. It is a condition of nerve-tire or exhaustion, and hence the nervous energy necessary for functional activity of any particular organ may be wanting, a fair example being seen in cases of nervous dyspepsia. One of the earliest manifestations of nervous exhaustion is an irri- tability or weakness of the mental faculties, as shown by inability to concentrate the thoughts, and efforts to do so causing headache, ver- tigo, restlessness, fear, a feeling of weariness and depression, together with the army of symptoms attendant on nervousness. There may be ocular disturbances, cardiac palpitation, coldness of the hands and feet, chilliness followed by flashes of heat, followed in turn by slight sweating. Patients are troubled with insomnia, or fatiguing sleep, accompanied with unpleasant dreams. In the male there are genito-urinary disorders, with pains in the back, giving the dread of impotence. In females, painful menstrua- tion, ovarian irritation, and irritable uterus. Diagnosis. It is of importance to determine between a true ner- vous exhaustion, and nervous debility the result of organic disease. A study of the history of the case, together with the symptoms, should prevent error. GENERAL OR NUTRITIONAL DISEASES. 443 Prognosis. Unless there be a tendency to mental disorders the prognosis is good. Treatment. Attention to the secretions, diet, and surroundings. Rest and diversion of the mind are essential to success. Travel, short of fatigue, pleasant companionship, and relief from responsibility. Bathing, massage, and galvanism are important aids to the manage- ment of cases. Among the internal remedies that are of benefit may be mentioned, arsenicum , strychnina , ferrum , zinci valerianas , phosphorus , ex- tractum cocoe fiuidum , vinum cocce , and syrupus hypophosphitis compositus. Quinince Sulphas , in small doses, gr. i-ij, daily, for weeks, seems to lessen the excitability of the nervous system. EXOPHTHALMIC GOITRE. Synonyms. Graves’ disease ; Basedow’s disease. Definition. A disease of the nervous system ; characterized by protrusion of the eyeballs, enlargement of the thyroid gland, dilata- tion of the arteries, and palpitation of the heart. Causes. An undemonstrable condition of the nervous system, either inherited or acquired, is the predisposing cause of Graves’ disease. Among the exciting causes are anaemia, shock, fright, chagrin, worry, and reverses of fortune. It is more common in women than in men. Pathological Anatomy. “ Some structural alterations have been found, in a majority of cases, in the sympathetic ganglia, and especially in the inferior ganglia.” (Bartholow.) The veins and arteries of the thyroid gland are dilated, the result of a vasomotor paralysis. The enlargement of the gland is the result of the dilated vessels, and a serous infiltration of its tissues, followed, if long con- tinued, by hypertrophy. A considerable increase of fat behind the eyeballs has been observed. In the majority of cases more or less anaemia exists.' Symptoms. The development of the quaternary of symptoms may occur suddenly, the result of some great shock to the nervous system, but in the majority of instances the symptoms develop slowly and insidiously, with cardiac palpitation , with paroxysms of more marked acceleration, tachycardia, the pulse rate varying from 90 to 120, 1 50, and rarely as high as 200 beats per minute ; soon pulsations 444 PRACTICE OF MEDICINE. of the vessels of the neck and thyroid gland may be felt and seen. The enlargejnent of the thyroid gland — the goitre — appears gradually after the development of the circulatory disturbances, although rarely it may be the first symptom observed. The goitre is elastic, rather soft, and has a thrill similar to an aneurism. The degree of enlarge- ment varies in different cases, and in none ever attains a very great size. Following the development of the goitre occurs the protrusion of the eyeball — the exophthalmos — which may be confined to one eye, but usually occurs in both. Prominence of the eyeball may be the first symptom observed, but usually it does not develop until after the appearance of the goitre. The degree of protrusion varies from a slight staring expression to a point so great that the eyelids cannot cover the balls. Associated with the protrusion of the eyeballs is inco-ordination in the movements of the eyelids and the eyeball, the sign of Graefe, so that when the eyes are quickly cast down the eye- lids do not follow them, the sclerotic being visible below the upper lid. Vision is unimpaired. Conjunctivitis may arise, the result of the imperfect protection of the protruding ball by the eyelids. Associated with the pathognomonic symptoms are nervousness, irritability of temper, headache, insomnia, vertigo, fits of despondency, aphonia, and cough the result of pressure of the goitre, disorders of digestion, increase of temperature, anaemia, and loss of flesh. Diagnosis. The fully developed disease presents no difficulties in diagnosis, but during its incipiency, before the characteristic symp- toms have appeared, the disease may be confounded with such con- ditions as cardiac disease, neurasthenia, lithaemia, malaria, or incipi- ent phthisis. Prognosis. Recovery occurs in a fair number of cases, but is slow and tedious. The disorders of the circulation lead to dilated heart in many cases, and ultimately death occurs from this cause. Relapses are frequent. Treatment. One of the first injunctions to be placed on a case of exophthalmic goitre is rest , both physical and mental, as well as freedom from worry or emotional excitement ; little progress will be made if this point be neglected. The general nervousness, restless- ness, and insomnia will often call for special treatment, when use may be made of chloral , potassii bromidum , sulphonal , or trional. It is better, however, not to use this class of drugs in a routine manner, but for the special indications only. The chief indication, next to rest, is the condition of the circulation. GENERAL OR NUTRITIONAL DISEASES. 445 To control this two remedies are of inestimable value ; they are digi- talis and strophanthus. The results I have seen from tinctura stro- phanthi , tr^v, from three to six times daily, have been most satisfac- tory. Dr. Bartholow “ has had good effects from quinina, belladonna, and ergotin in combination.” I have had a complete and quite rapid recovery, from dried extract of thyroid gland in three-grain doses, twice, and thrice daily. Argenti nitras, gr. l /i, after meals, is often a valuable remedy, alternating with strophanthus , or digitalis. The associated anaemia is to be treated by ferrum , arsenicum, and an easily digestible and nutritious diet. Galvanism to the cervical sym- pathetic and pneumogastric is an important adjuvant to the medici- nal treatment. TETANY. Synonyms. Tetanilla ; intermittent tetanus. Definition. A succession of tonic, usually bilateral, painful mus- cular spasms, occurring at irregular intervals, without loss of con- sciousness. Causes. Unknown. Probably a special germ. It has been observed in those having a family history of nervous disorders. Pathology. The disease is very rare in America, and no lesion has as yet been determined. Symptoms. Tetany is the occurrence of intermittent spasms in the muscles of the arms, hands, legs or feet, or rarely the face and larynx (laryngismus stridulus), associated vr\\.h. pain. The hands are thrown into a position such as they assume in writ- ing, or such as is taken by the hand of a midwife ; or the hand may be tightly closed, or one or more fingers may be cramped. The elbows and shoulders may be, at times, affected. In the feet the toes are drawn down and the instep upward, like in equinus. The knees may be cramped or the legs extended. Any muscles may be involved. Trousseau pointed out that in those suffering from tetany, pressure upon the affected extremities at certain points will excite the spasms. The duration of the spasms varies from a few moments to several hours, the intervals being from an hour to a day or more. A certain periodicity is noticed as to the hour of the day or night. The electro-contractility is increased, as are also the reflexes. The consciousness is always preserved, although the patients are very nervous. 446 PRACTICE OF MEDICINE. Diagnosis. Tetanus and tetany may be confounded, and yet trismus is rare in the latter, and always present in the former. Prognosis. Favorable. Treatment. Attention to the secretions and excretions, and the use of potassii bromidum , gr. xx-xl, well diluted, three times daily. Gowers recommends digitalis for nocturnal tetany — those painful cramps in the calves in the early morning hours. Urethan , gr. x, every three or four hours, is highly spoken of. Gray says : “ Cold to the extremities and ice to the spine have had an excellent effect.” TETANUS. Synonyms. Lockjaw ; trismus ; cephalic tetanus. Definition. An acute or subacute infective disease, characterized by muscular rigidity, with paroxysms of tonic convulsions, the mind remaining clear. Idiopathic tetanus when no open wound is discoverable. Traumatic tetanus when an open wound is present. Tetanus neonatorum when it attacks infants. Lockjaw or trismus when the jaw alone is involved. Cephalic tetanus when the throat and face are affected. Causes. The result of a specific bacillus, which usually gains access to the system through an abrasion. Pathological Anatomy. In the post-mortem examinations which have been made, no uniform morbid appearance was dis- covered, on microscopical examination. The brain, cord, lungs, and muscles are markedly congested, and show minute hemorrhages, such as are met with in all cases of death from convulsions, and which occur chiefly during the process of death. In four post-mortem examinations of cases dying from tetanus, at the Philadelphia Hospital, marked chronic nephritis was observed. Probably the future may show some connection between nephritis and tetanus, by which the specific poison is not eliminated as it might be were the kidneys normal. Symptoms. The onset is rather sudden, with stiffness of the jaw, neck , and tongue , and some difficulty in swallowing , which increases in extent, the stiffness passing* down the spinal muscles to the legs, which are held in a firm spasm. Gradually tonic spasms develop which, involving the jaw muscles, GENERAL OR NUTRITIONAL DISEASES. 447 cause “ lockjaw ; ” the face muscles, “ risus sardonicus ; ” neck and trunk muscles, “ opisthotonos ; ” these tonic convulsions are associated with intense pain and the patient suffers the greatest distress, par- ticularly if the chest muscles are involved. Usually the febrile reaction is slight, but in many cases 102° F. to 104° F. is reached and in some instances, as death approaches, 108° F. to 1 io° F. may occur, rising still higher after death; The mind remains clear till carbonic acid poisoning occurs. Usually a wound , not severe, can be found, the symptoms developing some two weeks after its occurrence. The tonic spasms are developed by any sources of irritation, a draught of air, shaking of the bed or floor, suddenly opening the door of the room, the presence of a visitor, or attempts at speaking or movement. Diagnosis. The symptoms are so characteristic, with the addi- tion of a history of a wound, that an error seems hardly probable. Tetany. The spasms chiefly affect the extremities, the muscles being free in the interval and trismus a late or very rare condition. Strychnine poisoning often closely resembles tetanus, but there is no beginning trismus and more rapid development of the symp- toms. No history. Hydrophobia does not have trismus, but respiratory spasm, excited by attempts at swallowing, with increasing mental symptoms. Prognosis. Unfavorable. The great majority die. Treatment. Rest and quiet in a dark room. Chloral , potassii hromidum , chloralamid , morphince sulphas, and paraldehyde are each useful in cases to hold in check or lessen the severity of the spasm for a time. Inhalations of chloroformum will control the spasms, and recoveries have been attributed to its use. Physostigrna , and anti- pyrin , are recommended to remove the spasms. The nutrition must be maintained ; often, on account of the stiffness of the masseters, rectal alimentation has to be used. OCCUPATION NEUROSES. Synonyms. Professional neuroses ; artisans’ cramp. Varieties. Writers’ cramp ; piano-players’ cramp ; telegraphists’ cramp ; violin-players’ cramp ; dancefs’ cramp. Definition. A group of affections of the nervous system, charac- terized by the occurrence of spasm (cramp) and pain in groups of mus- cles, in consequence of overuse or frequently-repeated muscular acts. 448 PRACTICE OF MEDICINE. Cause. Undetermined. It has been noticed that many persons suffering from occupation neuroses have a family history of nervous affections. Symptoms. The symptoms of any of the varieties named gener- ally develop gradually and slowly, by a feeling of stiffness in the used member, the part feels fatigued and heavy, until it is impossible to use it, from the occurrence of spasmodic contractions ; pain on using the affected muscles, often associated with tremor , and in many cases with an actual paralysis. Associated with the loss of power to follow the usual occupation is nervousness , mental worry , and often depression. There is often the sensation of prickling and numbness in the crippled member. The electro-contractility is preserved until the atrophy of non-use develops. Diagnosis. Calling to mind the history of the case and its re- sults, in being limited to one member, the nature of the condition is evident. Prognosis. Often unfavorable. Some recoveries are reported. Treatment. Rest of the part and mental quiet, with tonics and other means to improve the general nutrition. Faradism in weak doses once or twice weekly seems useful. The following combination was of value in one case of writers’ cramp and in a most aggravated case of ballet-dancers’ cramp, each affecting the left limb : — R • Zinci phosphidi, gr. ij Ext. nucis vomicae, , . . gr. x Ferri albuminat, gr. xxx. M. Ft. pil. No. xxx. Sig.— O ne after meals. PARALYSIS AGITANS. Synonyms. Shaking palsy ; Parkinson’s disease. Definition. A nervous disease of unknown pathology, charac- terized by tremors, progressive loss of power in the affected muscles, moderate rigidity, with alterations in the gait and at times mental changes. Cause. Age seems to be an etiological factor, most cases devel- oping after fifty years. Most frequent in women. Pathological Anatomy. No characteristic lesion yet deter- GENERAL OR NUTRITIONAL DISEASES. 449 mined. It being a disease of past middle life, there is probably an interstitial hyperplasia of some layer of the cortex, from alterations in the intima of the vessels. Symptoms. The onset is gradual, the tremor beginning in one of the extremities, oftenest the hand and forearm. At first it can be controlled by the will, for a time at least, and is suspended by voluntary movement. The disease gradually extends until an entire side or the upper or lower limbs are involved. The face and head rarely present tremors but are not exempt. A peculiar rigidity of the affected muscles is characteristic of the advanced stage. “ At this stage of the disease the hands are apt to assume the so-called bread- crumbling position, i.e ., the thumb and the fingers approximate and move restlessly over one another, as in the act of crumbling bread. There is often a tendency on the patient’s part to go forward — so- called propulsion — and this is sometimes so marked that if the patient is once started in a walk forward, his gait becomes more and more rapid, and he cannot stop himself” (Gray). The patients are usually restless and annoyed with insomnia. The general health is fair. The mind is generally retained, although melancholia and mild dementia have been noted in a few cases. Diagnosis. Disseminated sclerosis has a tremor , but only on vol- untary movements — intention tremor. There is also scanning speech and ataxic gait, with mental enfeeblement, as shown by an unnatural contentment with the physical condition and surroundings. Chorea is a tremor, but the movements are general, and particu- larly involving the muscles of the face. Again, chorea is a disease of children and young adults. Prognosis. Radical cure not seen. Improvement often results from early treatment. The disease does not tend to shorten life. Treatment. The patient should be placed at rest, bodily and mental. Nutritious food, oleum morrhuce , hypophosphites , and arsen- icum. Hyoscyamince sulphas , gr. , three times daily, is a valuable remedy. Good results have followed the use of hyoscince hydro- brojnas, gr. three times daily. Mild galvanism , twice or three times a week, acts as a nervous stimulant. 450 PRACTICE OF MEDICINE. MENTAL DISEASES. MELANCHOLIA. Synonyms. Depression of spirits ; psychalgia. ) Definition. A variety of mental alienation, characterized by more or less profound depression of the emotions, with either no marked intellectual disturbance, or the presence of more or less incoherence, and the association of hallucinations and delusions. The cerebral mechanism developing a condition of super-sensitiveness, all impres- sions are exaggerated, and a state of abnormal self-consciousness ex- isting. Varieties. Melancholia simplex; melancholia hallucinatory; melancholia agitata ; melancholia attonita ; chronic melancholia. Causes. Hereditary predisposition. Failing health. Grief. Do- mestic and financial worries. Neurasthenia. Menstrual irregularities, pregnancy, childbirth, or lactation. Climacteric. Gastric and intes- tinal irregularities. Alcoholic and sexual excesses. Organic brain diseases. Religion rarely causes insanity, though it frequently gives color to it. Most common in females and in the young. Pathology. The alterations in the nerve structure, underlying an attack of melancholia, are undetermined. Anaemia and sluggish nervous energy are constant phenomena, but are hardly the only conditions disturbing the cortex. Symptoms. Melancholia may be the initial stage of mania, delusional insanity, or paretic dementia, or a stage of folie circularis. Mental : The cardial condition is a feeling of depression , misery , or mental anguish or pain , for which no adequate cause exists. The onset is usually gradual, with a disposition to neglect duties and self, the patients worrying over a something they cannot explain. The world is dark and gloomy, with a foreboding of some awful calamity that is to affect or wreck the patient or his family. Suspicion, dis- trust, and often, fear of wife, children, relatives, or friends. Insom- nia is a constant and stubborn symptom. The memory is maintained, and the reasoning faculties are usually intact, except upon the painful MENTAL DISEASES. 451 sensations. The patient may sit quietly or be restless, according to the character of the emotions affected. Physical : The patient presents either an anxious or a woe-begone expression. Headache, and particularly a post-cervical ache, is a very constant symptom. The skin is dry and harsh, the respirations superficial, the cardiac action slow and feeble ; there is gastric catarrh, constipation, and scanty, high-colored urine. The tongue is flabby and coated, and the appetite is poor. The refusal to take food is most characteristic. Hallucinatory melancholia is an aggravated form of the disease, where, in addition to the painful mental reflexes, are distressing hal- lucinations and illusions, the patient living in a realm of terror. The attack may be the result of a delusion, but much more frequently the depression and foreboding gives rise to the delusion. The delusions of melancholia are usually of self-accusation, self-abasement and justi- fied persecution ; the patient feels that he is being punished for some transgression, imaginary or otherwise. Melancholia agitata is those sad cases seen in continual agitations, in which the fearful and distressful thoughts and imaginations cause wringing of the hands, and prayers beseeching help, with tears flow- ing down their cheeks, crying out for assistance and protection. In- coherence and violent impulses are frequent. Melancholia attonita , or melancholia with stupor, the patients seem- ing to be overwhelmed, sitting mute, motionless, and expressionless, refusing to assist themselves in any way whatever, often requiring mechanical feeding. Memory is usually impaired in this form ; attacks of violence may occur. Chronic melancholia is the continuation of the depression over a long period, the individual living in the fear of impending danger or punishment for supposed acts for months, often with apparent lucid periods. Suicidal impulses are present in a fair proportion of cases of melan- choliacs, and unless there be everlasting vigilance the patient will succeed in his insane desire. Diagnosis. The cases of simple melancholia are readily deter- mined. Melancholia agitata is frequently mistaken for acute mania. Melancholia attonita closely resembles acute dementia, a condition, it is but fair to mention, many alienists deny the existence of. Prognosis. A typical attack of melancholia runs a definite 452 PRACTICE OF MEDICINE. course, not unlike the typical course of a fever. Favorable in the mild cases of all forms not associated with organic disease, and who have not reached the climacteric. Pronounced cases of melancholia attonita are more apt to terminate in dementia than any other variety. Treatment. Change of environment, and rest are essential. Attention to the gastro-intestinal canal is of the greatest value, as the dyspepsia and constipation of melancholiac patients is the greatest barrier to their recovery. Frequent bathing, with friction to the sur- face, aids in the eliminative action of the skin. The diet must be of the most nutritious character the patient can assimilate. If food be persistently refused, mechanical feeding must be practised. The late Dr. Gray was a strong advocate of small doses of opium, or mor- phina, in acute melancholia, but it has always disappointed me. Such tonics as quinines sulphas , arsenicum, ferrum, and strychnines sulphas are all of value in building up the patient. As the strength improves, open-air exercise must be added to the other means used. Insomnia must be combated by evening bathing ai the use of trional , suiphonal , or hyoscina at bedtime. A.' i MANIA. Synonyms. Insanity ; madness. Definition. An intense mental exaltation, with great excitement, loss of self-control, with, at times, absolute incoherence of speech, ^and loss of consciousness and memory. (Clouston.) A mental condition in which there is an emotional exaltation, ac- companied by illusions, hallucinations, delusions, great mental and physical excitement, and a complete loss of the inhibitory power of the will ; in acute cases, and frequently in chronic forms of the dis- ease, there is a marked destructiveness and a tendency to violence. (Wood.) An attack of mania may be acute , subacute , or chronic. Causes. Inflammation or other organic disease of the brain or its membranes. Mental shock or strain. Worry — domestic, moral, or financial. Excesses in alcohol, venery, or tobacco. Ovarian dis- ease, or menstrual irregularities. Climacteric in those of nervous disposition. Pregnancy, parturition, or lactation. Nephritis. Anaemia. Syphilis. Hereditary predisposition. Pathology. There are no constant morbid changes associated id feeding, and 7 MENTAL DISEASES. 453 with mania. In all varieties of acute insanity there exists vitiated nervous energy or impaired vitality, the result of over-excitement or over-stimulation, motor disturbance, or auto-infection, the result of the imperfect elimination of the products of tissue waste. “ There is no reason why a mere dynamical brain disturbance should not kill and leave no structural trace, any more than that it should for months abolish judgment, affection, and memory, and then pass off and leave the brain and all its functions intact.” (Clouston.) If death follow acute symptoms, the vessels of the brain and mem- branes are engorged, but in the majority of instances the brain structure is normal. If death occur in chronic mania, the most frequent change found will be a thickened and adherent dura mater. As observed, any form of organic change may be found post-mortem in those dying of any form of mania. Symptoms. Acute mania : The onset may be abrupt, or fol- lowing a period of emotional depression, associated with lassitude, feeling of unrest, disinclination to work, and disorders of the gastro- intestinal canal, with insomnia and an introspection ; these symptoms are termed the melancholiac stage of mania. The maniacal stage is characterized by loud talking, intense ego- tism, violent motions of the limbs and body, great restlessness, and excitement ; the thoughts flow in wonderful freedom and with amazing rapidity, the condition often resembling the symptoms of early alco- holic intoxication; as the condition continues the patient becomes, either sullen, irritable, and angry, offering violence to those around him, or he becomes garrulous, talking of his personal affairs, is confidential and communicative to strangers, often making ego- tistic offers, passing frequently into incoherence of language and action. Sexual passions are frequently exalted, and acts of mastur- bation practised. Delusions are an almost constant symptom, of a superficial or transitory character, changing with every new appear- ing mood. The maniacal patient is sleepless, or may have short naps, at once continuing his chatter on awakening. Any attack may show all of the symptoms mentioned, or any one or more of them, but the great majority of cases show intense egotism , loud talking , violent motion of limbs or body , hurry , excitement , insom- nia , incoherence , and incessant noise. The course of an attack is periods of remissions and exacerbations, 454 PRACTICE OF MEDICINE. with nocturnal crises ; loss of flesh and mental weakness are often marked as the attack progresses. Acute delirious mania , typhomania, is a psychosis of sudden onset, attended with increased bodily temperature, and marked by delirium with sensuous hallucinations, marked incoherence, restlessness, re- fusal of food, loss of memory, and rapid bodily wasting, terminating frequently in death. Mania amenorrhceal is often used for attacks of mania occurring at the menstrual epoch. Homicidal, suicidal, and various hysterical impulses are frequent. Mania-a-potu is an attack of acute delirium, due to alcoholic ex- cesses in those engaged in a sudden debauch, or who have drunk heavily and eaten little, for a comparatively short period. Mania asthenic , in which there is general anaemia associated with neurasthenic symptoms. Mania chronic ; a condition of continual mental exaltation, the acute symptoms having continued in a chronic course. The line that distinguishes between an acute and a chronic mania must always be somewhat arbitrary and unscientific. The duration of the mania beyond twelve months, is usually considered sufficient to determine the condition, and this is well, as it precludes the possibility of term- ing the condition incurable. If the term chronic mania was restricted to those cases in which, between the exacerbations of restlessness, excitement and destructiveness, were evidences of dementia, less confusion would occur. Mania dancing is a hysterical mental state in which, through sym- pathy and imitation, dancing of a most grotesque and extravagant character occurs. Usually epidemic. Mania delusional is the result of fixed delusions, either causing or associated with the maniacal outbreak. Mania erotic , erotomania, presents systematized delusions of an erotic character, not necessarily accompanied by animal sexual desire. Nymphomania is a morbid, irresistible impulse to satisfy the sexual appetite, peculiar to the female sex. Mania epileptic a follows an epileptic paroxysm, and is often of a most violent kind, the maniacal acts being of the most treacherous and malicious character. Mania hallucinatoria presents visual, auditory, olfactory, and other sense hallucinations. MENTAL DISEASES. 455 Mania homicidal is any variety of mental disease in which there is a desire or an attempt on the part of the patient to commit murder. The condition may be the result of delusions that the persons attacked either are persecuting, or going to kill the patient, or of the excessive excitement that vents itself in destructiveness, combativeness, or desire to kill, or there may be a morbid desire, impulse, or craving to do murder, or the homicidal act may be unconsciously done during an acute delirium, or a paretic, or epileptic maniacal impulse. Morphiomania is the insane craving for the stimulating action of morphia — a moral insanity. Mania puerperal is the maniacal outbreak as seen in the puerperal woman. This is now thought to be of septic origin, although the mental strain through which the female has been passing is a pre- disposing factor. Mania recurrent , or chronic mania with lucid intervals of longer or shorter duration. Generally of alcoholic origin. Mania transitoria , or ephemeral mania, is a rare form of maniacal excitement of sudden onset, violent and decided in character, accom- panied by great insomnia, incoherence, and more or less complete unconsciousness of familiar surroundings. The attack as suddenly terminates, the duration being from a few hours to a few days. Mania senile is the mental exaltation occurring in persons with senile arterial changes, or senile cerebral atrophy. Soon followed by dementia. A maniacal outbreak may present any one, or a number of the varieties named. Terminations of Mania. About fifty per centum of acute manias, not due to organic disease, recover after periods varying from one month to several years. A fair proportion of cases make a partial recovery, and are able to return to their work, but always showing some alteration in character or affection, or some eccentri- city, or a slight mental weakness. About twenty per centum of cases terminate in dementia or mental death, and this is always the fear in each case. Two per centum of cases die, either the result of exhaus- tion or from the organic condition causing or associated with the attack. Prognosis. The question of recovery, partial or complete, is always difficult to determine, depending upon the cause, tempera- ment, disposition, education, nationality, and the normal mentality of the individual. Recovery is usually gradual ; rarely sudden restora- tion occurs. 456 PRACTICE OF MEDICINE. Favorable indications are : sudden onset, short duration, youth of patient, absence of fixed delusions, good appetite, increasing hours of sleep, moderate or no increase in temperature, pulse, and respira- tion, no evidences of mental weakness, no paralysis or alteration of pupils or articulation, no epilepsy, no unconsciousness to the calls of nature, and no former attacks. Unfavorable indications are the opposite of these, and also the presence of organic brain disease, or a strong hereditary inheritance, or the possession of an excitable dis- position, or nervous diathesis. Treatment. The indications for treatment are to quiet the exalted mentality and to promote constructive metamorphosis. Every means should be used to lessen the excitement of the patient and produce refreshing sleep. A hot or warm bath is frequently one of the most soothing means of reducing excitement ; changing the environment of the patient and placing him under the care of a good, firm, but kind and intelligent attendant is of importance. If means of this character are unavailing, and, unfortunately, in the majority of attacks they will be, then resort must be had to sedatives, for every day’s con- tinuance of the maniacal outbreak lessens the chances of restoration. Amongst the drugs having a distinct value are hyoscince hydrobromas , gr. ^ oo - eV , repeated once or twice daily, watching its effect on the pupils; sulphonal, gr. xx, repeated with caution, watching its effect upon the heart and respiration ; chloralamid , gr. xxx-xl, repeated three or four times daily ; or, trional , gr. xxx, repeated in two or four hours ; this latter is one of the most reliable drugs for maniacal excitement and insomnia we now possess. Patients with much excitement and a weak pulse are benefited with full doses of the bromides and digitalis. If the muscular excitement is pronounced, good results follow mor- phince sulphas , hypodermically ; it may be combined with, either atropince sulphas , hyoscince hydrobromas, or duboisince sulphas. In attacks of acute mania, with flushed face, throbbing arteries, full pulse, and delirious excitement, excellent results follow the use of exlracti gelsemii fiuidi , rr^ij , every hour, until dilatation of the pupils and ptsosis occur, unless improvement sooner occur ; tincturce veratri viridis , Tipij-v, is also useful. Post-epileptic excitement is best con- trolled with large doses of chloral , by the mouth or rectum. Ice, or cold to the head, is useful in cases with flushed face and throbbing temporals. The general condition of the patient needs the most prompt and MENTAL DISEASES. 457 efficient treatment. Attention to the gastro-intestinal canal and kid- neys is of paramount importance, as many attacks of mania are the result of auto-intoxication from the retention of the products of mal- assimilation and tissue waste. The diet should be of the most nutri- tious character, administered at frequent intervals — peptonized or hot milk, hot broths, eggs, and often alcoholic or malt liquors. Patients not infrequently refuse food on account of lack of appe- tite, abhorrence for food, or from fear of poisoning, when recourse must be had to the naso-stomachic tube, or nutritive enemata. Tonics are of great value, a combination like the following always being beneficial : — R . Quininae sulphat., gr. xlviij Strychnine sulphat., gr. ss Acid, hydrochlor., dil., f.^iij Aquae chloroformi, f ^ lij .Aquae menthaepip., ad q. s. . . f ^ vj. M. SlG. — Dessertspoonful, diluted, every four or six hours. The question of removal to a hospital for the insane arises in nearly all cases, and should in my judgment be answered, in the vast ma- jority of instances, in the affirmative, as the discipline, regular hours, and order of a well-managed hospital for the insane, has a most remarkable effect on the majority of insane patients. EPILEPTIC INSANITY. Definition. A mental condition caused by or the result of epi- lepsy. Causes. The careful study of the brain of those dying having epileptic insanity has failed to determine why some epileptics suffer from any of the insanities and others have their normal mentality, and another group are better after a convulsion. I am familiar with ten cases of epilepsy who all seem much brighter, mentally, after their paroxysm, but in whom, after a drinking bout, each epileptic attack is followed by a wicked homicidal mania of many months’ duration. Varieties. Pre-epileptic mania ; post-epileptic mania ; dementia epileptica ; imbecility with epilepsy. Symptoms. The mental changes constituting epileptic insanity, save in the cases of epilepsy with imbecility or idiocy, develop after some years of the ordinary epileptic paroxysms. 38 458 PRACTICE OF MEDICINE. Pre-epileptic mania has attacks of mania some days or hours pre- ceding the epileptic convulsion. The patient is morose, irritable, and threatening, often making homicidal attacks on those around him, be they friend or foe. Rarely the epileptic seizure is replaced by various insane, or so-called hysterical acts, as fits of dancing, laughing, crying, screaming, swearing, or scolding. Post-epileptic mania follows the epileptic paroxysm, either taking the place of the comatose stage or following after it. The maniacal acts during these outbreaks are often of the most desperate and im- pulsive character, many an asylum physician and attendant carrying scars, the result of attacks of post-epileptic maniacs. Epileptic dementia is the terminal mental obliquity resulting in about thirty per centum of insane epileptics, who do not succumb before to nephritis or tuberculosis. Epileptic imbecility is a congenital condition in which the two con- ditions are associated. Prognosis. The great majority of cases of epileptic insanity de- velop, sooner or later, either nephritis or tuberculosis. Recoveries from epileptic mania is a rare occurrence, although I am familiar with two cases. Thirty per centum of epileptic maniacs progress to dementia in from five to ten years. Treatment. There is no doubt but that full doses of the bromides lessen the severity and frequency of the paroxysms. If the attack can be anticipated, it may sometimes be averted by an enema of chloral , gr. xx-xxx, or chloralamid , gr. xl-lx ; or amyl nitris, Tr^v, by inhalation, or by stomach. The general condition of the patient must receive careful attention, as there is a strong tendency to the development of nephritis, tuber- culosis, and gastric catarrh. This class of patients are great feeders — often gluttons — and are sure to eat more than they can properly as- similate. Never contradict, nor attempt to reason with, an epileptic, during their period of excitement. CIRCULAR INSANITY. Synonym. Folie circulaire.. Definition. A mental disease charatterized by regularly alternat- ing and recurring periods of mental exaltation, depression, and sanity. MENTAL DISEASES. 459 Causes. Hereditary predisposition. The exciting causes are any of those conditions which depress the brain or general system. Pathology. There is no characteristic lesion associated with cir- cular insanity. Symptoms. Essentially a chronic condition and probably incur- able. The disease usually begins as a melancholia , the depression being an apathy and torpor rather than a mental pain ; and suicidal feelings and impulses are rare ; this condition is soon succeeded by a mania , a mental exaltation with hyperaesthesia and exaggeration of nervous functions, the reasoning power well retained ; this is in turn followed by a lucid interval , often giving promise of recovery, to be sooner or later followed by another cycle. These periods follow each other with remarkable regularity, each being of the same duration. Rarely the various periods are of irregular duration. The general health is well maintained, the patient gaining in flesh during the stages of depression and lucidity and losing during the period of exaltation. Diagnosis. The regularity of the different periods soon estab- lishes the diagnosis. Prognosis. Generally incurable. Treatment. Attention to the general health and meeting the symptoms of the different periods as they recur. KATATONIA. Synonyms. Alternating insanity ; Kahlbaum’s insanity. Definition. A mental disease, characterized by irregular cyclical symptoms, ranging from melancholia to mania, followed by stupidity and confusion, with cataleptoid phenomena, followed by lucidity for a time, recovery, or passing to a dementia. Causes. Hereditary predisposition. The exciting causes are usu- ally the result of some excess. Rarely associated with organic brain disease. Pathology. No characteristic lesions have been found associated with katatonia. Symptoms. A typical case begins as a melancholia , the mental depression, uneasiness, and distress followed after a variable period by mania , associated with hallucinations and delusions. This period is followed in turn by a condition of attonita , or rigidity and immobility, 460 PRACTICE OF MEDICINE. or a cateleptoid paroxysm : any of the stages may be followed by confusional symptoms, or a true dementia may develop. During the maniacal stage there is a tendency, in many cases, to histrionic and sermon-like declamation, or the speech may be of the verbigeration character — that noisy, incoherent, and meaningless speech seen in many manias, composed largely of the constant repetition of a few words or phrases. During the stage of attonita the presence of the so-called inutism or mutacismus , “a pathological tendency to be silent,” may continue for days, weeks, or months, or it may be interrupted by periods of verbigeration. The immobility or rigidity so characteristic of a period of katatonia is frequently alternated with automatic, incessant, and monotonous movements — the stereotyped movements. Patients suffering from katatonia often refuse food for days at a time and then suddenly present symptoms of boulimia. Vasomotor and trophic changes are frequent, one of the most constant being cyanosis of the hands and other peripheral parts. Haematoma auris, insane ear, or perichondritis auriculas, is frequent. Epileptiform attacks may usher in the disease or occur during any of its stages. Diagnosis. It may be diagnosed as melancholia, mania, or a dementia, depending upon which of the cycles be first observed, but after being under observation long enough to observe a complete cycle, the diagnosis is readily determined. Katatonia differs from circular insanity in the absence of a genuine lucid interval, and the presence of the stage of attonita and catalepsy. Prognosis. The disease may continue for a number of years and recovery follow,, but as a rule the prognosis is unfavorable. Treatment. Attention to the general condition, and combatting the various symptoms as they arise. In cases associated with anaemia, arsenicum , and strychnina , seem to be valuable. Two cases were rapidly improved with small doses of hyoscince hydrobromas, gr. imo-sno- morning and evening. DELUSIONAL INSANITY. Synonyms. Delusional mania ; delusional melancholia ; primary delusional insanity. Definition. A mental state, with fixed or partly systematized MENTAL DISEASES. 461 delusions, associated with either brain exaltation or excitement with- out maniacal acts, or a mental depression, minus the somatic symptoms of melancholia. “An insane delusion is a belief in something that would be in- credible to sane people of the same class, education, or race as the person who expresses it, this resulting from diseased working of the brain convolutions.” Causes. Cerebral and bodily exhaustion the result of overwork, neglect of personal hygiene, or alcoholic, tobacco, drug, or sexual excesses — a neurasthenia. Impairment of the nervous centres, the result of fevers or shock. Climacteric period, worry, and insufficient food. Pathology. Delusional insanity is a subacute, or chronic condi- tion ; death seldom occurring, and when it does ist he result of an intercurrent physical malady. In the few such cases in which post- mortem examinations have been made, the vessels of the brain were found torpid or dilated — a vasomotor paresis causing an imperfect cerebral circulation. Symptoms. Either following an attack of acute mania or melan- cholia, but more commonly without either of these conditions, occurs a set delusion or delusions , which, to the patient, are so real that no amount of argument can dispel his or her belief. These cases are often classed as manias or melancholias, but, as they do not run the ordi- nary course of either of these conditions, they are best classed clinic- ally by themselves. The acuteness or subacuteness of the attack distin- guishes them from paranoia. Amongst the almost endless variety of delusions I will mention a few that have come to my notice recently : A young man of twenty believes he is President Cleveland ; another patient, a driver, believed for ten months he was the owner of a thousand horses, any one of which was worth thousands of dollars ; he made a perfect recovery and- now laughs at his old delusions. A young man of twenty-five believes his mother is not his mother, but the woman he boarded with, and that his brothers and sisters are her children and no relation to him. A young woman of thirty believes she is pregnant by a prominent merchant ; the fact being she is not and never has been pregnant. The majority of the delusions are of an egotistical character, but lack the conduct or appearance of the position due to the character of the delusion. A patient with ragged clothing will assure you that he is worth millions, and yet sees noth- ing inconsistent between his delusion and his personal appearance. 462 PRACTICE OF MEDICINE. Another will assure you of his vast business interests, and yet remains contented in the hospital wards, laboring faithfully in the kitchen or laundry. A woman assures you she is the great Patti, receiving thousands of dollars for each operatic performance, and yet is ap- parently happy in the sewing-room. Delusional insanity is often based upon the development of hallu- cinations of the special senses, that of hearing being the most fre- quent; patients hear “ voices ” telling them what to do or not to do, and a delusion is built up and developed; again, “voices” upbraid them, or charge them with various acts, and upon this is developed a persecutory delusion that causes them much unrest. The following case has lasted for five years, and while the patient is at times apprehensive of some evil that may result to her, and uses judgment to protect herself, yet is not, nor never has been, melan- choliac, or shown any evidences, other than her present belief, of mental failure. She enjoys fair health and partakes of the world’s pleasures. Six years ago her husband suddenly died and the settling of a large estate was thrown upon the patient. Sitting in her hotel, at the window, about five years ago, she saw a man come to the window, in a building opposite to where she was, and make some motion to her. She was greatly alarmed. That evening, while walk- ing on one of the busiest streets of the city, she distinctly heard a young man, in passing, make an improper proposal to her, and she has never walked on that street since without the same thing occur- ring, although not always by the same person. Her daughter, who accompanied her, did not hear the proposal, nor has ever heard it, although, I regret to say, is gradually becoming convinced it must be true. Now for the sequel : the woman is not depressed or worried, shows no evidences of melancholia, talks about the affair as if it were a fact, which it unfortunately appears to her, and avoids the unpleas- antness by never again walking on the particular street nor going in that neighborhood. Again, visions appear which result in delusions of personal import- ance. Taste and smell may be perverted, causing prolonged fasting, often from fear of poisoning. Diagnosis. Delusional mania and delusional melancholia are confounded with delusional insanity, the points of distinction being the absence of severe maniacal and melancholiac acts ; the patient simply possesses his insane delusion and may never refer to it unless questioned. Paranoia or monomania and delusional insanity have MENTAL DISEASES. 463 many symptoms in common, but in the former, if the patient believes he is Christ, he wishes to be so respected, and considers himself wronged if not so treated, while the delusional patient will say he is Christ and immediately drop the subject. There are, however, many border-land cases in which the diagnosis is difficult. Prognosis. Recovery the rule, although the delusions may exist for a number of years. Many patients who make a complete recovery will still believe that their delusions were facts. Treatment. A supporting plan of treatment, with thorough action upon the bowels, kidneys, and skin, and plenty of fresh air, is of great value in all cases of delusional insanity. If the disease is the result of excesses, a course of strychnina , and arsenicum , are indi- cated. A tranquil condition of the brain is essential, and few com- binations are so valuable as digitalis , and hyoscina, in small, repeated doses. Insomnia is an annoying symptom in many cases and is best overcome by a digestible meal at bed-time, or a warm or hot bath in the evening, and if these fail a full dose of somnal well diluted, or trional , gr. xxx, an hour before bedtime, in milk or spirits. PARANOIA. Synonyms. Monomania ; chronic delusional insanity ; reason- ing mania ; verriicktheit. Definition. A chronic mental disease characterized by fixed logical or systematized delusions of persecution, unseen or impossible agencies, or of self-exaltation, the emotions and memory being only paroxysmally defective, while, however, the life of the individual is dominated by the delusions. The term paranoia, as it is now commonly used, to cover a group of insanities which are degenerative in origin, chronic in course, and characterized by systematized delusions, with little impairment of the emotional faculties, is not generally accepted as a synonym for monomania. Causes. There is generally a hereditary predisposition to insanity in monomania or paranoia. The exciting cause may be the result of an acute mania or melancholia, or the result of alcoholism, or the result of malnutrition in those who have had a struggle to keep their position in the world. Extreme worry in individuals with mental in- stability. Following primary or acute delusional insanity. 464 PRACTICE OF MEDICINE. Symptoms. The course of monomania is essentially chronic, the delusions becoming perfectly fixed and unchanging upon one particular subject or sets of subjects, which in turn dominate the life of the individual. The most common character of these systematized delusions are, delusions of persecution or suspicion, delusions of exaltation or of pride, and delusions of unseen agents or influences. A delusion of persecution is shown in a woman of average talents and education, who has devoted much time, thought, and worry to a number of worthless patents, and now that she is in an insane asylum believes she has been placed there that others may reap the rewards of her inventive genius ; she is constantly annoyed by what the physicians, attendants, and patients are doing, claiming that many such acts are for the purpose of annoying or harming her, her sus- picions being of the most aggravating character. Delusion of exaltation or pride is well shown in the case of a man who believes he is Jesus Christ, and is angered to the point of almost homicide if great consideration is not shown him. Another male, whose origin is from the lower walks, believes he is to marry a distin- guished authoress, and will resent any doubt of his purpose with blows. Delusion of unseen agencies is well shown in case of a female, aged forty years, who labored under the delusion that she was beset by numerous devils in her abdomen, the real cause being the presence of a cancer of the liver. Patients complain of electrical influences, telephonic communications, and invisible agents tormenting them. The range the delusions of monomania assume are most wide and varied, but always associated with the ego. The patient is being per- secuted not because, as in melancholia, he has committed some sin, or thinks he has, and deserves punishment, but because the perse- cutors wish to deprive him of his rights, titles, or estate, or degrade him or in some way injure him. Diagnosis. In the diagnosis of monomania there are three points to ever keep in mind ; first, the duration ; the fixed, systematized de- lusions must have existed over one year ; second, the absence of symptoms of mania or melancholia ; and third, the presence of sys- tematized delusions affecting the personnel of the individual. Prognosis. Monomania is an incurable disease. Unless tuber- culosis develop within a few years, dementia results. Treatment. Symptomatic, and all means that promote construct- ive metamorphosis. MENTAL DISEASES. 465 DEMENTIA. Synonym. Acquired feeble-mindedness. Definition. A progressive general weakening of the mind, char- acterized by a loss of reasoning capacity, a diminution of feeling, a weakened volitional and inhibitory power, failure of memory, associ- ated with lack of the power of attention, interest, and curiosity, in varying degrees, in an individual who at one time possessed these mental qualities. Forms. Dementia acute ; dementia alcoholic ; dementia apo- plectica ; dementia choreica ; dementia chronic, or secondary ; de- mentia epileptica ; dementia organic ; dementia paralytica ; dementia partial ; dementia primary ; dementia secondary, sequential, or chronic ; dementia senilis ; dementia syphilitica ; dementia toxica. Causes. Deficient or feeble mental inheritance ; age ; atheroma ; following mania, melancholia, paranoia, and other forms of insanity ; the result of organic brain conditions ; alcoholism ; syphilis ; de- velopmental changes ; climacteric. Pathology. In acute dementia the changes are dynamic. In the primary dementia there is probably atrophy of certain cells from over-stimulation, the tissues being normally deficient. In secondary dementia the chief changes are, “ alteration in the size of the vessels, owing to thickening and distention, the thickening being most marked in the deep layers, and in the walls of the vessels are fatty granules and haematoidin. The perivascular canals are enlarged. The changes in the cells may be described as deficiency in the number of pyra- midal cells, and a want of distinctness of outline and branches, the nuclei being larger, but changed in form, and only capable of slight carmine staining.” In senile dementia there is general atrophy and degeneration of all the tissues of the brain. Symptoms. The onset, extent, and variety of the impaired mentality differs greatly. In some patients the evidences of the failing mind are seen with the subsidence of the mania, melan- cholia, or other insanity, or soon after the development of the particu- lar cause, while in another group of cases the development is slow and insidious. The difference in the intensity is marked ; in one case the changes being scarcely noticeable, the patient being simply less active than before, showing a slight indifference to his environ- ment, while in others, the patients remain for hours alone, making no effort at movement and with little or no expression of the face, 39 466 PRACTICE OF MEDICINE. while another class of cases are oblivious to the demands for food or drink, or the calls of nature, existing “ in the darkness of per- petual intellectual and moral night.” Between these symptoms are all varieties and degrees of mental enfeeblement, the physical symp- toms of dementia varying with the particular cases, many enjoying the best of health, eating and sleeping well, while others are always unwell, first one organ and then another, while another group suffer from chronic diarrhoea, which finally causes death. Dementia patients seem predisposed to tuberculosis, nephritis, and apoplexy. Acute dementia , or “ stupor with dementia,” is to be distinguished from “ stupor with melancholia.” The onset is rather sudden, with or without mania or melancholia, after some brain or bodily exhaus- tion, shock, or fright; the patient, a young person, “is horror-stricken, paralyzed in mind, not merely deranged, not depressed or excited, but deprived of feeling and intellect; his movements, if there be any, are automatic, but frequently he is motionless, standing or sitting, staring at vacancy for hours and days” (Blandford). These patients will not converse, and do not reply to questions, or but slowly, and in monosyllables, and their face has a blank expression. One young man of twenty-three years, but three years in America, having an extraordinary musical education, and a remarkable skill as a piano performer, being unable to secure pupils to teach, was obliged to accept a position as a piano-player at a questionable summer-resort garden, where he contracted the alcoholic and sexual habit. His excesses increased, although never intoxicated ; he suddenly de- veloped symptoms of dementia, his mind becoming a complete blank, his circulation feeble, the surface cold ; and he never offered to enter the dining-room, and yet attended to the calls of nature. He never spoke, and would remain alone and motionless for hours. The sweetest music caused no movement showing intelligence. He was placed on the Mitchell rest treatment for six weeks, and, as his bodily condition improved, he was daily taken to the piano, and his fingers made to touch the keys. For weeks he showed no interest, when, slowly, one day he feebly ran his fingers over the keys, and from that day improved, until, within four weeks, his performance on the piano attracted wide attention, and, after recovery, which was complete, with no recollection of this sickness, he secured pupils and is to-day a successful teacher. He has assured me that he suffered no pain, no depression, but that all is a blank to him. Dementia alcoholic , the mental weakness resulting from excessive MENTAL DISEASES. 467 use of alcohol. Inebriety is a form of dementia, there existing an uncontrollable alcoholic habit with weakened or absent will power, and impaired mentality. Dementia apoplectica , an organic or terminal dementia due to the cerebral changes sometimes following a severe apoplectic seizure. Dementia choreica is a feeble-mindedness associated with chronic chorea or, in some cases, probably the result of the chorea. Dementia chronic is the designation applied to all forms of dementia that have existed after one or more years. Dementia epileptica is the slow mental impairment resulting from long-continued and frequently occurring epileptic convulsions. Dementia organic , the mental deterioration resulting from gross or- ganic brain lesions, such as sclerosis, tumor, embolism, or trauma. An intelligent machinist, aged forty years, fell a distance of twenty feet, striking on his head, but not causing any determined fracture. He was unconscious one week, and on slowly recovering it was no- ticed that there was some change of character, which has grown most decided, and is associated with persistent insomnia. He is rest- less, indifferent, has loss of memory, is vulgar and profane and in- clined to be talkative, opposite traits to his former self, has violent outbreaks, and has a delusion that he is to make a fortune out of a polish, the formula for which was given him by God, but which he has mislaid. He cannot read or write, or, at least, he will never make the attempt. His physical condition is good. Dementia paralytica is a synonym for general paralysis of the insane. Dementia partial is an incomplete form of dementia, in which the mental enfeeblement is associated with such a degree of intelligence and memory that the qualifying term “partial ” is correct. Dementia primary is seen most frequently in the young, developing slowly and insidiously, without any symptoms of mania or melan- cholia, usually in a youth who has given promise of a bright future, by a slowly progressive indifference to his former occupation, studies, or surroundings, with developing carelessness and negligence of per- son and proprieties, no amount of external stimulus serving to rouse the receding mentality, until finally the downward course ends in dementia so decided that, but for the history of the individual, the case would be classed as a congenital. Dementia secondary , sequential , or chronic, is the most common variety of mental impairment, following mania, melancholia, and other 468 PRACTICE OF MEDICINE. insanities. According to Bevan Lewis, twenty per centum of manias, and fifteen per centum of melancholias, become permanent dements. Dementia senilis, the result of cerebral atrophy, with its consequent failing mental power. Loss of memory for recent events is one of the most common symptoms. The disease often begins as a senile mania, melancholia, or delusional insanity. A female aged sixty years, with intemperate history, was, on admission, exceedingly filthy and with many vermin. She says she has been persecuted in her poverty ; that she could not obtain goods from the store when she had no money, though the shopkeeper was rich ; that she was neglected by others ; insists that she ought to have been assisted, is unconcerned with her surroundings, is trifling and disrespectful, restless, moving her hands and body almost continually, is childish and silly in manner, frequently laughing, claiming she is happy and will not work, cannot remember her only sister’s name or where she herself last resided. Dementia syphilitica is the feeble-mindedness resulting from cere- bral syphilis. This group of patients are always sanguine and assert they are “ all right,” “ never sick in my life,” and yet unable to as- sist or care for themselves. Dementia toxica is the mental failure produced by the long- continued and excessive use of opium, cocaine, and chloral. Chronic plumbism is also given as a cause. Diagnosis. Acute dementia is often misnamed, melancholia with stupor, but if the patient is in the teens the probabilities are that it is a case of the former, while if past forty it is almost certainly the latter. The distinction between dementia and idiocy or imbecility must always be determined. Esquirol’s graphic description is well worth re- membering : “ The dement was a rich man who has become poor ; the idiot, on the contrary, has always been in a state of want and misery.” Prognosis. Acute dementia is generally favorable. All other varieties are incurable. The average lifetime of dements is placed at about twelve years, the great majority dying of tuberculosis, nephritis, or apoplexy. Treatment. Patients suffering from acute dementia should be placed on the Mitchell rest regime, with attention to all the secretions. If Dr. Mitchell’s directions are carefully followed, the great majority of cases of acute dementia will recover within nine to twelve months. For the other forms of dementia, unfortunately, there is no cure, the treatment resolving itself into attention to the general health, with proper custodial oversight. MENTAL DISEASES. 469 GENERAL PARALYSIS. Synonyms. Paralytic dementia ; general paresis ; general paralysis of the insane ; dementia paralytica ; paresis ; paretic de- mentia. Definition. A subacute, or chronic, degenerative, disease of the brain, sometimes involving the spinal cord ; characterized by altera- tions in the intellectual and moral character, with the development of unsystematized ideas of self-importance, or delusions of grandeur, finally merging into dementia (preceded by either a mania or a melancholia), and the gradual development of tremor, slurring speech, pupillary changes, ataxia, tropic changes, and finally paresis. Causes. General paralysis occurs chiefly between thirty and fifty-five years of age, and in the male more frequently than in the female. It usually affects the robust, middle-aged individual, rapidly destroying all intelligence and judgment, leaving him to exist, often for months, as a demented human automaton. Predisposing causes ; hereditary ; an ambitious over-straining for prominence, learning, or wealth ; forced intellectual activity in those with imperfect or improper early training ; cranial injuries ; atheroma. Exciting causes ; alcoholic and sexual excesses ; syphilis ; mental and physical overstrain ; worry. “ In many cases I think the middle- aged general paralytic is suffering for the sins of his youth ” (Clous- ton). “ General paralysis is not a penalty of high cerebral develop- ment, but the expression of a discrepancy — an inadequacy of some brains to sustain the strain to which the race, as a whole, is sub- jected” (Spitzka). Pathological Anatomy. A condensed description of the pathological basis of general paralysis is difficult. It may be de- scribed as a chronic diffuse cortical encephalitis. The microscopical changes in the cortex, according to Mendel as quoted by Folsom, are as follows : — i. Increase of nuclei and new cell formation, some nuclei small, some large, and with such varying reactions to coloring agents as to suggest dissimilarity of origin. The stellate or “spider” cells are increased in the upper layer of the cortex, where some may be nor- mally found, and extend to lower layers, as is not the case in normal brains ; they, too, may be several times the usual size and also push through the white substance to the ependyma of the ventricles. Pro- 470 PRACTICE OF MEDICINE. liferation of neuroglia or connective tissue, and in time sclerosis of the cortex, which involves the medullary substance also in a greater or less degree. 2. The larger blood-vessels may or may not be atheromatous ; in the capillaries there is an increase of nuclei in the walls, with thick- ening and hyaloid degeneration. 3. In the nerve cells, the ganglion cells, granular and fatty degen- eration of protoplasm, sclerosis, atrophy. 4. Atrophy and final disappearance of the nerve-fibres, not limited to the cortex and found in other brain diseases also — senile dementia and epilepsy, for instance. 5. Focal lesions of the most various kinds, and degenerative changes in the spinal cord, the several forms of sclerosis and mye- litis. The spinal cord undergoes atrophy with grey degeneration in pos- terior and posterior-medium columns, and of posterior spinal nerve- roots. Symptoms. — For clinical convenience the disease is divided into three stages , prodromal, maniacal, rarely melancholiac, and the stage of dementia, although there is seldom a marked division between each. Prodromal stage may exist unrecognized for months or longer. It begins by an alteration in the habits and character of the individual ; the patient has spells of irritability and obstinacy, which will not admit of contradiction or opposition ; there is a general feeling of elation and bien-etre , an egoism shown by the exalted opinion of his own attainments and importance, and a great laudation of his family. He becomes boastful, untruthful, dishonest, and forgetful, neglecting engagements, business, self, and family. He frequently makes extravagant purchases and may waste large sums of money before his condition of irresponsibility is recognized, or, may unwit- tingly resort to dishonest means to obtain money to squander on new- made friends, as was shown in the case of an intelligent gentleman, who had squandered considerable money in unprofitable property, going to a railroad ticket office, asking for a ticket, remarking he was without cash, writing a check for one hundred dollars on a bank he never had an account with, receiving ninety-nine dollars in change, immediately going to a jewelry store and purchasing a lady’s gold watch and chain, paying sixty dollars for the same, and then going MENTAL DISEASES. 471 to a pawnbroker’s and pledging the watch and chain for forty dollars, and the following day going to the same ticket office and buying another ticket of the same kind he had purchased with the fraudulent check, and on being arrested protested he had done nothing dis- honest. In many instances the patient develops ideas of an enter- prising character, and resorts to all forms of expedients, which, to his mind, are going to improve his or his family’s station and worldly condition ; he determines to change his occupation or business, or attempts to instruct the authorities in what he conceives should be their duties. The moral lapses of paretics are most frequent during this stage, consisting of acts of theft, drunkenness, violent impulses or indecent assaults, in individuals who have possessed a good moral character. They become profane and vulgar, and often resort to sexual excesses. Associated with any of the above symptoms may be any one or more of the following physical conditions : tremor of the muscles about the mouth , naso-labial folds, and of the tongue , causing a slight slur or hesitating speech ; alterations in the pupils , or one pupil becoming somewhat larger than the other ; attacks of ver- tigo, or epileptiform or apoplectiform seizures ; the gastric, intestinal, hepatic, and nephritic secretions are disturbed, and there may be headache and insomnia. After a variable duration, continuing in a mild degree for many months, is ushered in the — Second , or maniacal stage, which is much the same as a severe attack of acute mania, plus the physical signs of paresis and the de- lusions or ideas of grandeur. The patient is excessively restless, boast- ing of his great wealth, intentions, prospects, and influence, one moment the most important of individuals, the next giving away thousands, and if doubt is expressed as to his ability to do so, making it millions and often billions, presenting houses and lands, titles and offices, with unstinted liberality. It is to be noted that these so-called delusions of the paretic are in reality conceptions, or an expansive delirium, for when contradicted the patient makes no effort to defend them ; they seem to be really assertions and reassertions, continuing until incoherency restrains the airy imagination. The patient is sleepless, noisy, destructive, with attacks of blind, uncalculating vio- lence, resisting all who attempt to restrain or molest him ; the violent impulses of paretics are similar to the furious excitement of the post- epileptic maniac. Th e. physical signs are more pronounced, the char- acteristic hesitating and slurring speech increases, the pupillary 472 PRACTICE OF MEDICINE. changes become more marked, the tremor of the tongue and lips in- creasing, and spreading to the upper extremities, th z gait ataxic , the patellar reflex increased , or rarely, diminished, the sphincter of the bladder disordered, and there often occurs paralysis of the anal sphincters. During the progress of the second stage are developed cerebral crises , — syncope, petit or grand mal , apoplectiform attacks, or paralytic seizures. Few cases but show one or more of these con- ditions. There also occurs myosis and loss of light reaction, and increased wrist and elbow jerks. The maniacal stage is of shorter duration than any other, and is usually succeeded by the — Stage of dementia, the patient presenting all the evidences of failing mentality, with paralysis, trophic changes, as shown by the occur- rence of bed sores, cystitis, diarrhoea , and arthropathies, or Charcot’s joints, the patient emaciating rapidly, death closing the scene within a few months. Rarely the maniacal stage is preceded or replaced by a condition of melancholia with expansive hypochondriacal delusions. In a few instances, a genuine lucid interval has followed either the prodromal or maniacal stage. The spinal form of general paresis is fairly fre- quent, in which symptoms of spinal sclerosis are added to the mental and ataxic phenomena of the usual form. “Of the many divisions of general paralysis into several clinical types, all of them naturally more or less arbitrary, I know no other so satisfactory as Meynert’s eight ” (Folsom). 1. Simple progressive dementia with the usual motor impairment which accompanies it, but, excepting hypochondriacal depression, not necessarily exhibiting other mental symptoms than dementia. 2. With the expansive delusions and the distinctive motor disturb- ances which appear simultaneously and are progressive, constituting the “ classic ” form of general paralysis. The mental state is usually of self-satisfaction and exultation, but there may be depression. 3. Of the same type as the last, but failing its steadily progressive character through arrest of the active process. The remissions, which seldom last so long as a year, raise hopes of recovery, but still manifest unmistakable impairment of the reasoning faculties. The psychic disturbances are much greater than can be accounted for by the atrophy of the brain alone. 4. Cases in which the characteristic exultation and grand delusions reach such an astounding height that manifest motor symptoms are MENTAL DISEASES. 473 looked for with confidence from day to day and yet may not appear even for a year, any slight incoordination naturally being obscured by the general muscular disturbance. Meanwhile there may be such an improvement that the patient leaves the hospital for a while, once, rarely twice, on the responsibility of his family, but to return with marked motor, as well as mental signs. 5. A very rare form, with alternate symptoms of exaltation and de- pression of the type of circular insanity. 6. With early furious delirium, painful hallucinations, confusion and incoherence somewhat resembling acute delirium. 7. Progressive general paralysis, in which the characteristic indica- tions appear secondary to other forms of insanity ; for instance, after paranoia or melancholia, first described by Hoestermann. 8. The combined form with sclerosis in the whole cerebro-spinal tract, the symptoms of tabes or spastic paralysis predominating, ac- cording as the posterior or lateral columns of the spinal cord are chiefly involved. The ascending type, in which the cord is first affected, is rare. Optic neuritis ending in atrophy and paralysis, es- pecially of the ocular muscles, may precede marked mental symptoms. Diagnosis. The development of the following symptoms re- moves all difficulties in diagnosis : mental — alteration in character, loss of memory, defective will power, changed moral sense, insomnia, violent impulses, melancholia or mania, unsystematized delusions of expansive character, with an exalted sense of well being, gradually ending in dementia ; physical — hesitating, slurring speech, tremor of the lips, tongue, and upper extremities, pupillary changes, myosis, loss of light reaction, exaggerated wrist, elbow, and knee jerk, attacks of syncope, vertigo, epileptiform or apoplectiform seizures, ataxia, trophic changes, and finally paralysis. Paralytic insanity , or organic dementia, is not the same condition as general paralysis. It is the form of mental failure succeeding to gross brain lesions, such as apoplexy, tumors, softening, trauma, and sclerosis. Prognosis. Unfavorable. Remissions very, very rarely occur. Treatment. The care of the general health and caring for the symptoms as they arise is all that can be done for paresis. It is claimed, that if the condition be recognized early in the prodromal stage, the stage of cerebral congestion or vasomotor paresis, much good may be accomplished, and if the disease be not cured, may be 474 PRACTICE OF MEDICINE. held in check for a long time, by the use of such drugs as digitalis, ergota, or the bromides. The maniacal excitement maybe quieted by the use of the hot bath, isolation (not seclusion), and the administration of small doses of hy- oscince hydrobromas, which seems to exert an alterative action on the brain. For the insomnia, trional, gr. xx-xxx, repeated, is usually satisfactory. If a reliable syphilitic history is obtained, a thorough course of hydrargyrum and iodides should be administered. All means that promote the constructive metamorphosis are indicated, in this most characteristic, progressive malady. ~ DISEASES OF THE SKIN. DISORDERS OF SECRETION. SEBORRHCEA. Synonyms. Acne sebacea; pityriasis; tinea furfuracea; dan- druff. Definition. A functional disorder of the sebaceous glands of the skin ; characterized by an excessive and abnormal secretion of seba- ceous matter, forming upon the skin either as an oily coating, or in crusts and scales. Varieties. Seborrhoea oleoso ; seborrhoea sicca. Causes. In newly-born infants an increased secretion of seba- ceous matter — the vernix caseosa — is a physiological process. The origin of the disease is for the most part illy understood, anaemia being a factor in many cases. Pathology. Seborrhoea is a functional derangement of the glands ; if it be allowed to become very chronic, there occurs atrophy of the glands and follicles. Symptoms. The affection may occur upon any portion of the body, its most frequent seat being, however, the scalp {seborrhoea capitis ox pityriasis capitis'), and next in frequency the face {seborrhoea faciei). DISEASES OF THE SKIN. 475 Seborrhoea oleosa appears as an oily, greasy coating upon the skin, without hyperaemia, and not attended with itching. The secre- tion is of an oily character, the quantity at times being so great as to collect in minute drops of a clear, yellowish fluid upon the surface. The most common seat for this variety is the face — seborrhoea faciei — and nose — seborrhoea nasi. Seborrhoea sicca consists in the formation of dry, more or less greasy, masses of scales or crusts of a grayish, yellowish , or brownish- yellow color, having a strong tendency to adhere to the skin, and attended with decided itching. Occurring upon the scalp — seborrhoea capitis — it is a frequent source of premature baldness. Diagnosis. Seborrhoea capitis may be mistaken for dry eczema, but the former is always a dry disease, while in eczema moisture has occurred at some period of the affection. The scales in seborrhoea are very abundant and pale ; in eczema the scales are scanty and reddish, the parts irritated, infiltrated, and thickened. Seborrhoea sicca and psoriasis have many points of resemblance, whether occurring on the scalp or on the body. In seborrhoea the scales are minute or caked, grayish or yellowish in color, of an unctu- ous feel and usually uniformly diffused. In psoriasis the scales are very dry, abundant, thick, white, irregularly dispersed, with interven- ing healthy skin, and the surface beneath the scales is always reddish and inflamed. The clinical histories of the diseases are entirely different. Prognosis. If properly treated, favorable, although the affection is obstinate to eradicate. Treatment. The secretions require attention. If anaemia be present, ferrum and arsenicum are indicated. The following formula of Sir Erasmus Wilson, and lauded by Hebra, is valuable : — R . Vini ferri, f ^ iss Syr. simplex, Liq. potassii arsenit., . . . . aa ij Aquae destil., f ^ ij. M. SiG. — Teaspoonful three times a day, with meals. Duhring recommends calcii sulfhid., gr. xVi several times daily. Local measures are the most important in seborrhoea. For sebor- rhoea capitis the following plan will usually be successful : — The scales are to be thoroughly moistened with either oleum olivce , 476 PRACTICE OF MEDICINE. oleum morrhuce or adeps , to facilitate their removal ; it is best applied at night and the head covered with a flannel or other cap. As soon as the crusts are well soaked they should be removed by washing with soap and warm water, or equal parts of soap, glycerine, and water, or the following will be found valuable : — $ . Saponis viridis (Hebra), f.^iv Spts. vini rect., f^ij. M. Solve et filtra. Sig. — D ilute and use as a soap- wash or shampoo. The scalp is to be thoroughly cleansed of either of the above by again washing with warm water and then dried by means of soft towels. Then should be applied some oily or fatty substance, depend- ing upon the condition of the scalp. If much irritation, either vaseline or oleum amygdale ex pres sum. If no irritation be present, a stimulating preparation will be found of great benefit. Either of the following may be used : — Or, R . Tinct. cantharidis, Tinct. capsici, 01. ricini, . . . Alcoholis, . . . Spt. rosmarini, f 3 “j f.^ij f|j. M. — Duhring. R. Bismuthi subnitratis, Ung. hydrargyri ammon., 3 ij-iv. Ung. aquae rosae, ad ^j. M. The above should be repeated every day or two, as the symptoms may require, until a cure is effected. The following combination is useful for dandruff : — R. Ammonii muriat., Glycerinae, . . . Aq. rosae, . . . Sig. — Apply to head. £ r - X !I f Ji M. The seborrhcea of other portions of the body are to be treated upon the same general principles. DISEASES OF THE SKIN. 477 COMEDO. Synonyms. Acne punctata nigra ; black-heads or worms. Definition. A disorder of the sebaceous glands ; characterized by retention in the excretory ducts of an inspissated secretion which is visible upon the surface as yellowish or whitish pin-point and pin- head-sized elevations, containing in their centre blackish points. Causes. The true etiology is unknown. Among the causes as- signed are anaemia, menstrual disorders, urethral irritations, dyspepsia, and constipation. Pathology. Comedo is an affection of the sebaceous glands and ducts, consisting of an accumulation of sebum and epithelial cells in the glands and follicles, dilating the ducts to such an extent as to pro- duce the point or elevation upon the surface. The obstructed gland may relieve itself, or it may continue distending until a papule is formed. The duct sometimes contains small hairs, and also the microscopic mite — demodex folliculorum — having a length of from to of an inch, and breadth of about of an inch, which was at one time erroneously supposed to be the cause of the affec- tion. Symptoms. Essentially a chronic affection, observed for the most part on the face, neck, chest, and back. Each single elevation or black-head or point is designated a comedo, or if a number, in the plural, as comedones. Each comedo is small, varying from a pin-point to a pin-head in size, having a brownish or blackish appearance, from the dust or dirt that has adhered to their unctuous surface. If they form in great numbers upon the face they are disfiguring, giving the individual the appearance of having had minute grains of powder implanted in the skin. There are no evidences of inflammation unless acne is asso- ciated, but, on the contrary, the skin has a dirty, greasy, unwashed appearance. Diagnosis. There is no condition resembling comedo, so that its recognition is easy, unless complicated with acne ; but even then the inflammatory appearance of acne should prevent an error. Prognosis. Favorable, although often remarkably obstinate. Treatment. Derangements of any of the functions of the body should be corrected, and strict attention be given to the rules for pro- moting the general health. 478 PRACTICE OF MEDICINE. Local measures are usually sufficient to promote a cure of the affection. The parts affected should be thoroughly softened by bathing with soap and warm water, when the comedones are removed by friction with a Turkish towel, pressure between the thumb nails, the applica- tion of a watch key, or the instrument known as the “ comedo extrac- tor,” and their return prevented by an unguentum medicated, to meet the indications, with either sulphur , alkalies , or hydrargyrum. Dr. Shoemaker recommends the following formula : — R . Thymol, gr. x Acidi borici, ^ij Aquae hamamel. Virg. dest., f^iv Aquae rosae, fgj. M. SiG. — Mop well over the surface once or twice daily. MILIUM. Synonyms. Grutum ; tubercula miliaria or sebacea ; acne punc- tata albida. Definition. An accumulation of sebum in the sebaceous glands which are minus their excretory ducts ; characterized by the forma- tion of small, roundish, whitish, sebaceous, non-inflammatory eleva- tions, situated immediately beneath the epidermis. Cause. The origin of the affection is not understood. Pathology. The sebaceous gland is distended with the sebum, which is unable to escape, owing to the obliteration of the duct, nor can the contents be squeezed out, as no sign of aperture is to be found, the formation being completely enclosed. Rarely the retained secretion undergoes a metamorphosis into hard, calcareous, stone-like masses — sebaceous concretions or cutaneous cal- culi. Symptoms. Milia may occur upon any portion of the body ; their usual seat, however, is upon the face, forehead, and about the eyes. They form gradually, are about the size of a millet seed, of a whitish, pearl, or yellowish color, hard, and of a rounded shape, giv- ing the sensation to the touch of hard bodies embedded in the skin. They are not associated with inflammatory symptoms. Diagnosis. Milium and comedo are somewhat similar in ap- pearance ; the differences are that in milium the sebaceous gland is DISEASES OF THE SKIN. 479 distended without an opening, while in comedo the duct of the gland is always patulous upon the surface. Milium usually exists singly, the skin looking normal ; while comedo is more general, the surface having a soiled and greasy appearance. Prognosis. Favorable. Treatment. As a rule, no treatment is needed, the number being few and their presence of no consequence. If their removal be desirable, two modes suggest themselves : one, to open the cyst with a fine-bladed bistoury, and turning the contents out, destroying the remaining sack by the application of either tinctura iodi , or acidum chromici; or, the cyst may be destroyed by electrolysis. If a tendency to recur is shown, the plan may be repeated. SEBACEOUS CYST. Synonyms. Wen ; sebaceous tumor ; encysted tumor. Definition. A distention of the sebaceous gland and duct, with hypertrophy of the walls, which forms a thick, tough sack or cyst ; characterized by the appearance of a firm or soft, more or less rounded tumor, having its seat in the skin or subcutaneous connective tissue. Cause. Unknown. Pathology. Hypertrophy of the gland and duct walls, the result of pressure from the accumulated contents, which consist of the altered products of the sebaceous secretion. Symptoms. The development of wens is slow and insidious. The localities where they are more commonly developed are the scalp, face, back, and scrotum. The tumors occur singly or in numbers, in size from a pea to a walnut, or larger, in shape either rounded, flattened, or semi-globular ; in consistency they are either hard or soft, and doughy ; they are freely movable and painless. Diagnosis. Sebaceous cysts may be confounded with fatty tumors. Treatment. Excision and careful and thorough dissection of the cyst. HYPERIDROSIS. Synonyms. Hydrosis ; ephidrosis ; excessive sweating. Definition. A functional disorder of the sweat glands ; charac- terized by an increased secretion of sweat. The sweating may be either general or partial. 480 PRACTICE OF MEDICINE. Causes. Often undetermined; occasionally inherited; nervous derangements ; malaria ; diseases of the heart and lungs. Pathology. A functional derangement of the sudoriparous glands, over which the vaso-motor system has control. The charac- ter of the secretion, chemically, may not differ from the normal. Symptoms. Universal general sweating, such as occurs during the course of pneumonia, rheumatism, tuberculosis, typhoid and other febrile maladies, can hardly be considered a distinct affection. Hyperidrosis may be acute or chronic, the amount slight or large, being constant or paroxysmal, the extent general or local, and it may or may not be symmetrical. Bromidrosis is the designation when the secretion has an offensive odor. Chromidrosis is the designation when the fluid poured forth is vari- ously colored. Uridrosis is the designation when the excretion from the sweat glands contains the elements of the urine and particularly urea. Phosphoridrosis is the designation when the perspiration appears luminous in the dark. Local hyperidrosis occurs most commonly upon the palms, soles, axilla, and genitalia. Hyperidrosis of the palms may be so profuse that the fluid accumu- lates and keeps the parts constantly macerated, the wearing of gloves being impossible, for as soon as the parts are wiped dry they are again bathed in the secretion. Jamieson states that hyperidrosis of the hands is very common in those who are daily excessive spirit drink- ers ; this is not my experience. Hyperidrosis of the soles is a disagreeable and often distressing condition, as' the socks and shoes become saturated, and thus keep the soles constantly bathed, allowing the macerated epidermis to peel off, leaving a more tender skin exposed, causing pain and distress when walking. The maceration of the epidermis, the secretion about the toes, together with the moisture of the socks and the soles of the shoes, promote the rapid development of the bacteria foetidum ; all these together produce a most disagreeable, disgusting, and persistent odor, which is termed bromidrosis pedum. Hyperidrosis of the genitalia attacks males more particularly, giving rise to a disagreeable, penetrating odor. The sweating may be limited to one side — unilateral hyperidrosis. DISEASES OF THE SKIN. 481 Prognosis. The majority of cases are extremely intractable ; complete recovery is rare in a fair proportion, while some cases are easily relieved. Treatment. The general condition of the patient must receive proper attention. Local treatment is the most valuable, however, in this affection. The parts should be cleansed and immediately dried, and then dusted with some one of the numerous dusting powders. The follow- ing is a valuable powder : — R . Acidi salicylat., gr. xx Zinci oleat., ^j. M. Perhaps the very best local application is tinctura belladonnce , either diluted or full strength. Aristol as a dusting powder is very satisfactory. In hyperidrosis of the palms and soles, the following are valuable, first washing the parts with a weak solution of acidum carbolicum : — R . Acidi salicylici, z ss Cretse praep., ]|j Aluminis exsic., ^j. M. et powder finely. SlG. — Apply to parts with puff ball. Or — R . Acid, salicylici, 3 parts. Pulv. amyli, 10 parts. Pulv. soapstone, 87 parts. SlG. — Sift into shoes and stockings. Or — R . Sulphur, lotum., gr. xxx Pulv. arrowroot, 3 iv Acid salicylici, gr. vij. SlG. — Dust over feet and between toes. Or — R. Potassii permanganat., gr. ij Aquae, destil., f jj. M. M. M. A saturated solution of acidum boracicum applied frequently to the hands and feet often proves curative. For obstinate cases, involving the palms or soles, the following plan of treatment, as suggested by Hebra, will be found of the greatest service. It is imperative that the various steps be closely followed : 40 482 PRACTICE OF MEDICINE. “ The parts are to be cleansed with water and soap, and the follow- ing ointment applied on pieces of cloth cut to the size of the region. Lint smeared with the ointment is also to be placed between the toes or fingers, so that every portion of the skin may be covered with a layer of the ointment. R . Emplast. diachyli, ^ iv Olei olivae, f ^ iv. The plaster to be melted, and the oil added and stirred until a homo- geneous mass results. Sig. — T o be used on cloths. “ The cloths are to be changed every twelve hours, when the parts are not to be washed, but rubbed with dry lint and starch dusting powder, after which new dressings are again to be applied in the same manner. This proceeding is to be continued from one to two weeks. When the disease is upon the soles, the patient may walk about in loose shoes.” After a week or ten days the ointment can be discontinued, but the dusting powder is td be continued for a con- siderable period. If relapses occur, the original treatment should again be instituted. SUDAMINA. Synonyms. Sudamen ; miliaria crystallina (Hebra). Definition. A non-inflammatory affection of the sweat glands ; characterized by the rapid development of millet-seed-sized, translu- cent, whitish vesicles, in great numbers, upon any portion of the body. Causes. A high temperature, causing unusual activity of the sudoriparous glands. Pathology. The glands being excited beyond their capacity for normal excretion, the excessive fluid, instead of escaping upon the surface, from some cause collects between the layers of the epidermis, in the form of minute, translucent, pin-point-sized vesicles. Symptoms. Each minute vesicle is distinct, but they exist in great numbers, very closely resembling drops of free sweat. They develop rapidly, never coalesce, become puriform, or rupture. Fresh crops form from time to time. Their duration is transitory ; the fluid is absorbed, the covering of each dries, forming a thin, delicate mem- brane, which disappears as a slight desquamation. Treatment. The treatment is that of the disease with which they occur. DISEASES OF THE SKIN. 483 ANIDROSIS. Definition. A functional disorder of the sweat glands ; charac- terized by a diminished or insufficient secretion of sweat. Cause. The result of a congenital deficiency of the sweat gland- ular apparatus. Local anidrosis may result from injury to a nerve, during the course of chronic diseases of the skin, as ichthyosis, eczema, psoriasis, lepra, and elephantiasis arabum. In rare cases an individual ceases to sweat entirely at times ; in such cases the general health is impaired, and during the hot season much suffering may ensue. Treatment. Means to promote the activity of the skin and glands is the indication, such as the ingestion of large quantities of water, hot baths and steam baths, friction, and the use of sudorifics, the most valuable of which is pilocarpus. HYPEREMIAS OF THE SKIN. ERYTHEMA SIMPLEX. Definition. An acute affection of the skin, in which occurs an abnormal quantity of blood in the dermal vessels ; characterized by discoloration, which disappears upon pressure and with more or less local increase of temperature. Varieties. Idiopathic erythema ; symptomatic erythema. Causes. Idiopathic erythema; heat, cold, pressure, friction, or the contact of irritants, such as mustard, arnica, and dyestuffs. Symptomatic erythema occurs most frequently in childhood, from diseases of the stomach and intestines ; during the course of the various exanthemata. Symptoms. A more or less rapidly developed redness of the skin, varying in color from pink or light red to dark red, which dis- appears upon pressure, to rapidly return again. The extent and form of the congestion varies according to the cause, at times being as small as a coin and isolated, and again diffused over a large area. The temperature of the congested part is slightly above the normal. Slight itching and burning are, usually, associated with the discol- oration. Diagnosis. Erythema resembles acute dermatitis in color, but 484 PRACTICE OF MEDICINE. the subjective symptoms of the latter are so decided that an error should not occur. Treatment. Controlled by the cause, which should be removed, and the local application of some one of the various dusting powders. ERYTHEMA INTERTRIGO. Definition. An acute congestion of the skin ; characterized by redness, heat, increased perspiration, and an abraded surface, with maceration of the epidermis. Causes. In the fleshy, from contact or friction of opposing sur- faces exposed to warmth — chafing. In children and infants contact of moist clothing ; also disorders of digestion. Symptoms. Parts where the natural folds of the skin come in contact with one another, as the nates, perineum, groins, axillae, and beneath the mammae, in the fleshy and in infants, become red , hot , painful, and have an increased flow of perspiration , which in turn softens the epidermis , giving rise to an acrid, mucoid fluid. If not checked by the removal of the cause and the application of the dust- ing powders, inflammation — dermatitis — results. Treatment. The congested parts should be thoroughly washed with water and castile soap, or with bran-water, and carefully dried with a soft towel. The opposing folds of the skin are to be kept sep- arated with lint or soft linen, the parts first covered with cretce prce- parata , zinci oxidum , bismuthi subnitras, amylum , lycopodium , or buckwheat flour. INFLAMMATIONS OF THE SKIN. ECZEMA. Synonyms. Tetter ; salt rheum ; scall. Definition. A non-contagious inflammation of the skin, charac- terized by any or all of the results of inflammation, at once, or in suc- cession, such as erythema, papules, vesicles or pustules, accompanied by more or less infiltration and itching, terminating in a serous dis- charge, with the formation of crusts, or in desquamation. Forms. Acute ; chronic. Varieties. Eczema erythematosum ; eczema vesiculosum ; eczema DISEASES OF THE SKIN. 485 papillosum ; eczema pustulosum; eczema rubrum ; eczema squamosum ; eczema fissum ; eczema verrucosum ; eczema sclerosum. Causes. Eczema attacks persons in all spheres, the rich, the poor, the infant or the aged, and males or females. Many families, espe- cially those having the “ catarrhal predisposition or peculiarity of con- stitution,” seem more liable; indeed, it appears probable that a pre- disposition to eczema may be transmitted from parent to child. Among the causes suggested are ; dentition, improper food, gastro- intestinal disorders, intestinal parasites, deficient urinary secretion, the rheumatic and gouty diathesis, vaccination, prolonged contact of hot fomentations, heat and cold, and contact with the poison vine, (rhus toxicodendron), and poison tree, (rhus venenata). Pathology. Eczema is a catarrhal inflammation of the skin — a dermatitis, with superficial serous exudation. There is first hyper- cemia or congestion of the vessels of the skin — eczema erythemato- sum when uniformly distributed, eczema papillosum, when the con- gestion is limited to distinct points. The hyperaemia is soon followed by a serous exudation. If the superficial exudation be profuse enough to form small drops, and if the epidermis possess sufficient resisting power not to give away immediately before it, vesicles form, producing the variety known as eczema vesiculosum ; if the vesicles contain a large admixture of young cells, so that the serum be turbid, yellow and purulent, the vesicles become pustules, termed eczema pustulo- sum ; if the serous exudation be not sufficient to either elevate or break through the epidermis, instead of either vesicles or pustules forming there occur dry scales, rising from the reddened skin — ec- zema squamosum. When the exudation is sufficient to detach the epidermis, thus exposing the red and moist corium, it is termed eczema rubrum. In chronic eczema the skin is subacutely inflamed ; is very much thickened, hardened, and infiltrated with cells which extend through- out the entire corium, even into the subcutaneous connective tissue. The papillae are enlarged, and at times, may be distinguished with the naked eye. Pigmentation may take place in the deep layers of the rete, and in the corium, especially about the vessels. Symptoms. Eczema is the most common of all cutaneous af- fections, with symptoms varying in accordance with the particular va- riety of the affection and its location, although the general character- istics of a catarrhal inflammation are present in all ; these are redness , 486 PRACTICE OF MEDICINE. either limited or diffused ; heat , of the part affected ; swelling , the re- sult of the serous exudation, giving rise either to a discharge (weep- ing), with subsequent crusting , or to the deposition of plastic mate- rial. The most constant, annoying, and troublesome symptom is the itching , or at times burning , which varies from that which is simply annoying to that which is almost unendurable. Eczema runs its course either as an acute affection, lasting a few weeks, not to return, or to return acutely at wide intervals, or, as is much more frequently the case, it assumes a chronic state, continuing with more or less variations for months, years, or even a lifetime. It may appear upon any portion of the body, or involve the whole integument ( eczema universale). The varieties are named in the order which the lesions assume at their commencement. Eczema Erythematosum. An erythema or redness of the surface, with a yellow tinge. The size of the macule may be very small or quite extensive, with irregular outlines. There may be slight swelling of the patch, but no discharge occurs unless it be where two surfaces come into contact, ( eczema intertrigo ), as about the genitalia. Cases without discharge are covered after a few days with a thin film of dry, exfoliating epidermis or scale ( eczema squamosum). When a discharge (weeping) or moisture occurs, it is followed with more or less crusting. Intense itching is a constant symptom. Eczema Papulosum, or Lichen Simplex. This variety of eczema appears in the form of small, rounded papules, the size of a pin-head, of bright red, or at times dark red color ; they may be either discrete or confluent. In some cases all, while in others a greater or less number, of the papules pass into vesicles and run much the same course as vesicular eczema. The itching is of the most intense char- acter, leading to severe scratching, by which the summits of the papules are torn, causing them to bleed, the blood forming dark red crusts. Eczema Vesiculosum. Begins with burning, pain, redness, and swelling, followed by an immense number of minute vesicles, either discrete or confluent, rapidly distending with a clear or yellowish fluid and attended with intense itching. Soon the vesicles rupture, the fluid rapidly diffusing over the surface and drying into yellowish, honey -like crusts. New crops of vesicles soon follow, or if subsequent vesications do not occur, the fluid rapidly diffuses over the excoriated DISEASES OF THE SKIN. 487 surface, which also, in turn, dries into large, yellowish crusts. After a variable time the various symptoms gradually subside. Itching is the most prominent subjective symptom, is intense, and gives rise to an irresistible desire to scratch. All portions of the body are liable to this variety of eczema, the most frequent location, however, being the face, and when occurring in children is commonly known as crusta lactea. Eczema Pustulosum, or Eczema Impetiginosum. This variety usually begins as vesicular eczema, the fluid rapidly changing to pus. After a short period, during which the pustules have increased in size, they burst and the escaped fluid forms thick, greenish-yellow crusts, which, in turn, rapidly dry and fall off, or crumble away. The location of this variety is most usually upon the scalp and face. It is stubborn to treatment. Itching is a prominent symptom. Eczema Rubrum, or Eczema Madidans. This is a variety only from a clinical standpoint. It may result from any of the fore- going varieties. The surface of the skin is inflamed and infiltrated, red , moist , and weeping , the profuse serum rapidly drying into thick, yellowish, greenish, or brownish crusts, the color depending upon the character of the fluid, which may be serum, pus, or blood from the exposed and lacerated corium. The crusts adhere closely and firmly to the part, and, unless removed by mechanical means, may remain indefinitely, the disease pursuing its course beneath. Eczema rubrum , or madidans, “ then, presents two appearances — as it occurs with its crust, and as it exists without this covering. In the one case the skin itself is altogether obscured by a dirty, yellowish, or brownish crust ; in the other the skin presents a bright or violaceous red, punc- tate, wounded surface, deprived in great part of its epidermis, and exuding a scanty or profuse, clear or opaque, syrupy, yellowish fluid. Sometimes this is streaked with blood.” The itching and burning are severe. It may develop upon any portion of the body, but is most commonly seen upon the legs, particularly in elderly peo- ple. Its course is chronic and increasing in severity. Eczema Squamosum. This is also a clinical variety. It results from the erythematous, vesicular, pustular, or papular varieties of the affection, but more particularly the first named. A typical case pre- sents itself in the form of variously sized and shaped reddish patches, which are dry, or more or less scaly, the skin being more or less infil- trated or thickened. Its course is usually chronic. 488 PRACTICE OF MEDICINE. Eczema Fissum, or Rimosum. Another clinical variety. During the progress of the erythematous, vesicular, or pustular varieties of eczema, cracks or fissures result when the lesion occurs upon regions subject to constant motion, such as between the fingers, toes, and the various joints. At times the fissures are extensive and deep and of a bright red color, showing the true skin, and intensely painful upon motion. Chapped hands are typical instances of fissured eczema. Eczema Sclerosum. This variety of eczema, occurring most commonly on the palms, soles, and finger tips, is characterized by hy- pertrophy of the papillae, showing itself as hard, thickened, infiltrated, localized patches, which are most apt to crack (eczema fissum). Eczema Verrucosum, or Papillomatosum, differs from the foregoing in that the thickened, infiltrated patch has a warty verru- cous appearance. Its course is chronic. Eczema Acutum et chronicum. The line which divides these two conditions is drawn by means of the clinical and patho- logical features. The course of eczema, in the majority of instances, is chronic. It may be said that so long as the general inflammatory symptoms are high and the secondary changes slight, the affection is acute, and that when the process has settled itself into a definite line of action, continually repeating itself and accompanied by secondary changes, it is chronic. Diagnosis. The many varieties in which eczema manifests itself renders the diagnosis a matter of importance. The following charac- teristic features of eczema are of value in arriving at a diagnosis : inflammation, swelling and oedema, thickening from cell infiltration, redness, the discharge or moisture, followed by crusting, on removal of which a moist surface is presented, and itching and burning . Erysipelas may be confounded with erythematous or vesicular eczema. The points of difference are the fever and other general disturbances. The deep-seated inflammation of the skin, rapidly spreading with heat, swelling and oedema without moisture, giving the surface a deep red, shining, and tense appearance, are character- istic of erysipelas and very different from eczema. Herpes and vesicular eczema bear some resemblance to each other ; herpes zoster is distinguished by the neuralgic pains which are asso- ciated with it and are never associated with eczema. The other varie- ties of herpes occurring about the face and genitalia run their course DISEASES OF THE SKIN. 489 in a few days, while eczema is of much longer duration and has a discharge followed by crusting. Seborrhosa of the scalp and squamous eczema of the same region closely resemble each other. In eczema, however, the skin is more or less red, inflamed, and thickened, and the scales larger, less abun- dant, and less greasy and drier than seborrhcea. In eczema the scales are usually seated upon a circumscribed patch, while in seborrhcea, as a rule, they cover the scalp uniformly. Itching occurs with both dis- orders. The history of the two affections should be of material aid to render the diagnosis clear ; still, however, in many cases the diffi- culty is marked. Both are frequent affections. Psoriasis should never be confounded with a typical case of eczema, but chronic eczema, with infiltrated, inflammatory, scaly patches, fre- quently looks very much like psoriasis. Treatment. There is no specific. The indications are for the removal of the cause, where it can be ascertained, if it be possible, and attention to the general health. The diet should be of the most nutritious, but easily digestible character ; fresh air and moderate exercise are also essential elements in the treatment, together with attention to the secretions. If the bowels be sluggish, much benefit follows the use of such laxative mineral spring waters as the Hathorn, or Hunyadi Arpad, or a morning dose of magnesii sulphas. For chil- dren, syrupus rhei , to which may be added magnesia ; or, what is per- haps more efficient, a small dose of hydrargyri chloridum mite. If the urinary secretion be small and the urine heavy, use should be made of full doses of potassii acetas, and large draughts of water. If either a rheumatic or gouty disposition exist, lithium salts, to which may be added vinum colchici seminis. If a scrofulous tendency exist, use oleum morrhuce and syrupus ferri iodidi. If anaemia, ferrum , quinina , strychnina , and the mineral acids , or syrupus hypo- phosphitis comp., are indicated. Locally : the most important means of treatment for all the varie- ties of eczema are with local remedies, suiting the appropriate ones for each particular case, as no one combination is applicable for all varieties. It may be stated, as a principle, that nothing irritant is ever to be applied to the surface in acute eczema, and that in the chronic form nothing can hardly be too stimulating. The too frequent wash- ing or general baths are to be avoided, as they have a tendency to 4i 490 PRACTICE OF MEDICINE. macerate the already softened epidermis. For cleansing purposes, in the majority of instances, ordinary Castile soap is sufficient. Crusts and scales are nearly always present in eczema, and are to be removed before medicaments can be successfully applied. Their removal is to be secured by saturation with oily preparations, a starch or other mild poultice, or a saturated solution of acidum boricum. After their removal the parts are to be cleansed with Castile soap and water. For acute erythematous or vesicular eczema, use but little, or what is better, no, soap or water ; instead, coyer the parts with a dusting powder, one of the most useful being Acidum boricum , or $ . Pulv. camphorae, 7 t ) Zinci oleat., 3 ij Pulv. amyli., Jj. M. Sig. — D usting powder. For acute vesicular eczema , Dr. J. C. White recommends bathing the affected part with lotio nigra (hydrargyri chlor. mite gr. viij, liquor calcis f^j), full strength, or diluted with equal parts of lime- water, applied by means of a sponge or a piece of cloth, for ten or fifteen minutes at a time, and at intervals of a few hours or longer, the sediment being allowed to remain on the skin ; after which ung. zinci oxid. is to be gently rubbed over the part. As a rule, the itching and burning are relieved at once, and the affection often arrested. Good results follow the use of a saturated solution of acidum bora- cicum . There are cases which do better from the application of ointments, of which the following is valuable : — ]& . Zinci oleat., Olei olivae, aa giv. M. Or, bismuth oleate , made according to the following formula of Dr. McCall Anderson : — R . Bismuthi oxidi, Acidi oleici, . Cerae albae, . . Vaselini, T . . Ol. rosae, . . . IL 3 u j 3 * x rr^ij. M. DISEASES OF THE SKIN. 491 If the discharge be excessive, the following formula of Prof. Bar- tholow I have seen useful : — R . Plumbi acetat., ^ ss Pulv. camphorae, gr. xv Ol. amygdal., f ^ ij Cerat. flav., ^j. M. The late Dr. Frank Maury was partial to the following formula in vesicular eczema : — R . Hydrargyri chlor. mitjs, gr. xx Ung. zinci oxid. benz., . . . ^j. M. For eczema papulosum the following lotions are particularly valuable : — R . Acid, carbolici, Glycerini, . . Alcoholis, . . Aquae destil., . Or — R . Thymol, Alcoholis, . Aquae destil., 3H f 3 iv f 3 iv ~ v j ad .... Oj. — Duhring. gr. x-xx fZi M. M. After the disappearance of the more acute symptoms, more stimu- lating applications are indicated, among which are acidum carboli- cum , thymol , pix liquida , or oleum cadinum. It is to be remembered, however, that the more chronic the affection and the less the inflam- matory symptoms, the more successful is tar in the treatment of eczema. Dr. Duhring considers the following one of the most elegant of the tarry ointments : — R . Olei cadini, f % iss Cerati simplicis, %j 01. amygdal amar., gtt. x. M. Ft. ungt. Or— R. Picis liquidae, f^j Glycerini, fgj Alcoholis, . f.^vj 01. amygdal. amar., gtt. xv. M. Sig. — To be rubbed firmly into the skin. 492 PRACTICE OF MEDICINE. The following is Dr. Bulkley’s valuable “liquor picis alkalinus : ’’ — R . Picis liquidse, Potassse causticse, Aquse destillatse, O J ffi v. M. The potassa to be dissolved in water and gradually added to the tar with rubbing in a mortar. Sig. — T o be used diluted. A very elegant preparation of tar is the French mixture known as “ Goudron de Guyot.” For eczema rubrum, one of the most intractable varieties of the disease, especially the chronic eczema of the legs, the following mode of treatment, first suggested by Hebra, is the treatment par excellence. The accompanying instructions are to be adhered to. A lump of the sapo viridis (made originally of herring fat and potassa, and con- taining three per cent, of caustic potassa), the size of a small nut, is smeared upon a piece of wet flannel and applied to the affected part, and firmly rubbed until the soap has disappeared, when the flannel is to be dipped into warm water and again applied to the part and rubbed until an abundant lather forms, more water being added from time to time until the suds are most abundant, when the surface is thoroughly washed and freed from all the soap and carefully dried, after which the following (Hebra’s diachylon) ointment, having been spread before the application of the soap, is to be applied. It is pre- pared as follows : — “ Fifteen ounces of the best olive oil are added to two pounds of water, and heated to boiling in the water bath. Three ounces and six drachms of an equally good article of litharge (plumbi oxidum) are dusted over the fluid in ebullition, which is constantly stirred throughout, in order to prevent the formation of fatty acids. During the cooking, water is occasionally added as required. The stirring is to be continued until the ointment is quite cold.” The ointment is spread upon strips of soft muslin and the affected part enveloped, care being exercised that neither folds nor wrinkles occur, the whole being covered by a firm roller and the patient being able to go about as usual. The entire operation is to be repeated twice daily. A modification of the above ointment, technically known as “ un- DISEASES OF THE SKIN. 493 guentum diachyli albi of Hebraf has been successful in my hands in a number of cases. The formula is : — R . Emplast. plumbi, Vaseline, aa . 01. lavandulse, Dissolve with heat and stir till cold. Sig. — A pply on strips, etc. Prof. Da Costa has used with success in eczema rubra, liquor arsenici et hydrargyri iodidi , rr^i j — y , after meals, and — R . Ung. plumbi subacet., 3 iv Acid, carbolici cryst., gr. iij Ungt. petrolei, 3 iv. M. Sig. — A pply freely on muslin strips. An excellent formula in eczema of the vulva is : — R . Iodoformi, 3 ss Bal. peru., f^j Vaseline, gj. M. Sig. — A pply on soft cloths. Eczema capitis is either erythematous, vesicular, or pustular in character. If the first named, it at once tends to become chronic, settling into the variety known as eczema squamosum , often involving the entire scalp and accompanied with intense itching. The pustular variety is the more common form, occurring upon the scalp of chil- dren and young adults, existing as a few patches, or, what is more frequent, involving the entire scalp. The pustules soon rupture, the liquid drying into greenish-yellow crusts, which, if the affection be extensive, cover the whole scalp with a cap of crust. The hair be- comes matted and caked, the sebaceous secretions collect, and if the part be not cleansed the head becomes offensive. In severe cases of pustular eczema of the scalp, enlargement of the lymphatic glands of the back of the neck and of those behind the ear occur ; they never suppurate. Pediculi are frequently associated with eczema capitis of children, either as a primary cause or a result of the matted condition of the hair constituting a favorable habitat for them. When present they call for active treatment. Eczema capitis may be confounded with psoriasis, seborrhoea, syphilis, tinea favosa, and tinea tonsurans. Si q. s. M. 494 PRACTICE OF MEDICINE. Treatment. If the pustular variety, removal of the crusts is the first indication. This is accomplished by saturating the scalp either with oleum olivce or oleum amygdala dulcis , and then washing with warm water and soap, or the use of a starch poultice or a twenty-five per centum solution of boroglyceride ; after their removal the applica- tion of the following ointment, recommended by Prof. Da Costa : — R . Hydrargyri chlor. mitis., gr. xx. Acid, carbol. cryst., gr. iij. Ung. petrolei, ^j. M. Sig. — T horoughly applied. The late Prof. Ellerslie Wallace was fond of the following : — R . Sodii carb., gr. xxx. Ung. petrolei, ^j. M. Sig. — Apply thoroughly after removal of the crusts. I have usually been successful with cleanliness, proper dietary, the internal use of liquor arsenici et hydrargyri iodidi , truss— j , well diluted, after meals, and the local use of acidum boricum , or ung. zinci oxidi to which has been added a few drops of acidum car- bo licum. In cases associated with pediculi, I have succeeded with the follow- ing, after removal of the crusts : — R . Hydrargyri ammoniat gr. x-xx. Adeps benzoat., %). M. Sig. — Thoroughly applied. For the squamous variety of the scalp, the following formula, re- commended by Dr. Duhring, is excellent : — R. Picis liquidae, f^j. Glycerini, {’&). Alcoholis, f 3 vj. 01. amygdalae amar., gtt. xv. M. Sig. — Diluted or full strength, rubbed thoroughly into scalp. Eczema faciei. In this location the affection may be either acute or chronic. In adults the erythematous variety is frequently encoun- tered in patches about the forehead and cheeks. Eczema of the face is more common in children, however, the varieties being the vesicu- DISEASES OF THE SKIN. 495 lar and pustular. It is seen on the forehead, nose, and upper lip, and is associated with severe itching. Treatment. The same as eczema capitis, or the following : — R. Zinc oleat., . . Ung. petrolei, M. Eczema labiorum. Eczema attacks the lips, either alone or in con- nection with other parts of the face. One or both lips may be affected. The symptoms are : swelling, redness, heat, infiltration, slight scali- ness, and fissures. The affection may be in the skin around the border of the mouth, or the vermilion and mucous membrane of the lips. The mouth may be contracted and the lips partly glued together by the exudation and crusts. Eczema labiorum may be confounded with herpes labialis and syphilis. Treatinent. Very difficult and discomforting to the patient. Among the remedies at times successful are : argenti ?iitras , potassa nitras, acidumcarbolicum, pix liquida, oleum ergota , and collodium flexile. Eczema palpebrarum. A frequent occurrence in scrofulous chil- dren, showing itself along the edges of the eyelids. Pustules involve the hair follicles, followed by the usual crusting. The symptoms are ^welling, redness, and itching, and unless the parts are frequently cleansed, the lids tend to glue together. Conjunctivitis frequently complicates the affection. Treatment. In mild cases success follows the use of zinci oleat, or glyceritum acidi tannici. In severe cases the plan recommended by McCall Anderson should be pursued. It consists in the extraction of the eyelashes and touching the edges of the lids with a solution of potassa in water, ten grains to the ounce. The edges should be care- fully dried and the lid everted, a very small quantity on a delicate brush being applied, immediately neutralizing the alkali with acidum aceticum or vinegar. Eczema barbce. Eczema of the beard is characterized by the forma- tion of extensive pustules, with preference for about the hairs, drying as yellowish or greenish crusts, matting the hairs together and adher- ing to the parts. The affection may be confined to the hairy portions of the face, or extend to other regions of the face, be localized or general, acute or chronic. Eczema barbae in general features somewhat resembles both tinea 496 PRACTICE OF MEDICINE. sycosis and sycosis non-parasitica, but sycosis is an inflammation of the hair follicles only and is rarely associated with crusting, while crusting is abundant in eczema. Treatment. Must be energetic and decided. The crusts are to be removed by poultice or warm water and soap. Then the part is to be cautiously shaved ; although quite painful the first time, it is hardly so afterward, as it is to be repeated every two or three days. After shav- ing, if the attack be acute, the same plan of medication as recom- mended by Hebra for eczema rubrum is to be practised, the application to be continuous both day and night, or only at night. If the attack be chronic, the following ointment should be applied after cleansing and shaving the beard : — R. Hydrargyri ammoniat. gr. xv-xxx Sulphur, % ss-j Ung. petrolei, ^j. M. Sig. — T o be thoroughly applied. In this variety of eczema I have seen marked benefit from the use of liquor arsenici et hydrargyri iodidi, tt\,ij-v, three or four times daily. Eczema aurium. Eczema of the ears may be either erythematous, vesicular, or pustular. If the former, thickening results, with desqua- mation of flakes or large scales ; if either of the latter, crusts form, which may envelop the whole ear, the symptoms being swelling, red- ness, and severe burning and itching, and if the process extend into the meatus, occlusion may result, causing temporary deafness. The most characteristic symptoms of erythematous eczema of the external auditory canal, besides the appearance of small flakes, is intense and persistent itching. Treat?nent. For acute vesicular or pustular eczema, removal of the crusts and the use of hydrargyri chloridi ?nite as an ointment of the strength of thirty grains to the ounce. If chronic, the use of ftix liquida , as already suggested. For chronic erythematous eczema of the external auditory canal, the following formula has generally con- trolled this stubborn condition : — R . Hydrargyri flav. oxid., Morphinse sulph., . . Vaseline, Sig. — A pply to the canal. Eczema genitalium. This is a most distressing condition. In the male the scrotum and penis are involved alone or together, the former g r - J-»J g r - j 39 M. DISEASES OF THE SKIN. 497 alone being the more common, and is complicated with eczema of the inner side of the thigh or thighs. The symptoms of eczema of the scrotum are, swelling, often oedema as well, moisture, crusts, and painful fissures, followed by extensive thickening and accompanied by intense itching. In the female the affection attacks the labiae, and, rarely, the vagina and mons veneris, and may extend to the surround- ing parts, especially to the perineum. The symptoms of eczema of the labia are, great swelling, oedema, redness, with great heat and a free discharge, forming crusts, which are apt to glue the opposing surfaces together. If the variety be the erythematous, in place of a discharge with crusts, the symptoms named are followed by slight scales. The itching is most violent and distressing. Treatment. The parts attacked should be kept constantly envel- oped in cloths wet with a saturated solution of acidum boricum until the more pronounced inflammatory symptoms subside, when the acidum boricum may be used as a dusting powder, completely en- veloping the parts. Mild solutions of menthol are valuable. Tinct- ura myrrh , well diluted, is an excellent application. Ointments of zinci oleat. or hydrargyri chloridum mite are sometimes valuable. Persistent cases will often succumb to the plan of treatment sug- gested by Hebra for eczema rubrum. Eczema ani. The anus may be attacked alone or associated with eczema of the perineum and genitalia. The symptoms are : redness, swelling, infiltration and thickening, with or without fluid exudation. Fissures of the anus are usually present, and add to the distress of the patient, severe pain attending each stool. Persistent itching and burning, worse after retiring, adds to the misery of the patient. Pruritus ani may be mistaken for eczema ani. In the former the itching is only associated with such symptoms of inflammation as result from the irritation of scratching, while in the latter inflammatory symptoms precede the itching. Treatment. The more acute symptoms are relieved by bathing the parts with a solution of acidum boricum , after which a weak applica- tion of acidum carbolicum , either as a lotion or ointment. The late Prof. S. D. Gross recommended the application of the following : — R . Zinci oxidi, 3 vj Hydrargyri chlor. corrosiv., gr'. j Glycerini, f 3 ij. SlG. — Apply thoroughly to affected parts. M. 498 PRACTICE OF MEDICINE. Eczema intertrigo. Parts of the body that naturally come into con- tact with each other, as about the joints, the inner surfaces of the nates, in the groins and beneath the mammae, are frequently attacked with erythematous eczema, which is frequently, but erroneously, termed erythema intertrigo or chafing. The symptoms are : redness, heat, and a moist, macerated surface, aggravated by movement of the affected parts. Treatment. The application of a solution of acidum boricum , or the use of dusting powders, such as zinci oleat., amylum , or hydrar- gyri chloridum mite. It is essential for successful treatment that the opposing surfaces be separated by means of lint or cloths. Eczema mammarum. The nipples, and more particularly those of primiparae, are at times the seat of a vesicular eczema, with the for- mation of crusts and fissures, and unless speedily relieved develops eczema rubrum. The pain on nursing becomes so severe that the mother is compelled to refuse the child. It must be borne in mind that eczema mammarum occurs in women who are not nursing and in single women. Treatment. Dr. Tilbury Fox advises the following plan : — “ i. Great cleanliness and care in washing away any remnants of milk after each time that the child is put to the breast ; and, if the nipple be tender and excoriated, use — “ 2. A little liquor plumbi and calamine powder, as follows : — Liq. plumbi, Pulv. calaminae praep., . . Glycerini, • • fkj Adipis, • • 3J- “ 3. I cover over the nipple with a lead nipple shield. This ex- cludes the air, keeps the part from being chafed, and I think the lead does good after the part has become less red and sore. I often use a little glyceritum acidi tannici , painted on night and morning. “ The above application can always be removed with a little cold cream and a little warm water sponging before the child goes to the breast.” Eczema palmarum et plantarum. The features of the affection in both these regions are identical. The diagnosis is often obscured by the thickened state of the epidermis. The symptoms are : infiltration, thickening, callosity, moisture followed by dryness, and Assuring, the DISEASES OF THE SKIN. 499 last named frequently becoming so deep and painful that the patient is unable to use his hands, or, if on the soles, to walk. The affection is always chronic, affecting either of the parts alone, or all at one and the same time. Itching is a constant and annoying symptom. The diagnosis is to be made between eczema of these parts and psoriasis or syphilis. Treatment. The plan of Hebra for eczema rubrum will usually be successful for this variety. The following formula is also valuable : — R. Hydrargyri oleat. 5-15 per cent., 3 iv Olei cadini, 3 ss Cerat simp., ^ iv. M. SiG. — Rub well into part morning and night, first macerating with hot water. Eczema unguium. The nails are seldom attacked alone, but in connection with eczema manuum. The symptoms are roughness, want of polish, unevenness, and a punctate or honeycomb appearance similar to that seen in psoriasis of the nails. The nail becomes de- pressed, particularly at its root, thus interfering with its nutrition, resulting in loss of this appendage. Treatment. Internally, arsenicum is of the greatest value. Locally, the following : — R . Ung. picis liq., 3 iv Hydrargyri chlor. mitis, gss Vaselini, 3 iv. M. SiG. — Apply thoroughly. It is a remarkable clinical fact, that very many cases of eczema, whether acute, subacute, or chronic, are rapidly cured by the use of potassii iodidum in variable doses. URTICARIA. Synonyms. Hives ; nettle-rash. Definition. An inflammation of the skin characterized by the development of wheals of a whitish, pinkish, or reddish color, accom- panied by stinging, pricking, and tingling sensations. Causes. Very frequently the result of sudden surface hyperaemia, or rather too rapid circulation through the superficial capillaries, the 500 PRACTICE OF MEDICINE. result of exposure to heat. Irritants and poison produce an attack when brought in contact with the skin. Gastric, intestinal, hepatic, nephritic, ovarian, uterine, and bladder derangements are very fre- quent causes. Certain medicaments ; malaria ; nervous disorders ; associated with purpura and rheumatism ; pregnancy ; lactation ; menopause. Pathology. An acute inflammation of the papillary layer of the skin, characterized by the rapid development of a “ wheal ” — a more or less firm elevation — consisting of a circumscribed collection of a semi-fluid material, the result of a rapid exudation into the upper layers of the skin. The production of the wheal is the immediate result of a disturbance of the vasomotor system, which is shown by the interference of the circulation in the wheal, the blood being driven from its center to its periphery, causing the whitish apex and red areola, so characteristic of the developed wheal. Symptoms. An attack of “ hives ” is characterized by the sud- den development of wheals upon the cutaneous surface, which usually as suddenly disappear, their site being temporarily marked by a spot of redness or hyperaemia. With the appearance of the wheal occur distressing itching , burn- ing , tingling , crawling , pricking , and stinging sensations , to relieve which the patient still further irritates, tears, or otherwise wounds the surface by scratching, whence are often developed deep-colored, flat, lenticular papules. Very frequently an attack of “ hives ” is associated with fever , headache , and gastric disorder. The “wheals” may appear upon any portion of the body ; their size varies from that of a pea to that of a walnut or an egg — the “ giant wheals the number varying from a very few to being so numerous as to cover the whole surface of the body. The shape, size, color, and number of the wheals that may occur in any given case have given rise to a number of names to designate the lesions. Thus, urticaria annularis occurs in rings ; urticaria figurata occurs in spirals ; urticaria vesiculosa has a vesic- ular development on the summit of the wheal ; urticaria bullosa , a bullous development at the summit; urticaria papulosa, or lichen urticatus , the wheal and a small papule are combined ; urticaria tuberosa , or giant wheals ; urticaria hemorrhagica , or purpurata urticaria , a combination of urticaria and purpura ; urticaria evanida , a rapid appearance and disappearance of the lesion ; urticaria per- DISEASES OF THE SKIN. 501 stans, slow disappearance ; urticaria conferta , when the wheals are confluent ; urticaria pigmentosa, where the wheals are succeeded by pigmentations of the site, the tints varying from dark brown, green- ish yellow, to a chocolate color ; urticaria febrilis, when the wheals are associated with fever ; urticaria ab ingestis, when associated with indigestion. Treatment. To prevent the recurrence of the disorder, a thor- ough investigation of the cause must be made, and when found (not always possible) be removed. Attention should be directed to the state of the general health, the diet, and the secretions. The following remedies, alone or variously combined, are often of benefit : quinina , pilocarpus, atropina, tinciura belladonnce, ammonii chloridum, arsenicum, and potassii bromidum. Sodii salicylas, gr. iij-v every two or three hours, often acts like a specific, followed by a thorough purgative. The following pill is valuable in many cases : — R . Pulv. pilocarpi, Ext. guiaci, aa gr. iss Lithii benzoat., gr. iij. M. SiG. — Two to four each twenty-four hours. If there be atonic dyspepsia and constipation, the following com- bination is useful : — R. Magnesii sulphat., Jj Ferri sulphat., gr. xvj Sodii chloridi, ^ss Acidi sulphurici dil., . . . • . f^ij Infus. cascarillae, f ^ iv. M. Sig. — T ablespoonful before breakfast, diluted. Local measures are of the greatest value, either as baths, lotions, or dusting powders. The following are among the most serviceable : sponging with alcohol, brandy , whiskey , vinegar and water, salt water, alkaline baths, and acid baths. Duhring recommends the fol- lowing : — R . Acidi carbolici, g iss Glycerini, f ^ ij Alcoholis, {\ viij Aq. amygdal. amar., f ^ viij. M. Sig. — Use as a lotion, two or three times daily. 502 PRACTICE OF MEDICINE. Bulkley suggests the following : — R . Chloralis, Camphorse, aa . . . . f^j Misce, and rub and incorporate with Pulveris amyli, Sjj-ij. Misce, and keep tightly corked in a wide-mouthed bottle. SiG. — Rub in with hand. A serviceable formula is the following : — R. Chloroformi, fzj Ung. zinci oxid., ^ij. M. SiG. — Apply with hand. HERPES. Definition. An acute inflammation of the skin, characterized by the development of one or more groups of vesicles , filled with a clear serum, occurring for the most part about the face ( herpes facialis') and genitalia ( herpes progenitalis ). Causes. Herpes facialis ; during the course of febrile and nervous disorders ; in connection with digestive disorders and colds. Herpes progenitalis ; the origin is local, from uncleanliness or friction. Pathology. Hebra defines the various forms of herpes as “ a series of acute cutaneous diseases of cyclical course, marked by an exudation which collects in drops under the epidermis and elevates it; forming vesicles which are never solitary, but always appear in groups. Symptoms. The appearance of the vesicles is usually preceded by a feeling of heat in the region, together with slight tumefaction or swelling. Rarely the herpetic attack is attended with malaise and pyrexia. The eruption usually appears in the form of a small cluster of pin- head to split-pea-sized vesicles, containing a clear fluid, becoming cloudy, afterward puriform, and dries in small, yellowish or brownish crusts ; they are few in number and may coalesce. They disappear without leaving a scar. Herpes facialis ; occur upon any portion of the face, but most fre- quently about the lips — herpes labialis. The alae of the nose, auricles and the mucous membranes of the mouth and tongue are frequent DISEASES OF THE SKIN. 503 locations, in the latter appearing as excoriated patches from rupture of the vesicles. Herpes progenitalis ; in the male the chief site is the prepuce ( herpes prceputialis'). In the female they are comparatively rare ; but when occurring it is upon the labia majora and minora and the skin about the vulva. This variety is preceded by burning, itching, or neuralgic pains, accompanied with redness, congestion, and more or less oedema. The lesion in these parts is likely to be mistaken for one form or other of venereal disease. Herpes gesiationis ; a rare affection of the skin occurring during pregnancy, consisting of erythema, papules, vesicles, and bullae, at- tended with intense burning and itching. It may appear at any time of pregnancy up to the seventh month, and continues until some time after delivery. Treatment. Herpes facialis seldom calls for treatment, although in marked cases of herpes labialis protection with liquor gutta-percha or collodium flexile promotes desiccation. Herpes progenitalis ; cleanliness is of the first importance. Coat- ing the eruption with the medicaments mentioned above or washing with a saturated solution of acidum boricum , and afterward dusting with hydrargyri chloridum mite , are useful. The parts may be rendered less sensitive in frequently recurring cases by astringent lotions, as acidum tannicum or zinci sulphas. Circumcision, where required, may be practised. HERPES ZOSTER. Synonyms. Zona ; shingles ; a girdle ; intercostal neuralgia. Definition. An acute, inflammatory disease ; characterized by the development of groups of firm and distended vesicles situated upon inflamed bases corresponding to a definite nerve trunk, and accompanied by more or less severe neuralgic pains. Causes. The eruption and consequent neuralgic pains are the immediate result of an inflammation of the ganglia or of the nerve trunks and branches — a neuritis — probably of the trophic fibres of the affected part ; but the cause producing this condition is obscure. Among the many that have been suggested are : cold, injuries to nerves, anaemia, and the medicinal use of arsenicum. 504 PRACTICE OF MEDICINE. Pathology. An inflammation of either the ganglia, the nerve trunk or branches — probably the trophic system — causing the de- velopment of vesicles in the lower strata of the rete, with “ the infiltration of serum and inflammatory cells” of the papillae and corium. Symptoms. Begins with neuralgic pains , either of the burning or lightning-like character, with slight febrile phenomena, followed by the appearance of papulo-ve sides along the tract of pain ; these soon become vesicles situated on bright red, highly-inflamed bases. The vesicles are about the size of pin-heads, or perhaps a little larger, usually discrete, although they frequently coalesce, forming irregular patches, coming in groups until the third to the fifth or even tenth day, when they gradually desiccate, and at the end of the second week nothing remains but a slight scar, which may also disappear after a time or, rarely, is permanent. When the eruption is at its height it is perfect in its anatomical formation, each vesicle being well-shaped and seated on a bright red, inflamed patch of skin, and distended with a translucent, yellowish fluid. The eruption is almost invariably confined to one side (unilateral) of the body, although, in rare instances, it is seen upon both (bi- lateral) sides. It is usually found upon well-known nerve tracts. According to the region affected it is termed zoster capitis , zoster frontalis , zoster faciei , zoster ophthalmicus , zoster auricularis , zoster nuchce , zoster brachialis , zoster pectoralis , zoster abdominalis, zoster fe7noralis. In the very young the eruption may develop and pursue its course without the neuralgic pains. Diagnosis. The characteristics of herpes zoster or shingles are usually so well marked that an error in diagnosis should not occur. The neuralgic pain preceding the eruption and its development in distinct groups upon inflamed bases following a nerve tract are so different from the simple herpes of the face, or genitalia, or from the lesion of eczema. Prognosis. Favorable. The affection is self-limited, the dura- tion being about two weeks. It is said that “ zoster of the orbital region may seriously involve the eye and prove fatal.” Treatment. The affection being self-limited, it follows that reme- DISEASES OF THE SKIN. 505 dies to cut it short are useless. The following combination diminishes the pain and modifies the duration : — R . Zinci phosphidi, Ex. nucisvom., aa gr. x. M. et ft. pil. No. xxx. Sig. — O ne every two to four hours. (Bulkley.) Prof. Bartholow “has seen excellent results in cases of shingles from galvanization of the affected intercostal nerves — the positive pole being placed over the point of emergence of the nerves, and the negative brushed over the terminal filaments in the skin.” The general symptoms are to be treated as indicated. Anaemia or depression are benefited by full doses ferri et quinince citras. For the pain no remedy seems comparable with the hypodermic use of morphince sulph ., gr. yi-yi, with atropince sulph ., gr. near the lesion. Antipyrme , gr. xv, repeated every three or four hours, or phenacetin , gr. v, every three or four hours, relieves the pain in many cases. Locally , relief follows coating the “ shingles ” with either collodium flexile or liquor gutta-perchce , to which morphince sulphas may be added. Aristol dusted over the parts, or acidum boricum y as a pow- der, or combined with lanolin , are useful. MILIARIA. Synonyms. Lichen tropicus ; miliaria rubra ; miliaria alba ; prickly heat. Definition. An acute inflammation of the sweat glands ; char- acterized by the development of discrete, whitish or reddish, pin-point and millet-seed-sized papules, vesicles, or vesiculo-papules, productive of pricking, tingling, and burning sensations of a most aggravated character. Causes. Excessive heat, the result of excessive or tightly-fitting clothing, or a high external temperature. Most common in fleshy adults who perspire freely, and in children. Nervous prostration ; severe dyspepsia and general debility seem to predispose to “prickly heat.’ ’ Varieties. Miliaria papulosa ; miliaria vesiculosa. Pathology. The pathology of the two varieties is the same, both 42 506 PRACTICE OF MEDICINE. being inflammatory affections of the sweat glands; in the one papules, and in the other vesicles develop about the orifices of the excretory ducts. In either variety there occurs hypersemia of the vascular plexus of the sweat gland, followed by slight exudation about the ducts, giving rise to the minute papule or vesicle, which remain until the cause has been modified or removed, when they are rapidly absorbed. Symptoms. Miliaria papulosa ; known as lichen tropicus and “ prickly heat,” is of sudden onset, with the occurrence of numerous minute, acuminated bright red papules , about the size of a pin head or millet-seed, and but slightly raised above the level of the skin. The papules are preceded by and accompanied with sweating (hyperi- drosis), and distressing tingling , pricking , and burning sensations. If the attack be severe, vesico-papules and vesicles are freely inter- spersed among the numerous papules. Rarely the secretion of sweat is notably diminished. Miliaria vesiculosa ; in this variety, instead of papules, immense numbers of vesicles develop, of the size of pin points and pin heads, of a whitish ( miliaria alba) or yellowish-white color. The surface from which they arise is of a bright-red color, owing to each vesicle being surrounded by an areola ( miliaria rubra). The vesicles are preceded and accompanied with sweating (hyperidrosis) and most distressing , tingling , pricking , and burning sensations. Either variety may attack all parts of the body, but the abdomen, chest, back, neck, and arms are the regions usually invaded. Duration. This varies with the cause. It may appear, fully de- velop, and disappear in a few hours. In those predisposed, it may continue more or less marked throughout the entire summer. Diagnosis. If the cause, nature, and seat of the affection are taken into consideration, no error should occur. Eczema papulosum has a resemblance to “ prickly heat,” but the course of eczema is slow, and the papules are larger, more elevated, and firmer than those of miliaria papulosa. Eczema vesiculosum and miliaria vesiculosa are to be differentiated by the marked differences in the progress of each, the former slow, the latter rapid, the vesicles of the former rupturing spontaneously, those of the latter only when severely irritated. Sudamen is not an inflammatory affection, while miliaria is. Prognosis. The affection is often most rebellious in fleshy per- DISEASES OF THE SKIN. 507 sons and children, and 'if neglected it passes into eczema or an erythematous intertrigo. Treatment. The patient should be kept as cool as possible, and avoid undue perspiration. The fears entertained by the laity, of danger from retrocession of the eruption, are groundless ; the sooner it disappears the better for the comfort of the patient. The food should be light and unstimulating, dispensing with meats and condiments for a few days ; wine, spirits, and beer are to be avoided. The ingestion of water, lemonade, Apollinaris water, Vichy water, together with refrigerant diuretics, as potassii citras vel acetas, a cool apartment, and absolute rest will ordinarily insure speedy relief. Saline cathartics are invaluable. Locally : sponging with alkaline lotions, liquor plumbi subacetatis dilutus , extractum grindelice fluidum well diluted, or cupri sulphas , in solution (gr. x, aquce , f^j), or acidi carbolici , gr. xx, glyceriti amyli , ^iij, or a dusting powder, consisting of lycopodium , zinci oxidum, and amylum , singly or combined. PEMPHIGUS. Synonym. Water blisters. Definition. An inflammatory disease of the skin, either acute or chronic, characterized by the development of a succession of rounded, irregular-shaped blebs or bullae, varying in size from a pea to an egg. Varieties. Pemphigus vulgaris ; pemphigus foliaceus. Causes. Obscure. It is usually associated with a depressed state of the general, system ; disorders of menstruation ; during preg- nancy. Pathology. Hebra thus describes the appearance of the blebs : “ Sometimes a circumscribed, light-red spot appears, perhaps of the size of a bean or a large coin ; this is paler in the centre, and may even present a tinge of white, indicating the point at which the bleb is to form, and from which it will spread outward over the surrounding skin, and, in fact, is at first a wheal, passing afterward into a bleb. In other cases the bleb is not preceded either by a red spot or by a wheal, but begins originally as a small collection of clear fluid beneath the cuticle. Thus, hyperaemia of the skin may exist before exudation 508 PRACTICE OF MEDICINE. is poured out, or the latter may be formed before any congestion of the papillary layer is discoverable.” The contents of the blebs or bullae are yellowish or colorless serum, of a neutral or alkaline reaction, the older the fluid the more alkaline it becomes. In the late stages of a bleb the fluid becomes puriform. In rare instances blood is contained in the bleb ( pemphigus hemor- rhagicus). Symptoms. Pemphigus vulgaris ; the onset is slow ( pemphigus chronicus ), without constitutional symptoms, or acute ( pemphigus acutus) preceded by febrile reaction. The lesions are the successive development of blebs, usually from half a dozen to a dozen, varying in size from a pea to an egg, of a round or oval shape, their walls distended with a colorless fluid, the color becoming yellowish or puri- form as they grow older. They develop abruptly from the sound skin, with a definite line of demarcation, unattended with symptoms of inflammation. A characteristic phenomena of the lesion is their successive appearance ; a crop no sooner disappears than another forms, throughout the course of the affection, each crop running its course in from three to six or ten days. With the appearance of the blebs occur itchmg and burning, usually of a mild character, although occasionally in a distressing degree {pemphigus pruriginosus). Pemphigus malignus is characterized by the great size and number of the blebs, which coalesce, rupture and are succeeded by excoriated surfaces which occasionally take on ulcerative action, the patient’s health being seriously impaired. Pemphigus foliaceus differs from pemphigus vulgaris in that the blebs, instead of being distended or tense, are flaccid and only par- tially filled with fluid, as they rupture before arriving at their state of full development. This variety also appears and disappears in crops. After rupture the fluid immediately dries into thin whitish flakes, which are detached in quantity, leaving a red, excoriated surface — the rete and corium. If the affection has continued for some time, the skin presents the appearance of a superficial scald. The course of this variety is essentially chronic. All portions of the body are liable to the lesion, as also the mucous membrane of the mouth and vagina. It is most common, however, upon the limbs. Diagnosis. In a typical case no difficulty should be experienced in making a diagnosis. The mere presence of blebs, however, does DISEASES OF THE SKIN. 509 not necessarily constitute pemphigus, for it must be remembered that they are at times developed in other diseases as well as by artificial means ; the appearance of blebs in crops is a strong diagnostic point. Prognosis. The course of the affection is most uncertain, and relapses are frequent. In arriving at an opinion, the occurrence of fatal cases must not be forgotten. Treatment. Attention to the general health of the patient is of the greatest moment. A careful study of the cause should be made, and if determined, means for its removal are of the first importance. Two remedies, arsenicum and quinina , are of great value, the secret of success being the persistent use of the former ; or if the latter be used, the dose should be large. Local measures are also of importance. The blebs should be punctured and evacuated as soon as formed. The use of dusting powders of acidum boricum , zincii oxidum , amylum , or violet-powder , or lotions of liquor plumbi subacetatis dilutum , are valuable Hebra recommends the continuous bath. IMPETIGO. Definition. An acute inflammatory disease, characterized by the development of one or more discrete, rounded, and elevated, firm pustules , about the size of a pea, unattended with itching. Causes. Occurs for the most part between the ages of three and ten years, in the well-nourished and healthy. It is not associated with eczema. It is not contagious. Pathology. The lesion is a well-formed, typical pustule , develop- ing abruptly from the surface, containing a whitish-yellow fluid, pus corpuscles, blood corpuscles, epithelial cells, and cellular detritis. The abscess or pustule is about the size of a pea, circumscribed, and superficial. Synonyms. The affection manifests itself by the development of from one or two to a dozen or more distinct pustules, about the size of a split pea, of a rounded shape, raised above the surface, with thick walls, of a yellowish or whitish color, surrounded by a distinct areola, which, soon fades, are without a central depression or umbilication, and unattended with either itching or burning. The affection runs an acute course, usually lasting a couple of weeks. The pustules, after attaining their full size, remain stationary 510 PRACTICE OF MEDICINE. for a few days, when they disappear by absorption and desiccation, the crusts dropping off, displaying a reddish base, which soon disap- pears with pigmentation or scar. The pustules occur on all portions of the body, the most frequent locations being the face, hands, fingers, feet, toes, and lower extremi- ties. Diagnosis. Impetigo is unassociated with general symptoms, and its particular lesion — the pustule — is discrete, points of import- ance in the diagnosis. Eczema pustulosum is also a pustular affection, but the large num- ber, their disposition to coalesce, their location upon an inflammatory base, their rupture and subsequent crusting and itching, are diag- nostic points. The diagnostic points from ecthyma will be pointed out when describing that affection. Prognosis. Favorable. Treatment. The pustules should be opened as soon as they mature, the contents removed by washing with tepid water and soap, and the floor covered with hydrargyri chloridum mite or zinci oleat. Coating the pustules with collodium flexile , or liquor gutta-percha, if they are located where irritation be liable, is a valuable mode of treatment. ECTHYMA. Definition. An affection of the skin, characterized by the forma- tion of one or more large, isolated, flat pustules , situated upon an inflammatory base. Causes. It is most common among those who live in squalor and poverty, and in delicate and poorly-nourished children. Improper and insufficient diet, want of ventilation, excessive work, and un- cleanliness are all prominent causes. Pathology. The lesion is a typical pustular process, severe but superficial, and not extending beyond the papillary layer of the corium. The pustule is situated upon a firm and highly-inflamed base ; the number varies from one to a dozen or more. Symptoms. The disease is characterized by the development of one or more round or oval, yet flat , pustules , about the size of a pea- bean, attended with moderate heat , burning , and pain , and if the number be large, slight febrile reaction. The pustules are first DISEASES OF THE SKIN. 511 yellowish in color , surrounded by a firm and sensitive bright-red areola , the pustule afterward becoming reddish from the admixture of blood, soon drying into flat crusts of a brownish color. The dura- tion of each pustule is between two and three weeks, new ones form- ing, until the cause is removed. The most prominent sites are the thighs, legs, shoulders, and back. Diagnosis. Ecthyma and eczema pustulosum have points of resemblance, but a study of the clinical history of the latter should prevent error. Impetigo differs from ecthyma in the size of the pustule and crust. Ecthyma differs from a boil in not having a central core. Prognosis. With care and the removal of the cause, recovery is always prompt. Treatment. The general treatment of the patient is of the first importance. Nutritious and wholesome food, cleanliness, bathing, fresh air, and regulated exercise should be advised, together with such tonics as ferritin , arsenicum , quinina , strychnin a, and mineral acids. Locally : remove the crusts by first soaking with oil or fat, or water dressings, and apply — & . Ungt. zinci oxid. benz., % ss V aselini, J ss Hydrargyri ammoniati, ^j. M. Ft. ungt. — Duhring. Pustules showing a sluggish disposition to heal should be stimulated by touching with either argenti nitras , or acidum carbolicum. FURUNCULUS. Synonyms. Furunculosis; furuncle ; boil. Definition. An acute affection of the skin, characterized by the occurrence of one or more circumscribed cutaneous or subcutaneous abscesses (boils), which usually terminate by necrosis of the central tissue, its subsequent expulsion in the form of pus or a core, and a resulting cicatrix. Causes. The result of a depraved condition of the system, induced by general debility, excessive fatigue, nervous depression, improper food and exercise, anaemia, diabetes, uraemia, or the result of local friction, pressure, or contusions. Pathology. The process resulting in a “boil” has its origin in 512 PRACTICE OF MEDICINE. either a sebaceous gland, a sweat gland, or a piliary follicle, and never begins in the meshes of the corium. “ It begins as a small, roundish spot, which increases in size until certain dimensions are attained, when it undergoes suppurative change, resulting in the formation of a central point or core, composed of the tissue of the gland in which the furuncle originated, which, together with the pus, is cast off. It shows no disposition to become diffuse, being always a circumscribed in- flammation. After the discharge of the core, a cavity of more or less depth remains, showing the tissues around it to be hard and infiltrated. After a few days or a week it fills up by granulation, leaving a cicatrix, which is often permanent. The central point or core, when thrown off, is composed of a whitish, tough, pultaceous mass of dead tissue, varying in size with the extent and depth of the inflammation.” (Duhring.) Hydro-adenitis , as seen in the axillae, around the nipples, and about the anus or perineum, differs from the ordinary “boil” merely in being deeper seated. Symptoms. “ Boils ” may occur singly, or more commonly in crops of two, three, or more, another crop following their disappear- ance ( furunculosis ). The abscess begins as a small, rounded, imperfectly defined, iso- lated, reddish spot , of a highly inflamed character , painful on pres- sure , its size gradually increasing, its central point presenting evidences of suppuration. It reaches its full development in about a week, when it consists of a slightly raised, rounded, and pointed inflammatory swelling with a yellowish point in the centre — the “ core.” Abscesses with no central suppuration or core are called “ blind boils.” The size of a developed boil varies from a split pea to a walnut, the color deep red, with a yellow centre, and is surrounded by a slight areola. The pain of a boil is dull and throbbing, painful on pressure, and is usually worse at night. The constitutional symptoms are mild or severe, according to the number and size of the lesions. Any portion of the body may be attacked ; its preference, however, is for the face, neck, back, axillae, nipples, buttocks, anus, perineum, and labiae. Diagnosis. The characteristics of furuncle are so marked that an error seems impossible. It may be, however, mistaken for car- buncle, the differences between which will be pointed out when dis- cussing that affection. DISEASES OF THE SKIN. 513 Prognosis. No danger results from occasional boils, but when occurring in crops they impair the general health and are rebellious to treatment. Treatment. The treatment of a single boil is well expressed in the word “time.” Warm applications are said to hasten the stage of suppuration, and when reached an incision permits the expulsion of the “ core,” after which the cure soon follows. If the lesion is located where friction or pressure is likely, protection by either covering with adhesive or soap -plaster, smoothly spread, is ample. When, however, successive crops of boils occur ( furunculosis ), the treatment should be both constitutional and local. The general health being below par, such tonics as arsenicum , quinina , and ferrum , are of value. Calcii sulphid ., gr. |, every two or three hours, is valuable in these cases. Locally , attempts to abort the process may well claim attention, among which are : crucial incisions, to relieve the tension of the cen- tral point, will often abate the inflammation and prevent the gangrene ; this little operation is rendered painless by the use of the ether spray. Acidurn carbolicum , used in five per cent, solution, of which two to five drops injected into the apex of the boil, is valuable. Painting the forming boil with argenti nitras, or tinctura iodi, are also recom- mended ; a paste made by adding together equal parts of glycerinum, and extractum belladonna, will often abort a boil ; the same is also claimed for unguentum hydrargyri nitratis. CARBUNCULUS. Synonyms. Carbuncle; anthrax. Definition. An indurated, more or less circumscribed, dark red, painful, deep-seated inflammation of the skin and subcutaneous con- nective tissue, terminating in a slough and the subsequent production of a permanent cicatrix. Causes. Not positively determined. A deep-seated bruise is a supposed caus^ Perhaps, as in furuncle, impairment of the general health is the important factor. It is generally noted to occur in middle life and old age, and in men more frequently than in women. A “specific ” cause for anthrax is not an improbable discovery. Pathology. Although Billroth regards furuncle and carbuncle as differing only in degree, the explanation of Warren, of Boston, 43 514 PRACTICE OF MEDICINE. seems the more probable, he being the first to call the attention of histologists “ to the existence of small columns of adipose tissue lead- ing from the panniculus adiposus up to the roots of the lanugo hairs, taking an oblique direction in a line with theerectores pilorum. The inflammation resulting in suppuration of the subcutaneous adipose tissue must either form an abscess or become diffuse. In phlegmo- nous erysipelas the latter condition is observed. But when the inflam- mation is in the dermoid texture, the exudates infiltrate the skin and naturally follow the canals occupied by the ‘ columnse adiposae.’ The pressure thus exerted upon the whole dermoid tissue cannot fail to strangulate the circulation, and thus produce gangrene of the tissue, even if the exudate be not poisonous enough to destroy the cell by its presence. It can, by this explanation, be easily understood why this disease is apt to affect the skin on the nape of the neck and the back more than on other parts of the body. At this point the skin is dense, its fibrous element extending deep into the adipose layer, which is surrounded with strong bands ; hence, the pus confined in such a place, seeking the easiest outlet, will travel along these minia- ture adipose canals, producing the peculiar appearance pathognomo- nic of carbuncle.” Symptoms. Carbuncle is recognized by its peculiar form ; com- mencing in the lower layers of the cutaneous tissue, it first resembles somewhat a phlegmon minus its bright redness. At first it is some- what rounded, with a strong tendency to the production of vesicles on its surface, soon, however, becoming firm, circular, and flat, and raised above the surrounding parts, spreading through the subcuta- neous tissue and skin, becoming at times enormously large, and hav- ing a dark red or violaceous color. As the disease progresses, the pressure results in the softening of the tissues, the skin becoming gangrenous, breaking down at numerous points, forming perforations, through which centres of suppuration appear in different stages of advancement, either as whitish, fibrous plugs, or as cavities, from which a yellowish, sanious fluid oozes, the surface of the anthrax having a cribriform appearance, perforated like a si^e. The entire mass terminates in a slough, which, on being detached, leaves a large, open, deep ulcer, with firm, everted edges, granulating slowly, a per- manent cicatrix marking the site of the lesion. The development of the carbuncle is attended with severe pain , of a deep , throbbing , and burning character . DISEASES OF THE SKIN. 515 The constitutional symptoms vary with the size, number, and severity of the disease ; loss of appetite, coated tongue, general malaise, and moderate febrile reaction accompanies all cases, to which are added those of septicaemia in severe cases. The duration is from two to six weeks. Its favorite site is the back of the neck, shoulders, back, and buttocks. It is usually single. Diagnosis. The disease is distinguished from furuncle by its great size, its flat form, its course, the multiple points of suppuration, and the character of the slough. Also by the pain ; in furuncle, sen- sitive and painful to the touch, carbuncle not being particularly sensitive. Furuncles generally occur in numbers or in crops ; car- buncle is almost always single. Prognosis. A guarded opinion should always be given, as death is not infrequent from anthrax, especially in elderly people with impaired health. The mortality, however, is not so great as the laity suppose. A great danger is septicaemia, from the action of the poison on the blood, or the result of secondary abscesses. Treatment. Constitutional and local measures are both of the greatest value. Nutritious diet, stimulants, and full doses of such remedies as tinctura ferri chloridi , quinines sulphas , arsenicum , and ammonii carbonas are beneficial. Good results are reported from calcii sulphid. y gr. yi every two hours. Locally ; the crucial incision, so generally practised in former years, is seldom performed now, the frequent occurrence of hemor- rhages being too debilitating. The following are valuable plans : — Caustic potash , applied to the carbuncle before an opening occurs, until an eschar is fully formed ; or, making several small punctures with a scalpel and inserting a small piece of caustic potash well into the diseased tissue ; or, if openings have already occurred, insertion of the caustic stick into them, allowing it to remain until melted. By either of these methods I have seen the slough cast off more readily than in cases where the crucial incision was made or in those left to nature. Another method is, “ a saturated solution of pure acidum carbolicum is injected through the several apertures in every direction into the sloughing tissues, by the aid of an hypodermic syringe. The pain is severe but short-lived.” Prof. Agnew recommends painting collodium cum cantharide , around the anthrax, in the form of a broad zone, the effect of the 516 PRACTICE OF MEDICINE. blister being to relieve the tension. Tinctui a iodi , is also used for a similar purpose. Hebra advocates cloths wrung out in ice water, or ice bags, in the early stage, changing to warm fomentations as soon as suppuration has begun. Dr. Ashhurst has practised with success the use of pressure by means of adhesive plaster applied in much the same manner as for swelled testicle. Success ojten follows the application of unguentum hydrargyri nitratis , spread at least one- eighth of an inch thick and covered with adhesive plaster, changing every twenty-four hours. The resulting ulcer, after expulsion of the slough, is to be treated on general principles. ACNE. Synonyms. Acne vulgaris; acne disseminata; varus; stone- pock. Definition. An inflammation, usually chronic, of the sebaceous glands ; characterized by the development of papules, tubercles or pustules, or by a combination of such lesions, usually in various stages of formation, occurring for the most part upon the face. Varieties. Acne papulosa ; acne pustulosa ; acne artificialis. Causes. Not always understood, as the affection is frequently associated with apparently the most robust health. A frequent cause is puberty. Among the other causes observed are gastro-intestinal disorders, anaemia, chlorosis, uterine disorders, urethral irritation, scrofula, and the use of large doses of the bromides and iodides. Acne may exist alone or be associated with comedo or seborrhoea. Pathology. An inflammation of the sebaceous gland structure and surrounding tissues. There first occurs retention of the sebaceous secretion, which is soon followed by hyperaemia and exudation about the glands and in the gland wall ( acne papulosa ), infiltration of the connective tissue ( acne tubercula ), followed by suppuration {acne pus- tu/osa). If the inflammatory action be severe, destruction of the gland with a resulting cicatrix occurs. Symptoms. Acne papulosa or acne punctata. This variety of the affection is the earliest stage of the inflammatory action, and is usually of short duration, being soon followed by the development of pus. It is characterized by the occurrence of pin-head to pea-sized , flat, more or less pointed papules, situated about the sebaceous follicles, lightish in color, with a minute central black point, the opening of the DISEASES OF THE SKIN. 517 sebaceous duct. Pustules are not infrequently observed scattered among the papules. The lesion is unaccompanied with either local or constitutional symptoms. While the forehead is the most frequent seat for this variety, they sometimes are seen elsewhere, Acne pustulosa. This is the fully developed affection. It is seen upon the face, neck, shoulders, and back, as pin-head to pea-sized , rounded or acuminated pustules , seated upon an infiltrated, reddish base of superficial or deep inflammatory product ( acne indurata ). Scattered among the pustules may be seen numerous papules. There are no constitutional symptoms, nor is pain complained of unless the pustule be handled. Acne artificialis is rather a clinical variety, the result, usually, of large doses of the bromides or iodides, the lesion being identical with acne pustulosa. Diagnosis. The lesion is so characteristic, the course so chronic, and the location so frequently upon the face, that an error seems impossible if care be exercised. The resemblance of the papular and pustular syphiloderms must not be mistaken for acne. Prognosis. Essentially a chronic affection, lasting for a number of years ; but if persistent treatment be employed recovery will occur. Treatment. To successfully combat an attack of acne, both con- stitutional and local measures must be employed. Constitutional treatment. The successful treatment of a case of acne depends upon a knowledge of its cause and familiarity with the constitutional habits of the patient. Disorders of digestion and consti- pation should be corrected. If anaemia be present ,ferrum and arseni- cum are indicated. Scrofula is an indication for oleum morrhuce and ferri iodidum. Uterine disorders, if present, should receive proper attention. In young adult males I have seen wonderful improve- ment follow the passage of a fair-sized bougie once or twice weekly. Calcii sulphid ., gr. every two or three hours, is valuable in many cases, as is hydrargyri chloridum corrosivum, gr. too - so* three times daily. A remedy highly spoken of by Dr. Bulkley is glycer- inum in tablespoonful doses, two or three times daily. Dr. Duhring recommends that it be given in combination with ferri et quinines citras. Prof. Bartholow “ has seen excellent results from the use of syrupus hypophosphitum comp, in acne indurata.” Local treatment. In acne of not very long duration I have seen 518 PRACTICE OF MEDICINE. excellent results from the following plan : Just before retiring, the parts affected are to be thoroughly washed with water as hot as can possibly be borne, and after the water has partly dried the parts are to be thoroughly covered with sulphur sublimatum , applied by means of a powder-puff ball, no rubbing or friction to be employed, and on arising in the morning the sulphur is to be washed off with hot water and the face lightly mopped dry, or what is better, sulphur again applied, if the patient is willing to permit it, during the day. Dr. Hyde recommends that the contents of the papules and pustules be evacuated by means of a needle, rather encouraging slight bleed- ing, after which the parts are to be bathed with water as hot as can be tolerated ; and while the part is still wet, it is thoroughly scrubbed with lotio saponis viridis , then cleansed with water, carefully dried, and anointed with a sulphur ointment. Prof. Bartholow suggested, in a case of acne indurata seen with the author, the following successful plan. To dissolve the sebaceous matter — R. Liquor potassae, f^j Aquae destil., fi|j. M. Sig. — Applied to the acne spots only. After which they were anointed with — R. Plumbi nitrat., gr xv Ung. petrolei, Jj. M. Sig. — A pply twice daily. Dr. Duhring recommends the use of the following, after washing the parts with hot water : — R. Sulphuris praecip., gj Glycerini, f % ss Adipis benz., ifj 01. rosae, • gtt. iij. M. Ft. ung. Sig. — To be thoroughly rubbed into the skin at night. ACNE ROSACEA. Synonyms. Gutta rosea ; gutta rosacea. Definition. A chronic hyperaemia or inflammatory affection of the nose and cheeks ; characterized by redness, hypertrophy of the skin and dilatation and enlargement of the blood-vessels supplying DISEASES OF THE SKIN. 519 the part, and the development of more or less acne. The nose and cheeks are the most frequent location. Causes. Not always determined. It occurs in young women about puberty who are anaemic, or suffer from a general debility, nervous irritability, or prostration, dyspepsia, or menstrual irregulari- ties. It often appears during the menopause. In young males the affection can often be traced to nervous or general debility or dys- pepsia. The use of spirituous liquors or of large amounts of condi- ments are frequent causes, as is constant exposure to the weather. It is frequently associated with seborrhoea. Pathology. There first occurs blood stasis in the vessels of the part, producing the undue redness first noticed. As a result of the stasis, sooner or later the capillaries are dilated and hypertrophied, and as a result of the interrupted circulation inflammation of the sebaceous gland (acne) results, with the development of papules and pustules. This constitutes the typical acne rosacea. The affection may proceed no further, remaining at this point for years, or, rarely, the pathology of this stage is exaggerated, the involved tissues all hypertrophy ing, and the connective tissue undergoing a true hyperplasia, causing increased size and abnormal shape of the nose. Symptoms. The onset of the affection is slow and insidious, characterized at first by more or less diffused redness of the part, the color aggravated by water or cold air. If the nose be the part at- tacked, it is usually greasy (seborrhoeic), and is apt to be cool or even cold. This condition may remain for years, but sooner or later the evidence of dilatation and hypertrophy of the capillaries is apparent by the more decided and permanent redness, and upon close exami- nation the enlarged minute cutaneous blood-vessels are seen as deli- cate or coarse red lines, running superficially over the skin in an irregular and tortuous course. Soon are developed upon the hyperasmic and hypertrophied skin papules (acne papulosa) and pustules (acne pustulosa), their number never, however, being very great. This constitutes true acne rosacea. The disease may remain in this state, or, rarely, the cutaneous tissues are greatly hypertrophied, the blood- vessels enormously dilated, the glands enlarged, and the connective tissue undergoes hyperplasia, resulting in permanent, dark red, bulky formations, the shape of the nose being contorted into various irregular forms. Duhring reports a case in which the nose was the size of the patient’s fist (rhinophyma). 520 PRACTICE OF MEDICINE. The nose and cheeks are the usual location of the disease, although rarely it involves the forehead. Diagnosis. The characteristics of the disease are so marked, consisting of rosacea — the dilated and hypertrophic blood-vessels — with papular and pustular acne superadded, that an error can hardly occur if due care be exercised. Lupus vulgaris bears some resemblance to acne rosacea, as it is apt to develop about the face, and especially the nose ; but the papules, tubercles, and pustules of lupus vulgaris soon ulcerate, followed by crusts and cicatrices, which never occur in acne rosacea. Lupus erythematosus may be confounded with acne rosacea if it occurs upon the end of the nose ; but in the former the skin is harsh and covered with adherent whitish and yellowish scales connected with the openings of the sebaceous follicles, which is never the case in acne rosacea. Frostbite resembles the first stage of acne rosacea, but the history of the two conditions soon determines the diagnosis. Prognosis. Favorable, if treatment be instituted during the first stage. After hypertrophy has occurred but little can be accom- plished. Treatment. The cause is to be sought after and removed, and the general health to be promoted. The use of all alcoholic drinks is to be interdicted and but small amounts of tea and coffee are to be allowed. In the first stage good results may be obtained from the following formula, known as “ Kummerfeld’s lotion : ” — Or— R. SlG.- Sulphur praecipitat., 3 iv Pulv. camphorae, gr. x Pulv. tragacanthae Aquae calcis, f % ij Aquae rosae, f 3 ij. — Shake the bottle before using and apply every few hours. R. Hydrargyri chlor. corrosiv., gr. ij Ung. petrolei, SiG. — Apply thoroughly. M. M. Or, the following, suggested by G. H. Fox — R . Chrysarobini, ss Collodii, ^j. M. SiG. — Put a brush through the cork and paint lesion every evening. DISEASES OF THE SKIN. 521 For the second stage stronger applications are usually required. The dilated capillaries should be incised with a sharp knife, in the hope that adhesive inflammation may close the calibre of the vessels, cold water compresses being used to control the bleeding, a few of the dilated vessels being thus treated every day or two, until all have been incised. Another plan is to paint the affected parts, once or twice a week, with a ten to twenty grain solution of ftotassa, following its application with an emollient poultice. Electrolysis has also been recommended. In the third stage the knife is the only effectual remedy. PSORIASIS. Synonyms. Lepra ; alphos ; psora ; English leprosy. Definition. A ehronic affection of the skin, characterized by reddish, more or less thickened and elevated, dry, inflammatory, and somewhat wrinkled patches, variable as to size, shape, and number, and covered with abundant whitish or grayish-colored, imbricated scales. It is not contagious. Cause. Not known. The source of the affection is, no doubt, limited to the skin itself, as no external or internal factors can produce it. It occurs in the robust and in the feeble, and in males and females. It usually first appears in early life, and recurs at intervals for years. Pathology. According to Dr. A. R. Robinson, of New York, “ the disease is essentially a hyperplasia of the normal constituents of the Malpighian layer (mucous layer). The increase takes place chiefly in the interpapillary portion of the layer, the growth of which downward causes an apparent increase in the size of the papillae of the corium, which, however, on closer examination, are found not to be enlarged. In the later stages of the disease the more superficial blood-vessels of the corium become dilated, a more or less consider- able emigration of the white blood corpuscles takes place, and the immediate neighborhood of the vessels, together with the connective tissue of the corium, becomes the seat of a round-cell infiltration, which, with the effusion of serum, separates the connective-tissue bundles and fibres into an open meshwork. During the period of disappearance of the disease there is a gradual return to the normal condition, until the hyperplasia, dilatation of the blood-vessels, and cell infiltration have completely disappeared. The hair in psoriasis is 522 PRACTICE OF MEDICINE. affected from the beginning of the disease, hyperplasia of the external root sheath, the structure corresponding to the Malpighian layer of the epidermis, taking place, with extension of the hyperplastic structure into the surrounding cutis. The sebaceous and sweat glands are not at any time affected.” Symptoms. Psoriasis begins as small, reddish spots , of the size of a pin’s head, which immediately become covered with scanty or abundant whitish ox grayish, imbricated scales. The spots gradually increase in diameter, forming patches of various sizes and shapes. If one of the scales be detached by means of the finger nail, it will be found to adhere quite firmly to the skin, and to be about the thick- ness of a card-board. If the reddish patch thus made bare be pinched up between the finger and thumb, and compared with a simi- lar pinch of the healthy skin, its inflammatory thickening will be dis- cerned. There is no watery discharge at any time. The skin between the patches is perfectly healthy. ' While the anatomical lesions are always identical, the eruption assumes such features, as to the size and shape of the patches, as to give rise to special names. Psoriasis punctata. The eruption occurs as small, rounded patches, about the size of a pin’s head. This is a rare variety, as the lesion rapidly increases in size. Psoriasis guttata. The eruption occurs in the form and size of drops, and when covered with scales gives the skin the appearance of having been splashed with mortar. A quite frequent variety. Psoriasis mummularis. The eruption resembles variously sized coins. This is frequently as large as the patches grow. Psoriasis circinata. The eruption about the size of the former variety, the centre clearing away, leaving the skin normal, although it may continue to enlarge at the periphery, after the manner of tinea circinata. Psoriasis gyrata. The eruption in wavy lines, of the width of about half an inch, resembling circles and semicircles. This variety is a continuation of the former, from the joining of the patches of psoriasis circinata. Psoriasis diffusa. The patches of eruption are large and of irregu- lar shape, covering a considerable amount of surface. This variety occurs more frequently on the front of the leg and the outer aspect of the forearm. DISEASES OF THE SKIN. 523 Psoriasis palmaris et plantaris. In these regions the eruption is characterized by larger, thicker, and less lustreless scales, and by the occurrence of deep and painful fissures, from which exudes either a serous or sanguineous fluid. Psoriasis unguium. In psoriasis of the nails they become thick- ened, opaque, grayish in color, deeply grooved transversely, and often pitted, and in rare cases the nails are replaced by a scaly incrustation. Any portion of the body is liable to be attacked with psoriasis. The only discomfort the patient suffers is the itching , which at times is very severe and distressing. Diagnosis. A typical case of psoriasis presents no difficulty in diagnosis. There are a few affections, however, which may be con- founding in irregular cases. Eczema squamosum occurring upon the legs closely resembles psoriasis, and if the former has been attended with a very small amount of moisture and the latter has been considerably irritated by scratching, the diagnosis will be very difficult. The papulo-squamous syphiloderm and psoriasis are frequently mistaken for each other, the diagnosis at times being extremely difficult. Tinea circinata and psoriasis circinata resemble each other, but the patches of the latter are less inflammatory, red, and infiltrated, and the scales more abundant and larger than the former. Tinea circinata is usually the result of contagion, and the scales contain a fungus. Seborrhoea of the scalp and psoriasis of the same region frequently are difficult of diagnosis. In the former the scalp is paler, the scales are finer, smaller, more generally diffused, of a grayish or yellowish color, and greasy, sebaceous character. Psoriasis of the scalp is in patches, which are reddish and infiltrated, and there are almost always patches of the disease on other parts of the body. Prognosis. An attack can easily be removed, but it is always apt to return, so that a permanent cure can never be promised. Treatment. Constitutional and local measures are both needed in the majority of attacks of psoriasis. Constitutional treat7nent. Attention to the general health, remov- ing all deleterious influences, such as dyspepsia, constipation, lithia- sis, malaria, anaemia, or catarrhs. 524 PRACTICE OF MEDICINE. Among the most valuable remedies used in the treatment of psoriasis is arsenicum , given in full doses for a long period. It is to be borne in mind, however, that the drug is contraindicated in all acute and inflammatory cases. Chrysarobin, gr. t. d., gradually increased, has been suggested, but of its utility I have had no experience. Phosphorus , acidurn carbolicum , and pix liquida have all been used with variable success. Local treatment. The character of the local measures should be controlled by the duration of the disease, its extent, location, and obstinacy. The first step is the thorough removal of the scales. This may be accomplished by repeated washings with soft soap and water, by either plain or alkaline baths, medicated washes, or caustic ointments. In the early stage, with highly inflammatory symptoms, soothing applications, such as water dressings, or inunctions with oils, of which oleum olivce rubbed over the patch several times each day is very serviceable. For chronic cases nothing seems comparable with the following formula, suggested by Dr. G. H. Fox : — R. Chrysarobin, gr. x-xx-jj ALtheris et alcoholis, ad .... q. s. Collodii, %). M. Sig. — R ub the chrysarobin with a little alcohol and ether and add to the collodion. If a camel’s hair pencil be placed through the cork, this may be painted over the affected patch after the removal of the scales, and after drying it will not stain the clothing. Care must be exercised that the strength be not too great, or a dermatitis may result. The following formula I have never seen fail : — R . Chrysarobin, gr. x-xv-xxx Ung. petrolei, gj. M. Sig. — Apply to each spot, twice daily. Dr. Bramwell, of Edinburgh, reports remarkable success in the cure of psoriasis, by the internal administration of “a quarter of a raw thyroid gland, finely minced and concealed in rice paper, daily,” “and no application whatever was made locally.” Amongst local remedies are : pix liquida , saponis viridis, creaso- tum, sulphur , calcium sulphuretum , and acidurn carbolicum. DISEASES OF THE SKIN. 525 HYPERTROPHIES OF THE SKIN. LENTIGO. Synonym. Freckles. Definition. A pigmentary deposit of the skin, characterized by irregularly shaped, pin-head, or pea-sized, yellowish, brownish, or blackish spots, occurring for the most part about the face and back of the hands. Cause. In the majority of instances exposure to the sun is the exciting cause. Pathology. In anatomical structure freckles consist of a circum- scribed, increased amount of normal pigment, differing from chloasma only in the peculiar form and size of the deposit. Symptoms. The number of “ freckles” varies from a very few to immense numbers. They occur as brownish or yellowish-brown, small, roundish, irregular spots, most commonly upon the face and hands. Rarely the number is very great, and they give to the skin an uncleanly appearance. They are apt to occur at all ages, but rarely before the third year. They are unattended with itching or other subjective symptoms. Prognosis. Usually favorable. Their course, when left to them- selves, is chronic, lasting for years or a lifetime. They ordinarily appear in the summer, fading away as cold weather approaches, to return the following summer. Treatment. The following application has been usually success- ful in my hands : — R . Hydrargyri chlor. corrosiv., gr. iij Acid, hydrochlorici dil., f^j Alcoholis, j Glycerini, f^ss Aquae rosae, ad f^iv. ' M. SiG. — Apply at bedtime, and remove with soap and water in the morn- ing. CHLOASMA. Synonyms. Liver spots ; moth. Definition. A pigmentary discoloration of the skin, characterized by variously-sized and shaped, more or less defined, smooth patches, or of a discoloration, yellowish, brownish, or blackish in color. 526 PRACTICE OF MEDICINE. Cause. The etiology of chloasma depends upon whether the pigmentation is idiopathic or symptomatic in its occurrence. Idiopathic chloasma results from the irritation of long-continued scratching, such as is practised in severe eczema or pediculosis, the application of blisters and sinapisms, heat, the direct rays of the sun, and various medicinal and chemical substances, such as follows the prolonged use of argentum (argyria). Symptomatic chloasma occurs in connection with cancer, malaria, tuberculosis, disease of the supra-renal capsule (Addison’s disease), disease of the womb, pregnancy (chloasma uterinum), neurotic dis- turbances, anaemia, and chlorosis. Pathology. The affection is an increased deposit of the normal pigment having its seat in the mucous layer of the epidermis. The deposition of the pigment is the result of a nervous derangement, possibly of the trophic system. Symptoms. Chloasma is simply a discoloration of the skin, un- attended with alteration of the surface. The patches vary in size and shape ; they may be as minute as a coin or as large as the hand, or much larger, even to a universal discoloration of the entire surface, and they may be roundish or irregular in outline. The usual color is yellowish, brownish , or muddy , or even blackish (; melasma melanoderma). In Addison's Disease , of a typical character, “ the coloration is brownish, with an olive-greenish or bronze tint, and is general, although, as a rule, especially pronounced upon regions having a dis- position to normal increase of pigment, as the face, backs of the hands, axillae, areolae of the nipples, and the genital organs; the hair, also, may become darkened. It may, also, occur with or follow other pigmentary changes, as of the hair. Gaskoin reports a case, occurring in a woman aged forty-five, where the patch, situated on the cheek, near the nose, was intensely dark. It had existed nine years. The color of the hair had, fifteen years previously, changed from carroty- red to black.” For additional symptoms, see page 180. In Argyria, or discoloration of the skin resulting from the internal use of nitrate of silver, the color is a bluish, bluish-gray, slate, bronze, or blackish, varying as to the shade. It occurs over the surface generally, but is more pronounced upon parts exposed, as the face and hands. DISEASES OF THE SKIN. 527 Chloasma uterinum occurs most frequently between the ages of twenty-five and fifty, seldom after the menopause, caused, in the greater number of instances, by changes, physiological and patho- logical, which take place in connection with the uterus. It is seen in the married and single, although much commoner in the former. Pregnancy is the most frequent cause, although also associated with either dysmenorrhoea, chlorosis, anaemia, or hysteria. It is seen in the mildest degree about the eyelids, especially during the menstrual epoch, as a duskiness or swarthiness of the complexion, either lasting a few days or being permanent. As usually encoun- tered, however, chloasma of this variety consists in the presence of one or several patches, appearing generally about the forehead or other parts of the face, upon the trunk, about the nipples, and upon the abdomen. Rarely the entire face is covered with a discoloration, resembling a mask. Cases are recorded in which the pigmentary deposit was general, resembling Addison’s disease. Diagnosis. Tinea versicolor and chloasma resemble each other in the color of the patches, but otherwise they have nothing in com- mon. Tinea versicolor occurs on the trunk, while chloasma occurs upon the face and about the nipples, and in cases the result of preg- nancy about the umbilicus, except in those comparatively rare instances in which the discoloration is diffused. The patches of chloasma are smooth, those of tinea versicolor furfuraceous, as can readily be demonstrated by gently scraping the discoloration with the finger nail. Prognosis. Unless the result of Addison’s disease, the prolonged use of argentum, tuberculosis, or cancer, favorable. Treatment. Chloasma, not the result of organic disease, or the use of argentum, is usually removed by either of the following formulae : — Or— R . Hydrargyri chloridi corrosiv., gr. viiss Zinci sulphat., 3 ss Plumbi acetatis, 3 ss Aquae, f Jiv. Sig. — L otion. Apply morning and evening. — Hardy. R . Hydrargyri chloridi corrosiv., Acidi acetici dil., Boracis, Aquae rosae, Sig. — L otion. Apply twice daily. . . gr. vj . . f 3 ij • • au . . f J iv. — Bulki.ey. M. M. 528 PRACTICE OF MEDICINE. Or— R. Hydrarg. ammoniat., Bismuthi subnit., 3j Ung. petrolei., %j. M. SiG. — Apply frequently. For argyria , the first step is the withdrawal of the argentum, and, according to Prof. Bartholow, “ a persistent and long-continued use of potassii iodidum and sodii hypophosphis has, in a few fortunate in- stances, caused the absorption and excretion of the silver deposits. The action of these systemic remedies for the discoloration may be aided by baths of the hyposulphites, and by the cautious use of lotions containing potassii cyanidum, which possesses a decided solvent power over the silver deposits. * CALLOSITAS. Synonyms. Tyloma; callus; callosity. Definition. Callositas or tyloma consists in the development of a hard or horny, thickened patch of skin, variable in extent, and of a grayish, yellowish, or brownish color, and unattended with pain. The most frequent location is upon the hands and feet. Causes. The result of pressure or friction, as in the case of the hands of the mechanic, the effect of his tools; or, if upon the foot, the result of ill-fitting shoes or from long marches. Callosities are also seen upon the fingers of violin, banjo, and harp players. Pathology. A hypertrophy of the horny layer of the skin, the corium remaining normal. The cells of the epidermis become so closely packed together as often to simulate horn substance. Symptoms. Callositas consists in an increase in the thickness of the skin of the affected part, presenting a firm, dense, more or less circumscribed structure, the extent of hardness varying considerably, sometimes being horny. The patch of hardness is generally about the size of a coin, roundish in shape, and somewhat elevated above the surrounding skin. The color of the patch may be either grayish, yellowish, or brownish. Callosities are usually upon the palms, fingers, soles, and toes, although other parts, if exposed to the cause, may also be the seat. At times great pain and discomfort are experienced from the growth. Occasionally callosities are complicated by hyperaemia, fissure, acute / DISEASES OF THE SKIN. 529 inflammation, abscess, erysipelas, and serve readily as foci for such cutaneous diseases as eczema and psoriasis. Course. Their formation and development is always slow and gradual. If the cause be removed, the prognosis is favorable. Treatment. If the removal of the callous growth be desirable, the part should be repeatedly soaked in warm water, or a poultice applied, or warmed oil kept in contact by compresses of flannel, which will soften the induration and permit its removal by paring or scraping, layer by layer, with a sharp knife. Success has been reported from the use of a plaster of india-rubber containing acidum salicylicum . CLAVUS. Synonym. Corn. Definition. A corn is a small, circumscribed, usually flat, deep- seated hypertrophy of the epidermis, having a horny feel, projecting slightly from the skin, painful upon pressure, situated, for the most part, about the toes. Cause. Continued pressure or friction, usually from ill-fitting or tight boots or shoes. Pathology. A clavus consists of a circumscribed, excessive hypertrophy of the epidermis, of the same character as occurs in callosity, and of a central portion — the core. The core extends deeply into the tissues, in the shape of an inverted cone, the base of the cone being directed outward and appearing upon the surface as a roundish elevation, its apex resting upon the papillary layer of the coriuin. The core of a clavus consists of a whitish, opaque, firm, tenacious body, composed of epidermic cells, arranged in concentric laminae. The pain attending the presence of corns results from pressure upon the true skin by the hard core causing irritation of the nerve filaments of the papillae. Corns existing between two toes are constantly bathed with the moisture of the part, which macerates and softens the formation, which thus receives the name of soft corn , in contradistinction to the hard corn. Symptoms. Until the growth attains a considerable size no dis- comfort, as a rule, is felt. After, however, its depth has reached the true skin, pain of an intermittent character, aggravated by pressure, is the chief symptom. 44 530 PRACTICE OF MEDICINE. Corns are often weather-sensitive, being unusually painful before, during, or after the occurrence of storms, and should, therefore, not be confounded with gouty or rheumatic deposits below the skin. Treatment. If freedom from these annoying formations be de- sired, the use of a properly fitting foot-covering must be practised. The pressure which results in the severe pain is limited by the use of the ringed protective plasters in common use. To remove the corn, soaking with hot water, or a poultice kept in contact over night, will soften the part and permit of its ready removal with the knife. For soft corns , the application of argenli nitras, in solid stick form, is highly spoken of, to be used after the growth has been sufficiently softened. VERRUCA. Synonym. Wart. Definition. A wart consists of a circumscribed hypertrophy of the papillary layer, with more or less epidermal accumulation, char- acterized by the appearance of a hard or soft, rounded, flat, or acumi- nated formation, of variable size. Varieties. The following varieties have chiefly a descriptive value : verruca vulgaris ; verruca filana ; verruca filiformis ; verruca digitata ; verruca acuminata. Cause. Obscure. The various assigned causes are probably incapable of producing the affection. Pathology. While the anatomy of warts differs somewhat accord- ing to their variety, in all forms there exist as a basis of their forma- tion a connective-tissue growth, from which the papillary hypertrophy takes place. The interior of the growth is supplied by one or more vascular loops, from which their vitality is obtained. Symptoms. The various forms are so different as to require a separate description. Verruca vulgaris , or the ordinary wart, commonly seen on the hands, consists of a small, circumscribed, elevated growth, having a broad base seated securely upon the skin. Their consistency is either soft or firm, the surface smooth or rough, the color that of the sur- rounding skin, or yellowish, brownish, or even blackish. They may develop upon any region of the body, but are most commonly seen upon the hands and fingers. DISEASES OF THE SKIN. 531 Verruca plana differs from the vulgaris in being flat and broad in form, and but slightly raised above the level of the surrounding skin. Their most common location is either on the back or forehead. Verruca filiformis assumes the shape of a minute, thin, conical, or thread-like formation, about an eighth of an inch in length. The most frequent location is the face, eyelids, and neck. Verruca digitata consists of a slightly elevated, broad formation, about the size of a split pea, and marked by a number of digitations coming from its border, giving an appearance, in marked cases, resembling a crab. Their most frequent site is upon the scalp. Verruca acuminata , known, also, as the pointed wart, the moist wart, the pointed condyloma, cauliflower excrescence, and venereal wart, consists of one or more groups of irregularly-shaped elevations, often so closely packed together as to form a more or less solid mass of vegetations (verrucae vegetantes). Their color depends somewhat upon the degreq of vascularity, varying from a pinkish, bright red to a purple color. They occur, for the most part, about the genitalia of either sex. Upon the penis, they usually spring from the glans and the inner surface of the prepuce ; the inner surface of the labia and from the vagina in the female. They are also seen about the anus, mouth, axillae, umbilicus, and toes. They may be either moist or dry, according to their location ; about the genitalia, a yellowish, puriform secretion usually covers their surface, due to friction and maceration, which, owing to the heat of the parts, rapidly decomposes, producing a highly offensive, penetrating, and disgusting odor. Their size varies from that of a pea to that of an almond, an egg, or even the fist. Their development is rapid, attaining considerable size in a few weeks. Prognosis. Favorable. Treatment. For the smaller warts, excision by means of the knife or scissors affords the most satisfactory results. If the growth be large and likely to be attended with considerable hemorrhage, as in cases of the condyloma about the genitalia, the galvano-caustic wire or the Paquelin cautery are to be preferred. Transfixing the growth in several directions with long needles dipped in a fifty per cent, solution of aciduin chromicum has been recommended. The topical application of caustics, such as acidum aceticum , acidum 532 PRACTICE OF MEDICINE. nitricum , argenti nitras, or ferri perchloridum are often satisfactory. I have been successful in some cases by painting the growth with tinctura thuja occidentalis until their size was considerably reduced, and then snipping them off with the scissors. The following formula for warts and corns is generally sold by pharmacists : — li . Acidi salicylici, 3 ss Ext. cannab. indicae, gr. v-x Collodii, .... f^ss-j. M. Sig. — A pply once or twice daily. An excellent formula is : — R. Acidi salicylici, Acidi boracici, aa gr. xv. Hydrargyri chlor. mitis, gr. x. M. Sig. — S prinkle over twice daily. ICHTHYOSIS. Synonyms. Ichthyosis vera; iish-skin disease. Definition. Ichthyosis is a congenital, chronic deformity or hyper- trophic disease of the skin, characterized by dryness, harshness, or general scaliness of the skin, or in the outgrowth of larger masses of a corneous consistency. Varieties. Ichthyosis simplex ; ichthyosis hystrix. Cause. Often hereditary, but not in all cases. It is to be regarded as an affection which is born with the individual, although it does not usually manifest itself until after the first or second year of life. Pathology. “ The diseased, or, better, deformed skin is found microscopically to be hypertrophied in various degrees, according to the development of the malady ; the proliferation of its elements occurring in the connective tissue, papillae, stratum corneum, and blood-vessels. In well-marked cases of ichthyosis hystrix, the elongated papillae are surrounded by dense cones of the horny layer of the epidermis, more or less concentrically disposed, with sclerosis of the connective tissue and a relatively unchanged rete. In this last particular the dense plaque of ichthyosis differs in texture from the wart.” (Hyde.) Symptoms. Ichthyosis displays a wide variation in its symp- toms. In one individual it amounts to but a slight inconvenience, DISEASES OF THE SKIN. 533 while in another it may manifest itself in so pronounced a manner as to be the source of great discomfort and deformity. The two varieties named represent merely accentuated types of the disorder, rare in its fullest development, and, in its slightest, much more common than is generally believed. A simple dryness and harshness of the skin, with only slight fur- furaceous exfoliation, is termed xeroderma. Ichthyosis simplex is the more common variety, consisting of a harsh, dry condition of the whole surface, accompanied by the pro- duction of variously sized and shaped reticulated scales, either small, thin and furfuraceous, like bran, or large and thick, resembling fish scales. Upon the extremities the scales usually form diamond-shaped or polygonal plates, separated from one another by furrows or lines, which extend down to the normal skin. In color the scales are either whitish, grayish, or yellowish, and often have a silvery or glistening appearance. Rarely the color is olive green or blackish ( ichthyosis nigricans ). The amount of scaling depends upon the age of the patient and the duration and severity of the disease. Ichthyosis hysirix. With or without the developments of the above variety, in this, the hypertrophy of the skin may occur in circum- scribed patches or large areas, consisting of irregularly-shaped, ver- rucous, corneous, corrugated, wrinkled, or rugous masses, usually darker in color than those of the simple variety. They may occur upon the arms, as solid, warty patches, or upon the back, in the form of elongated, linear patches. They may constitute roughened, corru- gated, papillary growths, or uneven, horny, blunt or pointed, spinous, warty formations. In the latter case the elevations may reach several lines or more, and stand out from the skin like quills upon the back of a porcupine — hence the name hystrix. The amount and extent of the hypertrophy varies ; the older the patient the more highly devel- oped it will usually be. Course. Ichthyosis simplex may involve the entire surface uni- formly or appear more marked on the extremities, from the hips to the ankles and the arms and forearms. The affection is always worse in winter than in summer, the increased activity of the sweat glands at this season producing the most beneficial results. The course of the affection is essentially chronic, continuing throughout life, now better, now worse. Slight itching usually occurs. Diagnosis. The characteristics of the affection are so peculiar 534 PRACTICE OF MEDICINE. that an error in diagnosis is hardly possible. It is to be distinguished from the inflammatory affections of the skin which terminate in des- quamation by the absence of any history of inflammation. Prognosis. While much can be done to alleviate the affection, the prognosis is unfavorable as regards permanent relief. Treatment. Local measures are alone of value for ichthyosis. The maceration of the accumulated masses of epithelial hypertrophy is accomplished by water baths, either simple or medicated. The relief thus afforded the patient, while temporary, is comforting. Duhring says : “ It may be stated, then, that, as a rule, the more fre- quently the ichthyotic patient bathes, and the longer he is able to remain in the water, the less will the deformity show itself.” Vapor and alkaline baths are also serviceable. Another valuable agent is sapo molis in conjunction with baths, or alone, as a discutient. For severe cases, “ a sufficient quantity is to be rubbed into the skin twice daily, for four or six days, during which period the patient is to refrain from bathing. A bath is first to be taken four or five days after the last rubbing, when, in fact, the epidermis has begun to peel off ; afterward inunction with a simple ointment is to be applied, in order to prevent Assuring of the new skin. The following is a useful formula: — Or— R. Adipisbenz., 3j Glycerini, . ir^xl Ung. petrolei, ^ss. Sig. — A pply daily, after washing or bathing. — Duhring. R . Potassii iodidi, gr. xx Olei bubuli, Adipis, aa ^ ss. Glycerini, fgj. Sig. — A pply after bathing. — Milton. M. M. PARASITIC DISEASES OF THE SKIN. TINEA FAVOSA. Synonyms. Favus; porrigo favosa; honeycombed ringworm; crusted ringworm. Definition. A contagious affection of the skin, due to a vegetable parasite — Achorion Schonleinii ; characterized by the development of DISEASES OF THE SKIN. 535 either discrete or confluent, small, circular, cup-shaped, pale yellow , friable crusts, usually perforated by hairs. Cause. The presence and growth of a vegetable parasite known as the Achorion Schonleinii is the cause of tinea favosa. It is com- moner in children than in adults, attacking the former, in the first place, either de novo or through direct contagion, and is from them communicated to adults. It is a disease confined almost exclusively to the lower classes. Pathology. Tinea favosa may have its seat either in the hair follicles and hair, or upon the surface of the skin or the nails ; the former, however, are the structures most commonly attacked. It is purely a local affection, due solely to the presence and growth of the vegetable parasite discovered by Schonlein, of Berlin, in 1839, and named after him — Achorion Schdfileinii. The crusts are made up almost entirely of fungus, which is seen, upon section, with the naked eye, to be composed of a porous mass and to possess a pale- yellow or whitish color. Under the microscope it is seen to consist of both mycelium and spores in great quantity and in all stages of development. Symptoms. When the affection attacks the hairs and follicles it is termed tinea favosa pilaris , when the epidermis, tinea favosa epi- dermis, and when the nails, tinea favosa unguium. Rarely all the structures may be attacked at one and the same time ; its usual seat, however, is the scalp. The disease begins by the development of one or of several pin- head-sized , pale-yellow crusts , seated about the hair follicles. In about a fortnight these crusts have increased in size and are umbili- cated, termed the favus cups , are circumscribed, circular inform, and very slightly elevated above the level of the skin. In their normal condition they are of a pale-yellow or sulphur- yellow color, but after a time, from dust and other matters, they become brownish- or greenish-yellow in color. The number of crusts vary from a very few to immense numbers. The usual size is about that of a split-pea. In tinea favosa pilaris et capitis the affection is often accompanied with pediculi, while swelling of the glands of the neck and small abscesses upon the scalp are not uncommon. The hairs become lustreless, opaque, brittle, and at times split longitudi- nally, and from atrophy of the follicles and sebaceous glands perma- nent baldness may result. 536 PRACTICE OF MEDICINE. In tinea favosa unguium the nails become thickened, yellow, opaque, and brittle. The disease has a peculiar odor , resembling that of mice , or of musty , stale straw. Diagnosis. In a recent case the characteristic favus cups, the pale-yellow color, the odor and the history of contagion should ren- der the diagnosis easy. If of long standing, however, and the favi destroyed by scratching, some doubt may exist ; but if a small fragment of a crust be placed upon a glass slide with a drop of liquor potasses, covered with a thin glass and placed under a micro- scope with a power of from two hundred and fifty to five hundred diameters, the features of the Achorion Schonleinii will determine the affection to be tinea favosa. Prognosis. Tinea favosa of the epidermis readily responds to treatment. Tinea favosa pilaris is more obstinate, and if of long duration may result in baldness. Treatment. The general health, in the majority of instances, requires tonics. Oleum morrhuce , and syrupus ferri iodidum , are invaluable in scrofulous patients. Cleanliness is essential to suc- cessful management. For tinea favosa pilaris et capitis two remedies are essential — parasiticides and depilation. The hair should be cut as short as possible, the crusts removed by the use of oil, or soap and hot water, or poultices, again well oiled and the hairs removed by means of broad-bladed forceps, a few hairs being removed at a time and only a small surface cleared at each sitting, when the following lotion is to be thoroughly applied : — $ . Hydrarg. chlorid. corrosiv. , gr. v-x. Ammonii chlorid. pur., Misturae amygdalae amar. M. SiG. — Apply thoroughly. — Bulki.ey. Dr. Shoemaker condemns epilation as injurious to the “ hair-folli- cles and painful to the patient, and should be discarded as a relic of medical barbarism of the last century.” He recommends “ the appli- cation of oleum ergotcE , for twenty-four hours, to soften the crusts, then apply a twenty-five to a fifty per cent, solution of boroglyceride, sponged thoroughly over the affected surface covered with the oil ; in DISEASES OF THE SKIN. 537 a few hours the crusts will peel off and the surface can be cleaned, when the following powerful antiparasitics should be applied : ” — R . Ung. hydrargyri oleat. (genuine), . . . . % ss Adipis, J ss. Sig. — A pply a small portion to each cup daily for two or three days. and then alternate with the following: — R . Cupri oleat, 3 ss Adipis, • • Ei Sig. — Small portion to the affected spots. “ These applications should be made every day or two, and con- tinued for three or four weeks. If, after a cessation of treatment for a week or two, the hair does not assume its natural aspect, and new favus crusts develop, the treatment should be begun afresh.” TINEA CIRCINATA. Synonyms. Tinea trichophytina corporis ; herpes circinatus ; ringworm of the body. Definition. A contagious, parasitic affection of the skin, due to th z. trichophyton fungus; characterized by the development of one or more circular or irregularly shaped, variously-sized, inflammatory, slightly vesicular or squamous patches, occurring upon the general surface of the body. Causes. Ringworm of the body is caused by the presence of a vegetable parasite discovered by Bazin, in 1854, termed the tricho- phyton , the same growth or fungus that produces tinea tonsurans and tinea sycosis. The affection is highly contagious, and is frequently communicated from one member of a family to another, although it has been determined that a certain unknown condition of the skin is requisite for its development. In children it is most frequently seen among the weakly and the poorly nourished. In adults it is usually associated with a decline in the general health. Pathology. The fungus is seated between the strata of the epi- dermis, more particularly in the superior layers of the rete. The presence of this foreign body produces the subsequent phenomena — a superficial dermatitis, erythema, exudation, minute vesiculation and 45 538 PRACTICE OF MEDICINE. papulation, and, in the severe grades, tubercles and pustules. The desquamative symptoms are exfoliative — nature’s efforts for relief. Symptoms. Tinea circinata varies greatly in the degree of its development, from the trivial complaint so often seen in children, to the chronic, extensive, and obstinate disease sometimes seen about the thighs in adults ( tinea circinata cruris). The disease usually begins as a small, reddish, scaly, rounded or irregularly-shaped spot of papules, which, in a very few days assumes a circular form (ringworm). It continues to increase in size, the papules often changing to vesicles. A characteristic of the eruption is its healing in the centre as it spreads on the periphery. Occasion- ally the circles or rings coalesce, forming serpiginous lesions. The usual size of a fully developed ringworm is about that of a silver quarter of a dollar. Chronic tinea circinata does not present the characteristic annular form, but “ are usually in the form of single or multiple, disseminated, small, reddish, slightly scaly, ill-defined spots, on a level with or but slightly raised above the surrounding skin. Not infrequently they are the size of a small or large finger nail, and are irregularly shaped, and, as a rule, without line of demarcation.” The “eczema marginatum” of Hebra is to be looked upon as a severe form of tinea circinata. Tinea circinata cruris , or ringworm of the thighs, a variety of the “eczema marginatum of Hebra,” is usually complicated with true eczema, and is a very obstinate, chronic form of the affection ; it is accompanied by severe itching. Tinea trichophytina unguium is a rare variety. The nails become opaque, whitish, thickened, and soft and brittle, especially along their free border. The microscope is essential for a diagnosis. Its course is chronic, and it is difficult to cure. Course. As commonly seen, ringworm is very amenable to treat- ment. Occasionally, however, it exhibits great obstinacy, showing itself repeatedly in the same region, in the form of relapses, or mani- festing itself from time to time in new localities. Diagnosis. Tinea circinata may be mistaken for squamous or other varieties of eczema, but the circular and often annular form, the well-defined margin, the slight desquamation, and the course and history of ringworm should prevent error. Chronic ringworm is more difficult, however. DISEASES OF THE SKIN. 539 Seborrhoea and psoriasis often assume a somewhat circular form, and then have a resemblance to ringworm ; but a study of the clini- cal history should render the diagnosis easy. All doubtful points in diagnosis should be determined by the micro- scope. The examination can readily be made in the following man- ner : “ A few of the scales may be scraped, with a blunt knife blade, from the suspected patch and placed upon a glass slide containing a drop of liquor potassae, over which is laid a thin glass cover. The cover should be pressed down and the epidermic mass flattened out. Permitting the specimen to remain fora few minutes, it maybe viewed with a power of from two hundred and fifty to five hundred diameters. The fungus will, in most cases, be detected here and there, having at first a faint outline, but becoming more distinct as the specimen stands.” Prognosis. Favorable, as a rule, although the affection is rebel- lious to treatment in some instances, and prone to relapses. Treatment. Local treatment is usually all that is required for the cure of tinea circinata. In the majority of instances the following plan will be successful. Washing the patch with soft soap and water and the application of one of the following ointments : — R. Cupri acetat., . . . gr. x Ung. aquae rosae, • • • lY M. SlG. — Keep in contact with the patch. R. Hydrargyri ammoniat., Ung. petrolei, ■ • • Si- M. Sig. — K eep in contact with the patch. R . Hydrargyri chloridi cor., . . . gr.j Tinct. benzoin co., . . .f|j. M. SlG. — Apply over eruption. “In obstinate tinea circinata cruris a saturated solution acidum boricum , applied for a few days, and afterwards cover the parts with the acid in powder, or unguentum hydrargyri a7nmoniatum. TINEA TONSURANS. Synonyms. Tinea trichophytina capitis ; herpes tonsurans ; ringworm of the scalp. Definition. A contagious , parasitic affection of the scalp, due to 540 PRACTICE OF MEDICINE. the trichophyton fungus ; characterized by the development of circum- scribed, vesicular or squamous, more or less bald patches, showing the hair to be diseased and usually broken off close to the scalp. Cause. The result of the presence and growth of the same fungus giving rise to tinea circinata — trichophyton. It is an affection of child- hood, seldom being seen after puberty. It is highly contagious, and may be communicated from a case of ringworm of the body. Pathology. The parasite originally named “ trichophyton tonsu- rans ” invades the hair, hair follicles, and epidermis of the scalp, the hair, however, suffering the most severely, becoming in a short time filled with the growth to such an extent, usually, as to cause its disin- tegration and destruction. The hair follicle, also, becomes distended and prominently raised. The hair shaft is fractured just above the level of the scalp, and usually presents a jagged, bristly, stubble-like extremity. The epidermis of the scalp may either present the changes of minute vesicles and desquamation, or, in severe cases, oedema and inflammatory symptoms, with fluid exudation ( tinea keriori). Symptoms. Ringworm of the scalp usually begins in the form of small circumscribed patches, which soon become the seat of small vesicles or pustules, which terminate in desquamation, or of furfur- aceous scales. The patches spread rapidly, soon reaching the size of a silver quarter to that of a silver dollar. They are circular in form, circumscribed, of a reddish, grayish, or greenish-yellow color, covered with fine or coarse scales, with the hairs broken off close to the scalp. The epidermis of the scalp is more or less raised, and the follicles are prominent, giving the characteristic appearance of the disease — the goose-skin or plucked-fowl appearance. As a result of the loss of hair, baldness, more or less complete, but temporary, exists. Itching , slight or severe, is a constant symptom. Ringworm of the face or body ( tinea circinatci) may complicate tinea tonsurans. Chronic ringworm of the scalp is the same condition in a more chronic form, having existed for six months to a year or two. Tinea kerion is a severe variety of tinea tonsurans, “ characterized by oedema, inflammation, and the exudation of a viscid, glutinous, yellowish secretion from the opening of the hair follicles. When fully developed the patches are yellowish, reddish, or purplish in color, and are more or less raised, oedematous, and boggy. They are uneven DISEASES OF THE SKIN. 541 and honeycomb-like (hence the name kerion), and studded with yellowish, suppurative points, or, later, with small cavities or foramina, the openings of the distended hair follicles deprived of their hairs, which discharge a mucoid, gummy, honey-like fluid.” The patches are tender, painful, and at times the seat of itching. The course of the affection is chronic. Diagnosis. The diagnosis is usually unattended with difficulty, if the characteristic circumscribed vesicular or scaly patches with stubby hair be present. Squamous eczema somewhat resembles tinea tonsurans, but the hairs are normal in eczema and firmly imbedded in the follicles, while they are almost always stumpy in ringworm, and in those cases in which they are not broken off, if pulled, they easily fall out. Ring- worm is contagious, eczema is not. Alopecia areata presents a white, shiny, ivory-like, bald patch, de- void of scales, eruption, or hair. Ringworm has the vesicular or scaly patch, with broken-off hairs. In any case of doubt the microscope will readily determine the diagnosis, if “ one or two of the short, stumpy hairs should be placed upon a slide with a drop of liquor potassce and permitted to stand a few minutes, when, under a power of two hundred and fifty diameters the fungus, as well as the lesions of the hair, will be visible. Prognosis. Favorable, although obstinate in chronic cases. Re- lapses are of frequent occurrence. Treatment. Local measures are satisfactory in the majority of instances of tinea tonsurans. Mild cases should be treated by cutting the hair as close as possible and thoroughly scrubbing the patches with sapo viridis and water, or the application twice daily of a twenty-five to a fifty per cent, solu- tion of boroglyceride, or a six per cent, solution of oleatum hydrar- gyri y or either of the following : — R. *Sodii borat., Aceti destil., f ^ ij. SiG. — Apply thoroughly several times daily. R . Acidi boracici, gr. xv Sulphur, flor., gr. xv Vaselini, f^iss. SiG. — Apply morning and night. M. M. 542 PRACTICE OF MEDICINE. Or — R. Cupri oleat., gss Ung. petrolei, £ ij. M. Sio. — Apply after using boric solution. Or, use may be made of Morris’ thymol solution, to wit : — R. Thymol, ^ss Chloroformi, fsjij Ol. olivse, f ^ vj. M. A preparation very popular in London, known as Coster’s paste, is used by painting the patches with a brush and allowing it to remain on until the crust is cast off, in the course of five or six days, when it may be reapplied. A few applications often suffice. Its formula is — R. Iodi, ^ i j Olei picis, f Jjj. M. The iodine and oil of tar should be gradually and slowly mixed. An excellent application in rebellious cases is — R . Potassse (caustic), gr. ix Acid carbolici, gr. xxiv Lanoline, % ss 01. theobromse, J ss. M. SiG. — A small amount rubbed into head night and morning. If the scalp is not shaved the application is retained better. Cases which resist these means are to be treated by removing the loose hairs about the edges of the patches, and the broken-off hairs over the surface, by means of small, broad-bladed, short forceps, a few hairs only being seized at a time ; a portion of the diseased hairs to be removed each day until the surface has been cleared. After each depilation, one of the above formulae is to be applied. TINEA SYCOSIS. Synonyms. Tinea trichophytina barbae; sycosis parasitica; barbers’ itch ; ringworm of the beard. Definition. A contagious , parasitic affection of the hair, hair- follicles, and subcutaneous tissues of the hairy portion of the face and neck in the adult male, due to the trichophyton fungus ; character- ized by the development of tubercles and pustules. Cause. Tinea sycosis is the result of the presence and growth of DISEASES OF THE SKIN. 543 the same vegetable parasite that causes tinea circinata and tinea ton- surans — trichophyton — which invades the hair follicle and hair. It is highly contagious, and is said to be acquired, in most cases, at the hands of the barber (?). It is not a very common affection. Like the other vegetable growths, it seems to require some peculiar, unknown condition of the skin for its development. It may develop from a case of tinea circinata or develop simultaneously with it. Pathology. The parasite finds its way into the hair follicles and attacks the root and shaft of the hair, causing inflammation, followed by more or less follicular suppuration and general infiltration of the surrounding tissues. The irritation caused by the presence of the fungus results in inflammation of the subcutaneous connective tissue apd the well-known tubercular formations peculiar to the affection. They are firm, comparatively painless, and manifest but little dispo- sition to undergo change, remaining during the presence of the fungus and finally gradually disappearing without leaving a scar. Under the microscope the parasite is plainly discernible. Symptoms. Barbers’ itch begins as an attack of tinea circinata — as one or more reddish, scaly patches. Soon the redness and des- quamation become more decided, attended with swelling and indura- tion. The hairs will also be dry, brittle, incline to break, and many of them are already loose. The process rapidly increases, the skin becomes distinctly nodular and lumpy, and points of pustulation de- velop about the openings of the hair follicles. The subcutaneous con- nective tissue is also involved, giving rise to thick, firm masses of in- duration. The surface has a dark red or purplish color, and is studded with variously-sized tubercles and pustules. In some instances the num- ber of tubercles are in excess, while in others the pustules are mdre numerous, numbers of them discharging, and are succeeded by thick crusts, which are often so abundant as to simulate pustular eczema. The hairs are always diseased, and break off, either in the follicles or just above the level of the surface. Those not breaking drop out, leaving the region partly or wholly devoid of hair. The most frequent location attacked is the chin, neck, and sub- maxillary region. One or, what is more common, both sides of the face are involved. Itching , burning , pain, and swelling always accompany the affec- tion, varying in intensity from moderate to very severe. 544 PRACTICE OF MEDICINE. The course of the affection is usually chronic. Relapses are fre- quent, unless most thoroughly eradicated. Diagnosis. Sycosis non-parasitica occasions difficulty of diag- nosis at times. The points of difference, however, are usually so marked that error should not occur. Sycosis non-parasitica is a chronic, inflammatory, non-contagious affection of the hair follicles, characterized by the development of papules and pustules, which are perforated with hairs, the hairs them- selves being unaffected. The upper lip, cheeks, and chin are the parts mostly involved. If of long duration, some inflammatory thickening results. In tinea sycosis or sycosis parasitica, the skin and subcutaneous connective tissue are extensively involved, as manifested by the in- duration and formation of the characteristic tubercles. The upper lip is rarely invaded, the hairs are diseased, broken off, or loose, and under the microscope reveal the parasite. Pustular eczema resembles tinea sycosis, with extensive pustulation and crusting. But in the former the hairs are not involved, nor are the characteristic tubercles present. Treatment. Local measures are sufficient for the cure of tinea sycosis. In the majority of instances the following procedure will effect a cure in three or four weeks. If crusts are present, and almost always some are, they are to be thoroughly saturated with inunctions of almond or olive oil, and removed by washing with soft soap and water. The part is then cleanly shaved, the first operation being more painful than subsequent ones. After shaving, the affected sur- face is bathed for ten minutes in water as hot as can be borne. All pustules are then opened with a fine needle, after which the parts are sponged freely for several minutes with a solution of sodii hyposul- phitis , 3j» aqua, f^j, after which the parts are again thoroughly washed with hot water, carefully dried, and smeared with an unguentum sul- phur., containing 3j-ij to the ounce. This procedure is preferably performed at night. The following morning the ointment is washed off with soap and water, the face bathed with the sodium solution, and dusted with any inert powder. This plan continued faithfully every night, omitting the shaving when the beard has not grown much, will usually be followed with success. Cases resisting the above means should, in addition to the above, have the hairs depilated, the shaving performed every two or three DISEASES OF THE SKIN. 545 days, thus allowing time for the hairs to grow sufficiently to depilate, the operation seldom being so painful as one would suppose. Shav- ing and depilation upon alternate days should be faithfully practised until the new hairs show themselves to be healthy. In addition to the parasiticides mentioned, any of those recom- mended for the other vegetable parasitic diseases may be used. TINEA VERSICOLOR. Synonyms. Pityriasis versicolor ; liver-spots. Definition. A contagious , parasitic affection of the skin, due to the microsporon furfur ; characterized by the occurrence of variously- sized, irregularly-shaped, dry, slightly furfuraceous, yellowish spots upon the chest or other portions of the body. Cause. Pityriasis versicolor is the result of the presence upon the surface of the skin of a vegetable fungus termed microsporon furfur. It is a mildly contagious affection seen after puberty. It is said to occur most frequently in those suffering from wasting diseases, partic- ularly phthisis pulmonalis. It is not connected with any affection of the liver, as supposed by the laity. Pathology. The fungus permeates the horny layer of the epidermis, never the hair or nail, and gives rise to the irregular- shaped and sized maculae, of a yellowish or brownish color. As a rule, it gives rise to neither hyperaemia nor inflammatory symp- toms. Symptoms. Tinea versicolor occurs in the form of irregular, roundish, circumscribed, or reticulated maculae. The spots vary in size from that of a small silver coin to that of the hand. By coal- escing they often cover a greater portion of the chest, their most usual site. Upon close inspection the surface of the macule is seen to be covered with furfuraceous scales, and if the scales be not visible, scraping with the finger nail will demonstrate their presence. In color the spots vary from a delicate buff or fawn shade to a yellowish, deep brown, and, rarely, even blackish hue. At times mild itching accompanies the eruption. Diagnosis. The characteristics of the eruption are so distinct that errors in diagnosis can hardly occur. If any doubt exist, a few of the scales placed upon a glass slide, with a drop of liquor potasses, and covered with a thin glass cover and placed under a microscope 546 PRACTICE OF MEDICINE. with a power of from two hundred and fifty to five hundred diameters will readily determine the presence of the fungus. Prognosis. Favorable. Treatment. The parts should be cleansed with soap and water, and either of the following lotions applied : — R . Sodii sulphitis, 3 iij Glycerini, . fzij Aquae, ad . . . . f^iv. SiG. — Apply frequently. Or— R . Hydrargyri chlorid. corrosiv., gr. iv Alcoholis, f 3 v j Ammonii muriat., ^ss Aquae rosae, ad . . . . f^vj. SiG. — Apply frequently. — Tilbury Fox. M. M. SCABIES. Synonym. The itch. Definition. A contagious , animal parasitic disease of the skin, due to the acarus or s arc op tes scabiei ; characterized by the formation of cuniculi (burrows), papules, vesicles, and pustules ; followed by excoriations, crusts, and general cutaneous inflammation, and accom- panied with itching. Cause. Contagion. The only cause is the presence of the ani- mal parasite, the acarus, or sarcoptes scabiei. The affection occurs at all ages and in every walk in life. Pathology. Scabies is an inflammation of the skin with the development of papules, vesicles, pustules, excoriations, and subse- quent crusting, the result of the ravages of the animal parasite, together with the irritation produced by the scratching of the patient. The parasite acarus , or sarcoptes scabiei, — is a minute creature, barely visible to the naked eye as a yellowish-white, rounded body. The female is the most commonly met with, the males being said to take no part in causing the affection, and so are rarely seen. They are said to die in about a week after copulation with the female. The female finds her way by boring through the horny layer into the mucous layer of the epidermis, and, being impregnated, begins at once laying her eggs and at the same time making her burrow. A variable number of eggs are deposited, usually about a dozen, after DISEASES OF THE SKIN. 547 which she perishes in the skin. The ova hatch out in eight or ten days. Symptoms. Scabies being an artificial dermatitis or eczema, according to the amount of irritation produced by the presence of the parasite and the traumatism the result of the severe scratching of the patient. Immediately upon the arrival of the itch mite upon the skin it begins its work of burrowing, and very soon a burrow or cuniculus is formed, in which the eggs are deposited, and which also becomes the habitat of the female during the remainder of her life. The ova are hatched in about one week after their deposit, and they at once begin to care for themselves and to burrow, resulting in the formation of as many additional cuniculi as there are active female mites. It is the presence of these burrowing parasites that constitutes the irritation resulting in the inflammation of the skin, characterized by the formation of minute papules , vesicles , and pustules , with more or less inflammatory indura- tion. Add to 'these the excoriations , scratch marks, fissures, torn vesicles, and pustules with yellow and bloody crusts, caused by the scratching, and a picture of the fully-developed disease is seen. The burrow, or cuniculus, as it is termed, is formed by the mite entering and making its way beneath the horny layer of the epidermis, which is raised, very much as a mole undermines the ground. It occurs as a slight linear elevation of the epidermis, varying from a half a line to four or five lines in length, and having an irregular or tortuous course. Its color is whitish or yellowish, speckled here and there with dark dots. At either end the cuniculus terminates as darkish points, the more prominent of which represent the parasite. The papules are the first inflammatory lesion, are numerous, and of small size, and may be the extent of the disease. The vesicles are the next stage, varying in size and number, having an inflamed base, sometimes presenting cunicula upon their summits. The pustules represent the completion of the inflammatory action, their size and number varying with the severity of the irritation. The intense itching , which is worse at night, results in excoriations, torn papules, vesicles, and pustules, followed by crustings, which after a time disguise the characteristic lesions. The regions of the body attacked are the hands, especially the sides of the fingers and the folds where they join the hands. After a time the wrists, penis, and mammae, and around about and upon the nipples, are invaded. 548 PRACTICE OF MEDICINE. Persons predisposed to eczema have this affection developed, in addition to the simple dermatitis, by the ravages of the itch mite. Diagnosis. A case of scabies seen before irritated by scratching presents no difficulty in diagnosis. The presence of the burrows always suffices for the diagnosis, but these are not always discover- able. The location of the eruption always points strongly to scabies. A history of contagion is of value. All doubt can be set at rest by the aid of the microscope. Prognosis. Always favorable, relapses only occurring when the treatment has been imperfectly carried out or where the individual has re-contracted the disease. Treatment. Local measures are alone required in the treatment of scabies. The strength of the parasiticides must be controlled by the severity of the inflammatory symptoms present. If eczema com- plicate scabies, it is to be treated as an ordinary attack after the death of the itch mites Scabies always succumbs to the following plan. The patient is to be thoroughly washed with soft soap and water, followed by a warm bath, after which one of the following ointments is to be thoroughly rubbed into every portion of the body, special attention being devoted to the hands, fingers, and other parts usually the seat of the disease. R . Styracis liquidis, 3 ij Ung. sulphuris, 3 ij-iv Ung. petrolei, ad gj. M. SiG. — Apply after washing. — Bulkley. Or — R . Sulphuris sublimat., gj Balsam Peruviani, 5 j ss Adipis, -|j. M. SiG. — For children. — Duhring. Or — R. Creolin, gr. viij-x Ung. petrolei, % ij. M. SiG. — Apply thoroughly. PEDICULOSIS. Synonyms. Phthiriasis ; morbus pedicularis ; lousiness. Definition. A contagious , animal parasitic disease of the head, body, or pubes, due to the presence of pediculi and characterized by DISEASES OF THE SKIN. 549 the wounds inflicted by the parasite, together with excoriations and scratch marks. Varieties. Pediculosis capitis ; pediculosis corporis ; pediculosis pubis. Cause. The cause is the presence of the parasite, the result of contagion, direct or indirect. The view of “ a spontaneous genera- tion ” of pediculi is not accepted by the great majority of observers. Pathology. The lesion produced by the presence of the pediculi is a minute hemorrhage, caused by the parasite inserting its sucking apparatus, or, as it is termed, its haustellum, into a follicle, and obtain- ing blood by a process of sucking, and not by biting, as is generally supposed. The presence of the parasite in any great numbers brings about a peculiar irritable state of the skin, which gives rise to an irre- sistible desire to scratch, as a consequence of which the surface is markedly excoriated and lacerated. Symptoms. The symptoms which arise from the presence of the parasite in different localities are somewhat different, and call for separate consideration. Pediculosis capitis. This variety is caused by the presence of the pediculus capitis, or head louse. The ova , or nits, are readily recog- nized at a distance. Their favorite seat is the occipital region, either upon the surface of the scalp or upon the hair. Their presence gives rise to considerable irritation, itching, and consequent scratching, re- sulting in the wounding of the scalp, with oozing of a serous or puru- lent fluid mixed with blood, which soon mats the hair and forms into crusts. In those predisposed to eczema, the presence of the parasite will give rise to that conditon. The general health is usually unaffected by the presence of the pediculi. Pediculosis corporis. This variety of the pediculosis is caused by the presence of the pediculus corporis, or body louse, or more properly termed the pediculus vestimenti, or clothes louse. Its color, when devoid of blood, is dirty-white or grayish, with a dark line around the margin of its abdomen. Its habitat is the clothing covering the general surface, remaining upon the skin only long enough to obtain sustenance. The ova are usually deposited in the seams of the cloth- ing, the lice being hatched within the week. Occasionally a few of the pediculi may be observed crawling about the surface, or in the act of drawing blood. As they move over the surface they give rise 550 PRACTICE OF MEDICINE. to an intensely disagreeable itching sensation, to relieve which the patient scratches, which in turn gives rise to the characteristic lesions of the affection. The lesions are numerous. The scratch marks are scattered here and there, either long and streaked, in other places short and jagged, the excoriations and blood crusts varying in size from a pin head to a split pea or even larger, with irregularly-shaped pustules. In addition to the lesions resulting from the scratching, are seen the primary lesions, consisting of minute reddish puncta with slight areolae, the points at which the parasite has drawn blood. In cases of long stand- ing, a brownish pigmentation of the whole skin may result from the long-continued irritation and scratching. The favorite site of the lesions are the back, especially about the scapular region, the chest, abdomen, hips, and thighs. Pediculosis is seen most commonly among the poorer classes, and especially the middle-aged and elderly. Pediculosis pubis. This variety of pediculosis is caused by the pre- sence of the pediculus pubis, or crab louse. Although having its seat of predilection about the pubes, it may also infest the axillae, sternal region in the male, beard, eyebrows, and even eyelashes. They may be found crawling about the hairs, but more commonly hugging the surface closely. They infest adults chiefly, and occasion symptoms similar to those described in connection with other species. They are usually contracted through sexual intercourse, although occasionally they are present in cases in which they have not been communicated in this way, and where no explanation as to the mode of contagion can be suggested. The itching varies from slight to severe. Diagnosis. When violent itching exists in any case, without marked eruption, the possibility of the presence of pediculi should always be entertained, and if carefully sought after are found. Prognosis. F avorable, if the treatment be thoroughly carried out. Treatment. Local measures alone are all that is necessary for the removal of the various forms of pediculosis. Pediculosis capitis. The most effective application of this variety is to thoroughly soak the head two or three times a day with ordinary petrole2im or kerosene oil , and keep it wrapped in a cloth for twenty- four hours. At the end of this time the head should be thoroughly washed with soft soap and hot water, dried, and saturated with the DISEASES OF THE SKIN. 551 official unguentum hydrargyri ammoniati. If required, this entire procedure may be repeated, but usually any pediculi escaping the petroleum are destroyed by the unguentum. Pediculosis corporis. In this variety, the habitat of the parasite being the clothing, they must be boiled or baked at a temperature sufficiently high to destroy their life. After this the clothing should be changed every day or two, carefully inspected, and if pediculi are seen they must again be baked or boiled. It is folly to expect satis- factory results unless these directions be faithfully adhered to. For the irritation, itching, and excoriations, mild alkaline baths or lotions of acidum carbolicum are sufficient. Pediculosis pubis. The parts should be washed twice daily with soft soap and water, after which the thorough application of tinctura cocculus indicus , full strength or diluted, or a lotion of hydrargyri chloridum corrosivum or unguentum hydrargyi ammoniati will be effectual. INDEX. Abdominal dropsy, 128. typhus, 21. Abscess, cerebral, 382. of the heart, 347. of the liver, 136. perityphlitic, 115. Acne, 516 artificialis, 517. disseminata, 516. indurata, 517. papulosa, 516. punctata, 477, 516. pustulosa, 517. rosacea, 518. sebacea, 474. tubercula, 516. vulgaris, 516. Aconite in erysipelas, 61. Aconitinae in neuralgia, 432. Acute articular rheumatism, 193. Bright’s disease, 150. gastric catarrh, 70. gastritis, 73. general diseases, 185. hepatitis, 136. meningitis, 364. nasal catarrh, 238. uraemia, 162. yellow atrophy, 138. Addison’s disease, 180, 526. Ague, 37 brow, 38. cake, 37. dumb, 38. Agraphia, 386. amnesic, 386. Albumin, tests for, 145. nitric-magnesian, 145. Albuminuria, 151. chronic, 153. Alcoholism, 392. acute, 392. 46 Alcoholism, chronic, 393. Amyloid kidney, 159. Anaemia, 172. Blaud’s pill for, 176. cerebral, 372. essential, 174, 176. lymphatic, 179. of fatty heart, 176. progressive pernicious, 176. splenica, 177. Anaematosis, 176. Anatomy, morbid, n. Aneurism of the arch of aorta, 361 of the abdominal aorta, 362. of the thoracic aorta, 362. Angina pectoris, 356. spartein in, 358. Anidrosis, 483. Antipyrine in migraine, 392. Anodynes, compound of, 86. Anthrax, 513. Aorta, aneurism of the, 360. Aphasia, 386. amnesic, 386. ataxic, 386. Aphonia, 387. Aphthae, 64. discrete, 64. confluens, 64. Aphthous stomatitis, 64. Apnoea, 13. Apoplexy, 373. ingravescent, 374. serous, 400. Appendicitis, 115. Arachnitis, 365. Argyria, 526. Arrhythmia, 356. Arteries, Cohnheim’s terminal, 379. Arterio-sclerosis, 358. Atheroma, 358. iodides in, 358 INDEX. 554 Arthritis deformans, 201. mono-, 194. poly-, 194. Artisans’ cramp, 447. Ascaris lumbricoides, 123. Ascites, 128. Asthenia, 13. Asthma, 274. bronchial, 274. hay, 277. Kopp’s, 259. spasmodic, 274. Ataxia, locomotor, 421. Ataxic paraplegia, 424. Atonic dyspepsia, 86. Atrophic paralysis of children, 413. Atrophy, acute yellow, 138. of the liver, 139. Atropia for hemorrhage, 285. Aura epileptica, 436. Auscultation, 226. Da Costa’s rules for, 227. Autumnal fever, 21. Bacillus, comma, 212. Klebs-Lceffler, 186. malaria, 37. of Eberth, 21. of Pfeiffer, 18 tuberculosis, 306. typhosus, 21. Bacteria of decomposition, 213. Barber’s itch, 542. Basedow’s disease, 443. Basham’s iron mixture, 152. Bell’s palsy, 433. Belt, hydropathic, 136. Beri-beri, 428. Biliary calculi, 133. Bile, test for, 147. pigment, test for, 147. Bilious fever, 39, 71. headache, 390. malignant fever, 45. remittent fever, 39. typhoid fever, 35. Biliousness, 134. Black-heads, 478. Bladder, catarrh of, 1 68. Blaud’s pill, 176. Bleeders’ disease, 18 1. Blepharospasm, 435. Blind headache, 390. Blisters in rheumatism, 198 water, 507. Blood currents, direct, 323. diseases of, 172. indirect, 323. test for, 146. white cell, 177. Bloody flux, 108. Boil, 5 1 1. Borborygmus, 82. Bothriocephalus latus, 121. Bowels, inflammation of, 96. Brachycardia, 355. Bradycardia, 355. Brain, congestion of, 370. Brand’s method, 29 Break-bone fever, 62. Bright’s disease, acute, 150. chronic, 153, 156. Bromidrosis, 480. pedum, 480. Bronchial dilatation, 271. hemorrhage, 284. Bronchitis, acute, 263. capillary, 266, 297. catarrhal, 263. chronic, 270. croupous, 268. diphtheritic, 268. fetid, 272. fibrinous, 268. membranous, 268. peri-, 297. plastic, 268. secondary, 270. senile, 270. Broncho-pneumonia, 266, 297 Bronchorrhagia, 284. Bronchorrhcea, 271. Bronzed-skin disease, 180. Caecum, catarrh of, 1 1 3. Calculi, alternating, 167. biliary, 133. cutaneous, 478. hepatic, 133. oxalate of lime, 166. phosphatic, 166. renal, 166. INDEX. 555 Calculi, uric acid, 166. Callositas, 528. Callus, 528. Cancer, gastric, 79. hepatic, 14 1. Cancrum oris, 70. Carbuncle, 513. Carbunculus, 513. Carcinoma, gastric, 79. of the liver, 141. Cardiac dilatation, 344. fatty degeneration, 351. hypertrophy, 342. murmurs, 322. paralysis, 189. see-saw murmurs, 339. valvular diseases, 334. Cardialgia, 84. Carditis, 347. chronic, 348. Catalepsy, 441. Catarrh, acute bronchial, 263. acute gastric, 7 1 . acute nasal, 238. autumnal, 277. chronic bronchial, 270. chronic gastric, 74. chronic nasal, 241. contagious, 18. dry, 271. mucous, 271. of the bile ducts, 131. of the bladder, 1 68. of the caecum, 113. of the mouth, 63. of the rectum, 117. sec. of Laennec, 271. Catarrh, suffocative, 266. Catarrhal enteritis, 96. jaundice, 131. nephritis, 149. pneumonia, 297. stomatitis, 63. tonsillitis, 243. Cephalic tetanus, 446. Cephalodynia, 198. Cerebral abscess, 382. anaemia, 372. congestion, 370. embolism, 378. fever, 365. Cerebral hemorrhage, 373. hyperaemia, 370. softening, 373. thrombosis, 378. tumors, 383. Cerebro-spinal fever, 33. neuroses, 434. Cervico-brachial neuralgia, 431. Cervico-occipital neuralgia, 431. Chicken-pox, 59. Child-crowing, 253. Chills and fever, 37. Chloasma 525. uterinum, 527. Chlorides, test for, 144. Chlorosis, 174. Cholera, 212. Asiatic, 212. asphyxia, 214. bilious, loo. English, 100. epidemic, 212. infantum, 106. malignant, 212. morbus, 100. saline fluids in, 217. solution, Bartholow’s, 216. spasmodic, 212. sporadic, 100. typhoid, 215. Cholerine, 214. Chorea, 434. post-hemiplegic, 376, 435. Chromidrosis, 480. Chronic dyspepsia, 74. endocarditis, 334. gastric catarrh, 74. ulcer, 77. gastritis, 74. interstitial myocarditis, 348. nasal catarrh, 241. spinal muscular atrophy, 417. Circular insanity, 458. Clark’s treatment of peritonitis, 127. Clavus, 529. Clinical history, 12. Cohnheim’s terminal arteries, 379. Cold on the chest, 263. in the head, 238. Colic, hepatic, 133. intestinal, 90. 556 INDEX. Colic, lead, 90. ovarian, 91. renal, 166. stomachic, 84. uterine, 91. Colitis, 108. ulcerative, 108. Coma, 13. uraemic, 162. Comedo, 477. Comedones, 477. Comma bacillus, 212. Congestion, cerebral, 370. hypostatic, 286. of the kidneys, 149. of the liver, 134. of the lungs, 286. spinal, 403. Congestive fever, 41. Constipation, 92. glycerinum for, 93. Consumption, pulmonary, 300. galloping, 301. throat, 261. Contagious fever, 31. catarrh, 18. Convulsions, uraemic, 162. Cordis, arrhythmia, 356. Corns, 529. soft, 529. Corrigan’s disease, 308. hammer, 397. sign, 81. Coryza, acute, 238. chronic, 241. Coster’s paste, 542. Costiveness, 92. Cough, winter, 270. Coup-de-soliel, 398. Crackling, 293. Crepitatio redux, 293. Crisis, 13. Croup, catarrhal, 21; 3. false, 253. membranous, 254. pseudo-, 259. spasmodic, 253. true, 254. Croupous enteritis, 99. laryngitis, 254. pneumonia, 289. | Croupous stomatitis, 64. Cry, hydrocephalic, 369. Cyst, renal, 161. sebaceous, 479. Cysticercus cellulosus, 121. bovis, 1 21. Cystitis, 168. acute, 168. chronic, 168. Dandruff, 474. Dandy fever, 62. Death, 13. Declat syrup, 5 1 . Degeneration, caseous, 303. reactions of, 414. Degenerative neuritis, 428. Delirium tremens, 398. Delusional insanity, 460. Dementia, 465. acute, 466. alcoholic, 466. apoplectica, 467. choreica, 467. chronic, 467. epileptic, 458. epileptica, 467. organic, 467. paralytica, 467, 469. paretic, 469. partial, 467. primary, 467. secondary, 467. senilis, 468. syphilitica, 468. toxica, 468. j Dengue, 62. Depression of spirits, 450. Dewees’ mouth caustic, 67. Diabetes insipidus, 209. mellitus, 205. Diagnosis, 14. by exclusion, 14. differential, 14. direct, 14. physical, 2 1 9. Diarrhoea, 93. acute, 94, 96. bilious, 94. choleriform, 106. chronic, 94. feculent, 93. INDEX. 557 Diarrhoea, inflammatory, 102. lienteric, 94. mixture, Squibb’s, 95. Diathesis, 12. Dilatation, bronchial, 271. cardiac, 344. gastric, 82. Diphtheria, 186. bronchial, 268. laryngeal, 188, 254. nasal, 188. Diphtheritic, paralysis, 189. stomatitis, 65. Diplococcus pneumoniae, 289. Dipsomania, 393. Discharges, chopped spinach, 103. rice water, 97, 100, 214. Disease, 9. acute, 13. Addison’s 180, 526. Basedow’s, 443. bleeders’, 181. Bright’s, 150, 153, 156. causes of, 1 1 . chronic, 13. Corrigan’s, 308. defined, 9. Duchenne’s, 419. fish-skin, 532. flesh-worm, 217. Fothergill’s, 430. functional, 9. Graves’, 443. Hodgkin’s, 179. Meniere’s, 388. organic, 9. predisposition to, 1 1 . subacute, 13. termination of, 13. Diseases, acute, general, 185. general or nutritional, 434. mental, 450. of the biliary passages, 13 1. of the blood, 1 72. of the bronchial tubes, 263. of the cerebral membranes, 364. of the cerebrum, 370. of the circulatory system, 319. of the intestinal canal, 88. of the kidneys, 142. of the larynx, 248. Diseases of the liver, 134. of the lungs, 286. of the mouth, 63. of the nasal passages, 238. of the nerves, 427. of the nervous system, 363. of the peritoneum, 124. of the pharynx, 243. of the pleura, 313. of the respiratory system, 219. of the skin, 474. of the spinal cord, 403. of the stomach, 71. Disorders of secretion, 474. Dizziness, 388. Dobell’s solution, 51. Dropsy, cutaneous, 49. of the abdomen, 128. of the pleura, 317. pericardial, 329. peritoneal, 128. pleural, 317. Duchenne’s disease, 419. Duodenitis, 96. Dysentery, acute, 108. chronic, 1 10. epidemic, 108. sporadic, 108. washing rectum in, 112. Dyspepsia, 86. acid, 87. atonic, 86. chronic, 74. drunkards’, 74. flatulent,- 87. hot water in, 76. intestinal, 88. irritative, 87. nervous, 86. Ecstasy, 441. Ecthyma, 510. Ectopia renis, 17 1. Eczema, 484. acute, 490! ani, 497. aurium, 496. barbae, 495. capitis, 493. chronic, 488. erythematosum, 486. INDEX. 558 Eczema, faciei, 494. fissum, 488. genitalium, 496. impetiginosum, 487. intertrigo, 486, 498. labiorum, 495. madidans, 487. mammarura, 498. marginatum, 538. palmarum, 498. palpebrarum, 495. papillomatosum, 488. papulosum, 486. plantarum, 498. pustulosum, 487. rimosum, 488. rubrum, 487, 492. sclerosum, 488. squamosum, 487. unguium, 498. universale, 486. verrucosum, 488. vesiculosum, 486. Electrical storm, 437. Elixirs, triple, 352. Embolism, cerebral, 378. Emetic, Dr. Fordyce Barker’s, 257. Emphysema, 281. Empyema, 314. Encephalitis, acute, 382. suppurative, 382. Endarteritis, chronica deformans, 358. Endocarditis, acute, 330. chronic, 334. diphtheritic, 332. mycotic, 332. septic, 332. ulcerative, 332. Enteralgia, 90. Enteric fever, 21. Enteritis, catarrhal, 96. croupous, 99. membranous, 99. Entero-colitis, 102. mesenteric fever, 21. Enterorrhoea, 93. Ephemeral fever, 17. Epidemic catarrhal fever, 18. cerebro-spinal fever, 33. roseola, 54. Epilepsy, 436. Epileptic insanity, 457. dementia, 458. imbecility, 458. Errhine, Ferrier’s, 240. Erysipelas, 59. ambulans, 60. of the brain, 60. phlegmonous, 60. Erysipelatous dermatitis, 59. Erythema simplex, 483. intertrigo, 484. Erythematous stomatitis, 63. Essential anaemia, 176. Etiology, 1 1 . Eucalyptol in cystitis, 1 70. Exophthalmic goitre, 443. Exudative endocarditis, 320. Facial paralysis, 433. Famine fever, 35. Fatty heart, 351. Favus, 534. Febricula, 17. Feeble-mindness, acquired, 465. Ferrier’s errhine, 240. Fever, 15. abdominal typhus, 21. autumnal, 21. bilious, 39, 71. bilious remittent, 39. bilious typhoid, 35. breakbone, 62. catarrhal, 18. cause of, 15. cerebral, 365. cerebro-spinal, 33. congestive, 41. contagious, 31. continued, 16. dandy, 62. enteric, 21. entero-mesenteric, 21. ephemeral, 17. epidemic cerebro-spinal, 33. famine, 35. gastric, 21, 71. hay, 277. intermittent, 37, irritative, 17. jail, 31. lung, 289. INDEX. 559 Fever, malarial, 37. malignant intermittent, 41 malignant remittent, 41 marsh, 39. Mediterranean, 45. nervous, 21. neuralgic, 62. pernicious, 41. relapsing, 35. remittent, 39. rheumatic, 193. rose, 277. sailors’, 45. scarlet, 48. ship, 31. simple, continued, 17. spotted, 31. swamp, 37. typhoid, 21. typho-malarial, 39. thermic, 398. typhus, 31. winter, 289. yellow, 45. Fevers, 15. continued, 16. eruptive, 47. general treatment of, 16. periodical, 36. primary cause of, 15. Fibroid heart, 348. Fibrosis, arterio-capill ary, 358. Fibrous myocarditis, 348. Fish-skin disease, 532. Flesh-worm disease, 217. Floating kidney, 1 7 1 . Fluxes, vicarious, 93. Folie circulaire, 458. Follicular stomatitis, 64. FothergilFs disease, 430. Freckles, 525. Fremitus, bronchial, 221. friction, 221. tussive, 221. vocal, 221. Furuncle, 511. Furunculus, 51 1. Furunculosis, 51 1. Gall stones, 133. Gastralgia, 84. Gastric cancer, 79. carcinoma, 79. dilatation, 82. fever, 21, 71. hemorrhage, 83. neuralgia, 84. ulcer, 77. Gastritis, acute, 73. chronic, 74. subacute, 71. toxic, 73. Gastrodynia, 84. Gastrorrhagia, 83. Gastroscope, uses of, 81. General paralysis, 469. German measles, 54. Girdle, a, 503. Glossitis, 68. Glottis, oedema of, 250. spasm of, 259. Glycosuria, 205. simple, 207. Goudron de Guyot, 492. Gout, 202. half, 21 1. rheumatic, 201. Gravel, 166. Graves’ disease, 443. Green sickness, 174. Gripes, 90. Gross’, Prof. S. D., neuralgic pill, 432. Grutum, 478. Gutta rosea, 518. rosacea, 518. Haematemesis, 83. Hasmatoma of the dura mater, 364. Haemophilia, 181. Haemoptysis, 284. Hay fever, 274. Heat stroke, 398. Heart, anaemia of fatty, 176. dilatation of, 344. fatty degeneration of, 35 1 . hypertrophy of, 342. irritable, 353. neuralgia of, 356. palpitation of, 353. physical examination of, 319. rapid, 354. valvular diseases of, 334. 560 INDEX. Heartburn, 86. Heat exhaustion, 398. stroke, 398. Hemicrania, 390. Hemiplegia, 375. Hemorrhage, bronchial, 284. cerebral, 373. gastric, 83. renal, 167. Hemorrhagic diathesis, 181. Hemorrhoea petechialis, 183. Hepatic cancer, 141. colic, 133. calculi, 133. Hepatitis, acute, 138. general parenchymatous, 138. interstitial, 139. parenchymatous, 138. suppurative, 138. Herpes, 502. circinatus, 537. facialis, 502. gestationis, 503. labialis, 502. praeputialis, 503. progenitalis, 503. tonsurans, 539. zoster, 503. Histology, 11. Hives, 499. Hodgkin’s disease, 179. Hooping cough, 279. Hydraemia, 172. Hydro-adenitis, 512. Hydrocephalus, acquired, 400. acute, 368, 400. chronic, 40 1. congenital, 401. Hydropathic belt, 136. Hydropericardium, 329. Hydropneumothorax, 318. Hydrosis, 479. Hydrothorax, 317. Hyperaemia, cerebral, 370. renal, 149. spinal, 403. Hyperaemias of the skin, 483. Hyperidrosis, 479. local, 480. unilateral, 480. Hypertrophies of the skin, 525. j Hypertrophy, cardiac, 342. j Hysteria, 438. Hystero-epilepsy, 441. Ichthyosis, 532. Icterus, 131. hemorrhagic, 138. Impetigo, 51 1. Incubation, period of, 13. Indigestion, 86. acute, 71. intestinal, 88. Inebriety, 467. Inflammations of the skin, 484. Influenza, 17. Insanity, 452. alternating 459. chronic delusional, 463. epileptic, 457. circular, 458. delusional, 460. Kahlbaum’s, 459. Insolation, 398. Inspection, 220. Intercostal neuralgia, 503. Intermittent fever, 37. tetanus, 445. Interstitial nephritis, 156. Intestinal colic, 90. dyspepsia, 88. obstruction, 118. parasites, 12 1. stricture, 118. torpor, 92. Intestines, diseases of, 88. irrigation of, 120. Introduction, 9. Invagination, 119. Ipecacuanha in dysentery, 112. Iron lemonade, 174. Irritative fever, 17. Ischaemia, 173. : Itch, 546. barber’s, 542. Jail fever, 31. Jaundice, catarrhal, 13 1. malignant, 138. Kahlbaum’s insanity, 459. I Kakke, 428. INDEX. 561 Katatonia, 459. Kidneys, amyloid, 159. congestion of, 149. contracted, 156. diseases of, 142. floating, 1 7 1. gouty, 156. lardaceous, 159. movable, 17 1. sclerosis of, 156. small red, 156. wandering, 17 1. waxy, 159. white, large, 153. Kleb’s micrococci, 48. Kummerfield’s lotion, 520. Laryngismus stridulus, 259. Laryngitis, acute catarrhal, 248. croupous, 254. oedematous, 250. spasmodic, 253. tuberculous, 261. Larynx, diseases of the, 248. Law of parallelism, 195. Lentigo, 525. Lepra, 521. Leprosy, English, 521. Leptomeningitis, acute, 365. spinalis, 406. Leucaemia, 176. Leucocythemia, 176. Lichen simplex, 486. tropicus, 506. Liquor picis alkalinus, 492. Lithaemia, 21 1. Lithiasis, 21 1. Liver, abscess of, 136. albuminous, 140. amyloid, 140. atrophy of, 139. carcinoma of, 141. cirrhosis of, 139. congestion, 134. diseases of, 134. gin drinkers’, 139. hobnailed, 139. hypertrophic sclerosis of, 139. lardaceous, 140. nutmeg, 135. sclerosis of, 139. 47 Liver, scrofulous, 140. spots, 525, 545. torpid, 134. waxy, 140. yellow atrophy of, 138. Localization of the functions of the segments of the spinal cord, 410. Lock-jaw, 446. Locomotor ataxia, 421. Lotio nigra, 490. Lousiness, 548. Lumbago, 198. Lumbo-abdominal neuralgia, 431. Lumbodynia, 199. Lungs, cirrhosis of, 308. congestion of, 286. consumption of, 300. gangrene of, 290. hyperaemia of, 286. oedema of, 287. Lymphadenoma, 179. Lysis, 13. Malariae, oscillaria, 11. Malignant endocarditis, 332. intermittent fever, 41. remittent fever, 41. Mai le grand, 436. Mai le petit, 436. Malarial fever, 37. Mania, 452. acute, 453. delirious, 454. amenorrhoeal, 454. asthenic, 454. chronic, 454. dancing, 454. delusional, 454, 460. erotic, 454. epileptica, 454. hallucinatoria, 454. homicidal, 455. post-epileptic, 458. pre-epileptic, 458. puerperal, 455. reasoning, 463. recurring, 455. senile, 455. terminations of, 455. transitoria, 455. INDEX. 562 Mania-a-potu, 392, 454. Marsh fever, 39. Measles, 53. black, 53. false, 54. French, 54. German, 54. Mediterranean fever, 45. Megrim, 390. Melanaemia, 37. Melancholia, 450. agitata, 451. attonita, 45 1 . chronic, 451. delusional, 460. hallucinatory, 451. Melasma, supra-renalis, 180 Melituria, 205. Membranous enteritis, 99. Meniere’s disease, 388. Meningitis, 364. acute, 365. basilar, 368. cerebro-spinal, epidemic, 33. spinal, 406. tubercular, 368. Mensuration, 220. Metastasis, 13. Microsporon furfur, 545. Migraine, 390. Miliaria, 505. alba, 506. crystalline, 482. papulosa, 506. rubra, 506. vesiculosa, 506. Milium, 478. Mixture, Bartholow’s cholera, 102. Basham’s iron, 152. Brown-Sequard’s, for epilep>y, 438 . Da Costa’s muscular cramps, 102. enterica, 98. ferro-salicylata, 197. Hope’s camphor, 98. Keating’s pertussis spray, 280. Pepper’s asthma, 276. Smith’s tonic, 174. Squibb’s diarrhoea, 95. Monomania, 463. Morbid anatomy, II. I Morbilli, 53. Morphina in acute uraemia, 164. in cardiac dilatation, 346. , Morphiomania, 455. Morris’s thymol solution, 542. Moth, 525. I Moussette’s pill, 433. I Mouth, catarrh of, 63. diseases of, 63. psoriasis of, 69. white, 67. Movable kidney, 170. Mucus, test for, 144. Muguet, 67. Mumps, 185. Murmurs, aortic, 323. endocardial, 322. exocardial, 322. mitral, 323. pericardial, 322. pulmonic, 324. see-saw, 339. tricuspid, 324. Muscles, insanity of, 434. Myelitis, acute, 408. Myocarditis, acute, 347. chronic, 348. Nasal, acute catarrh, 238. chronic catarrh, 241. passages, diseases of, 238. Nephritis, acute desquamative, 150. catarrhal, 149. chronic parenchymatous, 153. interstitial, 150. parenchymatous, 150. peri-, 162. pyelo , 160. suppurative, 160. tubal, 150, 153. Nephro-lithiasis, 166. Nephrosis-pyelo, 161. Nervous dyspepsia, 86. exhaustion, 442. fever, 21. prostration, 442. j Nettle-rash, 499. , Neuralgia, 430. cervico-brachial, 431. cervico occipital, 431. INDEX. 563 Neuralgia, dorso-intercostal, 431. intercostal, 503. lumbo-abdominal, 431. of the fifth nerve, 430. of the heart, 356. sciatic, 431. Neuralgic fever, 62. Neurasthenia, 442. Neuritis, simple, 427. multiple, 428. Neuroses, occupation, 447. Noma, 70. Nomenclature, 9, 10. Nystagmus, 435. Obstruction, aortic, 338. intestinal, 118. mitral, 338. pulmonic, 339. pyloric, 82. tricuspid, 339. Occlusion of cerebral vessels, 378. Occupation neuroses, 447. Oidium albicans, 67. Oinomania, 393. Ointment, diachylon, Hebra’s, 482. 493 - Oligsemia, 173. Oxyuris vermicularis, 123. Ozsena, 241. Pachymeningitis, 364. hypertrophic, 405. pseudo-membranous, 405. spinalis, 405. Pains, the girdle, 409. Palpation, 220. Palsy, Bell’s, 433. wasting, 417. Paragraphia, 386. Paralysis, 375. agitans, 448. alcoholic, 428. bilateral, 373. bulbar, 415. cardiac, 189. chronic progressive bulbar, 415. crossed, 376. diphtheritic, 189. Paralysis, essential, of children, 413. facial, 433. general, 469. glosso-labio-laryngeal, 415. infantile spinal, 413. of the insane, general, 469. of the tongue, 387. pharyngeal, 189. spastic spinal, 420. unilateral, 375. Paralytic dementia, 469. Paranoia, 463. Paraphasia, 386. Parasites, intestinal, 12 1. Parasitic diseases of the skin, 534. Paresis, general, 469. Parkinson’s disease, 448. Parotiditis, 185. metastatic, 185. Partial cerebral anaemia, 378. Paste, Coster’s, 542. Pathogenesis, 1 1 . Pathognomonic, 13. Pathology, 9. Pediculosis, 548. capitis, 549. corporis, 549. pubis, 550. Pemphigus, 507. foliaceus, 508. malignus, 508. pruriginosus, 508. vulgaris, 508. Peptic ulcer, 77. Percussion, 222. auscultatory, 226. immediate, 222. mediate, 222. objects of, 223. respiratory, 226. Perforating ulcer, 77. Pericarditis, acute, 325. chronic, 328. . dry, 325. Pericardium, adherent, 328. effusion of, 326. hydro-, 329. Peri-nephritis, 162. Periodical fevers, 36. Peripheral neuritis, 428. Peri-proctitis, 117. 564 INDEX. Peritoneal dropsy, 128. Peritonitis, 124. saline purgatives in, 127. Peri-typhlitis, 1 1 5. Pernicious fever, 41. Pertussis, 279. Pharyngeal paralysis, 189. Pharyngitis, acute catarrhal, 243. erysipelatous, 244. exanthematous, 244. fibrinous, 244. gangrenous, 244. phlegmonous, 244, 245. Phosphates, tests for, 144. Phosphoridrosis, 480. Phthiriasis, 548. Phthisis, 300. acute, 301. caseous, 303. catarrhal, 303. chronic, 306. ulcerative, 306. fibroid, 308. Florida, 304. incipient, 306. laryngeal, 261. pneumonic, 300, 303. pulmonalis, 300. tubercular, 300, 306. Physical diagnosis, 219. signs, 12. association of, 237. Pill, Bartholow’s gout, 204. Blaud’s, 176. DaCosta’s, for hemorrhage, 286. Gross’s neuralgic, 432. Moussette’s, 433: Niemeyer’s, 31 1. Pilocarpus for spreading erysipelas, 61. Pitting, to prevent, 58. Pityriasis, 474. versicolor, 545. Pleurisy, 313. Pleuritis, 313. chronic, 314. dry, 313. Pleurodynia, 198. Pleuro-pneumonia, 289. Pneumonia, bilious, 292. caseous, 303. Pneumonia, catarrhal, 297. chronic catarrhal, 303. chronic interstitial, 308. croupous, 289. lobar, 289. lobular, 297. typhoid, 291. Pneumonitis, 289. Pneumothorax, 318. Podagra, 202. Poliomyelitis anterior acuta, 413. chronic, 417. Polyuria, 209. Polydipsia, 209. Posterior spinal sclerosis, 421. Poultice, pilocarpus, 200. spice, 104. Predisposition, 11. acquired, 12. inherited, II. Prickly heat, 506. Primary delusional insanity, 460. Proctitis, 47. peri-, 1 1 7. Prodromes, 13. Professional neuroses, 447. Prognosis, 14. Progressive muscular atrophy, 417. pernicious anaemia, 176. Pseudo tabes, 428. Psoriasis, 521. circinata, 522. diffusa, 522. guttata, 522. gyrata, 522. mummularis, 522 of the mouth, 69. of the tongue, 70. palmaris, 523. plantaris, 523. punctata, 522. unguium, 523. Psychalgia, 450. Pulmonary, oedema, 287. tuberculosis, 300. Pulse, Corrigan, 336. irregularity of, 356. receding, 336. Purging, 93. Purpura, 183. haemorrhagica, 183. INDEX. 565 Purpura, simplex, 183. urticans, 183. Pus, test for, 146. Pyelitis, 160. Pyelo nephritis, 160. nephrosis, 161. Pyloric obstruction, 82. stenosis, 82. Pyrosis, 86. Quinina in trichinosis, 219. in typhoid fever, 29. Quinsy, 245. malignant, 186. Rales, 232. bronchial, 234. cavernous, 234. dry, 233. laryngeal, 233. moist, 233. pleural, 235. tracheal, 233. vesicular, 234. Reactions of degeneration, 414. Rectitis, 117. Rectum, catarrh of, 117. washing out the, 1 12. Regurgitation, aortic, 335. mitral, 334. pulmonic, 337. tricuspid, 337. Relapsing fever, 35. Remittent fever, 39. Renal calculi, 166. cyst, 161. Respiration, Cheyne-Stokes’, 352. oscillating, 352. Respiratory system, diseases of, 219. Rheumatic fever, 192. gout, 201. Rheumatism, acute articular, 193. gonorrhoeal, 1 95. hyperpyrexia of, 194. inflammatory, 193. muscular, 198. Rheumatoid arthritis, 201. Rhinitis, acute, 238. chronic, 241. Rhinophyma, 519. Ringworm, honeycombed, 534. of the body, 537. of the scalp, 539. of the beard, 542. Robinson’s errhine, 240. Rosacea gutta, 518. Rosea gutta, 518. Rose, the, 59. Rotheln, 54. Round worms, 123. Rubeola, 53. Sailors’ fever, 45. Salicinum in influenza, 20. Saline fluids in cholera, 217. Salt rheum, 485. Sand, renal, 167. Sapo viridis, 492. Scabies, 546. Scall, 485. Scarlatina, 48. Scarlet fever, 48. Sciatica, 431. Scleroses, spinal, 419. Sclerosis, lateral, 424. amyotrophic lateral, 417. antero-lateral, 420. cerebro-spinal, 425. disseminated, 425. hepatic hypertrophic, 139. of the liver, 139. posterior, 419. Sclerotic endocarditis, 334. Scorbutus, 1 81. Scurvy, 181. Sebaceous cyst, 479. Seborrhoea, 474. capitis, 475. faciei, 475. oleosa, 475. sicca, 475. Secondary processes, 13. .Secretion, disorders of, 475. Shaking palsy, 448. Shingles, 503. Ship fever, 31. Sick-headache, 390. antipyrine in, 392. Sickness, green, 174. 566 INDEX. Sign, Corrigan’s 81. Signs, 12. physical, association of, 237. Silver nitrate in phlegmonous erysipe- las, 62. Skin hypersemias of, 483. inflammations of, 484. Smallpox, 55. Smith’s Dr. A. H., tonic, 174. Softening of the cord, 408. Solution, Dobell’s, 242. Tanret’sof pelletierine, 122. Sore throat, acute, 248. putrid, 186. Sounds, in disease, chest, 229. in health, chest, 227. normal cardiac, 321. Spanaemia, 172. Spasm, histrionic, 434. of the glottis, 259. Spinal sclerosis, 419. hyperaemia, 403. irritation, 442. meningitis, 406. Spinalis pachymeningitis, 405. plethora, 403. Spirillum obermeieri, 36. Splenification, 286. Spotted fever, 31. Sprue, 67. St. Anthony’s fire, 59. Stomach, cancer of, 79. diseases of, 71. neuralgia of, 84. remorse of, 87. spasm of, 84. washing out the, 120. Stomatitis, catarrhal, 63. croupous, 64. diphtheritic, 65. erythematous, 63. follicular, 64. gangrenous, 70. parasitic, 67. simple, 63. ulcerative, 65. vesicular, 64. Stonepock, 517. Stones, chalk, 204. Stools, chopped spinach, 107. Storm, electrical, 437. Stricture, intestinal, 118. St. Vitus’s dance, 434. Succussion, 237. Sudamen, 482. Sudamina, 482. Sugar, test for, 147, 148. Suicidal impulses, 451. Summer complaint, 106. Sun stroke, 398. Swamp fever, 37. Sweating, excessive, 478. Sycosis parasitica, 542. Synocha, 17. Symptoms, 12. Syncope, 377. Syrup, Declat, 51. Tabes dorsalis, 421. spasmodic, 420. Tachycardia, 354. Tsenia saginata, 121. solium, 1 21. Tapeworm, armed, 121. unarmed, 121. Temulentia, 392. Test for albumin, 145. bile, 147. bile pigment, 147. blood, 146. chlorides, 144. mucus, 144. phosphates, 144. pus, 146. sugar, 147, 148. urates, 143. urea, 143. Tetanilla, 445. Tetanus, 446. Tetany, 259, 445. Tetter, 485. Thermic fever, 398. Throat, acute sore, 248. putrid sore, 186. Thrombosis, cerebral, 378. Thrush, 67. Thymol solution, Morris’s, 542. Tic-douloureux, 431. Tincture, Warburg’s, 44. Tinea circinata, 537. favosa, 534. furfuracea, 474. INDEX. 567 Tinea, kerion, 540. sycosis, 542. tonsurans, 539. versicolor, 545. Tinkling, metallic, 235. Tone, bandbox, of Bamberger, 275. Tongue, strawberry, 49. Tonic, Dr. A. H. Smith’s, 174. Sir Erasmus Wilson’s, 475. Tonsillitis, acute, 245. catarrhal, 243. Tormina, 90. Torticollis, 198. Toxic gastritis, 73. Trance, 441. Treatment, 14. abortive, 14. expectant, 14. preventive, 14. restorative, 14. palliative, 14. Tremens, delirium, 394. Trichinae, 217. spiralis, 217. Trichinosis, 217. Trismus, 446. Tubbing in typhoid fever, 29. Tubercular meningitis, 368. Tuberculous laryngitis, 261. Tuberculosis, 306. acute miliary, 301. Tumor, phantom, 441. sebaceous, 479. Tumors, abdominal, 81. intra-cranial, 383. Turpentine in purpura, 184. Turpeth mineral in croup, 254. Tyloma, 528. Tympanites, chronic, 129. Typhlitis, 1 13. Typho-malarial fever, 39. Typhoid fever, 21. Typhus fever, 31. icterode, 45. Ulcer, duodenal, 78. gastric, 77. perforating, 77. Ulcerative colitis, 90. stomatitis, 65. Ulcerosa gingivitis, 65 . Uraemia, acute, 162. morphina in, 164. | Uraemic coma, 162. convulsions, 162. intoxication, 162. sodii benzoas in, 166. ! Urates, test for, 143. Urea, test for, 143. Uric acid diathesis, 21 1. test for, 143, 144. Uridrosis, 480. Urine, 142. hysterical, 274. normal color, 142. normal constituents, 142. normal quantity, 142. reaction, 142. Urticaria, 499. Vaccination, 58. Vaccinia, 58. Valvular diseases of the heart, 334. diagnosis of, 340. Valvulitis, 330. Varicella, 59. Variola, 55. Varus, 516. Venesection in pneumonia, 294. Verruca, 530. Verriicktheit, 463. Vertigo, 388. aural, 388. auditory, 388. nervous, 388. senile, 388. stomachic, 71, 388. Vesicular emphysema, 281. stomatitis, 64. Voice in health, 229. in disease, 236. Vomit, black, 45. coffee ground, 45. Waddle, the, 420. Warburg’s tincture, 44. Wart, 530. venereal, 531. Wasting palsy, 417. Water blisters, 507. cancer, 70. colored as a treatment, 195. 568 INDEX. Wen, 479. Wheals, 500. White blood, 177. cell blood, 177. mouth, 67. Whooping-cough, 279. Wilson’s, Erasmus, tonic, 475. Worms, tape, 121. Worms, Tound, 123. seat, 124. Xeroderma, 533. Yellow fever, 45. Zona, 503. CATALOGUE No. 7. JUNE, 1894. BOOKS FOR STUDENTS, INCLUDING THE ? QUIZ-COMPENDS ? CONTENTS. PAGE New Series of Manuals, 1 2,3,4, 5 Anatomy, . 6 Biology, . 11 CHemistry, . Children’s Diseases, . . 6 . 7 Dentistry, . 8 Dictionaries, 8, 16 Eye Diseases, . 8 Electricity, . • 9 Gynaecology, . 10 Hygiene, • 9 Materia Medica, . • 9 Medical Jurisprudence, . 10 Nervous Diseases, . 10 PAGE Obstetrics 10 Pathology, Histology, . . n Pharmacy, . . . .12 Physical Diagnosis, . .11 Physiology, . . . .11 Practice of Medicine, . 11, 12 Prescription Books, . . 12 PQuiz-Compends ? . 14,15 Skin Diseases, . . .12 Surgery and Bandaging, . 13 Therapeutics, . . .9 Urine and Urinary Organs, 13 Venereal Diseases, . . 13 PUBLISHED BY P. BLAKISTON, SON & CO., Medical Booksellers , Importers and Publishers. LARGE STOCK OF ALL STUDENTS’ BOOKS, AT THE LOWEST PRICES. 1012 Walnut Street, Philadelphia. *** For sale by all Booksellers, or any book will be sent by mail, postpaid, upon receipt of price. Catalogues of books on all branches of Medicine, Dentistry, Pharmacy, etc., supplied upon application. GOULD’S 1 ~ - DICTIONARIES / see rage 10, “An excellent Series of Manuals.” — Archives of Gynaecology. A NEW SERIES OF STUDENTS’ MANUALS On the various Branches of Medicine and Surgery. Can be used by Students of any College. Price of each, Handsome Cloth, $3.00. Full Leather, $3.50 The object of this series is to furnish good manuals for the medical student, that will strike the medium between the compend on one hand and the prolix text- book on the other — to contain all that is necessary for the student, without embarrassing him with a flood of theory and involved statements. They have been pre- pared by well-known men, who have had large experience as teachers and writers, and who are, therefore, well informed as to the needs of the student. Their mechanical execution is of the best — good type and paper, handsomely illustrated whenever illustrations are of use, and strongly bound in uniform style. Each book is sold separately at a remarkably low price, and the immediate success of several of the volumes shows that the series has met with popular favor. No. 1. SURGERY. 318 Illustrations. Third Edition. A Manual of the Practice of Surgery. By Wm. J. Walsham, m.d., Asst. Surg. to, and Demonstrator of Surg. in, St. Bartholomew’s Hospital, London, etc. 318 Illustrations. Presents the introductory facts in Surgery in clear, precise language, and contains all the latest advances in Pathology, Antiseptics, etc. “ It aims to occupy a position midway between the pretentious manual and the cumbersome System of Surgery, and its general character may be summed up in one word — practical.” — The Medi- cal Bulletin. “ Walsham, besides being an excellent surgeon, is a teacher in its best sense, and having had very great experience in the preparation of candidates for examination, and their subsequent professional career, may be relied upon to have carried out his work successfully. 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By J. A. Ormerod, m.d., Oxon., f.r.c.p. (London), Mem. Path., Clin., Ophthal., and Neurological Societies; Phys. to National Hospital for Paralyzed and Epileptic ; Dem. of Morbid Anatomy, St. Bartholomew’s Hospital, etc. 75 Illustrations. Cloth, 2.00 OBSTETRICS AND GYNECOLOGY. Davis. A Manual of Obstetrics. By Edw. P. Davis, Clinical Lecturer on Obstetrics, Jefferson Medical College, Philadelphia. 16 Plates, and 134 Illustrations, umo. 2d Edition. Cloth, 2.50 Byford. Diseases of Women. By W. H. Byford, m.d., Prof, of Gynaecology in Rush Medical College and of Obstetrics in the Woman’s Medical College, etc., and H. T. Byford, m.d., Sur- geon to the Woman's Hospital, Chicago. Fourth Edition. En- larged. 306 Illustrations, over 100 of which are original. Octavo. 832 pages. Cloth, 2.00 ; Leather, 2.50 Lewers’ Diseases of Women. A Practical Text-book. 139 Illustrations. Second Edition. Cloth, 2.50 Wells. Compend of Gynaecology. Illustrated. Cloth, 1.00 Winckel’s Obstetrics. A Text-book on Midwifery, includ- ing the Diseases of Childbed. By Dr. F. Winckel, Professor of Gynaecology, University of Munich. Authorized Translation, by J. Clifton Edgar, m.d., Lecturer on Obstetrics, University Medical College, New York. Nearly 200 handsome Illustrations. 8vo. Cloth, 6.00 ; Leather, 7.00 See pages 2 to 5 for list of New Manuals. STUDENTS’ TEXT-BOOKS AND MANUALS. 11 Obstetrics and Gyncecology : — Continued. Parvin’s Winckel’s Diseases of Women. Second Edition. Including a Section on Diseases of the Bladder and Urethra. 150 Illus. Revised. See page 3. Cloth, 3.00; Leather, 3.50 Landis’ Compend of Obstetrics. Illustrated. 5th Edition, Enlarged. By Wells. Cloth, 1. 00; Interleaved for Notes, 1.25 PATHOLOGY, HISTOLOGY, ETC. Stirling. Outlines of Practical Histology. A Manual for Students. 2d Edition. 368 Illustrations. i2mo. Cloth, 3.00 Wethered. Medical Microscopy. By Frank J. Wethered. m.d., m r.c.p. 98 Illustrations. Cloth, 2.50 Hall. Compend of General Pathology and Morbid Anat- omy. 91 very fine Illustrations. Cloth, 1.00; Interleaved, 1.25 Gilliam’s Essentials of Pathology. A Handbook for Students. 47 Illustrations. i2mo. Cloth, .75 Virchow’s Post-Mortem Examinations. 3d Ed. Cloth, 1.00 PHYSICAL DIAGNOSIS. Tyson’s Student’s Handbook of Physical Diagnosis. Illus- trated. Second Edition, Enlarged. i2mo. Cloth, 1.50 PHYSIOLOGY. Yeo’s Physiology. Sixth Edition. The most Popular Stu- dents’ Book. By Gerald F. Yeo, m.d., f.r.c.s.. Professor of Physiology in King's College, London. Small Octavo. 254 carefully printed Illustrations. With a Full Glossary and Index. See Page 3. Cloth, 3.00; Leather, 3.50 Brubaker’s Compend of Physiology. Illustrated. Seventh Edition. Cloth, 1. 00; Interleaved for Notes, 1.25 Kirke’s Physiology. New 13th Ed. Thoroughly Revised and Enlarged. 502 Illustrations, some of which are printed in colors. ( Blakiston's Authorized Edition .) Red Cl. , 4.00 ; Leather, 5.00 Landois’ Human Physiology. Including Histology and Micro- scopical Anatomy, and with special reference to Practical Medi- cine. Fourth Edition. Translated and Edited by Prof. Stirling. 845 Illustrations. Cloth, 7.00; Leather, 8.00 “ With this Text-book at his command, no student could fail in his examination. ” — Lancet. PRACTICE. Taylor. Practice of Medicine. A Manual. By Frederick Taylor, m.d.. Physician to, and Lecturer on Medicine at, Guy's Hospital, London ; Physician to Evelina Hospital for Sick Chil- dren, and Examiner in Materia Medica and Pharmaceutical Chemistry, University of London. Cloth, 2.00; Leather, 2.50 fciT See pages 14 and 13 far list 0/ ? Quiz- Compends t 12 STUDENTS’ TEXT-BOOKS AND MANUALS. Practice : — Continued. Roberts’ Practice. Revised Edition. A Handbook of the Theory and Practice of Medicine. By Frederick T. Roberts, m.d., m.r.c.p.. Professor of Clinical Medicine and Therapeutics in University College Hospital, London. Seventh Edition. Octavo. Cloth, 5.50 ; Sheep, 6.50 Hughes. Compend of the Practice of Medicine. 5th Edi- tion. Two parts, each. Cloth, 1. 00; Interleaved for Notes, 1.25 Part i. — C ontinued, Eruptive and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc., and General Diseases, etc. Part ii. — Diseases of the Respiratory System, Circulatory System, and Nervous System; Diseases of the Blood, etc. Physicians’ Edition. Fifth Edition. Including a Section on Skin Diseases. With Index. 1 vol. Full Morocco, Gilt, 2.50 From John A. Robinson , M.D., Assistant to Chair of Clinical Medicine , now Lecturer on Materia Medica, Rush Medical Col- lege, Chicago. “ Meets with my hearty approbation as a substitute for the ordinary note books almost universally used by medical students. It is concise, accurate, well arranged, and lucid, . . . just the thing for students to use while studying physical diagnosis and the more practical departments of medicine." Wythe’s Dose and Symptom Book. Containing the Doses and Uses of all the principal Articles of the Materia Medica, etc. Seventeenth Edition. Completely Revised and Rewritten. 32mo. Cloth, 1. 00; Pocket-book style, 1.25 PHARMACY. U. S. Pharmacopoeia, 1890, 7th Revision. Cloth, net, 2.50; Sheep, net, 3.00. (Add 27 cents if to go by mail.) Sayre. Organic Materia Medica and Pharmacognosy. 400 Illustrations. See page q. Nearly Ready. Stewart’s Compend of Pharmacy. Based upon Remington's Text-book of Pharmacy. Fourth Edition, Revised in accordance with new U. S P., 1890. Cloth, 1.00 ; Interleaved for Notes, 1.25 Robinson. Latin Grammar of Pharmacy and Medicine. By H. D. Robinson, ph.d., Professor of Latin Language and Literature, University of Kansas, Lawrence. With an Intro- duction by L. E. Sayre, ph.g., Professor of Pharmacy in, and Dean of, the Dept, of Pharmacy, University of Kansas. i2mo. Second Edition. Cloth, 2. 00 SKIN DISEASES. Crocker. Diseases of the Skin, their Description, Pathology, Diagnosis, and Treatment, with Special Reference to the Skin b ruptions of Children. By H. RadclifFe Crocker, f.r.c p.. Phy- sician for Diseases of the Skin in University College Hospital. Second Edition. Revised and Enlarged, with 92 Wood-cuts. Cloth, 5.00 Van Harlingen on Skin Diseases. Third Edition. Enlarged and Illustrated. i2mo. In Press, tfcg* See pages 2 to 5 for list of New Manuals. STUDENTS' TEXT-BOOKS AND MANUALS. 13 SURGERY AND BANDAGING. Moullin’s Surgery, by Hamilton. 600 Illustrations (some colored), 200 of which are original. Second Edition. Cloth, net, 7.00; Leather, net, 8.00; Half Russia, net, 9.00 *** Complete circulars, with sample pages and Illustrations, free upon application. Jacobson. Operations in Surgery. A Systematic Handbook for Physicians, Students, and Hospital Surgeons. By W. H. A. Jacobson, b.a. Oxon., f.r.c.s. Eng.; Ass’t Surgeon Guy’s Hos- pital ; Surgeon at Royal Hospital for Children and Women, etc. 199 Illustrations. 1006 pages. 8vo. Cloth. 5.00; Leather, 6.00 Heath’s Minor Surgery, and Bandaging. Tenth Edition. 158 Illustrations. 62 Formulae, and Diet Lists. Cloth, 2.00 Horwitz’s Compend of Surgery, Minor Surgery and Bandaging, Amputations, Fractures, Dislocations, Surgical Diseases, and the Latest Antiseptic Rules, etc., with Differential Diagnosis and Treatment. By Orville Horwitz, b.s., m.d., Demonstrator of Surgery , Jefferson Medical College. 5th Edition, Enlarged and Rearranged. Many new Illustrations and Formulae. i2mo. Cloth, 1.00 ; Interleaved for the addition of Notes, 1.25 ***The new Section on Bandaging and Surgical Dressings con- sists of 32 Pages and 41 Illustrations. Every Bandage of any importance is figured. This, with the Section on Ligation ot Arteries, forms an ample Text-book for the Surgical Laboratory. Walsham. Manual of Practical Surgery. Third Edition. By Wm. J. Walsham, m.d., f.r.c.s.. Asst. Surg. to, and Dem- of Practical Surg. in, St. Bartholomew’s Hospital ; Surgeon to Metropolitan Free Hospital, London. With 318 Engravings. See page 2. Cloth, 3.00; Leather, 3.50 URINE, URINARY ORGANS, ETC. Holland. The Urine, and Common Poisons and The Milk. Chemical and Microscopical, for Laboratory Use. Illus- trated. Fourth Edition, nmo. Interleaved. Cloth, 1.00 Ralfe. Kidney Diseases and Urinary Derangements. 42 Illus- trations. i2mo. 572 pages. Cloth, 2.75 Marshall and Smith. On the Urine. The Chemical Analysis ot the Urine. Colored Plates. i2mo. Cloth, 1.00 Memminger. Diagnosis by the Urine. Illus. Cloth, 1.00 Tyson. On the Urine. A Practical Guide to the Examination of Urine. With Colored Plates and Wood Engravings. Eighth Edition, Enlarged. i2mo. Cloth, 1.50 Van Niiys, Urine Analysis. Illus. Cloth, 1.00 VENEREAL DISEASES. Hill and Cooper. Student’s Manual of Venereal Diseases, with Formulae. Fourth Edition, umo. Cloth, 1.00 See pages 14 and if for list of f Quiz-Compends f ? QUIZ-COMP ENDS? The Best Compends for Students’ Use in the Quiz Class, and when Pre- paring for Examinations. Compiled in accordance with the latest teachings op promi- nent Lecturers and the most popular Text-books. They form a most complete, practical, and exhaustive set of manuals, containing information nowhere else col- lected in such a condensed, practical shape. Thoroughly up to the times in every respect, containing many new prescriptions and formulae, and over six hundred illustra- tions, many of which have been drawn and engraved specially for this series. The authors have had large ex- perience as quiz-masters and attaches of colleges, with exceptional opportunities for noting the most recent ad- vances and methods. Cloth, each $1.00. Interleaved for Notes, $1.25. No. 1. HUMAN ANATOMY, “ Based upon Gray.” Fifth Enlarged Edition, including Visceral Anatomy, formerly published separately. 16 Lithograph Plates, New Tables, and 117 other Illustrations. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surgeon U. S. Army, Professor of Practice, Cooper Medical College, San Fran- cisco. Nos. 2 and 3. PRACTICE OF MEDICINE. Fifth Edi- tion. By Daniel E. Hughes, m.d., Demonstrator of Clinical Medicine in Jefferson Medical College, Philadelphia. In two parts. Part I. — Continued, Eruptive, and Periodical Fevers, Diseases of the Stomach, Intestines, Peritoneum, Biliary Passages, Liver, Kidneys, etc. (including Tests for Urine), General Diseases, etc. Part II. — Diseases of the Respiratory System (including Phy- sical Diagnosis), Circulatory System, and Nervous System; Dis- eases of the Blood, etc. * # * These little books can be regarded as a full set of notes upon the Practice of Medicine, containing the Synonyms, Definitions, Causes, Symptoms, Prognosis, Diagnosis, Treatment, etc., of each disease, and including a number of prescriptions hitherto unpub- lished. No. 4. PHYSIOLOGY, including Embryology. Seventh Edition. By Albert P. Brubaker, m.d., Prof, of Physiology, Penn’a College of Dental Surgery ; Demonstrator of Physiology in Jefferson Medical College, Philadelphia. Revised, Enlarged, with new Illustrations. No. 5. OBSTETRICS. Illustrated. Fifth Edition. By Henry G. Landis, m.d. Edited by William H. Wells, m.d.. Assistant Demonstrator of Clinical Obstetrics, Jefferson College, Philadelphia. New Illustrations. BLAKISTON’S ? QUIZ-COMPENDS ? No. 6. MATERIA MEDICA, THERAPEUTICS, AND PRESCRIPTION WRITING. Fifth Revised Edition. With especial Reference to the Physiological Action of Drugs, and a complete article on Prescription Writing. Based on the Last Revision of the U. S. Pharmacopoeia, and including many unofficinal remedies. By Samuel O. L. Potter, m.a., m.d., m.r.c.p. (Lond.), late A. A. Surg. U. S. Army; Prof, of Practice, Cooper Medical College, San Francisco. Improved and Enlarged, with Index. No. 7. GYNAECOLOGY. A Compend of Diseases of Women. By Wm. H. Wells, m.d., Ass’t Demonstrator of Obstetrics, Jefferson Medical College, Philadelphia. Illustrated. No. 8. DISEASES OF THE EYE AND REFRACTION, including Treatment and Surgery. By L. Webster Fox, m.d., Chief Clinical Assistant Ophthalmological Dept., Jefferson Med- ical College, etc., and Geo. M. Gould, m.d. 71 Illustrations, 39 Formulae. Second Enlarged and Improved Edition. Index. No. 9. SURGERY, Minor Surgery and Bandaging. Illus- trated. Fifth Edition. Including Fractures, Wounds, Dislocations, Sprains, Amputations, and other operations; Inflam- mation, Suppuration, Ulcers, Syphilis, Tumors, Shock, etc. Diseases of the Spine, Ear, Bladder, Testicles, Anus, and other Surgical Diseases. By Orville Horwitz, a.m., m.d., Demonstrator of Surgery, Jefferson Medical College. Revised and Enlarged. 98 Formulae and 167 Illustrations. No. 10. CHEMISTRY. Inorganic and Organic. For Medical and Dental Students. Including Urinary Analysis and Medical Chemistry. By Henry Leffmann, m.d., Prof, of Chemistry in Penn’a College of Dental Surgery, Phila. Third Edition, Revised and Rewritten, with Index. No. 11. PHARMACY. Based upon “ Remington’s Text-book of Pharmacy.’ ’ By F. E. Stewart, m.d., ph.g., Quiz-Master at Philadelphia College of Pharmacy. Fourth Edition, Revised. No. 12. VETERINARY ANATOMY AND PHYSIOL- OGY. 29 Illustrations. By Wm. R. Ballou, m.d.. Prof, of Equine Anatomy at N. Y. College of Veterinary Surgeons. No. 13. DENTAL PATHOLOGY AND DENTAL MEDI- CINE. Containing all the most noteworthy points of interest to the Dental student. Second Edition. By Geo. W. Warren, d.d.s., Clinical Chief, Penn'a College of Dental Surgery, Phila- delphia. Second Edition, Enlarged and Illustrated. No. 14. DISEASES OF CHILDREN. By Dr. Marcus P. Hatfield, Prof, of Diseases of Children, Chicago Medical College. Colored Plate. No. 15. GENERAL PATHOLOGY AND MORBID ANATOMY. By H. Newbery Hall, m. d., Professor of Pathology and Medical Chemistry Post-Graduate School ; Sur- geon Emergency Hospital, Chicago, etc. 91 Illustrations. Bound in Cloth, $1. Interleaved, for the Addition of Notes, $1.25. No series of books are so complete in detail, concise in language , or so well printed and bound. Each one forms a complete set of notes upon the subject under con- sideration. Illustrated Descriptive Circular Free. 25,000 COPIES Of These Books Have Already Been Sold. GOULD’S STUDENT’S Medical Dictionary. Based on Recent Medical Literature. Small 8vo, Half Morocco, as above, with Thumb Index, . . $4.25 Plain Dark Leather, without Thumb Index, 3.25 A compact, concise Vocabulary, including all the Words and Phrases used in medicine, with their proper Pronunciation and Definitions. “ One pleasing feature of the book is that the reader can almost invariably find the definition under the word he looks for, without being referred from one place to another, as is too commonly the case in medical dictionaries. The tables of the bacilli, micrococci, leucomai’nes and ptomaines are excellent, and contain a large amount of information in a limited space. The anatomical tables are also concise and clear. ... We should unhesitatingly recommend this dictionary to our readers, feeling sure that it will prove of much value to them .” — American Journal 0/ Medical Science. JUST PUBLISHED. GOULD’S POCKET DICTIONARY. 12,000 Medical Words Pronounced and Defined. Leather, gilt edges, $1.00; with Thumb Index, $1.25