(1;iss K C 4>Cp Book , w S* PRESENTED 1SY / THE Practice of Medicine. / A HANDBOOK Practitioners and Students. M. CHARTERIS, M.D., PROFESSOR OF THE PRACTICE OF MEDICINE AND PHYSICIAN AND LECTURER ON CLINICAL MEDICINE, GLASGOW ROYAL INFIRMARY. WITH MICROSCOPIC AND OTHER ILLUSTRATIONS. PHILADELPHIA : P. BLAKISTON, SON & CO., 1012 WALNUT STREET. 1882. < Gift Miss Frances S.Hay July 18,1931 The idea of compiling this Handbook was sug- gested by my own experience; and I have tried to write as one speaking to students. My aim having been to render it "handy" and practical, it is in many respects necessarily brief; and as I desired to present ascertained facts, some points still in dispute have been only incidentally mentioned, not discussed. I desire to record my special thanks to my friend and colleague Dr. A. M. Buchanan, and to my for- mer assistant and highly esteemed pupil Dr. T. O. Guthrie, for kind and willing assistance in preparing the sheets for the press. My obligations to Dr. Whittaker are seen in the illustrations. M. C. CONTENTS. PAGE General Diseases, ........ 13 Fevers, 21 Typhus Fever, 23 Typhoid Fever, 27 Relapsing Fever, 33 Intermittent Fever, or Ague, 35 Kemittent Fever, 38 Yellow Fever, . 40 • Dengue, Dandy Fever, Breakdown Fever, . . .42 The Plague, 43 Eruptive Fevers, 43 Small-pox, 44 Vaccinia, or Cow-pox, . .47 Varicella, or Chicken-pox, ...... 48 Scarlet Fever, 49 Measles, 53 Kubeola, Rotheln — German Measles, . . . .56 Dropsy, .......... 58 Tuberculosis, 62 Syphilis, 67 Rheumatism, ......... 70 Gout, * 74 Scurvy, 79 Purpura, 82 Chlorosis, Anaemia, 85 Erysipelas, 87 V1U CONTENTS. PAGE Diseases of Kespiratory Organs, .... 91 Catarrh, 95 Laryngitis, etc., 96 Diphtheria, ......... 98 Croup, 102 False Croup, .106 Hooping-cough, ........ 107 Influenza, . . . . . . . . 110 Acute Bronchitis, 112 Chronic Bronchitis, 116 Emphysema, 118 Asthma, . . . . . . . . . . 121 Pneumonia, . . . . . . . . 122 Pleurisy, 129 Chronic Pleurisy, 134 Phthisis, Pulmonary Consumption, .... 136 Acute Phthisis, 140- Cancer of the Lung, . . 142 Diseases of the Circulatory Organs, . . . 142 Angina Pectoris, 142 Hypertrophy of the Heart, 144 Atrophy of the Heart, 147 Pericarditis, . . 148 Endocarditis, 151 Cardiac Murmurs, 152 Palpitation of the Heart, . . % . . . . 159 Thoracic Aneurism, 159 Abdominal Aneurism, 161 Ulcers of the Tongue, 163 Stomatitis, . . . .164 Mumps, Cynanche Parotidea, ...... 165 Quinsy, Cynanche Tonsillaris, ...... 165 Diseases of the (Esophagus, 166 Dyspepsia, 166 Gastric Ulcer, 169 CONTENTS. IX Cancer of Stomach, . Constipation, .... Colic, Obstruction of the Bowels, Diarrhoea, ..... Dysentery, .... Epidemic Cholera, Intestinal Worms, Roundworms, .... Trichina Spiralis — Trichinosis, . Peritonitis, .... Chronic Peritonitis, . Typhlitis and Perityphlitis, Diseases of the Liver, . Painless Enlargements of Liver, Painful Enlargements of Liver, Contractions of the Liver, . Jaundice, Diseases of the Pancreas, Diseases of the Spleen, Leucocythsernia, Bronchocele, Goitre, .... Disease of the Suprarenal Capsules, Addison's Disease, Diseases of the Kidneys, Nephritis, Bright's Diseases, Acute Bright's Disease-, . Chronic Bright's Disease, The Large White Kidney, The Granular Contracting Kidney, The Waxy Kidney, . B X CONTENTS. PAGE Uraemia, 231 Chylous Urine, • . .232 Hematuria, 233 Haematinuria, 235 Gravel, Renal Calculus, or Colic, 236 Diabetes, 237 Diseases of the Neryotjs System, 243 Cerebral Anaemia, 244 Cerebral Congestion, . 245 Cerebral Embolism and Thrombosis, 246 Cerebral Haemorrhage, 247 Apoplexy, 250 Cerebral Softening, 252 Sclerosis, 253 Aphasia, 254 Acute Meningitis, 256 Tubercular Meningitis, 257 Chronic Hydrocephalus, 258 Encephalitis, .... 259 Tumors of Brain, 259 Paralysis, . 260 Neuralgia, . 267 Epilepsy, 269 Chorea, 274 Delirium Tremens, 276 Sunstroke, . 279 Hysteria, 279 Diseases of the Spinal Cord, 283 Locomotor Ataxy, . . * 286 Cerebro-Spinal Fever, Epidemic Cerebro-Spinal Men- ingitis, ......... 288 Hydrophobia, . . . . ' '■ % . . . .289 Tetanus, 291 CONTENTS. XI PAGE Diseases of the Skin, 292 Erythema, 296 Roseola, 297 Urticaria, 297 Sudamina, 298 Herpes, 298 Eczema, 299 Pemphigus, 300 Rupia, 300 Impetigo, ......... 301 Ecthyma, 301 Lichen, 302 Prurigo, 302 Psoriasis, 303 Pityriasis Rubra, 303 Acne, 304 Lupus, ......... 304 Parasitica, 306 Scabies, 306 Tinea Favosa, . . . ... . . . 307 Tinea Tricophytina, . . . . . . . 307 Tinea Decalvans, Alopecia Areata, .... 308 Tinea Versicolor, 308 Appendix, 309 Index, . 327 GENERAL CONSIDERATION OF DISEASE, WITH BEDSIDE HINTS. What is health ? The answer to this inquiry can scarcely be given in the form of a definition, yet it requires no medical education to suggest a picture of what health is at the typical eras of human existence, when all the various functions of the human body are performed easily, naturally, and well. The healthy individual breathes without difficulty, the food taken is relished and properly assimilated, the blood is forced, from its centre — the heart — onwards over the body, without valvular flaw or subsequent hindrance, and the brain, with its nervous expansion undisturbed by morbid fancies, controls the movements and the thoughts of the living organism. Disease is a devia- tion, to a greater or less extent, from what we thus realize, though we cannot define, as the standard of health. It may invade one or more of the systems we have alluded to, and it is the duty of the physi- cian to find out, by the varied appliances of his art, 2 14 GENERAL DISEASES. what and where the disease is. Thus the student will perceive, what practical bedside experience teaches, that diseases are to be referred in many cases to certain systems — viz., respiratory, circulatory, diges- tive, integumentary, genito-urinary, and nervous ; each of these systems being liable to various diseases ; and the allocation to one of these systems having been made, it is the further province of the physician to ascertain, by a careful examination of the phenom- ena presented to him, what the particular disease wdiich he is investigating may be. A little reflection or experience will, however, convince the student that all diseases cannot be brought under such a simple classification. There are certain diseases, by no means the least important, which, though presenting well- marked features during life, are found, by examina- tion after death, not to have involved any one particu- lar system. These must be called, for the want of a better term, General Diseases. The exact idea ex- pressed by this will be better understood when these diseases are individually considered. "When we are called to investigate real or imagin- ary disease, the question presents itself to us, How is the nature of the disease to be determined ? How is the inquiry to be prosecuted ? Pain is a prominent feature in disease, and im- portant information may be obtained by asking, " Where do you feel pain?" Follow this up by further inquiring, " How long have you been ill ?" The patient in this way refers his pain to some GENERAL DISEASES. 15 particular part or parts, and tells the story of his ill- ness in his own words, without any promptings on your side, which may be misleading. Now, with certain data to go upon, and with no preconceived, and therefore probably erroneous, ideas directing you, the systematic investigation can be justly commenced. If attention is directed to the chest, that region must be carefully explored, by the three great means of auscultation, percussion, and palpation. In order Fig. 1. to facilitate inquiry, and to localize its evidences, the chest has been divided into certain regions, as the accompanying diagram will at once show; a fact which beginners should realize, not merely by looking 16 • GENERAL DISEASES. at it, but by drawing the corresponding lines in ink on a friend or fellow-student's chest. In percussion the pleximeter and hammer may be used, or, in lieu of them, the first two fingers of the left hand may be applied flatly to the chest, and struck with the tips of corresponding ones of the right. Being already familiar with the sounds in health, you compare one region with the correspond- ing region on the opposite side, and note whether the sounds produced by percussion are healthy or the re- verse, abnormally dull or abnormally clear. Proceed in a similar way with auscultation, by means of the stethoscope, after carefully reading the chapter on Respiratory Sounds in Health. Palpation and mensuration will enable you to tell the exact dimensions, say of dulness, and the differ- ence in this respect between opposite sides. But supposing your patient does not refer his com- plaint to the chest, but to the stomach, then your inquiry must be directed primarily to the digestive system. Examine the tongue, ask as to his appetite and the state of the bowels. Percussion and men- suration are now of great importance. The abdomen has also been divided by lines, as in the accompanying diagram. If the patient refers his ailment to the kidneys or the bladder, your inquiry must be particularly di- rected to the urine, for this is the keynote to diag- nosis. Note its color, take its specific gravity, etc. (See chapter on Urinary Diseases.) GENERAL DISEASES. 17 If he refers his complaint to the nervous system, try to discover from the symptoms presented what disease it may be, remembering that the brain is an aggregation of various parts, and that the means which Fig. 2. assisted you before are now of little avail, — " For the brain you can neither see, nor touch, nor handle." The subject is thus beset with greater difficulty than in the case of the other systems mentioned. It is a matter of great importance, in the method of examination thus suggested, to remember that one system cannot be long involved without implicating, to a greater or less extent, some if not all of the others. While special attention is of course paid to the system containing the organ primarily diseased, it is essential that the others should not be forgotten. 18 GENERAL DISEASES. It is immaterial in what order they are considered, but it is essential that no one of them be neglected ; and it is astonishing how, after a little experience, Fig. 3. the student quickly and instinctively goes over them all. Negatively, " General Diseases" may be remembered as not being brought under the systems mentioned ; positively, they are associated with a constitutional state and have a. history of their own. Under the GENERAL DISEASES. 19 head of "General Diseases" are included what are termed zymotic diseases, or diseases which it is sup- posed can be prevented by attention to hygienic or other conditions. Zymotic diseases are distinguished by the following characters: "They are all of them febrile diseases. They all run naturally a definite course in definite though different periods of time. They all present during some (usually definite) portion of that course certain distinctive spots, making erup- tions on the surface of the body. As a rule, broken and proved by rare exceptions, they occur once only in the same person. Lastly, they are communicable from person to person by contagion, and arise in no other way. " Small-pox, chicken-pox, typhus fever, typhoid or enteric fever, scarlet fever, the plague, measles, hoop- ing-cough, mumps, constitute zymotic diseases." (Sir Thomas Watson.) In investigating these diseases it will be found that they appear to be propagated by some unknown though probably atmospheric influences, owning no general law, spreading over a wide area (epidemic), or peculiar to certain fixed localities (endemic). Under " General Diseases " it will thus be seen are numbered the various fevers, some of which seem the offspring of filth and the neglect of sanitary laws; while others depend on a specific something which is transmitted from person to person, probably through a disease- germ, and which, through its specific character, can originate only the disease from which it sprang. Under " General Diseases" also are included various 20 GENERAL DISEASES. states of the body, in which the blood seems chiefly implicated, and which reveal themselves by local and constitutional and characteristic symptoms, as will be pointed out when individually considered. The student therefore, in forming an opinion with regard to diseases connected with the various systems, or with regard to general diseases, will see that an important element in this opinion or diagnosis must be the causation, the etiology, of the disease in ques- tion. Is it peculiar to one country or to many ? Is it a disease of youth or age? Is it hereditary, or is it acquired ? Is it dependent on known or unknown agencies ? Is it characteristic of sex or occupation ? Having thought these things over, having gleaned what he can also from signs, symptoms, and history, his further duty is to form a prognosis, a forecast of the probable issue. Will it be fatal, or the reverse ? What complications may arise, and how may these be averted ? These, and all previous considerations have one definite object in view, viz.: Treatment, specially directed to the person who is ill, but also in certain cases prophylactic, i. e., guarding against the extension of the disease to others, if that be possible. We now take up the first great class of diseases. FEVERS. 21 FEVERS. Fever, generally expressed, is that state of the body in which, after an incubation stage of more or less duration, symptoms of debility and shivering su- pervene, and these afterwards give place to great heat of body, quickened pulse, and disturbance of most of the functions. Or, fever may be shortly defined as that state of the body in which there is an increase of temperature above the normal (Virchow). The temperature is taken by the clinical thermometer, which is introduced and kept in close contact with the axilla from ten to fifteen minutes, after which it is withdrawn, and the increase from the standard of health, 98.6°, is noted. In fever the temperature should always be carefully taken morning and evening, and, in hospital, a chart indicating the daily result from the commencement should b.e hung up in a convenient situation near the bed. In this country there are four kinds of continued fever — 1. Simple fever or febricula. 2. Typhus. 3. Typhoid. 4. Relapsing. Simple fever or febricula is non-contagious, and depends frequently on errors of diet, exposure to the 22 FEVERS. sun or cold, or other insanitary agencies which may fatigue or weaken the system. Symptoms. — Following on one or more of these causes, without almost any warning, the patient be- comes languid and disinclined for either mental or bodily work ; the appetite is lost, and headache en- sues; a dull aching pain is felt all over the body, es- pecially at the back, accompanied with " a creepy cold sensation," difficult to define. This creepy cold sensation is followed, in the course generally of a few hours, by increased heat of body (fever), rapid pulse, furred tongue, and scanty high- colored urine. Delirium, through sleeplessness, may supervene, and the state of matters may seem very alarming, when, after an interval of three or four days, there is a crisis. The pulse falls, the skin becomes moist, thirst abates, headache ceases, and a copious perspiration terminates the fever. The patient is left weak, yet convalescent, and the strength gradually returns. Prognosis. — This fever is rarely dangerous. It may be added that its division into catarrhal, bilious, mes- enteric, and brain fever seems unnecessary. Treatment — The indications for treatment, since the fever terminates in recovery, may be summed up in a few words. At the commencement give a saline purgative of sulphate of soda and sulphate of mag- nesia, or a seidlitz powder. After the bowels have acted, employ a diaphoretic or diuretic mixture (F. 31, 40). The patient has no inclination for solid food, and should not be urged to take anything but a sloppy TYPHUS FEVER. 23 diet, as arrowroot, milk, gruel, etc. Convalescence is to be assisted by nourishing food, such as beef tea, chicken soup, and wine. A tonic mixture is also ser- viceable (F. 75, 76, 77). Typhus Fever. The terra typhus is derived from the Greek word TOfoq, smoke. It was formerly called putrid, pesti- lential, jail, ship, or hospital fever. Etiology. — This fever is contagions, usually epi- demic, and most frequently follows or is the direct result of destitution, overcrowding, and bad ventila- tion. It is eminently a disease of the poor. Symptoms. — The fever poison having been absorbed into the system, there is a period of incubation from one to twelve days, during which time the patient feels out of sorts, with pains in his limbs, languor, loss of appetite, headache, thirst, and the " creepy sensation " formerly alluded to. These are succeeded after a varying interval by increased heat of skin, full and rapid pulse, restlessness, apathy, great thirst, and prostration. The patient no longer fights against his malady, but willingly keeps his bed. Is there anything particularly characteristic of this fever ? There is what is termed the typhus rash, somewhat dark and mulberry in appearance. It consists chiefly of irregular spots, sometimes single and easily defined, at other times patchy from a number of them coales- cing. They are most frequently seen on the chest and 24 FEVERS. abdomen, rarely on back or face, and at first disappear on pressure. Their dark color fades after a day or two into a brickdust hue or mottling, which appear- ance increases until the rash becomes ecchymosed or hemorrhagic, and in this later stage does not disap- pear on pressure, but remains permanent even after death, or until recovery ensues. The rash comes out once for all, not gradually, from the fifth to the eighth day of the fever, and is rarely absent in adults, although in young children it is not so frequently observed. In addition to this rash, characteristic of typhus fever, there is also peculiar to it a dull, heavy, stupid expres- sion of countenance. The eyelids droop, and the eyes have the appearance of those of a man recently re- covered from a debauch. With the fever there is generally delirium. This rarely comes on before the end of the first week, and usually continues until death or convalescence super- venes. The delirium is of a violent and painful char- acter, and at first is not continuous. The patient can be roused to answer questions, take drinks, or show his tongue. Yet his expression is vacant, and he mut- ters when alone. Generally this stage is succeeded by a loss of cognizance of external objects, and all kinds of illusions, especially during the night. The patient tosses about from side to side, or he may shout madly, or endeavor to get out of bed. The mind is, in one word, thoroughly unhinged. The pulse increases in rapidity, and at the same time gets more soft and feeble. The temperature rises in the first week to 104° or 105°, remaining about TYPHUS FEVER. 25 these points for a week, and then subsiding to the nor- mal or subnormal about the end of the second week. The tongue becomes dry, brown, tremulous, and is protruded with difficulty, while the teeth and lips are covered with sordes, emaciation all the time going on, with tendency to contraction of the pupil, cold ex- tremities, and congested conjunctivae. The crisis is reached on the fourteenth day from the commencement of the fever, and is ushered in by a prolonged sleep, by diarrhoea, or by profuse sweating, or there may be no marked crisis, but rather a gradual subsidence of pulse and temperature (a lysis). Should a fatal termination ensue, it usually happens between the twelfth and the twentieth day of the fever, death being preceded by great prostration, picking of the bedclothes, subsultus tendinum, involuntary pass- ing of feces and urine, and coma. The mortality is about one in five of those attacked, and the greater the age above ten years the greater the danger. Complications. — Typhus may be complicated by the occurrence of acute bronchitis, pleurisy, or pneumonia, rarely by affections of the larynx or pharynx. The heart is sometimes softened, especially the left ventri- cle, and this gives rise to depressed action of the organ, and a loss of the first sound. At other times the sounds are well developed, and are accompanied by a vigorous and heaving impulse, indicating over-excite- ment of the organ without softening. Other compli- cations are gangrene of the extremities, bedsores, very rarely diarrhoea — the bowels all through the disease rather being constipated. 26 FEVERS. Diagnosis. — The rash and the nature of the fever distinguish typhus from any inflammatory condition of the lungs. Its further diagnosis from typhoid will be alluded to afterwards. Acute meningitis, for which it has been mistaken, is attended with nausea and vom- iting, no rash, and delirium almost from the commence- ment. Morbid, Anatomy. — There is nothing characteristic in the postmortem appearances of a fatal case of ty- phus fever. If there has been marked delirium we may expect to find the sinuses engorged, but in the majority of cases the brain is seldom altered. The spleen is softened, and in some cases enlarged. The heart may be somewhat atrophied, and the blood fluid. Should there have been an inflammatory condition of the lungs, indications of this will of course be found on examining the thorax. The intestinal tract is healthy. Treatment.- — In the early incubatory stage, Dr. Hughes Bennett recommended an emetic, which he said had saved him from one or two attacks, when he was certain the poison was in his system. If this stage be over we must treat symptoms, remembering that we may guide, but can never cure a fever. A purga- tive of thirty to sixty grains of rhubarb may be given at the outset. Tepid water injections relieve after- constipation. The apartment should, if possible, be large and well ventilated, with a fire in the room. Intercourse with friends should be restricted, and at- tendance limited to skilled nurses. The head should be shaved, or the hair teased out, and cold lotions ap- TYPHOID FEVER. 27 plied. The diet should consist chiefly of milk and weak broth. Stimulants may be needed to tide over the dis- ease, and should be administered when there is signal loss of strength, or rapid feeble pulse, and weakness of the first sound of the heart. If it is found that the temperature does not increase, that the pulse be- comes fuller, and the general condition improved, brandy may be given in teaspoonful or tablespoonful doses every two hours. Care must be taken to give it at certain intervals, and if necessary the patient must be roused to take it. A mixture of chloral and bromide of potassium is beneficial, especially at the approach of the crisis, if there is great irritability and sleeplessness (F. 69). Bedsores must be prevented from forming, and attention should also be directed to the bladder. The pulmonary complications must be met if they arise by local and general treatment. Cold baths at about 65° Fahr. have been strongly recommended lately, and may be repeated day and night when the temperature rises above 102° Fahr. Typhoid Fever. Etiology. — The term typhoid literally means like typhus. It has also been termed enteric, gastric, or pythogenic fever. It is not, like typhus, markedly contagious, and it seems to be generated from bad drains, sewage gas, or fluids contaminated by sewage. Symptoms. — The patient is attacked by the disease 28 FEVERS. more insidiously than in typhus. There is no abrupt departure from health to disease. There may be a slight premonitory chill, followed by malaise and in- ability or aversion to work. The man feels out of sorts, and attends listlessly to his business ; the child inclines to rest, and not to play with its toys. Then lying in bed is found to be a welcome relief, and there is no inclination to leave it. At the early stage of typhoid, as well as during the whole continuance of the fever, the thermometer is found to be of great value. Thus, even although the pulse indicates little deviation from health, it will be found that the even- ing temperature is higher than the morning by about a degree, 99.9° morning, 100.5° evening ; and this characteristic of a high evening temperature com- pared with that of the morning is retained through- out the disease. The temperature rises gradually, and may reach 105° towards the end of the first week, after which it agains slowly falls to reach the normal state, by a series of oscillations between the morning and the evening temperatures, which may continue for an indefinite time, extending even to weeks after other symptoms have gone. The general symptoms qf fever are present — as thirst, loss of appetite, and headache. The tongue loses the color of health and becomes small and dry, having a pale brownish-yellow fur, with red tip and edges. About the seventh or eighth day of the fever small rose-colored spots sometimes, but not invariably, ap- pear on the abdomen, chest, or limbs, being situated on normal uncolored skin. They may be few in nurn- TYPHOID FEVER. 29 ber or numerous. Their form is circular, and they last three days, disappearing completely under pres- sure, to reappear when that is removed. Fresh crops succeed those previously formed until the termination of the fever. They are rarely seen after the thirtieth day unless a relapse occurs. The abdomen becomes somewhat enlarged, and on careful pressure over the right iliac fossa a gurgling sound is generally heard, with distinct wincing or even actual pain. Even when delirium is present this wincing is usually seen by looking at the face. Diarrhoea is almost always present. In some cases the stools are numerous, in others only two or three in the day. The color of the stools is characteristic, and is best described as being like that of pea-soup. Occasionally they are tinged with blood. With diar- rhoea there may be marked distension of the abdomen and tympanitis. Coarse and Progress of the Disease. — The disease may end in recovery or death. If the former, after the twenty-first day the severity of the symptoms abates, and gradual convalescence ensues. The tem- perature falls, presenting a gradual approximation of that of' the evening and that of the morning. If the latter, the patient may sink exhausted and worn out by the disease, or fatal haemorrhage may ensue, or peritonitis from perforation through the ulcerated spots on the small intestine. As in typhus, acute inflam- matory disease of the chest may complicate matters and be the more immediate cause of death. Again, 3 30 FEVERS. death may occur from inflammation arising from ab- sorption of fetid matter from ulcerated bowels. Morbid Anatomy, — Characteristic traces of the dis- ease are found after death, and are pathognomonic of typhoid fever. These are altered appearances of Peyer's patches and the adjacent mesenteric glands, and the lesions are most distinct in the group of glands nearest the ileo-csecal valve. If the disease termi- nates fatally before the fever has advanced far, we may find the mucous membrane over the glands simply congested and swollen. If, as most commonly hap A pens, death results at a later stage, this congested ap- pearance is succeeded by the detachment of the slough as a whole, or molecularly, leaving ulceration, with ragged irregular edges, varying in size from a pea to a florin. This ulceration may even go on to a perfo- ration. The mesenteric glands in the neighborhood of the patches are enlarged and softened. Diagnosis. — Typhus and typhoid fever are both dis- tinguished from febricula and relapsing fever by the longer continuance and course of the fever, along with the characteristic eruptions, and from one another by the following symptoms : 1. In typhus the rash is mulberry, mottled, and continuous, going on to ecchymosis, and hence resisting pressure. In typhoid the rash consists of rose-colored spots, fading in three days, and giving place to a fresh crop. These spots disappear on pressure, and are not surrounded by mottled skin. 2. In typhus the rash appears from the fifth to TYPHOID FEVER. 31 the eighth day. In typhoid between the seventh and the fourteenth. 3. In typhus there is no diarrhoea. In typhoid diar- rhoea is common, and the stools are of a pea-soup color. 4. In typhus the symptoms are generally cerebral; hence disquietude going on to coma, with an inter- mediate stage of delirium. In typhoid the symptoms are abdominal ; hence diarrhoea, and pain on pressure over right iliac fossa. In typhus we see contracted pupils, muttering delirium, preceded by disquietude and uneasy manner, and congested conjunctivce. In typhoid we see dilated pupils, delirium, preceded by apathy and somnolence, and no congestion of the con- junctiva?. 5. These fevers also differ in their duration, a crisis being reached in typhus on the fourtrenth day of the fever ; while in typhoid, not a crisis, but a lysis, is reached on the twenty-first day. Typhus may occur at any age, and is commonest amongst the poor. Ty- phoid is generally a disease of youth or adult life, is rare after forty, and it shows no partiality to the poor. Treatment. — A teaspoonful of ipecacuan wine may be given every ten minutes until vomiting ensues, if the patient is seen in the early stage, and before the spots have appeared. Purgatives should be avoided. After the disease has been established, it is necessary simply to watch and treat symptoms. Should the diarrhoea be excessive or weakening, astringents may be given. There is not the same 32 FEVERS. necessity for caution as in typhus with regard to the administration of opium, and the drug may be given either by the mouth or rectum ; if in the former way, combined with catechu (F. 17); in the latter, in the starch and laudanum injection. Should haemorrhage occur, gallic acid is requisite, with brandy if there be great depression and exhaustion ; or the pil. plumb, cum opio, turpentine, or the subcutaneous injection of ergotin may be tried. Delirium and sleeplessness may necessitate sedatives, such as chloral, the bromide of potassium, or both combined. Tincture of hyoscy- amus is also serviceable. All physical restraint should be forbidden, as patients are generally easily coaxed by a kind and skilful nurse to do what is requisite. Good ventilation, careful sanitary arrangements, clean- liness, and prevention of bedsores, should be matters of routine. The diet is of paramount importance. Nothing can be better than milk, and of this the patient may drink ad libitum at regulated intervals. On the re- turn of convalescence the patient should be warned against rising too soon, or changing the milk diet, or supplementing it by other. food. It must be remem- bered that the ulcers are now cicatrizing, and any error in diet may prevent this, and bring on alarming symptoms ; besides, relapses are not uncommon. An addition may gradually be made to the milk by a little weak soup or broth. Then give arrowroot with dry toast, and finally, beef tea ; although the latter should be avoided if there is any tendency to diarrhoea. No solid food should be ordered until the tongue is RELAPSING FEVER. 33 clean, all pain on pressure over the iliac region gone, and the temperature normal. Finally, it must be remembered that a careful ther- mometry chart of the temperature, as taken morning and evening, is the only satisfactory index of the fever. Liebermeister strongly recommends the use of a bath at 68° Fahr., of ten minutes' duration, if the temperature reaches or exceeds 102°, with quinine in the dose of 24 grains. In very severe cases he advises digitalis to be added to the quinine. In this way the high temperature is controlled. The statistics given of the results of this treatment seem very satisfactory. Relapsing Fever, Known also as recurrent typhus or famine fever, was long confounded with typhus ; the differential di- agnosis between them being only made by Jenner in 1850. Etiology. — It is intimately allied to typhus, being highly contagious, and originating from filth, over- crowding, and destitution. Lebert and other German observers find in the blood of relapsing fever patients thin threadlike spiral fungi. These are supposed to enter the system either directly or through the taking of fluids or solids. The period of incubation is from five to seven days. It is most common in early child- hood, and from the 20th to the 30th year. Between 30 and 50 it is rare ; and after 50 it is scarcely ever seen. 34 FEVERS. Symptoms. — Unlike the other fevers mentioned, there are no forewarners. The disease sets in sud- denly with headache and intense fever, which at once prostrate the patient, and it is accompanied with thirst, loss of appetite, pain in limbs, and burning heat of skin. The temperature for the first two days is usually 102° morning and 104° evening, and then it mounts to 105° and 107°. The pulse is weak and quick, and the skin moist. The tongue is thick and coated ; not parched and black as in typhus. The bowels are constipated. On the second day the liver atid spleen, especially the latter, notably enlarge, — not merely from day to day, but from morning to evening. There is little delirium. The high fever, the rapid loss of strength, the splenic enlargement, indicate a fever likely soon to be fatal ; when, as suddenly as it came, on the fifth, sixth, or more usually, on the seventh day, there is a crisis, with profuse sweating, rapid fall of tempera- ture, and complete improvement of all the symptoms, with entire decrease of the splenic enlargement. The only thing left is great languor, which sometimes may approach syncope. This interval of freedom lasts usually a week, when a relapse occurs, generally at night, with all the symp- toms which characterized the previous attack. This attack is, however, shorter, lasting only three or five days. It suddenly ceases, leaving the patient weak and anaemic, and entailing a lingering recovery of from four or five to six weeks. As many as four or five relapses have been known. INTERMITTENT FEVER, OR AGUE. 35 Prognosis and Complications. — In only two or three per cent, of the cases is the fever fatal. Death may occur from the intensity of the fever, or from compli- cations, as pneumonia or abscess of the spleen. Post-mortem Appearances. — If death occur from the disease, the spleen is found greatly enlarged, the cap- sule tense, the parenchyma soft and pulpy, with wedge- shaped impactions due to emboli. The liver and kid- neys are also congested. Nothing of special note is observed in the other organs. Treatment. — Rest in bed, cleanliness, milk, strong soup, and wine, are necessary. A bladder of ice may be applied to the head, to relieve headache, and w T ater charged with carbonic acid given to allay thirst. For splenic pain apply cold applications or continuous poultices. Ten drops of dilute phosphoric acid should be given in sweetened water every two hours; if symp- toms of collapse, carbonate of ammonia and alcohol ; if delirium, 15-grain doses of chloral every hour, until one or two drachms have been taken. During convalescence good nourishing diet, with wine, and the preparations of quinine and iron, are essential. Intermittent Fever, or Ague. These fevers constitute a class by themselves, and were well known to the ancients. They are dependent ou certain marshy miasms, and are endemic, not epidemic, in character. 36 FEVERS. The febrile phenomena occur in paroxysms, ushered in by rigors, and terminate by a critical sweat. There are three distinct changes : 1, a stage of chill ; 2, of heat; 3, of sweat. The fevers are divided into types according to the length of these stages, for the attacks occur pretty regularly — every twenty -four hours (quotidian); every forty-eight hours (tertian); every seventy-two hours (quartan). The time between the commencement of one par- oxysm and the beginning of the next is termed the interval. That between the termination of one par- oxysm and the commencement of the next the inter- mission. The type most common in temperate climates is the tertian. Etiology, — While the predisposing causes are those which weaken the system, as exhaustion, insufficient food, intemperance, or exposure to night air, the ex- citing causes are certain peculiar invisible emanations, undetected by chemistry or the microscope, which are known as malaria, and spring chiefly from marshy lands. Most probably decomposing animal and vege- table matters furnish the materies morbi, chiefly, if not entirely, the latter; for it is an established fact that ague in time past was common in certain tracts of country then uncultivated, whereas now, since the land has been purified by agriculture, the disease is unknown. Symptoms. — The invasion may be sudden or after INTERMITTENT FEVER, OR AGUE. 37 a few da) r s of indisposition, with headache, loss of appetite, and sneezing. The cold stage is characterized by chilliness, first in the limbs and afterwards over the whole body, with a sensation of streams of cold water running dow T n the back ; shrivelled skin, " cutis anserina," chattering of the teeth, blueness of the nails, hurried respiration, and small pulse. The duration of this stage varies from half an hour to three or four days, and is succeeded by the hot stage or reaction, with increased temperature, dry skin, great thirst, frequent pulse, and a peculiar ful- ness about the head. This hot stage usually lasts from three to four hours, but it may be prolonged to six, eight, or twelve hours, and is then followed by the sweating stage, beginning with a diminution of the heat, followed by a gentle moisture on the forehead and breast, and terminating in a copious sour-smelling steaming sweat, with an abundant flow of urine, normal pulse, and a cessation of all pain or uneasiness. This stage in its duration cannot be easily deter- mined, but it appears materially to exceed the other two. The fever thus described rarely results directly in death, but it often induces permanent enlargement of the spleen with induration, popularly known as the ague cake. The enlargement is a pure hypertrophy — that is, an enlargement of every element of the organ, and is accompanied by a peculiar cachexia. There is also congestion and permanent morbid 4 38 FEVERS. change in the liver, with serious disturbance of all the digestive organs. The patient is subject to cachexia from enlargement of spleen, and even after his recov- ery from that he is much more subject to recurrences of the fever, which do not necessarily require new ex- posure, but the periodic character may imprint itself upon other diseases, as epilepsy or neuralgia. He seems to carry the seeds about with him. Treatment. — In the cold stage the patient should be placed in bed, covered with blankets and rugs, with hot bottles applied to his feet, and hot drinks, such as tea or weak negus, should be given. In the hot stage cooling drinks are required, and the body should be sponged with tepid or cold water. In the sweating stage great care must be taken to prevent chills, and the action of the skin should be encouraged by tepid drinks. During the intervals quinine should be given in a large dose, 20 to 30 grains, either before or at the close of the paroxysm. Remittent Fever Appears to be dependent on the same causes as inter- mittent fever, viz., malaria. It is also endemic, non- contagious, and chiefly confined to tropical climates. The different localities in which it prevails have led to its being designated by various names. It is thus called Walcheren fever, Bengal fever, bilious remit- tent of the West Indies, jungle or hill fever of the East Indies, African fever, Mediterranean fever, etc. REMITTENT FEVER. 39 The symptoms resemble those of intermittent fever; it is distinguished from it, however, by the notable fact that in the intervals there is no entire cessation of the fever, but simply an abatement or diminution. The disease continues from twelve to fourteen days, and the period of remission varies from six to twelve or fourteen hours. It is worthy of note that a distinct sliding scale of periodicity can be traced from inter- mittent fever down through remittent to the severe tropical continued fevers. Symptoms. — The fever is ushered in with gastric symptoms, uneasiness, depression, and sinking at the epigastrium, with headache and languor. The cold stage is scarcely marked, or, if so, is rapidly succeeded by a severe hot stage, with burning skin, vomiting, sleeplessness, intense headache, or even delirium. This stage, usually lasting the time mentioned, is suc- ceeded by an indistinct stage of sweating or subsi- dence, and is followed by another attack similar to the first but more severe. These attacks and varying remissions constitute the fever, which terminates in recovery or death, often in permanent ill health. Oc- casionally there is jaundice, and the liver and spleen are enlarged and tender. The remissions usually set in during the morning, while the exacerbations take place towards the evening. Treatment. — The object of treatment is to mitigate the exacerbations, and lengthen the remissions, and is based on the same principles as those indicated in in- termittent fever. Thus see that the bowels are acted on, sponge the body, or use the cold pack, and give 40 FEVEKS. effervescing and saline drinks. When the remission occurs, give quinine in doses varying from four to six grains every three hours, omitting the remedy when the hot stage commences, but resuming it at the next remission. Cold should be applied to the head if the headache is severe, and sinapisms to the stomach to relieve the gastric irritation. If there be much ex- haustion, stimulants should be freely given. At the termination of the disease, the patient should, if possible, be sent to a temperate climate, or a non- malarious district. Iii very chronic cases fresh air and outdoor exercise seem to be beneficial, with the administration of iron. Dr. McLean highly recommends the use of the binio- dide of mercury ointment over the spleen, which has the advantage of never causing salivation. Yellow Fever Requires an average temperature of at least 72° Fahr. for some weeks to produce its appearance, and seems peculiarly to affect the West Indies, Africa, and some parts of America. It varies in severity, frequently terminating in death either by the acuteness of the fever, or by the exhaus- tion or intercurrent complications, such as ursemia or apoplexy. It is sometimes epidemic, and it is a matter of dispute whether or not it is contagious. It appears to be dependent on some morbid poison, probably of malarial origin. Symptoms. — The fever commences abruptly, often YELLOW FEVER. 41 in the middle of the night, and is attended with severe headache, great irritability of the stomach, with vomit- ing, and a peculiar yellowness of the skin ; the vomited matters at first being slimy and- tasteless, but after- wards black like coffee-grounds — hence. called black vomit. The urine is frequently suppressed; if passed it is loaded with albumen and tube-casts, and is smoky in appearance. The fever usually lasts from three to five or seven days. When the sixth day elapses without the occurrence of black vomit or suppression of urine, hopes of re- covery may be entertained. The mortality is usually one in three. The symptoms of the fever point to the poison specially affecting the liver, which is supposed to un- dergo acute fatty degeneration. The poison is con- sidered to produce certain specific changes in the blood, viz., destruction of the red corpuscles. . The blood thus loses its capacity for nourishing and regenerating the tissues, and when death does not take place there is a lingering convalescence, consequent on the feeble- ness of the whole organism. Treatment. — Although yellow fever is dependent on malaria like the preceding fever, it is to be remem- bered that the spleen does not seem to be affected, and hence, probably, quinine is of little service. We have no specific for the disease, and the treatment is thus symptomatic. At the outset, castor oil and calomel are given^to overcome the constipation which gener- ally exists. For the relief of the nausea and vomit- 42 FEVERS. ing, ice may be swallowed, and morphia subcutaneously injected in the epigastric region. Hsenisch suggests that transfusion after previous bloodletting might paralyze or modify the injurious operation of the yellow fever miasm. As soon as the stomach is able to retain food and drink, a light nutritious diet is essential, with wine and quinine and preparations of iron. Dengue, Dandy Fever, Breakdown Fever, Is unknown in this country, but prevails in America, the East and West Indies, and other parts. Its cause is not known, but it is believed to be con- tagious. Symptoms. — After an incubation stage of from twenty-four hours to ten days, the patient is suddenly attacked with chilliness and weakness, and pains in the joints and large bones, as in rheumatic fever, w r ith subsequent swelling. Fever is high, and with it there is often a red rash like that of scarlatina, but of short duration. About the third day, a peculiar eruption appears on the palms of the hands, rapidly spreading over the whole body, and disappearing within twenty-four hours. Remission of the fever succeeds, but is followed by two or three relapses. The average duration of the fever is about eight days, but recovery from it is tedious, as there is marked debility. It is rarely fatal. Treatment. — Emetics and purgatives are recom- ERUPTIVE FEVERS. 43 mended at the outset, followed by saline diaphoretics, with opium to allay the pain, and ice locally to relieve the headache. The diet must be regulated, and stimulants ordered if there is depression. Convalescence is assisted by the use of quinine and the mineral acids (F. 75). The Plague, Called by Heberden " the black death," was for- merly prevalent throughout Europe, and terribly fatal. Xow it is little known except in certain parts of the East, Egypt, and Asia Minor. It is caused by a morbid poison w T hich spreads by contagion, and is epi- demic in its nature. Post-mortem appearances reveal great congestion of internal organs, especially the spleen, with effusion into serous cavities. It is characterized during life by fever of a low type, with high delirium tending to a typhoid form, by enlargement of lymphatic glands and formation of buboes, with carbuncles and ecchymoses, vomiting of black matter, and haemorrhage from the mouth, stom- ach, and bowels. There is often, also, a cutaneous rash like that of typhus. It terminates most frequently in death. ERUPTIVE FEVERS. Small-pox, measles, and scarlet fever are simply continued fevers with a characteristic eruption super- added. In these fevers, a definite period of time 44 ERUPTIVE FEVERS. elapses from the reception of the fever until the ap- pearance of the eruption and its final disappearance. Thus, measles has an incubation of from twelve to fourteen days, the eruption appearing on the third or fourth day of the fever, and fading on the seventh. Scarlet fever has an incubation of from four to six days, the eruption appearing earlier than measles, viz., on the second day of the fever, and disappearing on the fifth. Small-pox has an incubation of from twelve to fourteen days, the eruption appearing on the third day of the fever. The eruption does not fade away so rapidly as in the other two ; scabs form on the tenth day of the fever, and commence to fall off about the fourteenth. These fevers are distinguished from one another not merely by the facts mentioned, but by other peculiari- ties. Small-pox. In small-pox * a specific poison is taken into the system, and after twelve days' incubation fever is ushered in with shivering, weariness, and pain in the small of the back, and very frequently vomiting. These two latter symptoms are very characteristic of small-pox, and may guide in distinguishing it, before the eruption appears, from the two other fevers men- tioned. Sometimes very acute delirium may appear in the first twenty-four hours, not remaining over three days. In children convulsions are substituted for the delirium. Lachrymation and salivation are often early symptoms. A papular eruption appears on the third day on the forehead, neck and hands, then SMALL-POX. 45 on the trunk, and lastly on the lower extremities. If the papules remain separate and distinct, we have what is termed simple small-pox, or variola discreta. If they are numerous they coalesce, and we have con- fluent small-pox, or variola confluens. Just after the eruption has made its appearance, the primary fever abates or disappears altogether, to be followed by the secondary fever, which differs from the primary in being of a typhoid, in other cases, inflammatory type. In variola discreta we observe on the third day a vesicle forming on the papulae, and around this an in- flamed area. Two days after this, the transparent lymph which the vesicle at first contains is changed into pus. After this the top becomes gradually de- pressed until it divides the pustule into two. This condition is termed umbilication, and is very charac- teristic of the small-pox eruption. A peculiar odor, difficult to describe, but never forgotten if once per- ceived, is now apparent in the room. About the eighth or ninth day the pustule breaks and a scab forms. Generally after ten days from the commencement of the fever, or on the eighth day of the eruption, the scab falls off, and a red stain is left on the skin, which gradually disappears. The second- ary fever culminates usually at this time along with the eruption. Should, however, the true skin be at- tacked, a permanent mark remains, and the patient becomes pock-marked. In variola confluens the pimple state of matters we have described is generally altered for the worse. The 46 ERUPTIVE FEVERS. headache, the pain in the back, and the vomiting are more severe, and a more copious eruption appears. Developing as the simple type did, the vesicles become so continuous as to render it sometimes impossible to put a pin's head between them. This is specially ob- served in the face, which becomes so swollen as to render the features unrecognizable. Large black scabs form, and the characteristic odor is sickening in the extreme. The mucous membranes of the mouth, larynx, and trachea are implicated. The voice is husky, throat sore, and swallowing is difficult. Cough and dyspnoea are also distressing, and there is delirium. There is thus a very apparent distinction between the general appearance and symptoms of the simple and confluent type of small-pox ; and there is also a great difference in the intensity of the secondary fever, which sets in in both cases on the eighth day of the eruption or eleventh of the fever. It is usually slight in the first variety, while it is violent in the second, and very often proves immediately fatal. It may be accompanied by boils, erysipelas, or ulceration of the cornea or membrana tympani. Prognosis. — In persons who have been previously vaccinated efficiently, or in whom the attack is non- confluent, the disease is rarely fatal. In those who have not been vaccinated the mortality is one in three. Further, if the papules be filled with blood (hemor- rhagic form of eruption) or serum, not umbilicated, and if extending, the prognosis is extremely unfa- vorable. Lastly, the " corymbose " form of eruption VACCINIA, OR COW-POX. 47 (where it groups itself into patches) is of very bad omen. Treatment — Neither vaccination nor medicine is of any avail when small-pox is incubating or has ap- peared. The disease must run its course, and all that can be done is to enable it to do so under the most favorable circumstances. The patient should be kept in a cool, well-ventilated room. The diet ought to be light, and saline draughts or lemon-juice may be administered to diminish the thirst and regulate the bowels. In the secondary fever, if it be severe, stimulants should be given, with good broth or strong beef tea. If there is great restlessness, opium or bromide of potass and chloral do good service. If sores are sloughy, and the system is greatly depressed, wine or brandy must be administered to sustain the strength through the attack. Locally no escharotic treatment seems of any avail. The pustules should be smeared with cold cream or carron oil, or carbolic acid lotion (F. 56a), or with oxide of zinc and hydrocyanic acid to relieve the itch- ing (F. 61). When the pustules have burst, some dry powder or starch or oxide of zinc should be applied. All scratching should be prevented, and to effect this the hands of young patients should be tied. Vaccinia, or Cow-pox. The remarkable discovery of Jenner towards the end of the last century makes an era in medicine. All 48 ERUPTIVE FEVERS. experience testifies that, while vaccination does not infallibly prevent small-pox, it yet so far modifies the disease as to rob it of its disgusting phenomena and sequelae, and to render it a comparatively trifling malady. It is unnecessary to detail the process of vaccination further than to state that after the simple operation has been performed, a little redness and ele- vation can be detected on the second day. A vesicle with depressed centre and raised edges is seen on the fifth, and reaches its acme on the eighth day. It is now observed to be composed of a number of cells containing clean lymph situated on a hardened base. On the ninth or tenth day these burst, and a scab is formed which finally falls off on the twenty-first day, leaving a well-marked permanent cicatrix. A little constitutional disturbance attends the * process. Varicella, or Chicken-pox, Is a trifling affection, attacking infants or young children, attended with only slight fever, if with any. The eruption consists at first of pimples, which on the second day are converted into vesicles. These burst on the fourth day, and rapidly dry up. The rash first appears on the shoulders or trunk, subsequently it may attack the scalp, but it rarely involves the face. It seems to have an incubation of four days, and is undoubtedly contagious. scarlet fever. 49 Scarlet Fever Is eminently contagious. It is usually a disease of childhood, occurring once in a lifetime, and it derives its name from the character of the eruption, which is red, minutely punctated, appearing on the second day of the fever or earlier, and lasting three days. It commences on the arm£ and trunk and lower side of the thighs, and thence proceeds to the face and the inferior extremities. In addition to the fever and the eruption the disease evidences itself on the tonsils and mucous membrane of the mouth and pharynx. It varies in severity, and hence has been divided into Scarlatina simplex, " anginosa, " maligna. In scarlatina simplex the fever runs a simple and natural course, the eruption appearing after the usual incubatory stage, disappearing on pressure, fading on the fifth day, and terminating generally with desqua- mation of the cuticle on the face and trunk. This des- quamation takes the form of scurf on the body, while on the hands and feet large patches of skin may come away at once. The process of desquamation may con- tinue for days or weeks, accompanied by itching. The tongue in scarlet fever is very characteristic. At first it may be covered with a white fur; as this clears away it becomes red, the lengthened filiform papillae pro- ject, and the organ presents a strawberry appearance. 50 ERUPTIVE FEVERS. The tonsils and mucous membrane of the mouth are congested, but in a mild degree. In scarlatina anginosa the fever is of a much more violent character, being often attended with delirium, great restlessness, and prostration. The temperature often reaches the highest point in the first twenty-four hours of the fever. This point varies much, and may, although rarely, reach 109° or 110°. The eruption may be delayed to the third or fourth day, is of a more livid color, and it may be even patchy and evanescent. The throat symptoms are more severe, the tonsils being greatly swollen, and ulcers frequently forming on them. The neck is stiff, the submaxillary glands enlarged, and deglutition is difficult. Even after the eruption has disappeared, the throat symptoms do not abate in severity as in the simple form. Scarlatina maligna is attended with marked cere- bral disturbance, passing into coma, and with great vital prostration. Tenacious phlegm hangs about the mouth and throat, the teeth are covered with sordes, the tonsil ulceration may become gangrenous, and the breath is very offensive. The rash is irregular in its appearance and its continuance, and is of a livid color. This variety, as its name implies, is usually fatal. The vital powers succumb to the strength of the poison on the fourth or fifth day. Hope may, however, be entertained if the seventh or eighth day is passed. The dangers arising from scarlet fever, considered as a whole, do not terminate with the subsidence of the fever. Troublesome and even fatal sequelae may result. The cervical glands may remain permanently SCARLET FEVER. 51 enlarged, abscesses may form, ophthalmia result, or a mueo-purulent discharge obstruct the nares, or the throat affection may spread from the pharynx up the Eustachian tube, causing disease of the ear and deaf- ness. One of the most common and not the least dangerous sequelae, however, is the affection of the kidneys, resulting in anasarca and albuminous urine. It is to be carefully observed that this result is most common in those cases where the primary fever was of a mild form. The patient has probably suffered little or no disturbance from the fever, and is perhaps exposed to cold or draughts during the stage of des- quamation. The excretory powers of the skin are impeded, and increased work is thrown on the kid- neys, bringing on acute desquamative nephritis (acute Bright's disease). This may be ushered in with shiv- ering, fever, and pains in the back, or it may come on insidiously. The face becomes puffy, and this is fol- lowed by general swelling, with scanty, high-colored, and albuminous urine. Microscopically, the urine presents blood-corpuscles, coagulated fibrin, and epi- thelial casts. Anatomical Changes. — There are no distinctive post- mortem appearances in scarlet fever. The ordinary anatomical changes may be summed up in a single sentence — erythematous inflammation of the skin, with superficial cedema ; inflammation of the fauces, and congestion and catarrh of the tubules of the kidneys. Prognosis. — The throat is the source of greatest danger. " Whenever," says Sir Thomas Watson, " I see the glands much enlarged at the angle of the jaw, 52 ERUPTIVE FEVERS. and beneath the jaw, in a child suffering from scarlet fever, I augur ill of the disease." If, in addition, the urine is very scanty and albuminous, the danger is increased by a tendency to uraemia. When these symptoms are absent the prognosis is more favorable. In the majority of cases the dropsy disappears, though serious permanent injury to the kidney may be the result. Treatment. — Attention to the bowels, with a slight febrifuge mixture, and rest in bed, are alone necessary in simple scarlet fever. For a drink in this, as in the severer forms, potass, chlor., 60 grains in a pint of water, may be given freely. The parents should be warned to keep the patient in bed in a warm room, until the desquamation is over, and after that flannel should be worn. A warm bath may be given to bring out the eruption. In scarlatina anginosa, in addition to the above, if the fever is considerable, tepid sponging, cold effusions, or wet-sheet packing may be employed. Shaving of the head, and the application of vinegar cloths after- wards, should be insisted on. If the throat is much inflamed, and the patient is an adult, five or six leeches should be applied. If a child, hot poultices should be applied instead of leeches. Beef tea, wine, and ammonia are necessary if the patient is weak and prostrated. The great prostration in scarlatina maligna necessi- tates from the first a stimulating treatment. Wine or brandy should be given freely. Three ounces of port MEASLES. 53 wine may be given to a child, and double or treble that quantity to an adult, in the twelve hours. The ulceration of the throat ought to be touched with nitrate of silver, or with a mixture of iron and glycerin. Ammonia and bark must also be given from the commencement. In all cases the body should be rubbed with oil, as this facilitates desquamation. Should, however, the desquamation be arrested and anasarca result, the loins ought to be cupped, and this should be followed by the constant application of hot linseed-meal poultices. Hydragogue cathartics are also necessary to relieve the strain on the kidney, and of these, pulv. jalapse co., or elaterium seem the best. Iron, either in the form of the tincture or ferr. amnion, cit., should be ordered, in as large doses as the system can bear with- out producing headache or nausea (F. 89). The diet should be generous, with plenty of milk, and a uni- form temperature of 60° Fahr. should be insisted on. Under such treatment the dropsy may be successfully combated, and the albumen disappear from the urine. Measles AVas long confounded with scarlet fever, and it is only since the beginning of the last century that it has been recognized as a specific and independent disease. Measles is contagious, but the cause of the contagion is unknown. Susceptibility to the contagion dimin- ishes with years, and second attacks are rare. The incubatory stage of measles, judging from the epidemic 5 54 ERUPTIVE FEVERS. in the Fiji Islands, and other isolated instances, lasts from 10 to 12 days. Symptoms. — Measles may be considered a catarrhal fever, with a characteristic eruption added to it, which appears first on the face and forehead, and afterwards on the trunk and extremities. The symptoms of catarrh — running at the eyes and nose, cough, and sneezing, with great oppression and foul tongue — pre- cede the eruption. The fever which accompanies these catarrhal symptoms indicates that an exanthem will follow. This fever, with a temperature it may be of 102° Fahr., lasts for three or four days, when an erup- tion of small circular dots, like fleabites, appears on the forehead, spreading to the trunk, limbs, and feet. These do not remain distinct, but coalesce until patches of a reddish color and of irregular shapes cover the parts affected, accompanied by flushing of the face. Thirty-six hours from the commencement of the erup- tion the temperature is highest. The eruption lasts three days, and disappears in the same local sequence as it came. There are two kinds of measles, — the essentially mild and the severe. Of the first variety there seem to be two forms — measles without catarrh and measles without erup- tion. The former attacks chiefly young persons, gives rise to little sickness, yet effectually destroys the after-sus- ceptibility to the disease. The latter variety is seen during an epidemic of measles, and we are justified in assuming a person to MEASLES. 55 have it if the catarrhal symptoms are as severe as if the patient had a measly rash, and if the person be- comes non-susceptible to the disease. The essentially severe form of measles, popularly termed "black measles/' is generally associated with the hemorrhagic diathesis. Before or after the erup- tion of measles, hemorrhage occurs in various regions ; in the skin, causing petechia or ecchymoses ; in mucous membranes, causing violent bleedings from the nose, or in organs and cavities. The general symptoms are those of a typhoid char- acter; sordes on the teeth, small pulse, debility, and diarrhoea. Complications. — Catarrhal pneumonia "and bron- chitis — an extension of the catarrh down the respira- tory tract — are chiefly to be dreaded in measles. They appear after the eruptive stages, and intensify the fever and increase the danger. Of fatal augury are livid lips, cold extremities, and a rapid feeble pulse. Cere- bral complications, peculiar forms of ophthalmia, dropsy, and albuminuria are not unknown. Prognosis. — As a general rule it may be stated that measles is essentially dangerous to very young chil- dren, and that the danger decreases rapidly with years, except in old age, when it may be fatal. Unusual sparseness or paleness of the eruption, or the hemor- rhagic diathesis, are bad omens. If the chest is only slightly affected, or not at all, we may predict a favor- able result. The great danger is not in the disease, but in what it leaves behind it, such as lobular con- 56 ERUPTIVE FEVERS. densation or collapse of the lung, or a tendency to emphysema in after-life. Treatment. — As the greatest danger in measles is an extension of the catarrh to the lungs, all exposure to cold must be avoided. The room should be darkened and the patient kept in bed. Milk diet, attention to the bowels, and a slight diaphoretic mixture, are all that is required in ordinary cases (F. 34). If there is severe coryza, warm water may be drawn through the nose. Emetics are useful at the com- mencement to prevent cough, and cold compresses may be applied to the abdomen if diarrhoea is excessive. Should chest complications ensue, the principles of treatment to be afterwards spoken of under acute bron- chitis should be adopted. Trousseau has recommended whipping the whole skin with nettles. In the typhoid state associated with the hemor- rhagic diathesis, wine and stimulating expectorants are essential (F. 72). Rubeola, Rotheln (German Measles). The term rubeola was brought into use by German physicians about the middle of the last century to characterize a disease which it was considered could belong to no one of the acute contagious or non-con- tagious eruptions, though closely resembling measles and scarlet fever. Opinions with regard to it have greatly varied, but latterly it has been shown that it is an independent disease by distinct epidemics of it, and by the fact RUBEOLA. 57 that while it insures against a second attack of itself, it affords no protection from measles or scarlet fever. Recognizing it therefore as a contagious and essen- tially epidemic, and thus also specific disease, it may also be noted that it is especially a disease of child- hood, attacking indiscriminately boys and girls, and older and younger children down to sucklings. A second attack is rare — as rare as that of measles. Its contagion is not quite so great as that of measles. It consists of an eruption on the skin of numerous discrete blotches, from the size of a pin's head to, at the utmost, that of a bean, slightly raised above the level of the skin, with at times a distinct, at others a faded border. The spots are round or oval, and are Avell marked on the face, their color being of a pale rose-red. They are seen on other parts of the body, especially on the neck, scalp, and thighs ; while on the forearms, hands, and lower parts of the legs they are not so common. The eruption lasts usually for two days, and then disappears without any desquamation. The size of the spots is less than that of measles, the form being more round and the color paler. Symjitoms. — The course of the disease in the ma- jority of cases is as follows : After the patients have coughed and sneezed somewhat, and manifested slight photophobia, from a few hours to a day, one notices — either at once or after the attention has been excited by a gradually increasing temperature — the beginning of the exanthem on the face. While now the exan- them gradually spreads over the body, the tempera- 58 GENERAL DISEASES. ture, if increased, becomes quickly normal again. Thus children generally object to stay in bed, and would prefer to be out of doors. In ordinary rubeola there are no other local symp- toms except slight catarrh at times, some difficulty in swallowing, and some diminution of appetite. Prognosis. — Its almost feverless course makes the prognosis most favorable, but the disease may be com- plicated with bronchitis, and may have a fatal termi- nation. Treatment. — The treatment of rubeola is restricted to a suitable regimen ; protection against exposure, keeping the patient in bed if feverish, and attending to probable catarrh of the air-passages and the pharynx. Other complications, if any, should be treated ac- cording to their nature. Dropsy. By dropsy is meant a collection of serous fluid in one or more of the shut cavities of the body, or in the meshes of the areolar tissue, or in both. Dropsy is not so much a disease per se as it is symptomatic of other diseases. And it may be viewed in two aspects : first, as to its cause — the organ implicated ; second, with regard to the dropsical eifusion. Differ- ent terms have been given to the effusion in relation to its different sites. DROPSY. 59 Hydrocephalus is the term applied when the effu- sion is in the ventricles of the brain, or in the sub- arachnoid space. When in the pericardium, hydropericardium. " " pleura, hydrothorax. " " peritoneal cavity, ascites. When it is situated more or less generally in the subcutaneous areolar tissue all over the body, it is termed anasarca ; when it is confined to one particular part of the areolar tissue, the term oedema is used. To account for dropsy, it is to be remembered that all closed cavities and interstitial tissues are kept moist during life, by a continual serous exhalation from these surfaces, wmich exhalation again is as con- tinually and constantly absorbed. When dropsy occurs the balance has been destroyed. There is either too much exhalation, an increase of fluid sent out, or absorption is impaired, while the exhalation continues the same. Dropsy is thus naturally divided as arising from defective absorption — chronic or passive dropsy; or excessive exhalation — active or acute. Similarly any interruption to the venous return, by favoring exuda- tion, originates dropsy. Although anything which tends to weaken the sys- tem and impoverish the blood, such as bad or insuffi- cient nourishment, or exhausting disease, may cause dropsy, yet there are three great kinds of dropsy, which are named after the organs implicated, cardiac, renal, or hepatic. 60 GENERAL DISEASES. Cardiac dropsy, due to disease of the heart, com- mences in the feet and hands, and mounts upwards, ultimately becoming diffused all over the body. Renal dropsy originates in the face and upper ex- tremities, and is frequently first observed in the loose cellular tissue about the eyelids, ultimately affecting the feet and serous membranes. Hepatic dropsy is localized at first, being confined to the peritoneal cavity. The portal system of veins is alone implicated, and hence the legs, feet, and hands may not give evidence of dropsy for some time. Dropsy in the subcutaneous areolar tissue is easily recognized. There is swelling; the skin is pale, and may be tense and glazed. There is no actual pain or tenderness, but simply a feeling of uneasiness and dis- comfort. Pressure on the skin causes what is termed "pitting," and this is due to its want of elasticity. The diagnosis of ascites, L e., the accumulation of fluid in the peritoneal cavity, is more difficult. That fluid is present is recognized by the fact that the abdomen is swollen, and that the liquid is free is shown by the ease with which it goes from side to side on varying the position of the patient; and further, on placing the hand on one side of the abdomen, and striking on the opposite side with the other, the wave of the fluid communicates a perceptible sensation. Ascites may be confounded with tympanitis, but the distinction between them is, that tympanitis gives an exaggerated sound to percussion all over the ab- domen ; whereas in ascites the centre is clear, but the gravitation of the fluid renders the flanks dull. To DROPSY. 61 distinguish it from distension of the bladder and from pregnancy, the history of the case, and the application of the catheter in the one instance, and the stethoscope in the other, are sufficient. The history of the swelling commencing on one side, and the facts that this swelling does not shift with the different positions of the patient, and that the sound on percussion is dull and deeply seated, in- dicate the presence of an abdominal tumor, which is confirmed by examination, showing that neither heart, kidney, nor liver is at fault. Dropsical fluid presents the following characters : It is thin and watery, generally of a pale straw color, and having a specific gravity of 1008 to 1014. Its reaction is usually alkaline. It is allied to blood serum in this, that it holds in solution albumen and alkaline and earthy salts, especially the chlorides. The proportion of solids is, however, much less, and the albumen, especially, varies in quantity. Treatment. — Without entering specially into the treatment of the different kinds of dropsy, it is to be observed that there are obvious indications — 1. To remove the fluid; 2. If possible to prevent its recurrence ; and, if neither the one nor the other is possible, palliative measures are necessary. Rest in the recumbent posture is of paramount im- portance, and the part in which is the greatest effu- sion must be elevated and supported. For this end raise the anasarcous limb, and support the scrotum. There are three great channels for getting rid of the effusion — the skin, the kidneys, and the intestines ; 6 62 GENERAL DISEASES. and if the remedies employed to eliminate it by these organs fail, then tapping or puncturing must be had recourse to (F. 33, 37a, 27). Tuberculosis. The term tuberculosis means a certain peculiar con- dition of the system, most probably originating in the blood, and showing itself in such conditions as scrofula, pulmonary consumption, tubercular hydrocephalus, tabes mesenterica, etc. We are ignorant of what change the blood undergoes; yet, we are justified in stating that it is a deficiency of red corpuscles, and an increase of the watery portion. In some towns, 35 per cent, of the death-rate is due to the tubercular diathesis, and all over the country it is the cause of the direct mortality of one-seventh of the classified forms of disease. Authorities seem to agree that the morbid state of the blood gives rise to the specific production of tu- bercle. After the admission of this fact, there are three widely different views of the subject. One is, that the liquor sanguinis is exuded from the capillaries, as in ordinary inflammation, and that this exudation, instead of forming pus, is, owing to the peculiar state of the system, transformed into tubercle. Another is, that while there may be an exudation, this is not the whole, but the minor part of the pro- cess, for the cells of the lung-tissue tend to increase TUBERCULOSIS. 63 for some time, then they shrivel up and die, thus con- stituting tubercle. A third view is that tubercle is the product of in- fectious disease — this infectious disease being due to the absorption of cheesy morbid products into the blood, which, in some peculiar manner, act as a specific inflammation in the production of tubercle. Some modify this opinion by saying that the caseous matter produces tubercle by a local influence, through the lymphatics, and not by general infection. There are two forms of tubercle — the gray and the yellow; the former consisting of minute, firm, bluish- gray granules, about the size of a millet-seed; hence the term miliary. Sometimes, however, they are as large as a small pea. They are generally firm, and of a semi-cartilaginous hardness. Yellow tubercle is not semi-transparent, but opaque, its color varying from a dirty white to a bright ap- pearance. It has been likened to cheese; and as the consistence of cheese is not uniform, in some cases being firm and tough, in others creamy and easily cut, so the yellow tubercle is firm and tough, or fluid and soft. This tubercle may be found alone in isolated masses, or a large portion of the lung may be infil- trated with it, or the large masses may tend to crowd together, resulting in the formation of cavities. We shall not enter further into the question of gray as distinguished from yellow tubercle, except to note that microscopically they are the same, and chemically they present no point of difference, consisting in both - of animal matter and earthy salts, and having 64 GENERAL DISEASES. the appearance of a group of round cells, with one or more giant cells in centre, obscured by products of inflammation. What becomes of tubercle thus deposited or formed in the lung? It may be absorbed, or it may be converted into a cheesy consistence by means of fatty degeneration, which again may become hardened, undergoing the change termed calcification. Bringing these points to a practical issue, it is to be observed, in regard to a cavity in the lungs, that, the matter being coughed up, the ulcerated walls may fall together and adhere, or they may become lined with a false membrane, and a chronic cavity may be the result. To establish the cure it is necessary that the blood should become so healthy as to prevent the deposition of further tuber- cle, or of what may become tubercle. It is impossible to deny that tuberculosis is heredi- tary, and that it may also originate from breathing a vitiated air, or from want of proper nourishment or exercise. Any disease which tends to weaken the body and impair digestion favors the development of tubercle; and it may be further added that, whenever an organ is specially weakened by previous disease, there tubercle may form. It may also be stated that general tuberculosis has been set up in animals by the inoculation of caseous material. What general symptoms indicate tubercle? A delicate white skin, which at times blushes with a rosy hue of characteristic beauty; a coldness of the body ; in youth great precocity both in walking and TUBERCULOSIS. 65 talking ; a somewhat swollen abdomen ; and a strong disinclination for all fatty food. When the tubercles are forming, or have actually formed, there is marked debility, loss of flesh, and a fever of a remittent character, as is indicated by a rise of the thermometer in the evening and a fall in the morning. The scrofulous diathesis cannot be considered to be distinct from the tuberculous. It is simply a coarser expression of the same picture. The lymphatic glands of the neck are enlarged, sometimes even they sup- purate; the face is not so intelligent, nor has it the same transparency or regularity of feature ; the lips are frequently thick and swollen; the nose flattened ; forehead low; the teeth carious; and the belly much enlarged during early life. Mr. Paget says: "The scrofulous constitution is peculiarly liable to tuberculous disease." This tubercular diathesis may be mistaken in early life for typhoid fever. The indications by the ther- mometer are similar; but there is an absence of gur- gling in the iliac region, of rose-colored spots, or of characteristic pea-soup stools ; and while night-sweats are associated with tuberculosis, they are unknown in typhoid fever. Tubercular disease is often preceded by what is called strumous dyspepsia. By that term is not meant ordinary dyspepsia, pain or vomiting after taking food, but a kind of shuddering distaste for all fatty food, and which, if taken, gives rise to nasty acid eructa- tions quite distinct from ordinary faulty digestion. 66 GENERAL DISEASES. . Statistics show that this dyspepsia was present in 77 per cent.; and out of 50 cases carefully tabulated by Mr. Hutchinson, it was found that it had preceded the chest symptoms in 33. Prophylactic measures are necessary to prevent the transmission of tubercular disease. 1st. Marriage should be well assorted, and should not be contracted by those laboring under this diathesis. 2d. If a child is born when there is evidence of this complaint on the part of one or other of the parents, it should be intrusted to a healthy wetnurse, and should be much in the open air both daring and after lactation. Cleanliness and friction of the skin should be attended to ; and substances which are likely to occasion diar- rhoea, such as fruits and pastry, should be avoided. If circumstances permit, such children should be sent to a warm and equable climate until the consti- tution is well developed. They will there be enabled to spend much time out of doors without risk of catch- ing cold, and thus obtain the most important hygienic factors — daily exercise and a pure atmosphere. On the same principle sea voyages are useful. There is not much risk of catching cold at sea, and the appetite and the digestion are improved. The appropriate treatment for each of the tubercu- lar complaints — phthisis, tabes mesenterica, etc., will be alluded to under the separate diseases. The gen- eral principles, however, are good nourishment, fresh air, warm clothing, .and great attention paid to the digestive system. By these means, aided by appro- SYPHILIS. 67 priate medicines, it is our hope to remedy the blood disease connected with tuberculosis (F. 81). Syphilis. Syphilis is a chronic infectious disease with different symptoms at different stages of the malady. As a separate and distinct disease, syphilis dates from the end of the fifteenth century, when a notorious epidemic of it occurred in Italy, which gradually became less malignant, and the physicians then inferred, falsely, as we now know, that it would wear itself out, and cease altogether to infect the human body. The dis- ease is at the present day prevalent throughout the world, although its principal sites, for obvious reasons, are large seaport towns and great commercial centres. The most common way by which syphilis can be communicated is by the genitals as the result of sexual connection. A little red papule appears, fol- lowed by hardness and induration. A few days after this the lymphatics of the groin are enlarged, become hard to the touch, without tenderness, and freely mov- able beneath the skin. Shortly after the affection of the lymphatics, the papule is seen to be scaly or covered with a thin crust, which, when removed, dis- closes a shining surface of a bright red color with a scanty secretion. Meanwhile, the patient begins to feel weak and somewhat indisposed, and in the course of from six to eight weeks from the appearance of the papule, an eruption is observed on the skin of a red color and unattended with itching. 68 GENERAL DISEASES. This is the commencement of constitutional syphilis. Simultaneously with the red eruption, or shortly after- wards, the throat begins to be inflamed; the inflam- mation leading to ulceration or to the production of circumscribed flat growths on the mucous membrane. There are frequently also more or less baldness, affec- tions of the nails, pains in the bones, inflammations of the iris, or of the deeper structures of the eye. Now the disease properly treated may take a favor- able course, with disappearance of the symptoms and restoration to health in from ten to twelve months from the time of affection. But in the majority of cases new crops of eruptions come and go on the skin and mucous membranes ; and thus we have small papules on the tongue, and scaly isolated patches of psoriasis on the palms of the hands or other parts of the body. If the constitution is weak and scrofulous, eruptions tending to suppurate may be developed. These become incrusted and form ulcers, which finally heal by cicatrization. Severe ulcerations may also be developed in the throat and nasal cavities, in which latter the bones may be laid bare and the nose become permanently depressed. Tumors may form in various internal organs, especially the liver, the testicles, and the brain; and, unlike tumors of a purely inflammatory charac- ter, they do not shrink up after the inflammation is over, but, from being hard, soften into a kind of gummy semifluid consistence; hence they are termed gummy tumors or gummata. Phthisis may now be SYPHILIS. 69 set up, with albuminuria and dropsy due to amyloid degeneration of the kidneys. Constitutional syphilis may also be communicated from local secondary lesions, as by kissing, etc., by syphilitic nurses, by vaccination when blood is taken along with the lymph of the vaccine vesicle, etc. The syphilitic cutaneous affections may be of various kinds; probably the squamous variety is the most common, appearing in patches of a coppery color, and having the scurf renewed as fast as it is shed. Treatment. — It is doubtful if the initial lesion can be destroyed at the seat of infection, opinions varying on this important point. Experience testifies that all treatment of constitutional syphilis is futile without the aid of mercury. How this remedy acts we cannot tell. There are three modes of employing it : 1. By inunction; rubbing in some ungt. hydrarg. every night, after washing the part with soap and water, and stopping the remedy whenever the mouth becomes in the slightest degree affected. 2. By fumigation ; 8, 15, to 20 grains of calomel being employed for this purpose. The patient, un- dressed and enveloped in a blanket, being seated on an ordinary cane-bottomed chair, the calomel, placed on a small metal vessel below which the spirit-lamp is burning, is evaporated in about 15 minutes and de- posited on the skin of the patient. This method may likewise be continued daily, until slight mercurializa- tion is produced. 3. By mercurial preparations internally, that one being chosen which can be continued for the greatest 70 GENERAL DISEASE'S. length of time without producing digestive derange- ments. Thus pil. hydrarg. is good, or hydrarg. cum creta, or the perchloride in the form of a pill, or in a mixture in doses of y^ of a grain. Thus, IJ. Hydrarg. Perchlor., . . gr ij. Ext. Gent., . . . . gr. xxx. M. Divide into xxiv pills, one thrice daily; or (F. 1), (F. 3), thrice daily. Iodide of potassium may be given alone for a considerable time afterwards. This remedy is specially serviceable in affections of the bones and pustular eruptions. If there is much anaemia, it may be combined w T ith carbonate of am- monia or ammonio-citrate of iron. Condylomata are best treated locally by dusting calomel over them. The patient should avoid sudden changes of tem- perature, go to bed early, and wear flannel. Beer and w 7 ine may be allowed, but no spirits. The teeth should be brushed daily with tincture of myrrh or chlorate of potass. The diet should be nourishing. Eheumatism. The word rheumatism is derived from psu/ia, a fluxion, and it arises from some disordered or abnormal con- dition of the blood. Its frequency has attracted the attention of physicians both in ancient and modern times, and much speculation has been excited as to what causes operate in determining its predisposition for the white fibrous tissue, which enters into the composition of sheaths, fascia, fibro-serous membranes, RHEUMATISM. 71 and ligaments, and thus in particular affecting the joints. The heart and its coverings, moreover, are often implicated. It is believed that the poison circulating in the blood is lactic acid. Dr. Prout first pointed out that the blood contained a superabundance of this acid; and Dr. Richardson's experiments indicate that the injection of a solution of seven drachms of lactic acid to two ounces of water into the peritoneum of a cat induces not peritoneal but endocardial inflammation (especially of the left side of the heart), and fibrous deposits on the mitral and aortic valves. The lactic acid is supposed to be formed in the pulmonary cir- cuit of the blood, and from thence carried into the left ventricle, to be propagated by the general circula- tion to the parts where the disease is manifested. The fibrin appears to preponderate over the saline elements of the blood during the disease. Few op- portunities have been afforded of examining the state of the parts affected when the attack is acute, as few people die of rheumatism per se; hence the somewhat contradictory statements of different authors. Rheumatism is most conveniently divided into acute and chronic. In the former, the general and local symptoms are well marked. There is usually a feeling of coldness, want of appetite, thirst, and more or less feverishness attendant on or caused by exposure to cold or wet. Pain is experienced in one or more joints, and is followed by inability to move, and by swelling and great tenderness. The large joints are often implicated, but the disease usually attacks the 72 GENERAL DISEASES. middle-sized ones. Hence the knee, ankle, wrist, and elbows are the chief seats. The disease tends to shift from one joint to another, and does not often remain fixed in the one first affected. When the disease is thoroughly established, the pain is severe, and is intensified by the slightest movement. The pulse is full and quick, and the fever is attended with a peculiar acrid, copious, and sour-smelling sweat. This sweat seems neither to mitigate the fever nor relieve the pain. The bowels are constipated, and the urine is high-colored, scanty, and deposits a quantity of urates on cooling. Unfortunately the disease is not limited to the joints. It has been found that in three cases out of four of acute articular rheumatism with high fever, the heart is affected by endocarditis or endopericarditis, and the foundation is laid for permanent chronic valv- ular disease. The cardiac complication is insidious, and frequently attended with no pain, and it is only discovered on examination with the stethoscope. While pneumonia is rare, pleurisy with effusion may complicate matters. The temperature ranges from 100° to 104°, gradu- ally ascending for at least a week, and subject to con- siderable variations. Sometimes it reaches as high as 108° or 109°, and then death quickly ensues. The duration of the attack varies from three to six weeks. Relapses are common, and although five to six weeks is the usual limit, the attack may extend over some months, as it has no fixed epoch for its de- parture. The termination is generally in recovery, RHEUMATISM. 73 but often the joint or joints may be left stiff, or may become chronically enlarged. The average number of deaths is usually 1 in 1000. Rheumatism is not thus so serious in itself as in the after-mischief which it entails by cardiac and other complications. Treatment. — The varying course and duration of the disease has clouded the actual value of medicinal agents, and hence a shifting therapeutics has charac- terized the treatment of acute articular rheumatism. Bleeding, mercury, and purgatives have had their day, but these are now practically abandoned, and at the present time the alkaline treatment is generally adopted. It is said that the heart is only implicated during the first week of the disease, when the fever is high and the urine acid, and that it is not attacked when the urine is alkaline. Hence two scruples of the bicarbonate of potass and soda should be given every three or four hours in half a bottle of soda-water, or in effervescing citrate of ammonia or potash draught, and should be continued steadily until the febrile dis- turbance is much lessened, the pulse reduced, and the urine rendered alkaline. If the patient is robust and the urine loaded with lithates, ten minims of vin. colch. should be added to each draught. Locally, alkaline lotions should also be applied. Half an ounce of carbonate of soda, and six drachms of liq. opii are put into nine ounces of hot water. Flannels are soaked in this, wrung out, and applied to the affected joints, while gutta-percha tissue is placed over all. A sort of local vapor-bath is thus estab- lished. 74 GENERAL DISEASES. Lemon-juice may be given as a drink, to the extent of two or three ounces daily. The patient should always lie between blankets. The perspiration is thus absorbed, and there is greater comfort, and less risk of catching cold. Milk slops and farinaceous food should be the diet at first, fol- lowed by beef tea and stimulants, if there be any signs of depression, sherry taken with soda-water being, by preference, the best stimulant. Undoubtedly, since the above was written, in 1876, salicin, in fifteen-grain doses every two hours, as rec- ommended by Dr. Maclagan, has established a thera- peutic era in the treatment of acute rheumatism. Like others, I can speak unhesitatingly of the benefits de- rived from its adoption, in lowering the temperature and diminishing the length of the disease, and also from the employment of salicylic acid, when the ex- pense of salicin becomes a matter of consideration, as it often does in the case of hospital or poor patients (F. 87, 88). Gout. Sydenham, the father of English medicine, was himself a martyr to gout, and thus congratulates him- self on the fact : " So have lived, and so have died, great kings, and leaders of armies and fleets, philosophers, and men of varied culture, of this peculiar disease. It kills more rich men than poor, more wise than simple." Gout was formerly considered to be a catarrh, and derived its name from the French goute, Latin gutta, GOUT. 75 a drop, because it was supposed to be produced by a liquid which was distilled drop by drop into the dis- eased part. It is now deemed a specific inflammation, attacking by preference those who live well, and es- pecially those who are hereditarily predisposed to it. It is not unknown in London hospitals, as boatmen, butchers, and footmen are admitted with it. In Scotch infirmaries it is never seen. It rarely attacks women. It is hereditary, and the result of living high, and eating too much, and of sedentary habits. It is specially induced by port wine, strong ale and porter, and rich food, and is rarely due to drinking gin or whisky. Its special seat is the great toe, but it has also been observed on the heel, the calf of the leg, the ankle, knee, wrist, thumb, and fingers. Symptoms. — An attack of gout is said to come on most frequently towards the close of January or be- ginning of February. For some days the patient feels ill, and out of sorts, with bad digestion, crudities of the stomach, flatulency, and heaviness. The temper is peevish and irritable. With or without these pre- liminary dyspeptic symptoms, the patient may go to bed at the usual hour, and awake to find himself suf- fering from the most severe and excruciating pain in the ball of the big toe, which is said to be similar " to dogs gnawing at a bone from which they have already eaten all that could be got." Even the weight of the bedclothes is oppressive, and no change of posture gives relief. After some hours the pain may abate, and the patient falls asleep, but on awakening he finds 76 GENERAL DISEASES. the joint inflamed and swollen. There is also fever and furred tongue, with great irritability and depres- sion. The urine is high-colored, acid, and deficient in quantity. It is also loaded with urates and uric acid. The pain continues, with paroxysms of acuteness, for two or three days, in a first and an acute seizure ; in other cases, and when the attack is not primary, it may last as many months. After the paroxysms have subsided, the urine is usually copious, with increase of uric acid, which, with phosphoric acid, is at first insufficiently elimi- nated. A violent itching of the toe sometimes precedes the attack, or it may sometimes attack the toe when the gout is disappearing, followed by decrease of the swell- ing and desquamation of the cuticle. Gout does not terminate with one attack, though after a first seizure some years may elapse before a second occurs. The intervals between the attacks be- come shorter and shorter, and the patient becomes a martyr to gout, which is now not confined to one joint, but invades both hands and feet, external ear, eyelids, and nose. Deposits of a chalky consistence, called tophi, are formed round the joints, these deposits con- sisting of urate of soda. Chronic gout is the term usually applied to this stage. Occasionally there is great distortion of the joints, and sometimes ulcer- ation, with discharge of the concretions. The same salt also invades the kidneys, being de- posited first within the tubules, and subsequently in GOUT. 77 the intertubular tissue, leading to contraction and in- duration, and constituting what has been termed the gouty kidney. Gout at times attacks internal organs, and then it is best termed retrocedent gout. A French author says : " Articular gout is a disease, internal gout is death." It may thus retrocede to the stomach, giving rise to vomiting, internal pain, spasm ; or to the heart, leading to disturbed action, small feeble pulse, or coma ; or to the brain, causing severe headache, sluggishness, apoplexy, or paralysis ; or to the lungs, originating a form of asthma, with severe cough. Dr. Gairdner has alluded to what is termed a gouty diathesis. By this is meant a habit of body, in which, without gout showing itself externally, flying pains are prevalent over the body, which are sometimes con- sidered neuralgic, and treated accordingly, whereas they are of a gouty nature, and can only be cured by colchicum and remedies serviceable in gout. Dr. Garrod's researches indicate that, while uric acid can be detected as a mere trace in the btood in health, in gout it exists in a much greater quantity, in fact in detectable excess, as the urate of soda. Re- cent investigations seem to indicate that, so long as the kidneys are able to carry away this excess, health may be maintained. If, on the other hand, the urin- iferous tubules become plugged up by deposits of urates within them, the urates accumulate in the blood, and becoming deposited in a joint or in joints, they lead to a .fit of the gout. Should these deposits be washed away, the attack is over, and health is regained. 7 78 GENERAL DISEASES. If this does not take place, the kidneys become atro- phied, and chronic gout is the result. Diagnosis. — Gout is allied in some measure to rheu- matism in its symptoms and pathology, yet differs materially from it. Gout attacks either one joint or the small joints, and usually occurs after thirty as the result of hereditary taint or high living. It is asso- ciated at first with a vivid redness, and afterwards with the formation of chalkstones ; while rheumatism invades the large joints, produces fluctuation there, occurs at any age, and is accompanied by fever and a peculiar sour-smelling sweat. Finally, rheumatism is a disease of the poor, gout of the rich, or of those who are able to afford the luxuries of the wealthy. In gout, before and during the fit, the urates are deficient, though they become excessive afterwards; while in rheumatism the urates are always abundant. Treatment resolves itself into what to do, and what not to do. Cold applied to the foot has been known to result in death or hemiplegia. Leeches are rarely productive of good, while general bloodletting is now abandoned. The indications of treatment resolve themselves into a brisk purgative of calomel and colocynth', fol- lowed by a black draught. When the bowels have been freely opened, but not till then, administer col- chicum in 10 or 15 TT£ doses every six or eight hours, with sedatives and alkalies, or in Vichy water (F. 68). Locally, enjoin perfect rest. Wrap the affected part in flannel, or cotton-wool, or oiled silk, or apply a poultice sprinkled with opium or belladonna, and, SCURVY. 79 when the inflammation has subsided, bandage, and use slight friction. During the height of the fever the diet should be light and sloppy — milk, arrowroot, tea. When the fever abates, give beef tea or chicken soup, with plenty of lithia water. For retrocedent gout sinapisms and antispasmodics are necessary. After the acute attack is over, regulate the digestive organs and bowels, and tell the patient to abstain from port, heavy sherry, fruit, ale, and porter. Claret and hock seem to do good rather than harm. The diet should not contain too much animal food, and plenty of exercise should be enjoined. The mineral waters of Bath, Cheltenham, and Lea- mington in this country are beneficial. Those of Wiesbaden, Vichy, Carlsbad, and Aix-la-Chapelle, on the continent, can be highly recommended. Scukvy. Scurvy is a disease of great antiquity. It is alluded to by Pliny, and at different times it has proved very fatal both by land and sea. It is essentially depend- ent on the want of fresh vegetables as an article of diet, and although it has frequently occurred on land, it is pre-eminently a sailor's disease. Other causes than that mentioned may predispose to the disease, such as great privation, bad food, a marshy soil, and defective hygienic conditions ; but these by themselves will not specially originate it. That which produces scurvy is essentially the want of a vegetable diet. While thus aware of the cause of scurvy and the 80 GENERAL DISEASES. means of preventing it, we are ignorant of the exact changes which it originates in the system. Different statements have been recorded by different observers. The blood seems to undergo some change. Older writers stated that the blood deposited a black, muddy sediment, subsiding from a reddish serum. Later writers explain the thickened crassamentum by stat- ing that the cohesive power of the fibrin is so much lessened as to prevent its being separated from the red corpuscles, and that this probably explains the meaning of the terms, so often mentioned, " aggluti- nated blood " and " thickened crassamentum." Dr. Garrod views scurvy as essentially due to the want of potash salts in the blood, through the food being de- ficient in them. The symptoms of scurvy are well marked. They come on gradually with weakness, anxiety, bad breath, a sallow muddy complexion, and the appearance of blotches on the legs. Some pains of a wandering character are felt all over the body, while the tem- perature is lower than normal, an evidence of deficient vitality. As the disease advances, the gums become swollen and spongy, bleed on being touched, and are said to present an appearance similar to that seen when a patient is salivated. As the disease reaches an ad- vanced stage, the teeth rot from the socket, and haemor- rhage takes place from the mouth, nose, stomach and intestines. Thedebility becomes extreme,and petechia, developing into ulcers or ecchymoses, form on the lower extremities. SCURVY. 81 A friend who was much exposed to Arctic privation, and who was surgeon to a ship when a fatal attack of scurvy broke out, thus describes the disease : "The men were listless and dispirited before there were positive indications of scurvy. They could scarcely drag their legs along, and were unable to go aloft, or, if they did so, this was attended with great pain and marked debility. The pain seemed rheu- matic in its character, and was always worst at night. The countenance was sallow and muddy long before actual manifestation of the disease. The pain was at first confined to the extremities, and upon these the effusion of blood first occurred, generally in the form of small petechia, which afterwards developed into vibices, and sometimes into ecchymoses. A bruise, a rebound from a rope, or any small injury, occasioned a steady development of an ulcer. Sometimes there was extensive and diffused infiltration beneath the subcutaneous and intermuscular areolar tissue. "The limbs, especially the calves of the legs, then became as hard as a board, while above the induration the skin w r as either immovable and unaltered in color, or had blood suffused under it. " When a fatal termination ensued, it either did so from extreme exhaustion or general dropsy, unless the patient was cut off at an earlier stage by pleurisy, peri- carditis, or profuse bloody diarrhoea/' Treatment. — From the description of the disease, and its cause, there are certain obvious indications for treatment. Rest is necessary, and the low vitality of the patient requires this rest to be in a warmatmos- 82 GENERAL DISEASES. phere. Antiscorbutics should be administered, such as potatoes, lime-juice, oranges, or the freshly squeezed out juice of watercresses, mustard, horseradish. The extract of these latter plants is useless. The diet should consist at first of soups and milk ; afterwards, when the digestion has improved, fresh meat and vegetables should be given. As a local treatment for ecchymoses and infiltra- tions, lotions and compresses of aromatic vinegar and spirits of camphor have a high reputation. Dr. Garrod's theory indicates the administration of the tartrate or chlorate of potash, to prevent or cure the disease. The barm of beer has also a high repu- tation, and of this six or eight ounces may be taken daily as an antiscorbutic. Purpura Seems to be dependent on a lowered vitality, the result of liver disease, affection of the spleen, syphilis, poverty, intemperance, or overwork. This lowered vitality in some way affects the blood, breaking up the red corpuscles, and allowing their contents to transude into the tissues. The blood thus passed through the capillaries is seen as circular spots, from the size of a pin's head to that of a pea, being apparent first on the legs, afterwards on the trunk. They are unaltered by pressure, and have no tendency to coalesce, unless exposed to pres- sure, when they seem to run into one another, causing vibices or ecchymoses. In their first or circular form they are termed petechia. PURPURA. 80 Purpura is usually ushered in with slight fever, and with the other usual concomitants of this, viz., thirst, headache, and quick yet compressible pulse. In other instances the premonitory symptoms may pass unnoted. Not merely does the skin suffer as described, but blood may also be effused into the several mucous, and occa- sionally also into the serous, membranes of the body. In these effusions lies the chief danger of purpura, and the disease has thus two great divisions: Purpura Simplex and Purpura Hcemorrhagica. — In purpura simplex the disease runs a simple course, with little constitutional disturbance. A few spots are probably found dispersed over the body on awaken- ing in the morning ; but not aggregated. Two or three successive crops may thus form ; and the disease usually subsides in from seven or eight days to a fortnight. Purpura hcemorrhagica is an aggravated form of the simple disorder, and in addition is specially char- acterized by an effusion of blood into those passages of the body lined with mucous membrane. Conse- quently, effusions are observed during life on the gums, tongue, and inside of the cheek; and, if the case ends fatally, they can be seen all over the digestive tract. Necessarily, the constitutional symptoms are more intense, the fever higher, the general oppression more apparent than in the other form ; and, in from twenty- four to forty-eight hours, spots are rapidly developed on the skin. These spots are of a bright-red color at first, but deepen into a purple-red. The skin 84 GENERAL DISEASES. becomes tender and blotched, and scratching occasions bleeding. The same exudation may take place into the mu- cous membranes from the first, but it usually follows after a few days. From the gums oozing of blood may occur, which it is sometimes difficult or impossi- ble to check, while from the same cause there may be epistaxis, or haemorrhage from lungs, stomach, or bowels. Thus there may be great and fatal loss of blood, or simply weakness, anaemia, and pallor. Diagnosis, — Purpura and scurvy may be confounded with one another. They agree in this, that they are due to some impoverished state of the blood which leads to effusion. They differ, however, as will be observed, in certain points. Scurvy appears gradually, purpura suddenly, and with some premonitory feverish ness. Scurvy is essen- tially characterized by sponginess and lividity of the gums, while these conditions are absent in purpura. A dusky sallow complexion accompanies scurvy, but not purpura. Further, scurvy is due mainly to the want of fresh vegetables, and can be cured by the ad- ministration of these. No single error of diet, no single cause, originates purpura, and it can neither be prevented nor cured by the antiscorbutic remedies. Treatment — Ignorant of the cause, we can only treat purpura symptomatically. We have no specific as in scurvy ; yet, knowing that poverty, bad diet, fatigue, and defective ventilation, are great predisposing causes, CHLOROSIS. 85 it is obvious that a good nourishing diet, rest, and a well-ventilated room, are essential. Ten or twelve drops of dilute sulphuric acid, com- bined with one grain of quinine, may be given every two hours, or (F. 75). When internal haemorrhage occurs, the oil of turpen- tine, combined with creasote to prevent nausea, is necessary. In cases of extreme anaemia there is danger of fatal swooning; hence the patient must preserve a hori- zontal attitude until all the prominent symptoms of anaemia disappear. Chlorosis (x* m P°s> 9 reen ), Ajlemia. Ansemia, a diminution in the color and specific gravity, especially of the red corpuscles of the blood, may be associated with many diseases, such as tuber- cular, syphilitic, or malignant affections of any organ, or general debility, and as such deserves no special mention. One form of anaemia, chlorosis, seems peculiar to young women from the age of puberty to twenty-five, and is usually associated with menstrual or uterine derangements. Symptoms. — The disease is revealed by certain symp- toms, the most prominent of which are palpitation and a loss of color, causing at first a pale sallow appear- ance of the surface, which may deepen into a greenish tinge, — hence the name. AVith the palpitation there are often combined various abnormal murmurs in the 8b GENERAL DISEASES. heart and bloodvessels. A soft murmur following the systole is frequently heard over the base of the heart, and along the course of the ascending arch. The pressure of the stethoscope on the veins of the neck, especially of the right side, evokes a peculiar hissing or droning sound (the " bruit de diable"). The res- pirations are frequent, becoming markedly increased by mental disturbance or bodily exertion; and the patient usually complains of shortness of breath and inability to do anything, with loss of appetite, and pain and flatulence after taking food. Menstruation is generally deranged, being sometimes scanty or irreg- ular; frequently there is amenorrhoea; neuralgic pains in the face and head, or intercostal muscles, are often concomitants of the affection. The disease tends to recovery in the space of a month or two, unless it leads to the development of phthisis or gastric ulcer. Relapses are, however, common. Pathology, — Trousseau regards chlorosis as a nerv- ous disease; others consider it due primarily to disor- ders of the reproductive or digestive system. Possibly it even originates from a combination of various de- rangements. It is questioned whether there is a nu- merical deterioration in the blood-corpuscles, though their quality and color are changed ; the specific gravity is reduced, and the color greenish. Virchow noticed that in these cases the aorta was found abnormally narrow, with thin elastic walls; that there was fre- quently fatty degeneration of the muscular structure ERYSIPELAS. 87 of the heart, and many other abnormalities in the cir- culatory system. Treatment. — Iron is a specific for chlorosis, and should be administered in the form of the perchlorides with a mineral acid and a vegetable tonic, associated with aloes and myrrh pills to correct constipation (F. 77, 78). Good food, a change of air, and moderate exercise, are also essential. Erysipelas. The term erysipelas is derived from the Greek words, ipow I draw, and nekaq near. It is so named from its tendency to spread. It is an exanthematous inflammation, characterized by a redness, more or less acute, on the skin, attended with hardness and swelling, and terminating gener- ally by resolution or desquamation, though it is some- times followed by suppuration, more rarely by gan- grene. It may be traumatic, following on a wound, or idiopathic, dependent on some disordered state of the constitution, and not due to any injury. In its latter phase it is a medical disease ; and, although it may be seen on any part of the body, it usually selects the head or face. Like other exanthematous affections, it has a period of incubation ; unlike them, however, the duration of this is not certain, but varies from a few hours to four- bb GENERAL DISEASES. teen days. Five to seven days may be taken as an average. It often sets in with chilliness and uneasiness rather than with distinct rigors ; and is attended with loss of appetite, thirstj and fever, in nineteen cases out of twenty. This general feverish condition may last a few hours or a few days, and then its local phenomena are mani- fested in a redness of the skin, more or less circum- scribed, accompanied by acute pain, which pressure augments. The temperature of the skin is increased at the particular spot sometimes as much as three or four degrees. The redness does not remain localized. It spreads from point to point. If it originates in the face, the scalp is invaded, and when such is the case the indi- vidual features are not recognizable. The distended eyelids obscure the eyes, the lips are swollen, the mouth is open, speaking is sometimes difficult or impossible, the nose acquires an enormous size, and the nostrils may be dry or obstructed by blood or mucus. Usually after a fever of three or four days' dura- tion, and in which a temperature of 105° may be reached, the redness fades, and the blisters or small vesicles which had been formed in the course of the disease presents a varying appearance ; in some parts being dried into a crust, while in others their contents are not yet absorbed, but are undergoing absorption. In other cases the vesicles become dark in color, ERYSIPELAS. 89 and the skin beneath is converted into a grayish dis- colored slough. Suppuration and gangrene ensue, accompanied by a low typhoid state of the system, with increased tem- perature, extreme prostration, and a fatal issue. It may also prove fatal by the extension of the in- flammation to the brain or its membranes, by the blood-poisoning and malignant character of the dis- ease, or by the glottis becoming so swollen as to in- duce suffocation. Erysipelas is sometimes complicated with bronchitis, acute nephritis, and pneumonia. Most English au- thorities believe that the disease can be propagated by actual contact, or disseminated by means of fomites. Atmospheric conditions favor its occurrence, in what way we do not know. It has also been observed that where puerperal fever prevails there is a predisposi- tion to erysipelas in the hospital wards. It may be seen in infants, but after infancy it is rare until adult life. Acute attacks are most common from twenty to forty. Asthenic, or less acute attacks^ from forty to old age. The sexes are affected in equal proportion. Diagnosis. — Erysipelas may be mistaken for scarlet fever, measles, or small-pox. The redness of scarlet fever is not, however, localized, and it is accompanied or preceded by throat complications. In measles there are nasal and catarrhal symptoms. A develop- ing small-pox pustule may simulate it, but a small- pox pustule is not solitary ; others may be seen in dif- ferent parts of the body, and there are premonitory 90 GENERAL DISEASES. symptoms in small-pox^ such as vomiting and pain in the back. Erythema and erysipelas have one feature in com- mon, viz., redness ; but they differ in this, that in ery- thema there is no fever, premonitory or coexistent; there is no inflammation of the deeper-seated parts of the skin, there is no vesication, there is no tendency to implicate the lymphatic glands, and it does not pe- culiarly affect the face or head. Treatment. — The patient, if possible, should be placed in a cool, well-ventilated apartment, and should be freed from all sources of irritation, either by officious nursing or fussy friends. The medicinal treatment may be fitly commenced by a calomel and jalap purgative. Then give tincture of steel, in 30 or 40 minim doses, every three hours, until the fever is lowered. When convalescence is certain, diminish the doses to 20 minims thrice daily for two days, after that give bark. If the cerebral symptoms are grave, cut away the hair ; and if the throat is implicated, let steam be in- haled, and the throat touched with tannin and glycerin (F. 49). The principle of all local applications consists in protecting the part affected. The old plan was to dust with flour and cover with flannel, or oxide of zinc and starch, as being less clogging to the skin, and more soothing. After applications such as these, it is un- necessary to be too curious in removing the coverings to see how things are getting on. As a more perfect covering, a mixture of castor oil DISEASES OF RESPIRATORY ORGANS. 91 and collodion has been recommended, or painting the whole surface lightly with the nitrate of silver in solu- tion, or with the solid stick. Dr. Wood is in favor of tincture of iodine as a local application. DISEASES OF RESPIRATORY ORGANS. Accurately and intelligently to understand these, it is necessary to be familar with the meaning and importance of certain terms which are met with in the description of diseases of the chest. The air in breathing passes into the trachea, the wall of which is rough and irregular in three-fourths of its circum- ference, with strongly marked cartilaginous rings, and the current of air entering is great and quick. Below the bifurcation of the trachea the bronchi di- vide into smaller and smaller tubes; the cartilaginous rings become less and less distinct, until, in the ter- minal ramifications of the bronchi, they cease to exist and the tubes are smooth on their internal surface. If the stethoscope is placed over the trachea, two rough harsh sounds will be heard, the one accompany- ing inspiration, the other expiration, with a distinct interval between them. This is what is termed " tracheal or cavernous respiration." Xext, placing the stethoscope on the upper bone of 92 DISEASES OF RESPIRATORY ORGANS. the sternum, opposite the point at which the trachea divides into the bronchi, there is heard a modification of the tracheal breathing, the character of the sound being hollow, blowing, and soft, and with the inspira- tion rather longer than the expiration. This is " bron- chial respiration " or " tubular breathing." Again, placing the stethoscope over other parts of the chest, it will be found that the blowing character is gone, that the inspiration is soft and gentle, that the expiration immediately follows it, and is less pro- longed. The combination of the two constitutes the healthy vesicular murmur. If the person is told to speak when the stethoscope is at the different situations mentioned it will be found that the character of the voice also varies. Thus over the trachea it seems as if he were speaking right into it, so loud and full is the sound ; even a whisper can be heard. This is " pectoriloquy." Over the sternum it is still distinct and clear, but not so loud. This is " bronchophony." While over other parts of the chest a buzzing scarcely audible sound is heard. These sounds, as will be seen, are significant of various diseases when heard in parts of the chest, where in health they are not detected. The mucous membrane lining the respiratory tract is in health moist, but not too much so, else this also would give rise to disease, and as illustrating terms used, and various conditions, let us suppose a common cold is caught. The effect of this on the mucous mem- brane of the respiratory tract, if it extends to it, is, DISEASES OF RESPIRATORY ORGANS. 93 first, to make it dry; secondly, swollen and inflamed. The consequence is an alteration in the character of the sounds where the vesicular murmur is heard. If the larger air-tubes are alone involved a deep-toned note will be produced like that of a person snoring in sleep, or humming like that of a spinning top ; hence it is often described under the terms cooing, snoring, buzzing, or technically, " sonorous rhonchi." If the dryness extends to the smaller air-tubes the sounds are shriller in character — piping, whistling, hissing, or technically, " sibilant rhonchi." These sounds may occur separately or together, and, if together, there is frequently a combination of the characters of both heard on auscultation, giving rise to a strange medley of cooing, whistling, piping, and snoring. The mucous membrane in a cold, although still in- flamed, does not remain dry, but becomes moist, and hence the dry sounds are replaced by moist ones. The air passes through liquids, and, in doing so, gives rise to bubbles, and to these liquid sounds the term rales is applied. If these are fine, and confined to the smaller air-tubes, the term " small crepitation " is used ; if on a larger and coarser scale, involving the larger air-tubes, they give rise to large crepitation. These two liquid sounds may and often do merge insensibly into one another, so that they are often heard on the same chest during the same complaint. It will thus be observed, as the following diagram will show, that we have " sonorous rhonchi" and "large crepitation " as representing the dry and the moist sounds of the larger air-passages; " sibilant 94 DISEASES OF RESPIRATORY ORGANS. rhonchi" and "small crepitation" in a similar manner, being applied to the smaller air-passages. Leaving the mucous membrane, as seen in its inflani- Fig. 4. Large crepitation. Small crepitation. Vesicular crepitation. Sonorous rhonchi. Sibilant rhonchi. mation from a common cold, we may say further that moist sounds are produced by bubbles of air traversing or bursting in a somewhat viscous fluid. Hence they may be formed, not merely in the bronchi, but in the terminal air-vesicles, or on a larger scale, in cavities or ulcers of various sizes. They may thus be fine, scarcely audible, or coarse, resembling gurgling and splashing, and between these two extremes there are CATARRH. 95 various gradations, hence such terms as "suberepi- tant," " mueo-crepitant," etc. The chest in health on being percussed gives every- where a clear reply, the note on both sides being simi- lar in similar situations, unless where on the left side the heart intervenes. In the course of some diseases it will be found that one side is more expanded or re- tracted than the other, and it is necessary to estimate the exact difference between them. For this purpose mark with ink the central spots over the spinal ver- tebrae and the sternum, and stretch a graduated tape between them on both sides, telling the patient to hold his breath during the experiment. In cases where there is any difference, note whether it increases or diminishes at regular periodical visits. If your hand is placed over the chest when the patient speaks, a distinct vibration is communicated to it. This is termed " vocal fremitus," which sensation may be altered by disease. Catarrh. We have commenced, and, to a certain extent, illus- trated in the preliminary remarks what effect a cold has upon the chest when it affects the mucous mem- brane of the respiratory tract. It may, however, stop at the head, affecting only the nose (coryza) or the frontal sinuses (gravedo), giving rise at first to dry- followed afterwards by what is termed running at the eyes or nose, and a profuse muco-purulent dis- charge. The general symptoms attending, vary from 96 DISEASES OP RESPIRATORY ORGANS. weariness and stuffiness of the head to actual headache and some distinct feverishness, with inability to attend to ordinary duties. The question in treatment is to endeavor to keep it at its place of origin. How are you to stop a cold ? Catch it at its commencement, and feed it by an opiate. Twenty drops of tincture of opium, or ten drops of liq. morph. and eight of vin. antimon. given twice at an interval of three hours will usually accomplish this. A simple and effective method has also been suggested — viz., to take no liquid of any kind for twenty-four or forty-eight hours. In this way the materials for flux are minimized, and it dies of inani- tion. A Turkish bath can also be recommended. Laryngitis, etc. The extension of a common cold to the larynx, leading to congestion and slight inflammation of the mucous membrane, is by no means uncommon. It is evidenced by hoarseness, soreness in drawing a breath, and a dry tickling cough. " Acute laryngitis" is a much more severe, and, fortunately, rare affection; peculiar, generally speaking, to adults, and due usually to exposure to cold, or inhaling vapors or dust. (Edema of the glottis may be produced immediately by the fumes of nitric and sulphuric acids, and by the accidental swallowing of boiling water. Sore throat is complained of, and is referred to the pomum Adami. The inspiration is protracted, wheezing, and laborious; the expiration comparatively easy, the voice hoarse or LARYNGITIS, ETC. 97 altogether lost, the face flushed, with livid lips, the fever high, and a peculiar imperfect cough is present. These symptoms, following rapidly on one another, are accompanied by intense restlessness and a feeling of suffocation — which actually does take place unless relief is afforded — with drowsiness, delirium, and coma. The patient dies strangled, and the cause of this is, as the symptoms indicate, due to the chink of the rima glottidis becoming closed from the swelling of the mucous membrane lining it, or from inflammatory effusion into the subjacent areolar tissue. The course of the disease is rapid, sometimes carrying off the patient in twelve hours, or at all events before the fifth day. At other times recovery ensues; or the affection may pass into chronic inflammation. Chronic laryngitis is characterized by tickling, dry- ness, cough, and soreness of the throat, and congestion of the pharynx or larynx. It is not usually danger- ous to life, and is often the result of over-exertion of the voice in clergymen, public speakers, or singers. " Ulceration of the larynx" may precede, or more fre- quently accompany, advanced cases of phthisis. It is also not uncommon as the result of secondary syphilis. " Tumors," or " polypi," may also form on the larynx, and give rise to symptoms like those of chronic laryn- gitis. They are recognized by the laryngoscope, and can sometimes be removed. Treatment in acute laryngitis must be prompt to be effectual, and consists in tracheotomy being per- formed, thus allowing rest to the inflamed part, and relief to the engorged lungs (Porter). The after-treat- 98 DISEASES OP RESPIRATORY ORGANS. ment must be conducted on the principle of support- ing the patient's strength by rnilk ? beef tea, and wine or brandy, if there be, as there usually is, much de- pression. Short of tracheotomy, general bloodletting sometimes does good. Scarification of the swollen parts by a curved bistoury protected to within a quarter of an inch of the point, has been followed by relief of the severe paroxysms. For chronic laryngitis, chlor- ide of zinc has been specially recommended as a local application, in the proportion of thirty grains to the ounce of water every day for a week, and afterwards on alternate days until amendment occurs. Tannin, with glycerin, is useful in phthisical, and nitrate of silver in syphilitic ulceration. If the secretion is ex- cessive, turpentine or creasote may be inhaled ; or if the irritation is great, inhalation of hops or chloroform with the steam of boiling water may give relief. Rest, a dry climate, the careful wearing of flannel, and some- times of a respirator, form valuable adjuncts, and in some cases are essential to the general treatment (F. 49, 52, 53). Diphtheria. Although this disease seems to have been well known to the ancient physicians, yet its existence in England under the term diphtheria (a skin or mem- brane) dates back only to 1856, when it spread from France to this country. The first accurate investiga- tions into the nature of diphtheria were made by M. Bretonneau in 1821. He considered that it was wholly a local disease, spreading by contagion through the DIPHTHERIA. 99 inoculation of the soft mucous membrane with the diphtheritic secretion. He was subsequently obliged to concede that blood-poisoning is one of its essential characteristics. Much controversy has been excited as to the causation of diphtheria, which hinges round the inquiry, Is it a local or constitutional disease in its origin ? Does the constitutional disease cause the local exudation ; or does the local exudation originate the constitutional disease? In support of the first hypothesis the epidemic char- acter of the disease has been insisted on ; the grave and serious disturbance of the system, with only a few minute exudations observed on the fauces, and the impossibility of destroying the diphtheritic process by any amount of cauterization. In support of the second hypothesis it is urged that diphtheria fixes itself at the point of inoculation, as shown by experiments on animals, and radiates from thence all over the body. Thus it is seen earliest and most constantly on the parts swept over in the acts of respiration or eating and drinking, when it attacks the human subject. Further, the diphtheritic process is always associated with vegetable organisms (micro- cocci), and their development poisons the blood. "Without entering further into the controversy, it may be stated that the results of diphtheritic inflam- mation are peculiar. Redness and swelling of the parts affected are succeeded by patches of lymph, which start from one or several points. This lymph- ous exudation is of a grayish ashy-white color, and its consistence is like that of wetted parchment or damp 100 DISEASES OF RESPIRATORY ORGANS. wash-leather. It can be stripped off, leaving a raw and bleeding surface, which is again speedily covered over with characteristic exudation. Not merely is there exudation, but there is often also on the site of the exudation marked ulceration, sloughing, or ab- scesses. In fact, true diphtheritic inflammation may be considered to be one of substance involving the mucous membrane, and tending to slough. Further, it may be stated that diphtheria seems to spread by direct contagion, and that bad hygienic conditions, especially defective drainage, appear, if not actually to originate it, at least to foster its occurrence. Symptoms. — The general features of diphtheria are prostration, restlessness, and muscular debility, with headache and nausea, and a sense of stiffness and sore- ness about the neck and the angles of the jaw. Fur- ther, there is often marked blanching. The local effects of the disease are manifested by the exudation first on the tonsils, and from thence spreading in dif- ferent directions. Thus it may creep backwards and upwards into the posterior nares ; or, more frequently, it passes over the epiglottis into the larynx and trachea. Attacking parts so intimately connected with life, the local gravity of the disease is obvious, and death may be caused by suffocation ; or, on the other hand, the grave constitutional disturbance may result in death by asthenia, either directly or through paralysis of certain nerves. The tongue is generally not much furred, the breath is fetid, saliva dribbles from the mouth, and there is great difficulty in and disinclination for swallowing. % DIPHTHERIA. 101 The submaxillary glands are enlarged, and, owing to the extension of the disease to the larynx, difficulty of breathing is a common late symptom. The fever is not great. The urine is found albuminous in fifty per cent, of the cases. In non-fatal cases the specific disease is supposed to terminate on the seventh day, although the con- valescence after this is slow and attended with great depression. After the complete healing of the local lesions, in the course of the second or third week of the disease various sequels may ensue, viz., paralysis of the soft palate and pharynx, paralysis of the mus- cles of the larynx, occasioning in the one case difficult deglutition, in the other impaired voice. Sometimes there are great disturbance of vision and progressive paralysis of the extremities. Treatment. — If, as later investigations indicate, diph- theria is at first a localized disease with after constitu- tional symptoms, it is obvious that treatment must be local and general. Tearing off the membranous exu- dation is absolutely negative, and even thorough cau- terization has not been attended with much success. It is said that nature unaided in diphtheria tends to heal by suppuration, and that in this way the false membrane is thrown off. Hence it has been suggested by Oertel to imitate nature and to establish a rapid and abundant production of pus by means of hot in- halations in quarter-hour sittings every half hour; with nourishment supplied during the intervals, and allowing a longer time to elapse as the membranes are thrown off. The mouth should also be rinsed and 102 DISEASES OF RESPIRATORY ORGANS. throat gargled with a solution of carbolic acid, per- manganate of potash, etc. In the general treatment an even temperature of 65° to 68° Fahr. is essential, with plenty of milk, ice, and cooling drinks, with alcoholic stimulants if the powers are failing. The best internal remedy appears to be tincture of the perchloride of iron, given in large doses (30 minims every two hours in water or glycerin). Iodide of potassium and chlorate of potass have also been advocated. If the disease at- tacks the larynx and is advancing in severity, trach- eotomy should be performed as soon as possible (F. 5, 7). For the secondary paralysis of diphtheria, tonics, change of air, and careful electric stimulation by the constant current are recommended. Croup. Two forms of croup are recognized. One form, having no inflammatory cause, no structural change, is considered to be of a nervous origin. It is termed u false or spasmodic croup," or " laryngismus stridu- lus." In the other form, true croup, there is local and catarrhal inflammation of the larynx or trachea, and this inflammation is accompanied by an exudation of false membrane on the parts attacked. Inflammatory or true croup is a disease of early life ; for although it may occur at any time between wean- ing and puberty, its most common epoch is in the second year of childhood. CROUP. 103 It seems to attack boys more frequently than girls. The chief seat of croup is said to be the trachea, but it may extend from this to the smallest bronchi, and hence bronchitis or pneumonia may complicate croup. The vessels of the mucous membrane of the trachea exude a material which stiffens and forms a layer of false membrane. In some cases it can be wiped off easily, in others it requires force to remove it ; hence it is said to be thick or thin, diffluent or consistent. Tfris stiffened croupal formation obstructs the breathing directly, gives rise to a spasmodic con- traction of the muscles of the larynx, and diminishes the calibre of the air-tubes. Serious results from this cause ensue, and in addition shreds of the false mem- brane partially detached may produce fatal spasm. The inflammation is essentially a simple non-specific or fibrinous one, confined to the surface, and hence dis- tinct from the diphtheritic. Symptoms. — A premonitory feverish catarrh, such as occurs in other chest affections, may attract atten- tion. If this catarrh be accompanied with hoarseness in young children, croup is to be apprehended. Pre- ceded or not by this feverish cold, when croup is well established it is characterized by marked symp- toms. The cough is brassy and ringing; the inspira- tion is loud and crowing ; the fauces are observed to be red and swollen. As the disease advances the fever increases, and from the obstruction to the passage of air and the proper arterialization of the blood, the skin gets dusky, the feet cold, and the pulse feeble. The character of the cough ceases to be ringing 104 DISEASES OF RESPIRATORY ORGANS. and becomes husky. There is great irritability and restlessness, the child frequently attempting to thrust its fingers down its throat to take away the obstruc- tion. If the case proceeds to a fatal termination, the breathing becomes more and more labored, the face pale and livid, cold clammy sweat forms, and drowsi- ness deepens into coma and death. Favorable symp- toms are the cessation of the crowing inspiration, the cough becoming moister and accompanied by expecto- ration of false membrane. The duration of croup is usually five days. Diphtheria and croup are closely allied, yet they are supposed to differ in this, that diphtheria is epidemic and contagious, is not so sudden in its attack, is not limited so much to the trachea, but beginning at the pharynx may so spread as to involve the whole re- spiratory tract, and membrane may be found in other regions ; — that, in fact, according to one theory, it is a specific constitutional disease, with throat complica- tions ; while croup is a local disease giving rise to constitutional symptoms. Further, diphtheria is accompanied often by albumi- nuria and swelling of the submaxillary glands and fol- lowed by paralytic sequelae. It is also much more asthenic than croup. The membrane in croup does not appear so often as in diphtheria. Treatment.— Formerly leeches were always applied in cases of croup ; now the most consistent line of practice seems to use them only where children are vigorous and plethoric. Leeches cannot stop the ex- udation, but they seem to prevent the swelling and infiltration which might prove fatal. They are ap- CROUP. 105 plied to the manubrium sterni, not to the larynx, as the bleeding is difficult to restrain. They ought never to be applied to puny and badly fed children. Emetics are useful, and of these the sulphate of copper is to be preferred to zinc, as tending less to weaken the sys- tem. Ten to fifteen grains should be dissolved in two ounces of water, and a large teaspoonful of this given every five minutes until vomiting is produced. Ipe- cacuanha may also be used — a teaspoonful of the wine being given at frequent intervals until the child vom- its (F. 42). If the vomiting relieves the dyspnoea and expels the false membrane, it has done good and ought to be repeated. If it fails in these objects its repetition is contraindicated. A solution of nitrate of silver should be applied at intervals of several hours to the entrance into the larynx. The bowels should also be acted on either by an enema or calomel. If, with the addition of a warm bath, hot pack, or hot sponging, these means fail, after a trial of twelve hours, tracheotomy should at once be resorted to. Niemyer says, " If it does not cure, it makes death less terrible." The diet should consist of milk and nourishing soups. Inhalations of simple steam or medicated va- por, containing hops, chloroform, or benzoin, are often pleasantly palliative (F. 52). AVhen the disease has terminated favorably, the cough should be encouraged by a mixture of carbonate of ammonia and squills in an infusion of senega (F. 44). 106 diseases of respiratory organs. False Croup. Non-inflammatory croup, to which also the names of " laryngismus stridulus," "spasm of the glottis," " spasmodic croup," and " spurious croup," have been applied, is met chiefly in scrofulous rickety children of one or two years of age. It may originate from the brain, as in hydrocephalus, or from direct irritation of the vagus or recurrent nerves, or from tumors or en- larged thymus gland, or from reflex causes, or from dentition, worms, improper feeding, mental emotion, fright, or anger. Symptoms. — The attack is sudden, usually occurring at night and during sleep, and is characterized by one prominent symptom, dyspnoea. No air enters the glottis for the moment, and respiration seems to cease. The child struggles for breath as if it were about to die from suffocation. There may be also convulsions and a contracted state of the flexor muscles of the thumb, fingers, and toes (carpo-pedal spasms). The paroxysm ceases suddenly, but may be suc- ceeded by others, and death sometimes takes place through suspended respiration, or by the stagnation of the blood in the lungs, heart, or brain. The train may be laid for serious after-results, and although termed false croup the disease is not free from peril. It is chiefly distinguished from true croup by its sudden accession and sudden departure, by the free- dom of breathing between the paroxysms, and by the absence of fever, hoarseness, and any attending cough. Treatment — During the paroxysm place the child HOOPING-COUGH. 107 in a warm bath, apply a hot sponge to the throat, and, after being taken from the bath, or before it, sprinkle the face and chest with cold water. As prophylactic remedies against its" recurrence, regulate the bowels, lance the gums if hot and tender, and recommend fresh air and nutritious diet. Depending as it frequently does, on a rickety state of the system, 5 to 10 grains of the phosphate of lime may be given thrice daily in chalk mixture. Hooping-cough Is an infectious disease, occurring usually in child- hood, preceded by a catarrh of from three to fourteen days' duration. Succeeding this there is a peculiar cough of a paroxysmal character, which is pathogno- monic of the disease. Hooping-cough usually ter- minates in six weeks ; at times it may be prolonged from two to three months. It is not attended w r ith much danger per se, but it may, and often does, origi- nate various chest diseases, notably emphysema. When hooping-cough has fairly determined itself, its features are very characteristic. The child has usually some premonitions of an attack, and runs to its mother or nurse for protection. Then commences a paroxysm of expiratory efforts and cough, with no intervening inspiration. The child becomes black in the face, and it would appear as if suffocation were imminent, when a long-drawn inspiration takes place, attended with a peculiar crowing sound. This sound is doubtless due to the air entering the contracted, or 108 DISEASES OF RESPIRATORY ORGANS. even partially closed, rima giottidis. When expan- sion of the glottis has been completed, and the air is permitted to enter freely, the fit for the time is over. Or a succession of forcible expirations and cough alter- nate with crowing inspirations, until a quantity of mucus is brought up, or actual vomiting ensues. The paroxysms occurring in the twenty-four hours vary as regards intensity. As a rule, they are worse at night. During the early stages of the disease the mucus expectorated is thick and sticky, but after- wards, with the decreasing intensity of the paroxysm, it becomes thinner, more abundant, and more easily brought up. Listening during the intermission of the paroxysm you hear simply catarrhal sounds, or perhaps nothing abnormal. During the expiratory paroxysm wheezing may be detected, but during the long-drawn inspira- tion no sound can be heard in the lungs at all. This may be partly explained by the slowness with which the air enters by the contracted glottis, and partly, as Laennec says, by " the spasmodic contraction of the muscular or contractile fibres of the bronchi not allow- ing the air to enter." Etiology, — The absence of fever in hooping-cough negatives the idea that the disease is due to inflamma- tion ; and it has been urged, from its spasmodic char- acter, that it is probably dependent on irritation of the pneumogastric nerve by some peculiar poison. Some consider that this poison affects the cervical glands, which lie in the course of the nerve itself or the recur- * HOOPING-COUGH. 109 rent, causing enlargement of these, as in a similar manner the parotid is enlarged in mumps. Fatal cases usually exhibit pulmonary collapse — the lobular pneumonia of former writers ; and with this there is also evidence of bronchial inflammation. Treatment, — The disease tends to run its course like all specific diseases, and the rule of practice appears to be best met by warding off complications and treating symptoms. Avoid all gastric irritation by keeping the patient on a regulated diet, with plenty of milk and little meat, and attend carefully to the bowels. Dr. Fuller recommends — R. Zinc, sulphat., .... gr. viij. Ext. belladon., .... gr. vij. Aq., §iv. M. A tablespoonful four times a day. For a child above three years old with hooping-cough, every other day the strength of the mixture may be augmented in the proportion of one dose. The belladonna is thus grad- ually increased to doses of five grains without mis- chief. Dr. Fuller states that by these means the hoop rarely lasts more than twenty-one, and may terminate in ten days. Xitric acid has been employed successfully by Dr. Gibb. Bromide of potass and hydrate of chloral and carbonate of iron have also been highly spoken of; so also have inhalations of carbolic acid (F. 15, 53 a). Locally, Roche's embrocation has considerable pop- ularity among the poorer classes. If bronchitis sets in, poultices should be applied to 10 110 DISEASES OF RESPIRATORY ORGANS. the chest, probably after leeching, with antimonial and ipecac, wine internally, followed, if requisite, by stimulants. ■ Head Symptoms. — Squinting, convulsions, or stupor must be met by small and repeated doses of hyd. cum cret., warm baths, etc. Niemeyer says, " Hooping-cough can be cured on the principle that c he who spareth the rod spoileth the child/ and that the cough of hooping-cough is not an exception to the physiological law, c that violent reflex symptoms are controllable by the will/ " Hence he advises coercion, the promise of no bonbons or toys if coughing is persisted in, and states that the effects of this mental dietetic are admirable. It is a question whether patients should be allowed out in the open air. In all but acute stages this may be permitted with much benefit, especially in the ward- ing off of succeeding tubercular disease. Influenza. This term is of Italian origin, indicating something fluid or transient, and first applied by Pringle in 1752 to designate a disease epidemic in its nature and at- tended with catarrh, especially affecting the respira- tory and digestive organs. It can be traced back with certainty to the sixteenth century, and since then ninety epidemics of more or less severity have been described. Its universality in later years has greatly diminished. An epidemic has not been noted for some time. In 1837 it w T as very prevalent in London; nearly INFLUENZA. Ill the whole population was attacked, and the mortality was great. The cause of the disease seems to be sui generis, and dependent on some poisonous influence in the atmos- phere, the nature of which is unknown. Influenza rarely ends fatally, and when it does, reveals no char- acteristic post-mortem features, there being simply swelling and redness of the respiratory tract, with signs of hyperemia also in the oesophagus and stomach. Symptoms. — The onset of the disease is sudden, hence the term "lightning catarrh." There is first a chill and malaise for several hours, followed by fever, most marked at night. There is also a dry torment- ing convulsive cough, with a fulness of the head, red- ness of the conjunctiva, throat, and mouth, and swell- ing of the tonsils and difficulty of swallowing. The sputa are scanty and muco-serous. There is intense prostration from the first, with dragging pains in the limbs and utter inability to move about. The disease lasts four or five days, and usually ter- minates in a critical sweat, with diarrhoea and an in- creased secretion of urine. During an epidemic of influenza the death-rate of a town is increased, especi- ally among the aged and feeble, through its setting up acute bronchitis or inflammation of the lungs. The great number of persons attacked and the severe prostration distinguish influenza from an ordinary catarrh, with which alone it can be confounded. Treatment. — By rest in bed, quietness, and a stimu- lating expectorant, influenza is best treated. Opium, inhalations of steam, and counter-irritants, are useful 112 DISEASES OP RESPIRATORY ORGANS. for the cough. Relief will be afforded to the head- ache by smearing the face with fat or snuffing up a solution of morphia in the proportion of 1 to 50 or 60 of cherry laurel water. During convalescence give quinine and iron. The diet should consist of mucilag- inous drinks and nourishing soups, with stimulants when the debility is great (F. 43). Bronchitis Is an essentially inflammatory affection of the bron- chial mucous membrane, and may be either acute or chronic. It is caused by exposure to cold or wet. local irri- tation from mechanical operations, e.g., needle-grind- ing, or it may be dependent on heart disease, or asso- ciated with various constitutional affections, such as rheumatism, gout, fever, Bright's disease. It is most common in childhood and old age. Two varieties of acute bronchitis have been recog- nized : 1. When the larger and medium-sized air-tubes are alone affected. 2. When the inflammation does not stop there, but involves all the bronchial ramifications — capillary or general bronchitis. The last form is rarely seen in adults, but chiefly among young children and old people, and is fre- quently fatal. Certain general symptoms accompany both varie- ties. Thus, there is chilliness, fever, running at the ACUTE BROXCniTIS. 113 eyes and nose, and general malaise. The extension of the inflammation down the respiratory tract causes irritation of the mucous membrane of the larynx and trachea, as is evidenced by a sense of tightness behind the sternum and a tickling sensation about the windpipe. The expectoration is at first dry and difficult to bring up, scanty, white, and frothy ; but in the course of a few days, or a few hours, it increases in quantity, and if the attack be severe or prolonged, it becomes muco-purulent. In the more severe form the symptoms, correspond- ing to the gravity of the case, are more urgent. The restlessness is great, the fever high, anxiety is depicted on the countenance, and the impaired and impeded circulation through the right side of the heart is evi- denced by the livid lips; and this lividity sometimes extends over the body, and is observed at the finger ends. Should the disease terminate favorably, there is a gradual remission of the severity of the symp- toms. The fever decreases. Respiration becomes easier, the cough less troublesome, and the expectora- tion freer. But if a fatal termination is likely, the symptoms increase in severity. Unable to sit up in bed, the patient sinks exhausted on the pillow. The breathing is thus more difficult, and the lividity be- comes more intense. There is not the power to bring up the mucus, which accumulates in the air-passages, and thus the patient dies from suffocation, or from apnoea, due to the arrest of the circulation through the lungs, in consequence of the coagulation of blood 114 DISEASES OF RESPIRATORY ORGANS. in the pulmonary arteries and in the right cavities of the heart. On auscultation during the first or dry stage of bronchitis we detect two coarse rough dry sounds all over the chest. The air-tubes are narrowed, but the air does not come through mucus ; hence the dryness of the sounds, which are termed rhonchi if the larger tubes are implicated, sibili if the smaller ones are in- volved. Percussion in this stage is clear. When the secretion of mucus commences these dry sounds are replaced by large bubbling in the larger air-tubes, or small bubbling if the disease has reached the smaller tubes. This has been termed the moist stage of bronchitis, and the sounds then heard have been technically called large and small crepitations. Percussion may sometimes detect dulness through cedema at the base of either lung ; while, if there is pulmonary collapse through tenacious mucus plugging up a bronchial tube, as not unfrequently happens, the percussion-note will lack resonance over that particular part. Prognosis. — From three-fourths to one-half of those attacked with capillary bronchitis die between the sixth and tenth days of the disease. In favorable cases improvement commences from the fourth to the eighth day. Bronchitis affecting the larger air-tubes is not dangerous. Relief generally supervenes when expectoration becomes abundant. Should this fail to return, pulmonary congestion ensues, and ultimately death. Circumstances increasing the gravity of the prognosis are very early or advanced life, the exist- ACUTE BRONCHITIS. 115 ence of some acute or chronic disease, or other com- plications. Anatomical Appearances. — The morbid appearances directly indicating bronchitis as a distinct affection may be summed up in one word — redness, which may, however, vary in intensity. With the redness there is swelling;, and at first dryness of the mucous mem- brane. The dryness is afterwards replaced by a muco- purulent secretion. Treatment. — Every case of bronchitis must be treated individually, as no general rule can be laid down. Yet it may be stated that bronchitis, during its early catarrhal stage, may be prevented from proceeding farther by the administration of a full dose of opium or wine in whey. If the fever is too intense for this, a hot bath, followed by a weak saline purgative, and diaphoretics and expectorant mixture, must be trusted to. R. Oxymel seillge, ^ss. Sp. seth. nit., Tinct. camph. co., aa . . . . gj. Mist, amygdal., gj. M. S. "To be taken every six hours for adults." Or antimonial wine, with liq. acet. amnion., for children, in doses proportioned to their years, or (F. 34, 45). Bronchitis occurring in people of a gouty habit must be met by adding cole hi cum to the above-men- tioned formula. The antimonial mixture may be omitted when the expectoration becomes freer. Steam 116 DISEASES OF RESPIRATORY ORGANS. or medicated inhalations are very grateful. When the depression is extreme and the lividity great, car- bonate of ammonia must be trusted to. Local applications will consist of sinapisms, turpen- tine stupes, jacket poultices of linseed meal, etc. The diet should be fluid, milk, beef tea, gruel, arrowroot, in ordinary cases, and to these wine or brandy must be added in the more severe types of the disease. In sthenic cases, occurring in adults, cupping, or the application of a few leeches, has been strongly recom- mended. General bloodletting has now been practi- cally abandoned. Sometimes, as the result of various chronic lung affections — as bronchitis, emphysema, or interstitial pneumonia — a bronchial tube may become so dilated as to form a single pouch, like an aneurism of an artery, or a series of pouches in the same tube. This condi- tion is termed bronchiectasis, and if the cavity is near the surface, and contains air as well as liquid, the signs will be identical with those of a phthisical cavity. The breath is very offensive, and the expectoration abundant and fetid. Chronic Bronchitis Sometimes follows the acute form, or it is the result of general bad health, or the sequela of what is termed coughs and colds. It is common in advanced life, ap- pearing in wintry inclement weather, and disappear- ing in summer. It may vary in its severity, at times being attended with little or no uneasiness except a CHRONIC BRONCHITIS. 117 slight cough and some expectoration ; in other cases the cough is very harassing, especially in the morning, the expectoration copious and resembling very much the nummular sputa of phthisis, or it may simply be frothy and muco-purulent. Fresh exposure to cold or atmospheric changes may at any time convert chronic into a dangerous form of acute bronchitis. Chronic bronchitis is sometimes dependent on cer- tain constitutional diseases, as syphilis, gout, rheuma- tism. It also specially affects workers at certain occu- pations, e. g., knife-grinders, miners, cotton opera- tives, etc. Auscultation after free expectoration reveals loud harsh sounds all over the chest. These are best described as snoring. They vary in their intensity according as the air-passages are well cleared from mucus, or the reverse. In advanced cases the respi- ration is of a hollow blowing character, and attended with gurgling. Percussion is unaltered unless there is great accumulation of matter to be expectorated, when it may be temporarily dull over a particular spot. Treatment. — Indications for treatment vary accord- ing to the different forms of the affection, but, in all cases, are based on certain obvious principles. The patient should always be w r ell clad, flannel being con- stantly worn, and he should be exposed as little as possible to the vicissitudes of the weather. During winter, if circumstances admit, the patient should reside where the climate is mild and dry. In addi- tion, an attempt must be made to relieve the cough, to promote or restrain free expectoration, and subdue 118 DISEASES OF RESPIRATORY ORGANS. spasm. As stimulating expectorants, vin. ipecac., squills, and senega may be mentioned. Jn checking the expectoration, when excessive, tincture of benzoin, dilute sulphuric acid, and the various preparations of opium may be employed. Inhalations of steam alone, or charged with hops, or w T ith dilute hydrocyanic acid, are serviceable for the cough or spasm. The treat- ment for bronchiectasis can only be palliative (F. 44, 45, 21, 52). Emphysema. There are three kinds of emphysema usually de- scribed by pathologists, viz., interlobular, lobular, and senile. These terms explain themselves, hence we shall postpone the separate consideration of them until w r e come to speak of the pathology, especially as the symptoms of the three forms are the same. Symptoms. — The patient generally has a livid or cyanotic appearance, and, if he be otherwise healthy, this points to a deficient aeration of the blood. In this disease also we find pigeon-breast in the child, and barrel-shaped chest in the adult. The history is of great importance, for, if the patient has had chronic bronchitis, asthma, tubercle, or violent hooping-cough, or difficult establishment of respiration in childhood, we may suspect emphysema. Dyspnoea, with a distressing feeling of oppression behind the sternum, accompanied by cough, with opaque yellow expectoration, are pretty constant signs. Physical Signs. — Regarding the percussion-note EMPHYSEMA. 119 there is much difference of opinion, some saving it is abnormally resonant, others that it is normal or dull (Gairdner). The respiratory murmur is deficient, and there are sonorous rales, and in rare cases crepitation. Vocal resonance is deficient, and the heart-sounds feeble or masked. The liver and heart are frequently depressed, and the latter may be pushed to one side if one lung only is affected. Prognosis. — This is most unfavorable, for although not so fatal as tubercular disease, emphysema is very intractable, disabling, and permanent. Pathology. — 1. Interlobular Form. — The air-vesicles may be ruptured from without as by a broken rib, or from within as by obstruction of the larynx from croup or diphtheria, causing great pressure. Thus air escapes into the connective tissue outside the vesicles, from which it may pass to the root of the lung, neck, or the subpleural tissue. 2. Lobular, or ordinary emphysema, is an inflation of the terminal air-cavities, with atrophy and destruc- tion of intervening septa from mutual pressure, ending in large cavities. This may be local or general, and the lung-tissue is bulky, although pale, and collapses on section. There are three views as to the cause of this— a. That there is a primary degeneration of lung- tissue, as in senile emphysema, to be noted afterwards. It may also occur in hereditary emphysema. 6. That violent expiratory efforts with closed glottis cause increased pressure, which acts on the least sup- ported parts of the lung; and it is in these positions 120 DISEASES OF RESPIRATORY ORGANS. that we most frequently find emphysema, viz., at the outer margin, apices, and margins of base. c. Inspiratory Theory. — When a portion of lung contracts, or adhesions exist, rendering inspiration impossible, some other part of the lung must be over- distended during inspiration, hence emphysema occurs, and we often find emphysematous vesicles round cica- trices at apex, or round adhesions. 3. Senile emphysema is simply an atrophy of the tissue between the vesicles, and between the infun- dibula. Pulmonary emphysema, owing to the great obstruc- tion to the pulmonary vessels, causes hypertrophy of right side of the heart, leading on to tricuspid insuffi- ciency and general venous congestion. The loss of inspiratory surface causes the breathless- ness. Treatment- — We can only palliate. Patient should be clothed in flannel, and avoid damp and cold. He should be very temperate in living, and if possible enjoy a warm climate. Medicinally, smoking stra- monium cigarettes, or the use of arseniate of soda, or potash-nitrates, may give relief. The latter may be prepared thus (F. 51). If the cough is very troublesome, an expectorant with ether may be given. If much difficulty in ex- pectorating, an emetic of ipecac, with sinapisms to feet and calves of legs, may be tried. If indicated, any of the antispasmodics may be of temporary benefit (F. 12, 13). ASTHMA. 121 Asthma Seems to be essentially a spasmodic disease, the patient being healthy in the intervals, although during the paroxysm, which seldom proves fatal, suffocation seems imminent. Symptoms, — The first invasion takes place during sleep. The patient wakens to find that he can scarcely get breath, hence he puts himself into the position that gives him most purchase for breathing. Respiration is accompanied by great wheezing, and yet hardly any respiratory murmur is heard. Tidal air is much dimin- ished. Patient feels that if he could cough and expecto- rate he would be relieved, but this he cannot do till the end of the paroxysm. The extremities are cold, the face livid, and the expression anxious. Pulse small and quick, but no fever. Towards the end of the paroxysm the expectoration appears, and is found to consist of frothy mucus free from blood or pus. Such patients are usually thin and round-shouldered, and the attacks often appear to take on a periodic char- acter. Asthma is most frequent during middle life, affecting men more than women, and being often hereditary. Asthma is termed idiopathic or spasmodic when un- complicated, and symptomatic or organic if it accom- panies bronchitis, heart disease, etc. Causes. — Direct. — As irritating inhalations, or over- eating, leading to distension of the stomach and pres- sure on the diaphragm. 122 DISEASES OF RESPIRATORY ORGANS. Indirect. — Through nervous system, as by strong emotions. Prognosis. — In itself most favorable, but by its complications, as congestion of lung, emphysema, and hypertrophy of heart, it is of much more serious im- port. Pathology.— Asthma consists essentially of a spas- modic contraction of the muscular fibres of the bron- chial tubes, by which means the admission of air is diminished, and the tubes become blocked up with expectoration, which it is partly the function of the muscular fibres to expel. Treatment. — During the Paroxysm. — First thing is to procure fresh air, and remove any tight clothing from neck and chest. Medicinally, stramonium, in the form of cigarettes or in a pipe, frequently gives relief. Tobacco also has been found useful. Inhala- tion of chloroform should be tried, care being taken to stop it if the lips become blue. Burning nitre paper under the nose may do good (F. 51). In Interval. — Change of air from town to country, or vice versa, may be tried. Avoidance of overeating and attention to bowels are necessary. Tonic and antispasmodic remedies may be given, and iodide of potass has been highly recommended, alone or with expectorants (F. 5, 46). Pneumonia. Acute inflammation of the substance of the lung is best recognized, probably, from its clinical history. PNEUMONIA. 123 A person catches cold, as the saving is. The cold settles in his chest. There is also feverishness 3 pre- ceded by shivering, and accompanied by gastric dis- order, and sometimes by jaundice. Then the breath- ing becomes accelerated, although not laborious, and there is cough, this cough causing pain, which is referred to the chest, and, as a rule, to that particular part of it which is affected. After a varying interval, the cough, which at first was hard, becomes softer, and a tough tenacious sputum is expectorated. This sputum is considered, and justly considered, character- istic of the disease. It is thick, adherent, glairy, sticking to the sides of the vessel, and through part of it a prune-juice color is observed; or what is more often termed the rusty sputum of pneumonia, which a student of mine once likened to badly mixed Gregory's mixture. The temperature, in accordance with the fever, is necessarily increased. The fever is usually intense, and may have a very high temperature (up to 105°); or there may be typhoid symptoms, with de- bility, dry tongue, or delirium — so much so as often to be mistaken for typhus fever. Pulse frequent, and hard at first. A herpetic eruption frequently appears on the lips or nostrils about the acme of the fever. Such are the general outward signs of pneumonia. What is going on inside? In answer to this it may be stated that the disease has been divided into three stages, which it is well to be familiar with, although it is absurd to suppose that they follow one another with mathematical precision. In the first stage, if an opportunity was afforded of examining the organ at- 124 DISEASES OF RESPIRATORY ORGANS. tacked with inflammation, the characteristic appear- ance of the part involved would be redness, with a quantity of red frothy serum escaping on section. The elasticity and sponginess of the lung is diminished, but it still will float in water. The vesicles contain fluid and air, hence fine crepitation is heard by the stethoscope. In the second stage the redness has yielded to solidification. The part affected has a thick heavy consistence. It no longer crepitates when pressed, and if thrown into water it sinks. Pressed between finger and thumb it breaks down, and from the appearance being like that of liver-tissue it has been termed "red hepatization." Here the fluid in the vesicles has coagulated. In the third stage reso- lution is taking place in the majority of cases, and the lung is coming back to its primary condition. When cut into, a great quantity of reddish or grayish fluid oozes out. Hence some call this " gray hepatization." This stage may, however, be carried farther into diffuse suppuration, and sometimes, though rarely, into ab- scesses and gangrene. The change from the first to the second stage goes on rapidly, twenty-four hours or even less being suf- ficient. It must also be remembered that you may have one part of the lung in the first, another in the second, and another in the third stage, so that the auscultatory phenomena, which come now to be con- sidered, will be found to vary at different sites. On applying the stethoscope over an inflamed lung, the healthy vesicular sound may in part be heard, with the addition of minute crepitation during inspiration. PNEUMONIA. 125 AY hat is this due to ? Very probably it is formed in the minute spaces of the bronchial terminations and pul- monary vesicles; the sound is best realized by rubbing a lock of hair in the immediate vicinity of the ear. In the second stage, over the part where the lung has become dense and solid, neither the vesicular murmurs nor the minute crepitation are heard, but there is a something else probably, viz., bronchial respiration or tubular breathing. This is due to the fact that there is entering the condensed mass a per- meable bronchus, and the sound is conveyed along the solid conducting medium. So, also, there may be no bronchial respiration, and no breath-sounds at all heard, because the bronchi may be filled up with ac- cumulated secretion. Sometimes this may be set free by a cough, and the bronchial respiration may be established. Ask the person to speak while the steth- oscope is applied over the site of the solidified lung, and the voice-sounds will be conducted to the ear in an intensified manner, and hence the term "bron- chophony." Similarly the vocal fremitus w T ill be in- creased. On percussing the same part, it can also be easily understood distinct dulness will be elicited. It is in this stage also that we hear "cegophony," or bleating sound of voice, as heard by the stethoscope. In the third stage moist sounds are detected, for the lung is permitting the air again to enter. It is the first stage on a larger and coarser scale, because the crepitations are heard both during inspiration and expiration. It has been termed the crepitatio redux, and it is usually a happy sign in pneumonia, because 11 126 DISEASES OF RESPIRATORY ORGANS. it indicates that the lung is returning to its duty, per- mitting the air to enter its wonted seat. It does not come on at once, neither does it invade the whole lung at once, and at last, as health is established, it is re- placed by the healthy vesicular murmur, if resolution has been thoroughly progressing. In pneumonia the right lung is more frequently attacked than the left, and the site of the inflamma- tion is at the base, hence the back and not the front is the proper place for hearing the phenomena indi- cated. Pneumonia is sometimes double. If it is not, the healthy lung, requiring to act with increased force, renders the respiration "puerile." Should the inflammation end in gangrene, there will be an intense fetid smell of the breath, great prostration, dyspnoea, and hectic fever; and a fatal result unless the part involved is very small. Gan- grene may also result from obstruction of vessels, from embolism, various septic poisons, and, it is also said, from nervous influences. The urine in pneumonia during the stage of hepatization shows a marked diminution in chlorides. It is frequently scanty, high- colored, and tends to deposit urates. The average duration of the disease in uncomplicated cases is four- teen days, when complicated about twenty-one. A certain amount of bronchitis must always accom- pany acute pneumonia; very often also pleurisy, when the disease is termed pleuro-pneumonia. It is necessary to mention two other varieties of pneumonia, "catarrhal" and "interstitial." In catar- rhal pneumonia the inflammation is limited to single PNEUMONIA. 127 lobules scattered more or less over the lung-substance in patches, and varying in size from a hemp-seed to an egg. It is always associated with, generally pre- ceded by, inflammation of the smaller bronchi, and in the great majority of cases occurs in lungs which are the seat of pulmonary collapse; a bronchial tube becomes obstructed, collapse of the air- vesicles beyond the obstruction takes place, and subsequently catar- rhal pneumonia is developed with rapid cell-formation in the collapsed lobule. It is essentially a disease of childhood, although it may occur in adults in connec- tion with pulmonary haemorrhage, pyaemia, or other affections. Its distinguishing characteristics, in addi- tion to those mentioned, are its high temperature, its affecting usually both lungs, its being preceded by bronchitis, and by the absence of a distinct chill or rusty expectoration. H Interstitial pneumonia," by some called fibroid pneumonia, is rarely a primary affection. The con- nective tissue of the lung becomes increased and hardened, the calibre of the air-cells is diminised, so that a lung, which is the seat of fully developed fibroid pneumonia, is solid and hard to the touch, and when cut it presents a smooth shining appearance, and gives a creaking sound under the knife. Prognosis. — Pneumonia occurring in the young or very old is attended with great danger. An unfavor- able prognosis mast also be given when it is double, when the temperature is above 104° Fahr., and when the patient has been addicted to drinking habits, and becomes delirious in the course of the disease. Al- 128 DISEASES OF RESPIRATORY ORGANS. though the pneumonia, per se, may terminate favora- bly, yet through its not resolving properly, or other circumstances, phthisis may supervene. In acute catarrhal pneumonia the prognosis depends entirely on the circumstances attending the development; occur- ring with measles or hooping-cough the prognosis is favorable. With scarlatina having a temperature above 105° it is unfavorable, especially if there is also a feeble pulse and a tendency to coma. In in- terstitial pneumonia the prognosis as to time is good, as people with it may live for many years, and suffer only from dyspnoea. Any intercurrent affection will, however, have a direct influence on the prognosis of a disease which can scarcely be regarded as an inde- pendent affection. Treatment — Bleeding, once so much in vogue in pneumonia, has now been practically abandoned. Sometimes, however, leeches are useful if the case is seen early and the patient is young and plethoric. I have usually found the antimonial treatment the best. Thus I give R. Vin. antimon., .... ^ss. Sp. chloroform., .... gij. Aqua, gvj. M. A tablespoonful every two hours. In the course of twenty-four hours the pulse is diminished in volume, the temperature decreased, and the body is bathed in perspiration. The expectoration also becomes freer. The same mixture is continued for the next two or three days, but instead of every two hours it is taken PLEURISY. 129 every four hours. Then it may be stopped, and ammonia and bark substituted. The advisability of giving stimulants must be judged of by the individual peculiarities of the case. If the patient is a broken- down and dissipated man, or has been accustomed to take them freely, the necessity for their administration is indicated from the first. In other cases common sense and prudence must guide the practitioner. Locally, hot linseed-meal poultices ought to be ap- plied and carefully attended to. The temperature of the room should be kept uniformly at 60° Fahr., and beef tea, given at regular intervals, should form an essential part of the dietary. Cold bathing or cold applications to the chest have found considerable favor in Germany. In addition to the general treatment laid down in acute bron- chitis, Dr. Flint strongly advises sulphate of quinine in full doses as an antipyretic. Pleurisy. Pleurisy was the designation given at one time to every pain connected with the chest, but now it is exclusively applied to inflammation of the serous mem- brane lining the walls of the thorax and investing the lungs. It may thus be either single or double, accord- ing as one or both sides are affected. It may also be either acute or chronic. Symptoms. — In acute pleurisy the attack is usually sudden, and there may be no premonitory chill, as in pneumonia. Pain is, however, generally felt acute and 130 DISEASES OF RESPIRATORY ORGANS. lancinating, chiefly in the mammary region, and is in- creased by cough and inspiration. On account of the pain the respiration is voluntarily impeded. The cough is short and dry. These local symptoms are attended with headache, anxious countenance, hot skin, and rapid pulse. The temperature does not rise so high as in pneumonia, nor decline so rapidly, but tends to fluctuate. In the early stages, if the stethoscope be applied to the place where the pain is felt, the opposed pleural surfaces are heard grating against one another, and producing what is termed " the friction-sound." This sound only lasts a short time, for, should reso- lution have occurred, it ceases, and the investing membranes glide over one another as in health ; or adhesions may have formed between them ; or, as most frequently happens, an effusion of serum has taken place into the cavity. This serum again- may degenerate into pus, constituting what is termed " em- pyema," and this pus may seek an exit either inter- nally or externally. If internally, an opening is made into the same lung through the pulmonary pleura, and the matter is evacuated by expectoration ; or it may make its way externally through an intercostal space, and usually at the most dependent part. If the opening thus formed does not close, we have what is termed bronchial fistula if the opening is internal, or parietal fistula if external. In this way air may reach the pleural cavity, and thus we have pneumothorax, or if pus as well, hydropneumothorax. The effused matter, consisting of serum, or serum PLEURISY. 131 degenerated into pus, gives well-marked indications of its presence. On percussion we find dulness corre- sponding to the extent of the effusion, and this dulness may be complete or partial according as the fluid fills the whole or only part of the pleura. The dulness, also, if the effusion is partial, will vary with the posi- tion of the patient, the fluid gravitating to the most dependent part, except where the fluid is bounded by adhesions. If, however, we find a very sharp fluid- level on the patient changing his position, we have probably air and fluid to deal with, and it is the air which gravitates. The lung is pressed back against the vertebral column, and if this compression is so complete as to prevent any air entering it, on auscultation we can hear no breath-sounds at all. If, however, we listen at the back, viz., at the part where the lung is ad- hering, we may detect increased resonance and bron- chial breathing; the bronchial or tubular breathing being like that of pneumonia, only softer to the ear and more superficial. Sometimes, when the patient speaks, the voice appears faint, distant, and trem- bling, like the bleating of a goat; it is then termed oegophony. The patient lies on his back or on the affected side if the pleurisy is single and the effusion great. The effusion, if great, may cause considerable displacement of organs. Thus the diaphragm may be depressed and the liver displaced downwards if the effusion is on the right side. In extreme cases on the left side the heart may be so shifted as to be seen beating on 132 DISEASES OF RESPIRATORY ORGANS. the opposite side. The unaffected lung in single pleurisy is thrown into increased activity, and the sounds becoming more distinct occasion what is termed puerile breathing. The intercostal spaces may also be flattened or even bulged out, while the inter- costal muscles do not rise and fall as in the healthy state. The measurement of the affected side will also show an increase as compared with the sound one. Duration. — This varies ; sometimes amounting to five or six days, sometimes to as many weeks. Termination. — The effusion may never have become purulent, but may be absorbed, as indicated by a grad-^ ual diminution of the dulness, and if there are no adhesions the lung will resume its natural size and functions. If it is bound down by adhesions w T e may find that it will not proportionately expand, but shrink in comparison with the other side; or empyema and hectic fever may result; or there may be an aggrava- tion of the symptoms, swelling of the hands, dyspnoea, and death ; or the disease may pass into the chronic state. Varieties. — Usually pleurisy is single, but the dis- ease, although primarily affecting one side, may spread to the other, constituting double pleurisy. Sometimes there is little fever, little pain, no dyspnoea, and yet an extensive pleuritic effusion — latent pleurisy. Dia- phragmatic pleurisy is characterized by pain in the hypochondriac region reflected to the clavicles, great dyspnoea, cough, intense fever, and vomiting. Diagnosis. — Pneumonia and pleurisy have certain things in common, viz., pain in the side, fever, dyspnoea, PLEURISY. 133 oppression, cough, and dulness on percussion. The dulness in pleurisy is, however, more complete, the elasticity of the lung being more fully lost, and in ad- dition there is no fine crepitation and no rusty sputum as in pneumonia. Intercostal neuralgia may simulate the first stage of pleurisy, but is distinguished from it by the pain not being aggravated by breathing, and by the absence of friction-murmur and fever. Prognosis. — Favorable if single and primary, un- favorable if the effusion becomes purulent. If sec- ondary to other diseases, it may so complicate matters as to be the immediate cause of death. As will be seen from the foregoing remarks, the pathology of pleurisy may be shortly stated thus: 1. Some redness of the pleural surfaces. 2. Exudation partly serous and partly fibrous, the fibrin being deposited on the inflamed surfaces; and as inflammation goes on this fibrin is replaced from below upwards by an inflammatory growth compara- ble to granulation-tissue. 3. The fluid may be absorbed, and thus the two granulating surfaces coalesce, obliterating the cavity. 4. The fluid may increase and degenerate into pus, as previously noted. The treatment most consistent with the sketch of pleurisy given seems to be this: If the case is seen 'in the early friction-stage, the application of leeches to the seat of pain, followed by hot poultices and the administration of a purgative. The latter to be suc- ceeded by a soothing expectorant mixture (F. 43). Opium hypodermically, or by the mouth, is of much 134 DISEASES OF RESPIRATORY ORGANS. benefit, especially if combined with calomel. Control- ling the movements of the affected side by straps of sticking plaster has been found useful in preventing effusion. If effusion has already taken place, then it is necessary to promote absorption. Of the remedies most useful for this, special mention must be made of a pill containing squill, digitalis, and mercury, given thrice daily (F. 36). This should be followed by the iodide of potassium, with rest in bed, nourishing diet, wine, and the local applications of small blisters, or the unguent, iod. hydrarg. (F. 5). Should the effusion not be removed by these means, or should it have become purulent, as indicated by hectic fever and sweats, paracentesis by the pneumatic aspirator should be performed. The site selected for the operation is at the inferior angle of the scapula of the side affected, and the fluid should be drawn away rather by repeated operations at intervals of a day or days than all at once. Chronic Pleurisy. As in simple pleurisy the pleura is full of fluid to a greater or less degree, but this fluid is milky or purulent, and often exists w T ith a pulmonary fistula. If the pleurisy be double it is often associated with tubercles. Symptoms. — As in acute pleurisy, after exudation there is absence of thoracic vibration, complete dulness, and loss of the respiratory murmur, which may be replaced by tubular bronchial breathing. The side CHRONIC PLEURISY. 135 affected remains immovable, the intercostal spaces are filled up, while any other position than lying on the back, or the side affected, is impossible. When chronic pleurisy is primitive, L e., does not follow on an acute affection, it does not announce itself by any local pain, the fever, if any, is irregular, with little or no dyspnoea. In fact, the pleura may sometimes be full of fluid without the patient being conscious of this. After this mode of invasion, tuberculosis is apt to set in with weakness and enfeebled digestion, followed by hectic fever and night-sweats. Treatment should be tonic, — cod-liver oil, syrup of the iodide of iron, and good nourishing soup and beef tea. Should there be no indication of tuberculosis or cancer, should the effusion seriously endanger the patient's life by suffocation, and should it fail to be removed by the means mentioned, or by absorbent or diuretic treatment, it is advisable to perform para- centesis (F. 35, 36, 37). Addenda to Chronic Pleurisy. — The condition termed pneumothorax may here be briefly alluded to. In- juries may lead directly to this, as from fractured ribs or blows, but in the great majority of cases the air is admitted as the result of the bursting of a small cavity into the pleura in the progress of phthisis. Sudden severe pain, faintness, and dyspnoea characterize this occurrence at first, and afterwards the face and lips become blue and swollen. The percussion-note is abnormally clear on the affected side, or dull; the intercostal spaces are bulged out, and the respiratory 136 DISEASES OF RESPIRATORY ORGANS. sounds, if not entirely absent, are either greatly di- minished or have an amphoric quality superadded. As there is generally fluid with the air, it may be detected at the base of the pleura by dulness on per- cussion, and by a splashing sound being sometimes produced when the patient is shaken. Fluid and air being both present, the condition is known as " hydro- pneumothorax." As the consequence of disease of the heart, kidney, or liver, obstructing the circulation, there may be a passive effusion of serum into both pleural cavities, and the condition termed " hydrothorax " is established. It is not a disease of the thorax per se, but simply marks the advance of the general dropsy to the lungs. Phthisis, Pulmonary Consumption, Is the most fatal and most common disease to which the human race is liable ; it may occur in any country, and may attack either sex at any age. It may be hereditary or acquired, and may run an acute or chronic course. Acute phthisis is, however, rare. Phthisis (chronic), as we generally observe it, is shown by certain general and local symptoms. The general symptoms are first dyspeptic: want of appetite, a faulty digestion, a marked aversion to all forms of fatty food, may for some time precede the cough, which is at first dry, and most severe at night or early morning, but is afterwards accompanied with a clear, sticky expectoration, or it may be tinged with streaks or dots of blood. If the expectoration of PHTHISIS, PULMONARY CONSUMPTION. 137 blood is abundant, vomiting accompanies the cough ; hence the term "vomiting of blood " so often employed by patients. In inquiring into the character of the blood it is necessary to remember that if it proceeds from the lungs, the succeeding coughs will generally bring up portions of blood which remain behind; the color becoming darker and darker, and finally turning to a dirty brownish-red. If from the stomach, the blood comes away by a single act of vomiting, and then follow black-colored discharges from the bowels. There is no fixed pain, but often a dull, varying, aching feeling between the shoulders or below the clavicles. Exertion, such as walking quickly, going upstairs, occasions dyspnoea, while hurried breathing is a constant symptom. Loss of weight and emacia- tion from the faulty digestion, or from the accom- panying fever, as evidenced by increased tempera- ture and quickened pulse, form valuable diagnostic signs. Sometimes a red line is seen on the gums, and the fingers are often clubshaped and the nails curved. Some, if not all, of these symptoms are found in the first stage of phthisis, and accompanying these, and evidencing the existence of the tubercular deposit in the lungs, are marked local symptoms. The deposit affects, as a rule, the apex of one lung at first, and on percussion in the supra-spinous or supra-clavicular region, want of elasticity is detected, or actual dulness. The expiration is prolonged, and accompanying the inspiration a feebleness or jerking is heard, or dry clicking. When the exudation has become more 138 DISEASES OF RESPIRATORY ORGANS. marked, and has set up more pulmonary irritation, localized evidence of this is shown by subcrepitant bubbling sounds, or by bronchial or tubular breathing. It should, however, be borne in mind that phthisis may have taken perfect hold of the system, and yet there may be an absence of physical signs, or only the slightest indication of them. In such cases the ther- mometer is of great service, as it will indicate an in- crease of the evening temperature over the morniug to a greater or less extent. In the second stage, with which, for convenience of description, the third or last stage is included, we find the general symptoms to have markedly increased in severity. There is distinct flattening above and be- low the clavicles of one or both sides. The fever is more pronounced, and hectic in its type. The system is further weakened by profuse night-sweats and diar- rhoea. The cough is frequent and irritable, often giving rise to vomiting ; the appetite capricious, and digestion greatly impaired. The expectoration is thick yellow, sinking in a kind of thin glairy liquid, pellet- shaped, or from its resemblance to a coin called num- mular ; later on it loses this character, and becomes distinctly purulent, sometimes having a greenish color and most offensive odor. Should a fatal issue result, as usually happens in this stage, the exhaustion becomes more profound, the night-sweats more severe, and finally, swelling of the feet and ankles is often observed. The tubercles formed in the first stage have softened and broken down, leaving cavities. The layer of lung PHTHISIS, PULMONARY CONSUMPTION. 139 forming the wall of the cavity or cavities is usually thick and solid. Hence, on percussion, the sound is dull, or if there is a free communication with the open bronchi and mouth, there is a cracked-pot sound (bruit de pot fele). Fig. 5. Section of lung, showing cavities. On auscultation gurgling is heard, caused by the air bubbling through liquid. Should the cavity be dry and hollow, " cavernous or amphoric respiration " will be present. These sounds may also often be combined if the cavity contains fluid at its lower part, while above it is to a great extent dry. The vocal reson- ance indicates " bronchophony " or well-marked " pec- toriloquy/' Frequently a murmur is heard below the clavicles, especially on the left side, following the first sound of the heart, and is presumed to be due to adhesion at 140 DISEASES OF RESPIRATORY ORGANS. the apex of the lung. The shrinking thus occasioned produces a bending, an alteration in the direction of the artery (subclavian), and the blood flowing through the narrowed part gives rise to the murmur. The elastic fibres of the lung-tissue can at times be detected in the sputa by mixing them with an equal quantity of caustic soda in distilled water, 18 : 100. Boil the mixture, frequently stirring, then add three or four times its bulk of water, and allow it to stand in a conical glass. The deposit contains the elastic fibres. Acute Phthisis Is a rare disease, and runs a rapid course. ' It seems dependent on tubercular degeneration following catar- rhal pneumonia; the pneumonic consolidation, instead of undergoing resolution, breaks down into soft cheesy matter, with the formation of cavities of various sizes, at times all oyer the chest. It is attended with a sudden onset, shivering fol- lowed by a high fever, pain, cough, dyspnoea, profuse sweatings, rapidly increasing weakness, and prostration. The pulmonary mischief is evidenced by hurried breathing, and small and large crepitations, not local- ized but general. In the only two cases I have seen death occurred in less than five weeks. Treatment — The general treatment is indicated under tuberculosis. With regard to other remedies, cod-liver oil has deservedly been the sheet-anchor of the profession for many years. It affords the greatest ACUTE PHTHISIS. 141 amount of nourishment in the smallest form, and should be commenced in teaspoonful doses, at first mixed with limewater, and gradually increased. The oil may also be rubbed externally, especially if the stomach cannot digest it. Glycerin can sometimes be taken with advantage in dessert or tablespoonful doses thrice daily, either alone or with the syrup of the iodide of iron in a bitter infusion. Pancreatic emul- sion has by some been considered beneficial. Counter- irritants, as croton oil or iodine paint, may also be employed over the front of the chest. It is better to allay the cough with inhalants than cough mixtures. The hop inhalation can be specially recommended (F. 52). Opium or some of its preparations forms the essen- tial ingredient in all useful cough mixtures, and must be given when it would be cruel and impossible to dispense with these (F. 71). The injection of ergotin is to be recommended in severe hemoptysis, with gallic acid internally (F. 19), ice cloths over the chest, and the sucking of ice. To control the diarrhoea chlorodyne is useful. And to prevent sweating the hypophosphite of lime or the injection of atropia is highly serviceable. I have seen much benefit follow- ing the use of the hypophosphites in the early stages of hereditary phthisis (F. 82). Alcohol may be given freelv in all stages of the disease. If the case is not too far advanced, and the patient can afford it, a sea voyage should be tried ; and, if circumstances admit, a residence for some time 142 DISEASES OF RESPIRATORY ORGANS. in a warm and equable climate, such as Torquay, Hastings, Mentone, Nice, Algiers, or Madeira. Cancer of the Lung Is usually of the medullary form, and originates from the bronchial glands — thence invading the sub- stance of one or both lungs. It may, however, be primary. The symptoms are obscure — the more prom- inent being dulness on percussion, dyspnoea, tubular respiration, and the expectoration of sputum of "red currant jelly " character and consistence. Rapid ema- ciation ensues, and ultimately death by exhaustion, through the malignant nature of the disease, and from its involving by pressure nerves, bloodvessels, and other structures. Its course is rapid, the mean dura- tion being 13.2 months. Angina Pectoris. The introduction of this term into medical nomen- clature is due to Dr. Heberden, who in 1768 first described the disease, and stated that the sense of strangling and anxiety with which it is attended may make it not improper to call it angina pectoris (anguish of the breast). It is a rare disease. Etiology. — Some consider it merely neuralgic, com- mencing for the most part in the pneumogastric nerve, and spreadfng in different directions. Militating against this theory is the fact that it seems brought about by what disturbs the heart's action, viz., mental emotion and bodily exertions, and further, that it is ANGINA PECTORIS. 143 so often suddenly fatal. Dr. Jenner believes it due to ossification of the coronary arteries, disordering the nutrition of the organ. This does not, however, ac- count for the sudden pain. Generally speaking, it may be said to be essentially connected with fatty de- generation, ossification of the coronary arteries, or some valvular disease of the heart. Symptoms. — The attack is sudden and without warn- ing, occurring sometimes when walking quickly up a hill or after early breakfast. The pain is referred to the cardiac region, and is intense in its character. It may radiate from the heart as its central origin, to the neck, back, left shoulder, and arm. The suffocating feeling with which it is accompanied gives rise to the fear of impending death. The countenance is pale and covered with sweat; the pulse feeble, small, and fluttering ; while consciousness is unimpaired. Fortunately the attack does not last long, gener- ally only a few seconds, but it may be prolonged even an hour. It is paroxysmal in its character, and may be evoked by unknown exciting causes. It is a dis- ease of middle life or advanced age, and is more com- mon in men than women. The prognosis is necessarily grave, and sooner or later death ensues in the course of a paroxysm. Treatment. — During the spasm, externally, mustard foot-baths, sinapisms to the back, or hot fomentations. Internally, give brandy, or a mixture of sp. amnion, aromat, sp. chloroform, and acid hydrocyan. dil. (F. 13). The inhalation of chloroform, or nitrite of amyl, is strongly recommended. 144 DISEASES OF CIRCULATORY ORGANS. The prophylactic treatment consists in a tranquil life, moderate diet, abstinence from wine and spirits, and the wearing of flannels, no constriction being placed about the abdomen. As the attacks often occur while walking against the wind or ascending a moun- tain, common sense and prudence interdict such ex- ercises. Hypertrophy of the Heart. To understand what is meant by the term hypertro- phy of the heart, it is necessary to have some definite idea of the size of the organ in health, and also of the relative thickness of the walls of its different chambers. The size of the heart, all authorities seem to agree, is, in health, about the same dimensions as the closed fist, and it weighs 8 to 10 ounces. The left side of the heart has to do more active work than the right, and nature has accordingly provided it with increased thickness of the muscular tissue to accomplish this. The relative thickness is as follows: The right side is to the left as two to five; or in other words, and generally, the thickness of the left ventricular wall more than doubles that of the right. Hypertrophy of the heart is therefore more fre- quently found in the left side of the organ, or that side of the pump which has the most work to do. This hypertrophy may be of two kinds. In the - first there is simple enlargement of the muscular walls without dilatation of the corresponding chamber. In the second, not merely are the walls thickened, but the chamber is also increased in size. The first HYPERTROPHY OF THE HEART. 145 is termed simple or passive, the latter active or eccen- tric. The first is rare, the second frequent. Dilata- tion and hypertrophy thus most frequently go together, and the reason for this is obvious if we look at what is the cause of hypertrophy. In nineteen cases out of twenty there is some obstacle to the transit of blood to or from the organ. This obstacle may be in the heart itself, or may be due to its being pushed from its ac- customed seat by disease of other organs, — such as pleurisy. The former cause is the more common. Thus, if the aortic valves, which act as sentinels to guard and guide the blood from the ventricles, be- come incompetent, allowing the blood to flow back again, or obstructed, not permitting it to get properly out of the chamber, hypertrophy must result. The heart has to put on increased force to overcome the obstacle, and has to acquire increased space to contain the greater quantity now in the chamber. If the mitral valve is diseased there will be an increased quantity of blood within the left auricle, and hence the chamber must be larger. The auricular action is not, however, strong, like the ventricular, and, as there is not so much increase of power needed, auric- ular dilatation often exists without hypertrophy. On the right side of the heart we find increased size and thickness of the right ventricle, where there is some obstacle or too great patency in the pulmo- nary or tricuspid valves, or some hindrance in the diseased state of the lungs to the proper circulation of the blood, as from emphysema. Symptoms. — In general the symptoms are developed 146 DISEASES OF CIRCULATORY ORGANS. slowly. They may be broadly enumerated as follows : Palpitation, dyspnoea, pain localized about the heart, and inability for active exertion, such as walking, run- ning, or going upstairs quickly. The character of the pulse is usually strong, powerful, jerking; but it varies with varying causes. On percussion the area of cardiac dulness is found to be increased. The direction of the increased dul- ness varies according to the part of the heart affected. If it be the left ventricle the extension will be down- wards and to the left, giving an elongated shape; while, if the right ventricle be hypertrophied, it comes to form the apex, and thus the outline is square, and the dulness extended to the right. There is a sensi- ble and very distinct heaving impulse communicated to the hand or the stethoscope. The heart-sounds are heard over a largely increased surface, and the apex-beat is removed from its place. Further, if the hypertrophy be simple, the first sound is obscure and muffled at the apex. If there is hypertrophy and di- latation, the first sound is loud, full, and pronounced; while, should there be valvular disease, murmurs will be heard, varying as to site and peculiarities with the valve implicated. Treatment must be guided by the state of the patient. If of full and plethoric habit, rich food should be avoided, also all alcoholic stimulants, and tea and coffee. If, on the other hand, of weak and feeble frame, nourishing diet and tonic medicines are neces- sary. To combat the violent impulse of the heart ATROPHY OF THE HEART. 147 digitalis is useful; while for dyspnoea, sp. chloroform or other stimulants must be administered (P. 12). Atrophy of t^e Heart. In contradistinction to hypertrophy or enlargement of the heart, with increase of the muscular substance, we sometimes find the heart atrophied or diminished in weight. The muscular substance becomes pale, soft, and flabby, and easily broken down. The weight of the organ may thus be reduced to one-half of what it ought to be, and its chambers are small. The simple form of atrophy is the result of debili- tating disease, such as fever, cancer, marasmus, phthisis, or it may be congenital, or the result of disease of the vessels which nourish the heart's substance, — the coronary arteries. It is thus rather a post-mortem appearance than a distinct disease. Symptoms. — If there is marked diminution of the size of the heart, the area of cardiac dulness will be decreased. The smaller quantity of blood contained in the cavities, and the feebler contracting power of the organ, will render the impulse weak and the heart's sounds indistinct. The pulse will also be found to be small. There are, however, no certain diagnostic signs. There is another form of atrophy in which the mus- cular texture becomes altered by fatty degeneration. The term fatty degeneration does not imply that the heart is overloaded with fat, and has on its outside, or even dipping in between its muscular fibres, an increase 148 DISEASES OF CIRCULATORY ORGANS. of adipose tissue. This is rather and better termed a fatty growth — a something superadded. What is meant by the term fatty degeneration of the heart in reality is, that the healthy transverse striae and nuclei of the muscular substance are transformed into a con- geries of oil-globules. The muscular fibres are short, easily broken, and some authorities (Dr. Quain) have pointed out that there is frequently ossification of the coronary arteries. Symptoms, — The diagnosis is beset with difficulties, the principal symptoms being a feeble action of the heart, — 45 to 50, — weakness, giddiness, and sometimes faintness. Then there is what was once considered diagnostic of this disease, well-marked "arcus senilis," due to fatty degeneration of the edges of the cornea. Yet it must be remembered we may have fatty degen- eration of the heart without the arcus senilis, and vice versa. Men are more often attacked than women. It comes on at all ages, but most frequently in advanced life. The prognosis is unfavorable. It will thus be observed that fatty degeneration differs from a fatty growth of the heart, the latter being usually associated with general obesity, the fat which is normally deposited on the heart being abnormally increased, especially among the muscular fibres. Treatment can only be symptomatic. Pericarditis. The fibro-serous membrane of the heart is liable to inflammation as the result of cold, of renal disease, of specific fevers, of wounds by fractured ribs, of the PERICARDITIS. 149 extension of inflammation from lungs or pleura; but, in the great majority of cases, pericarditis occurs during an attack of rheumatic fever. The female is less sub- ject to it than the male, in the proportion of one to five. The result of this inflammation is the exudation of lymph or serum, and in the early stage of the affec- tion, supposing we were enabled to open the body, we would find, most likely, the membranous sac partly filled with some serum, and with a plastic coagulable lymph. At a later stage the effusion would be found completely to separate the membranes with layers of lymph deposited, forming false membranes, while, at a still later stage, the effusion may have been absorbed, and the two sides become glued together (adherent pericardium). The deposited lymph we have mentioned, on account of the continual movement of the heart, is laid down in a somewhat unequal manner, or in layers, just as the tide leaves the sand ribbed ; or in some instances it is shaggy, like the rough surface of tripe. Symjrtoms. — On auscultating at an early stage of the disease, before effusion has occurred, a to-and-fro friction-sound is detected, from the serous membranes not gliding upon each other with the ease and smooth- ness of health. Essentially the sound is of a rubbing character, and has been compared to the unfolding of a crisp banknote, to the rustling of silk, or the creak- ing of new boots. As the endocardium, and especially the mitral valve, is generally also implicated with the pericardium, there is usually a systolic bellows mur- 150 DISEASES OF CIRCULATORY ORGANS. mur which may mask the friction-sound , and it is to be remembered that while the systolic murmur is per- manent, the to-and-fro friction-sound may not be de- tected, and, in any case, does not last long, for the patient may die during its continuance, or the effusion may be so great as to prevent the membranes rubbing on each other, or they become adherent — glued to- gether. When effusion has occurred, the dilated peri- cardial sac assumes a pyramidal form, with its apex upwards towards the second left costal cartilage, its base corresponding with the lower edge of the sixth rib; consequently dulness will be detected on percus- sion over this area, and varying to some extent with the position of the patient. If the pericardium becomes adherent, the dulness will be that of the normal heart. The general symptoms attendant on pericarditis vary, and are so insidious as sometimes to attract little attention. Pain is referred to the cardiac region, and is increased by cough or pressure, or lying on the left side. The heart's action is irregular and inter- mittent, and this is more apparent after the fatigue of speaking, or taking food, or any emotion. Patient lies propped up, complaining of headache, with anx- ious countenance and difficulty of breathing, and of disturbed and restless sleep. This restlessness passes into delirium in fatal cases, and is attended also with oedema of the lungs and other symptoms of malaera- tion of the blood. Prognosis. — Pericarditis is a grave malady, yet, when occurring in rheumatic fever, it is not so much to be dreaded for its immediate as its. after conse- ENDOCARDITIS. 151 quences, in producing endocarditis and leaving* per- manent valvular disease. Should it supervene in the course of a chronic disease it is generally fatal, the prognosis being specially grave in Bright's disease, and in cases of copious and rapid effusion. The prognosis should be determined rather by the complication than the disease itself. Treatment. — General bloodletting, once so preva- lent, has now been abandoned. The local application of leeches does good by easing the pain in the early stage of the disease, and should be followed by the application of hot linseed-meal poultices, and fomen- tations. AVhen effusion has occurred, the object is to promote absorption, and for this purpose blisters are serviceable. Mercury pushed to salivation "is now rarely employed ; combined with squills and digitalis it is a diuretic and absorbent, and as such may be given (F. 36). Iodide of potassium is also largely used (F.- 5). The strength should be supported by strong soup, beef tea, with wine and brandy, if these do not excite the action of the heart. Stimulation is specially necessary in pericarditis occurring in Bright's disease or fever. Endocarditis. By endocarditis is meant an inflammation attacking the lining membrane of the heart. It is usually asso- ciated, as has been indicated, with pericarditis; yet by some authors it is contended that it exists as an inde- pendent disease. In any case, we do not often see this 152 DISEASES OF CIRCULATORY ORGANS. endocardial inflammation in its early stage. If we did we would observe — 1st. Increased redness and vascularity. 2d. The membrane thickened, polished, and smooth. 3d. Fibrinous vegetations forming and attaching themselves to the valves, which are also involved in the inflammation. The valves may thus become thick- ened or puckered or adhering together, and their healthy action is permanently impaired. Symptoms. — Endocarditis, occurring as it does in the great majority of cases during an attack of acute articular rheumatism, Bright's disease, or pyaemia, has its symptoms so much masked by the severity of these affections that its actual existence is only recognized in many cases by the physical signs which it leaves of valvular mischief. There may be, however, an indi- cation of its existence at the moment — general uneasi- ness about the heart, palpitation, restlessness, cold sweats, and increased fever. In a variety of endocar- ditis an ulcerative destruction of the heart's substance occurs, and this form is characterized by typhoid symptoms, prostration, and a rapidly fatal issue. Treatment is the same as pericarditis. Cardiac Murmurs. On listening over the cardiac region in health, two distinct sounds are heard following each other at regu- lar intervals. These sounds have been termed first and second, systolic and diastolic, as the one corre- sponds to the contraction (systole), the other to the CARDIAC MURMURS. 153 filling up (diastole) of the ventricles. The first sound has its maximum intensity at the apex of the heart; the second at the base, or, more accurately, on a level with the third rib and a little above and to the right of the left nipple, near the left edge of the sternum. In determining therefore the state of the heart, it is Fig. 6. Ventricular svstole. necessary first to apply the stethoscope at the apex and next at the base on the spots mentioned, and to ascertain whether or not a murmur or murmurs exist, denoting a variation from the sounds of health, and if so, what valve or valves are implicated. In order to realize what is to follow it is advisable to leave out of account the right side of the heart and to fix the atten- 154 DISEASES OF CIRCULATORY ORGANS. tion entirely on the left side, and more particularly the left ventricle, which has two valves in connection with it, — the mitral and the aortic. With the con- traction or systole of the ventricle (Fig. 6), the mitral valve is closed, to prevent blood flowing back into the auricle, and the aortic valves are laid back to allow it to go freely away on its circuit. With the filling up Fig. 7. Ventricular diastole. or diastole of the ventricle, the reverse of this happens (Fig. 7). The mitral valve opens and the aortic valves are closed to prevent the blood flowing back from the aorta into the ventricle. If disease has involved one or more of these valves, interfering with their CARDIAC MURMURS. 155 healthy action, a murmur or murmurs are occasioned, which may be considered regurgitant or obstructive, according to rhythm, or the time when they are heard ; and thus we may have one or more of four great classes of murmurs, viz., mitral regurgitation, mitral obstruction, aortic regurgitation, aortic obstruction. The further great practical fact may be dogmatized thus: Mitral murmurs are heard loudest at the apex; aortic murmurs at the base; accordingly, if a murmur is heard following the first sound, it may be termed generally a ventricular systolic (V. S.) murmur, and if loudest at the apex and diminishing or lost at the base, it is due to mitral regurgitation; or if loudest at base, it is dependent on aortic obstruction. If a mur- mur follows the second sound it may be termed gen- erally a ventricular diastolic (V. D.) murmur, and as indicating its nature, aortic regurgitant. Again, a murmur may be heard following neither directly the first nor second sound, but immediately preceding the first, it may be termed auricular diastolic (A. S.) mur- mur or presystolic, or, as more definitely recognizing its causation, mitral obstruction. Attention to these considerations will enable the student generally to detect the nature of the lesion, aided as he will be by the state of the pulse, which as a rule is soft and compressible in mitral, and hard and jerking in aortic disease; and by the pulmonary symp- toms, which are more common and urgent in mitral, while cerebral symptoms or complications are more often associated with aortic disease. I purposely say nothing of diseases of the right side of the heart, as 156 DISEASES OF CIRCULATORY ORGANS. they are rare, and to enter completely into their causa- tion would confuse the conception desired to be re- tained by the student of a single-chambered organ in connection with the subject of heart murmurs. The following tables, read, however, in connection, with what has been said, can now be understood : A. — Mitral obstruction, stenosis, presystolic mur- mur, indicates an impediment to the flow of blood from the left auricle to the left ventricle. Recognized by a purring thrill at apex ; a murmur running up to the first sound and loudest at apex ; a feeble, often irregular pulse ; difficulty of breathing after exertion. It occasions sometimes little uneasiness; sometimes pulmonary congestion and spitting of blood; some- times it terminates in sudden death. J5. — Mitral regurgitation, incompetence, an imper- fect closure of mitral valve, permitting blood during contraction of ventricle to flow back to the auricle. Recognized by a blowing murmur following the first sound, and heard the loudest at the apex; di- minishing towards or inaudible at the base, confirmed by its being heard at inferior angle of left scapula; pulse feeble and irregular. Caused by contraction of segments of valves; by dilatation of left ventricle; by irregular contraction of papillary muscles. Resulting in more or less suffering from congestion of lungs, liver, and kidneys; rarely in sudden death. C. — Aortic obstruction, stenosis, narrowing of orifice, CARDIAC MURMURS. 157 preventing blood flowing easily from the left ventricle into the aorta. Recognized by a murmur following the first sound, heard loudest at the base, always propagated to the vessels of the neck, sometimes with considerable inten- sity downwards along the sternum ; pulse small, hard, regular. Resulting often in little suffering for years, in con- sequence of compensating hypertrophy of left ven- tricle. D. — Aortic regurgitation, incompetence, an imper- fect closure of the aortic valves, causing regurgitation. Characterized by a murmur following the second sound diffused more or less along the whole sternum, although perhaps loudest at third right costal cartilage; shotty jerking pulse. Resulting sometimes in sudden death; sudden attacks of dyspnoea and oppression are often promi- nent symptoms. E. —Tricuspid obstruction rare. F. — Tricuspid incompetence, regurgitation, imper- fect closure of tricuspid valve. Recognized by increased dulness of right side of heart; diffused pulsation over the right ventricle; murmur with the first sound ; pulsation and fulness of jugular veins; dyspnoea and dropsy; generally associated with mitral regurgitation or emphysema. G. — Pulmonary stenosis rare. Pulmonary incompetence also rare; detected by its situation over the pulmonary valves by its loudness and non-propagation from this spot. 14 158 DISEASES OF CIRCULATORY ORGANS. It must be remembered that these murmurs are frequently combined — the most frequent combination being aortic obstruction and regurgitation ; mitral obstruction and regurgitation ; various combinations of mitral regurgitant and aortic murmurs. These murmurs are termed organic murmurs, and are per- manent, while another class of murmurs, denominated functional, are associated with chlorosis or debility. They are heard at the base of the heart and in the vessels of the neck, follow the first sound, and may disappear under treatment. Treatment. — In valvular diseases of the heart of all kinds we have to face un fait accompli, and prophy- lactic treatment cannot thus be put in force. Post- mortem appearances indicate the compensatory efforts of nature to overcome the various obstacles to the flow of blood. The indications of all treatment, therefore, are to advance the development of compensation when already in existence, to maintain it as long as possible, and to moderate over-compensation. Hence the diet should be nourishing, not stimulating, all spirituous liquors and much smoking disallowed, and good di- gestion promoted by fresh air and cautious exercise. The mind should be kept at rest, and the attention never unnecessarily attracted to the state of the organ. To combat unusual irritability, to promote the nutri- tion of the cardiac walls, to render the pauses between the heart's contraction longer, digitalis is the sovereign remedy, either alone or combined with iron (F. 88). It acts as a cardiac tonic, not as a depressor, and its use may be continued for the purposes indicated THORACIC ANEURISM. 159 either in the form of the tincture or infusion, for a considerable length of time. Pain is best relieved by subcutaneous injections of morphia ; commencing dropsy by diuretics, such as squills and digitalis (F. 35, 37). AYhen the heart's action is irregular, the pulse low, the urine scanty, and disturbed compensation evident, the diuretic effects of digitalis and quinine are highly recommended (Rosenstein). Palpitation of the Heart Expresses increased frequency of cardiac action, ir- regularity, suddenness of impulse ; and varying causes may originate this, mental excitement, strong tea, tobacco, indigestion, exertion, gout. As a rule, the symptoms which accompany the pal- pitation without organic disease are flushings or pallor of the face, ringing in the ears, or some coldness of the extremities. The causes being removed, the palpi- tation is removed ; yet at times the heart may get hypertrophied or dilated through the chronicity of the palpitations. Thoracic Aneurism. There are three chief situations for thoracic aneu- risms ; viz., the ascending portion of the aortic arch, the transverse part of the arch, or the roots of the large vessels arising from the arch. Most frequently they spring from the ascending arch, and from the convexity rather than the concavity. Aneurisms of the arch embraced by pericardium 160 DISEASES OF CIRCULATORY ORGANS. are always small in size, and are usually associated or confounded with simple aortic valvular disease. When the aneurism is situated beyond the pericardium it frequently attains a very large size, displacing the lung outwards, especially on the right side, and an- teriorly coming in contact with the anterior thoracic wall, where it may ultimately form a visible pulsating tumor. In the interior of the chest it presses on the right lung, and may compress the descending vena cava, and involve the right pneumogastric nerve. An aneurism in this situation is liable to open externally or internally into the pericardium, right pleura, or lung itself; an aneurism of the transverse arch spring- ing from its convex portion spreads upwards, and to the left, pressing upon the manubrium sterni, the clavicle and the left upper ribs in the same situation. A tumor is thus formed in the region mentioned, which sometimes rises from the sternum into the root of the neck. If it springs from the posterior surface of the transverse portion of the arch, its course is often latent. Aneurisms of the descending part of the arch are rarely to be detected until they have attained a large size; although their presence may be suspected by dulness, pulsation, murmur, absence of respiration over a limited area, with dull aching or burning pain over the vertebra. General Symptoms. — When the tumor can be de- tected externally the diagnosis is easy, but if this is not the case the symptoms are obscure, and generally speaking consist in cough, dyspnoea, difficulty in ABDOMINAL ANEURISM. 161 swallowing, and pain about the chest and back. The cough is audibly brassy in character, and attended with a suffocative feeling if one or both recurrent laryngeal nerves are implicated; and if the tumor extends deeply backwards, pressing on the ganglia and branches of the sympathetic, there will be permanent contrac- tion of the pupil of the affected side. The physical signs are dulness, " bruit," absence of respiration, or bronchial respiration from pressure on a bronchus. Again, if the transverse part of the arch be the seat, the tumor or pulsation may be felt by placing the finger deeply in the supra-sternal notch. Heart murmurs and pain, or numbness of the arm or side, serve to confirm our diagnosis. The duration of the disease is uncertain. In thirty cases collected by Lebert the disease lasted from one year to four years. The disease seems to make more rapid progress in young people than in old. The prog- nosis is necessarily very unfavorable. For treatment, see page 162. Abdominal Aneurism. Aneurisms of the abdominal aorta are more frequent above than below the coeliac axis. They are spindle- shaped or saccular (from three to six inches in mean diameter), often of very considerable size, the contents being as much as ten pounds. They project from the anterior surface or sides of the artery, and tend to de- velop downwards and to the left more than upwards and to the right. 162 DISEASES OF CIRCULATORY ORGANS. Symptoms. — A tumor is usually found to the left, just above the navel. On palpation a forcible pulsa- tion is perceived, a little after the apex beat, and ac- companied with a thrill, and along with this thrill a murmur is heard. The murmur may be propagated into the iliac and femoral arteries. Functional disturbances may also be present in a greater or less degree. The most common of these is pain in the belly and in the back, corresponding to the seat of the tumor. There may also be vomiting, diarrhoea, or consti- pation. The general condition of the patient may remain unaltered for some time, or there may be progressive debility. Rupture of the aneurism is frequent, giving rise to sudden peritonitis ; or sometimes an aneurism of this kind may burst into the left pleural cavity. Treatment. — The general treatment must be that advisable in all forms of cardiac disease, viz., rest, and avoidance of all excitement, mental or bodily. Prob- ably Tuffnell's method in thoracic as in abdominal aneurism is the best; the principle being the giving of a spare dry diet, with few liquids, and the enjoining of strict and absolute rest in the recumbent position. Hence he orders six ounces of milk, two ounces of roast meat, and six ounces of bread and butter. By this means the blood tends to coagulate in the sac; just as water, through which a comparatively stag- nant stream flows, affords every opportunity for the accumulation of debris on the sides, so in this way, at the sides of the aneurismal sac fibrin becomes ac- ULCERS OF THE TONGUE. 163 cumulated in layers, and ultimately is moulded into the walls of the sac. Of medicinal agents, iodide of potassium, in large and increasing doses to the extent of 90 grains daily, is held most in repute. This drug has the support of eminent English and foreign authorities. The sub- cutaneous injection of ergotin has been tried in the immediate neighborhood of the tumor twice or thrice daily, the object being to diminish the sac by produc- ing contraction of its muscular elements. Galvano-puncture in some cases has been success- ful. Out of twenty-three cases related by Ciniselli, five were cured. " The mechanical action of the needles is combined with a chemical action produced by the electrolytic decomposition of water and of the salts of the blood." Ulcers of the Tongue. Simple ulcers, the result of gastric derangement may form on the tip or frsenum of the tongue. Ul- cers may be of syphilitic origin, and if so, are usually situated at the sides of the tongue and inside of the lips. Sometimes syphilis forms oval bald patches, without any ulceration. Treatment. — If the result of gastric derangement, attention to the diet and a 'mild purgative will gener- ally effect a cure (F. 8). If of syphilitic origin, then the constitutional remedies for that disease must be put in force. 164 STOMATITIS. Stomatitis. Several forms have been described : catarrhal, fol- licular, aphthous, ulcerative, parasitic, gangrenous, mercurial. Parasitic stomatitis depends on the presence of a parasite, Oidium albicans. There is heat and pain in the mouth, and the disease is revealed by whitish- gray patches, looking like curdled milk. It is pecu- liar to young infants, being known by nurses and mothers as the thrush. Sometimes it appears in the course of phthisis in adults. Gangrenous Stomatitis, or Canckum Oris, is a rare but dangerous affection, attacking weakly chil- dren recovering from measles or other acute diseases. The ulceration commences on the mucous membrane of the lip or cheek, and spreads to the deeper tissues, perforating the skin and destroying the jaw. Swelling of the cheek, intense fetor of the breath, great salivation, and rapid prostration, with a fatal termination, accompany the local changes described. Treatment — In all affections of the mouth, chlorate of potass seems beneficial, given in five-grain doses to an infant of a year old, but increased to twenty or thirty in an adult (F. 7). Borax and honey may be applied locally in thrush; and in cancrum oris the only chance for the child depends on its being put under chloroform, and having the part burnt with strong nitric acid. The strength must also be sup- ported by brandy and beef tea. mumps — quinsy. 165 Mumps, Cynanche Parotidea, Is an acute contagious affection of the parotid and other salivary glands, the parotid especially being much swollen and painful to the touch. It is attended with some fever, and difficulty of opening the mouth and swallowing. The disease extends over a period of four or five days, and terminates in recovery, its declension being occasionally marked by swelling of the testicles or mammae. Quinsy, Cynanche Tonsillaris, Is attended with fever, fetid breath, and pain in one or both tonsils, shooting along the Eustachian tube into the ear. The tonsil or tonsils are red and inflamed, the in- flammation terminating in resolution or progressing to suppuration, with speedy recovery following the dis- charge of pus. It is caused chiefly by exposure to cold, and is most common in youth. A form of chronic tonsillitis is not uncommonly seen in young and delicate children, where the tonsils are enlarged and the voice husky, with occasionally deafness. Treatment — In mumps a saline mixture and a flan- nel bandage over the glands are alone requisite (F. 66). In quinsy the inhalation of steam and the ap- plication of hot linseed-meal poultices hasten resolu- tion or promote suppuration. Sulphate of magnesia 166 DISEASES OF THE (ESOPHAGUS. (F. 24) can be recommended. Gaaiacum is by some considered a specific (F. 6). In chronic tonsillitis ex- cision of part of the gland is sometimes necessary. Diseases of the (Esophagus. The oesophagus may be the seat of stricture, either spasmodic or real, or of cancer. The affections are all characterized by one promi- nent symptom, difficulty of swallowing, with, in can- cer, also great pain, enlargement of the lymphatic glands, cough, and husky voice, through pressure on the trachea or recurrent laryngeal nerves. Non-can- cerous stricture is generally the result of swallowing some corrosive poison. Treatment can only be palliative, unless in the spas- modic stricture of young and hysterical females, when the general treatment recommended in hysteria may be adopted. Dyspepsia. The stomach is the natural receptacle of the food we eat and the liquid we drink. It starts on equal terms with other organs, but its powers of endurance are tried more than those of any other organ. Into it are thrown the most heterogeneous compounds, and it is expected to do its duty satisfactorily, whether we lead the life of an anchorite or an epicure ; or if we go to neither of these two extremes, if we neither eat too plainly nor too abundantly, we may yet try its staying powers by the rapidity with which we swallow DYSPEPSIA. 167 our food, or the length of time we allow to elapse be- tween meals. An organ tried so much naturally rebels, gets out gear, and sooner or later dyspepsia or indigestion supervenes, and the whole body sympathizes with its ailments. The mind becomes clouded, and the temper peevish, bodily vigor is impaired, and life is rendered not a pleasant holiday, but a sour and angry fact. Dyspepsia has many symptoms, and a brief consider- ation will be given to the most prominent of these, and how they may be met. Want of appetite may depend on mental causes, as joy, or anger, or anxiety, or it may appear without any apparent cause. Common sense must dictate how to deal with the former causes, and for the latter, an acid or a bitter infusion may be employed (F. 10). Nausea and Vomiting, — Xausea after taking food, which may or may not terminate in vomiting, some- times attracts attention — the vomited matters being sour at first, and if long continued mixed with bile. To soothe this irritability there are special therapeutic remedies, in additiou to careful regulatiou of the quan- tity and quality of food, such as creasote and hydro- cyanic acid (F. 9). Flatulence and Belching. — Flatulence, popularly termed " the wind on the stomach," may be due to many causes, prominent among which are food fer- menting, or the want of an accustomed meal at a cer- tain hour. It is often relieved by warm carminatives (F. 13), and by the injunction of a regulated interval between 168 DYSPEPSIA. meals. If it immediately follows the taking of food, pepsin is useful, or rhubarb (F. 91). Should belching be accompanied by a rotten-egg flavor, showing the evolution of sulphuretted hydrogen gas, charcoal biscuits should be ordered, and creasote ; if there is also great acidity, sal volatile and carbonate of potass (F. 73). Pain. — Cullen described two kinds, cardialgia or heartburn, and gastrodynia or cramp, or spasm of the stomach. For simple heartburn black sugar is effica- cious, or eating an apple, or a draught of liquor bis- muth and spirit of chloroform, or (F. 11). Gastro- dynia, Dr. Abercrombie thought, was due to a loaded colon, and hence ordered a brisk purgative, followed by carminatives (F. 25, 13). A mustard poultice often gives relief. Waterbrash, pyrosis, attended with the eructation of thin tasteless watery fluid, may be connected with organic disease of the stomach, or with the taking of some particular kind of food, as oatmeal. Treating it simply as a symptom, pulv. kino co. can be recom- mended, combined with a watery purgative in the morning, as Friedrichshall or Pullria. In 1842 John Goodsir discovered in the vomited matters of certain patients small flat bodies having a rectangular outline, and a somewhat oblong shape, and resembling little packets tied lengthwise and across with a string, hence he called them sarcinse (bundles). They are dependent on fungi, and are symptomatic of organic disease by which the stomach is prevented from completely emptying itself. Sulphite of soda GASTRIC ULCER. 169 given in 20 to 60 grain doses relieves what probably is an always incurable disorder, by the sulphurous acid being set free in the stomach. Dyspeptics constantly ask, What shall we eat, and what shall we drink ? and, although no fixed rules can be laid down, the following points are of practical importance. Mutton is probably the most digestible of all animal food, while all cured meats — ham, tongue, sausage — are indigestible. Animal food is more easily digested than vegetable. While man's organs of digestion ally him more to the carnivorous than the granivorous race, yet a mixture of animal and vegetable food suits the stomach best. Do not press prohibitions as to food too far, else you will convert the dyspeptic into a con- firmed hypochondriac. Interrogate the patient as to his own sensations with regard to liquids, as no definite rule can be given. Beer agrees with some, sherry or claret with others. Many men can be total abstainers with impunity, many others cannot, and require whisky or brandy with meals. The consideration of the idiosyncrasies of each individual case must thus be daily weighed in regulating the dietary of the dyspeptic. Gastric Ulcer. Ulceration of the stomach is by no means an un- common affection, and is much more prevalent in females than in males. Symptoms. — Painful intolerance of food is the chief 170 GASTRIC ULCER. symptom. The pain which is felt at the epigastrium varies in intensity, and appears within a quarter of an hour after food is taken, being increased by emotions or pressure over the umbilical or dorsal regions, ac- cording to the situation of the ulcer. Vomiting of food in all stages of digestion, with or without blood, is a pretty constant symptom. The quantity of blood varies greatly, but when present in any quantity it is a most important sign. Constipation almost invari- ably accompanies gastric ulcer, and the patient has a worn-out, low-spirited aspect. Lastly, the failure of all remedies and the chronic history help us in form- ing our diagnosis. The intensity of these symptoms varies more ac- cording to the position than size of the ulcers, on account of some positions being more exposed to con- stant friction than others. If the ulcer be close to the pylorus, we may have stricture from spasm of the pyloric muscle, and thus the vomited matter will be in a sour and fermented state from its long retention in the stomach. Again, if the ulceration goes on to perforation and no limiting adhesions form, the con- tents pass out of the stomach, and give rise to symp- toms of acute general peritonitis. The course of the disease is very chronic, lasting sometimes the greater part of a lifetime. It may occur at any age, tending more to cicatrization in the old and perforation in the young. * This chronic course runs on to one of three termi- nations. 1. After long suffering, sometimes with relapses, GASTRIC ULCER. 171 the patient gets better, owing to the ulcer cicatrizing ; still, great care must be observed. This occurs in half of the cases. 2. Sudden death, from shock, owing to its bursting into the peritoneum; from peritonitis, or from haemor- rhage. 3. Gradual death, from sheer wearing out. In such cases amenorrhoea or phthisis may supervene. Pathology. — It is a distinct local lesion. The ulcer seems punched out, and the edges may be bevelled off or thickened. The size varies from that of a pin's head to one-third of the mucous membrane of the stomach. It may be of all degrees, from partial re- moval of the mucous membrane to perforation, and it may be puckered, cicatrized, or healed. The com- monest seats are on the anterior or posterior wall, near the lesser curvature. If on the anterior wall, perforation more readily occurs on account of there being no place for limiting adhesions, while, if on the posterior, adhesions may take place to the pancreas, etc., and thus, although the stomach is actually per- forated, the adhesions prevent its contents passing into the peritoneum. It is worthy of note that, by means of adhesions, a communication may be set up between the stomach and colon, and thus fecal mat- ters will be vomited with ease, not with difficulty as in ordinary stercoraceous vomiting. The nearer the ulcer is to the coronary vessels, the greater the ten- dency to fatal haemorrhage. Treatment. — We have neither prophylactics nor specifics. All food should be given in very minute 172 CANCER OF STOMACH. quantities and in liquid form. Hence milk, solution of beef, or soups containing white of egg, are most useful. In order to get the stomach to retain sufficient food, opium should be given by the mouth, so as to act as a gastric sedative during digestion. Collections of acid matter in the stomach may be prevented by alkalies or alkaline saline mineral waters. If vomit- ing continues, we must have recourse to bismuth, hydrocyanic acid dilute, creasote, or ice, and if all these fail, make use in time of nutrient enemata (F. 9). When there is hsematemesis, if not severe, ice, gallic acid (F. 19), or turpentine, may be tried; but if much blood is being vomited, we should try at once the subcutaneous injection of ergotin, thus — R. Ergotin, gr. xv. Alcohol, n^xl. Aq. distil., gij. M. Fifteen drops a dose. Cancer of Stomach. Cancer has a partiality for the orifices of the stomach, being commonest at the pylorus. When in that situa- tion it is usually fungating or villous, of the scirrhous type, and may be associated with cancer elsewhere — especially of the liver. When at the cardiac orifice the cancer ~is always of the epithelial type, and fre- quently extends up the oesophagus. * The body of the stomach is very rarely affected without the orifices. Symptoms. — Vomiting and pairi are pretty constant symptoms. When the pylorus is involved the vomited CANCER OF STOMACH. 173 matter is frothy and fermented, containing sarcinse, and the pain comes some time after taking food. If the cardiac orifice be the seat, the vomited matter con- tains blood altered by the secretions (" coffee-grounds vomit"), and the pain comes on immediately after taking food, and is very lancinating. In either case vomited matter may contain cancer elements. Loss of appetite, with the general cancerous cachexia, are prominent symptoms, the latter being well marked, with great emaciation. The physical examination is most important. A hard, uneven, immovable tumor is felt an inch or two below the liver, to the right side, although it may be dragged to the left. When the pylorus is affected, the stomach is large and distended. The percussion is tympanitic, and hippocratic suc- cussion may be developed from the presence of fluid food and air. By grasping the stomach, the limit of the motion of the fluid, and thus the size of the stom- ach, may be seen, as well as an exaggerated peristaltic motion giving sometimes an hourglass appearance, and beginning at the left hypochondrium. The bowels being to a great extent empty, undue prominence of the epigastrium is a not uncommon sign. Duration is important, as it never exceeds two years. Treatment can only be palliative and supporting. Food should be given in small quantities, and — if it is pyloric obstruction — of such a kind as not to add to the discomfort by tending to ferment. Hence animal food is appropriate. Stimulants will often be required, 15 174 CONSTIPATION. and of these the effervescing ones, as champagne, are best. Laxatives are necessary. In some cases com- plete emptying of the stomach by the pump and then regulating the diet does good, or, as a last resource, feeding by the rectum. The vomiting may be con- trolled by morphia or ice, and the former will be fre- quently required for relief of pain (F. 71). Cundu- rango bark has been greatly advocated, of late. Constipation. Healthy people, as a rule, have an evacuation from the bowels once every day, and generally after break- fast; yet many in good health have two or three stools in the twenty-four hours, while others only have an operation every second or third day. Constipation, as independent of any acute or chronic disease, may be regarded simply as a deviation from the usual rou- tine, and as such may be considered, to a certain ex- tent, an independent disease. The accumulation of fecal matter is frequently due to a sluggish condition of the colon, and is attendant on old people, chlorotic females, persons having little exercise, and leading sedentary lives, or others w T ho think little of and thus neglect the calls of nature. As a result of constipa- tion there is little appetite, bad digestion, dusky com- plexion, and low spirits, with a flabby tongue indented at its edges. Sometimes long-continued constipation may lead to the formation of an abdominal tumor by pressure on the biliary ducts, causing jaundice, or on the vena cava, occasioning oedema of the lower ex- colic. 175 tremitics. Exceptional cases have been recorded where no motion was effected for ten or twelve weeks. Treatment, — A careful regulation of the diet is the most important desideratum in treating habitual cos- tiveness. For this purpose, the food taken should be carefully chosen and slowly masticated. Brown bread is serviceable, and ripe fruits may be taken early in the morning. Idiosyncrasies of diet should be studied, and habitual exercise insisted on. In addition to these means nature should be solicited at a certain hour daily, the best being immediately after breakfast. All pills or strongly purgative medicines should be avoided. Of mineral waters, the Hunyadi Janos can be strongly recommended. A wineglassful taken every morning about an hour before breakfast usually induces a stool neither too loose nor copious. Fried richshall and Pullna waters are also very useful. The Tamar In- dien is serviceable, especially if constipation is asso- ciated with piles. A cold shower-bath is advisable in the mornings, if there is a healthy reaction afterwards. For very old people stimulating the intestinal muscles by kneading and rubbing can be recommended. Colic. Colic is accompanied by severe twisting pain, espe- cially about the umbilicus. This pain occurs in par- oxysms, is unaccompanied by fever, and is relieved by pressure. The bowels are usually found to be con- stipated, and bile or mucus may be vomited during the attack. 176 OBSTRUCTION OF THE BOWELS. As various diseases of the abdomen have pain as a prominent feature, it is useful to remember that the pain of peritonitis is persistent, increased by pressure, and general over the abdomen ; the pain of the passage of a gallstone has a localized area in connection with the gall-bladder, and the vomiting is generally severe; the pain of a urinary calculus is in the back and tes- ticle, with frequent micturition ; the pain of hernia is attended with hernial protrusion. A peculiar kind of colic attacks painters, or those engaged in occupations which bring them in contact frequently with white lead. The pain is, however, more severe than in ordinary colic, the constipation is great, and a peculiar and characteristic blue line is observed round the edges of the gums. These symp- toms are followed, in advanced cases, by actual paraly- sis of the extensors of the wrist and fingers, and wasting of the ball of the thumb, constituting what has been termed " the drop wrist." Treatment — As colic is generally attended with con- stipation, and can only be remedied by its removal, it is necessary to give aperients, such as are recom- mended in the chapter on constipation. An enema is also often beneficial, followed by opium, or elec- tricity may be tried. For lead colic iodide of potas- sium must be given (F. 5). Obstruction of the Bowels. If obstruction of the bowels is diagnosed, it is the first duty of the practitioner, if possible, to elucidate OBSTRUCTION OF THE BOWELS. 177 the cause. Naturally he will investigate and make himself certain whether or not it is due to hernia, and act accordingly. Failing to discover any hernial strangulation at its most common sites, the obstruc- tion may be considered dependent on one of three great divisions, according to Dr. Haven : 1st. Intermural, where, as the name implies, the mucous and muscular coats of the intestinal walls are involved. a. Cancerous stricture. 6. Xon-cancerous stricture. Comprising — 1. Contractions of cicatrices following ulcera- tion. 2. Contractions of walls of intestines from in- flammation, non-cancerous deposit, or in- j ur 7- c. Intussusception. d. Intussusception, associated with polypi. 2d. Extramural, or those causes acting from with- out, or affecting the serous covering : a. Bands and adhesions from effusion of lymph. 6. Twists or displacements. c. Diverticula. d. External tumors or abscesses; diaphragmatic, omental, or obturator hernia. 3d. Intramural, or obstructions produced by the lodgment of foreign substances : a. Foreign bodies, hardened faeces ; or, should the obstruction be due to cancerous stricture, the sigmoid flexure of the colon or rectum is usually affected, and, 178 OBSTRUCTION OF THE BOWELS. in addition to the obstruction, there will also be evi- dences of the cancerous cachexia. The condition known as intussusception is not un- common in children, and is similar to what occurs when the finger of a glove is pulled within itself. The upper segment of the bowel is generally drawn into the lower; thus, the ileum or caecum may be protruded into the colon. The occurrence of intus- susception is marked by sudden pain, sickness, and constipation. Should the obstruction be due to bands or twists, the lower part of the ileum is the most frequent seat. Symptoms. — The principal symptoms are — 1st. Vomiting, ultimately becoming fecal. 2d. Pain, varying in severity. 3d. Increasing tympanitis. 4th. Hiccough and constipation. 5th. Inflammatory signs, taking effect on the pulse and temperature. Vomiting will naturally be most marked and early when the obstruction is situated at the upper part of the intestine ; and, if unrelieved, death will occur in five to ten days, — if in the colon, it may be delayed for weeks. Sometimes, by carefully feeling the abdo- men, the point of obstruction can be detected by in- creased fulness and diminished resonance over this particular spot. Besides this, hyperdistension is seen above, and diminished distension below, the obstruc- tion. This is best seen when the obstruction is low, and the gradual filling of the bowel above it may be OBSTRUCTION OF THE BOWELS. 179 observed , with sometimes the coils of intestine mark- ing themselves against the abdominal wall. Treatment, — At first, when the diagnosis is some- what uncertain, castor oil or an enema may be given, but neither should be continued if it becomes clear that there is a mechanical hindrance to the passage of feces. The two principal points then are, — endeavor- ing to sustain the strength of the patient by means of beef tea and milk, and the relief of pain by opium and hot fomentations. Opium sometimes is inadvisa- ble, from its tendency to stop peristaltic action of the bowels, hence belladonna may be substituted ; or, best of all, according to Brinton, a combination of ext. of opium, 2 parts, with ext. of belladonna, J part. Ice should always be given freely, to allay thirst. Thus calling time to our aid by the means indi- cated, nature may, in her own way, remove the ob- struction, unless, of course, it is due to an unremovable cause. At an early stage, before there is any possibility of gangrene having set in, the patient may be placed on his back, with his pelvis raised, and a long stomach- pump inserted as far as it wall go. Then warm water should be slowly thrown up until the bowels become distended. When this occurs the coils of intestine should be moved on one another by the hand placed on the abdomen. In this way, or by means of air in- stead of water, cases have been successfully treated ; and besides, we can by this means form an idea of the position of the point of obstruction by the amount of water capable of being thrown up. 180 DIARRHOEA. Ill some cases it is necessary to nourish by stimu- lating enemata. Should gastrotomy be resolved on, the advice of a surgeon ought to be obtained; keeping in mind, how- ever, before resolving on this, that not a few cases are spontaneously cured by nature in ways we are not well acquainted with. DlARRHCEA. Diarrhoea is rather a symptom than a disease, yet, when the discharge from the bowels is great, special treatment may be required for its relief. The charac- ter of the stools varies. Thus, they may be fecal, although liquid, bilious, watery, mucous, or thin serous. Diarrhoea is a prominent symptom in typhoid fever, phthisis, various kidney, liver, or nervous affec- tions. It may also result from dentition, errors of diet, influence of the season, malaria, or mental emo- tion. In all cases the stools should be carefully ex- amined, as much information can thus be obtained with regard to the cause of the diarrhoea. A severe kind of diarrhoea, called by some English cholera, is accompanied by pains in the abdomen, cramps in the legs, and dark bilious evacuations. Treatment will depend entirely on the cause. It is frequently inadvisable to check it, as it is nature's outlet for carrying away offending matter from the intestinal canal, or for relieving other organs which are diseased. Thus, if due to indigestible food, it is better to promote it (for this is the easiest way to stop DYSENTERY. 181 it) by giving tincture of rhubarb or castor oil ; if oc- curring in Bright's disease, it should not be interfered with, unless it produces great exhaustion. Should no direct cause be ascertained, it may be desirable to check it in whole or in part. The various prepara- tions of opium or other astringents, as sulphuric acid, catechu, tannin, etc., are serviceable for this purpose (F. 16, 17, 20). Boiled milk and lime-water are very useful in the diarrhoea of children, preceded by a few grains of grav powder if the motions are green and offensive (F.'8). In severe cases all solid articles of food, vegetables and fruit, should be forbidden, and the diet should consist of arrowroot, milk, and boiled rice. The local application of poultices and hot fomentations helps to relieve the pain. Dysentery. Dysentery consists chiefly in inflammation of the mucous membrane of the large intestine. The inflam- mation rarely involves the deeper layers, or extends past the ileo-csecal valve. It is supposed to commence in the solitary glands that lie scattered over the surface of this portion of the intestine. These become en- larged and prominent, looking somewhat like small- pox pustules. They probably form the foci for most of the ulcers, which are sometimes narrow and oblong, lying across the gut; sometimes very large and irreg- ular, with great patches of thickened mucous mem- brane. In the severe and fatal cases the whole bowel 16 182 DYSENTERY. is one tattered mass of disorganization, with fibrous shreds and commingled mucus, pus, and blood. Dysentery may be either epidemic or sporadic. The former is peculiar to tropical climates, and seems dependent on a miasma emanating from the soil, at- tacking the system generally, and locating itself in the intestine ; the latter may occur in all sorts of places, in adults as well as children, and is the result of the lodgment of masses of fecal matter in the lower bowel, which act as foreign bodies, giving rise to inflamma- tion ending in dysenteric symptoms. In neither form is the disease contagious. Symptoms. — Dysentery begins in both its sporadic and epidemic variety with diarrhoea, after there have been irregular stools or constipation. There are also lassitude, want of appetite, and a listless attention to ordinary occupations. On the third or fifth day, usually in the night, the diarrhoea becomes more severe, and attended with shivering and rigors. Pain is felt in the abdomen. The desire to go to stoolis intense. Little faeces after a time are passed, and there is a straining or burning pain at the anus and rectum (tenesmus). With the disappearance of the faeces there appears bloody mucus, or pure blood, in the midst of which are often seen little white clumps, or round bits looking like minced raw meat. The patient may seek to go to stool from twenty to thirty times in a night, and then, as might be ex- pected, becomes giddy and faint from loss of blood and exhaustion. The disease may last in this acute form from six to eight days, with remissions in the DYSENTERY. 183 morning and aggravations at night. As symptoms of amendment may be mentioned alternations of mushy even formed stools with the characteristic bloody mucous ones. In very severe cases the tenesmus in- creases; the dejections flow uncontrolled, and are largely mixed with blood, collapse sets in, and the patient dies of asthenia. When the disease becomes chronic, it is very in- tractable, with frequent relapses, offensive discharges, and. great pain and exhaustion. Sporadic dysentery generally terminates favorably. The mortality of the epidemie form may reach 40 or 50 per cent. In slight cases convalescence is complete in about three weeks, medium severe cases in about seven weeks. Severe cases, if they do not terminate fatally on the eighth or ninth dav, may last an indefinite length of time. Treatment. — During an epidemic of dysentery all unnecessary crowding should be avoided, and unclean- liness prevented. The discharges of the patient should be disinfected. Potatoes, salads, unripe fruit, greasy food, spices, or pickles, should not be taken ; while ripe fruit and stewed apples are advantageous. Flannel bandages should be worn round the abdo- men, and if the bowels are constipated, a gentle laxa- tive of rhubarb may be taken. Should an attack of dysentery set in, the patient must remain in bed in a room of an equal temperature. The diet should consist of milk, strong soup, yolk of eggs, the object of the dietary being to form small not 184 EPIDEMIC CHOLERA. bulky stools. Thirst is alleviated by meal gruel, and the tenesmus by starch enemas with five to ten drops of laudanum in each. Leeches ought to be applied at the commencement of the attack to the anus, and after- wards what is termed the cathartic or laxative treat- ment adopted. Thus, give an emetic of vin. ipecac, follow this up by castor oil or tamarinds. On the second day they may be omitted, and morphia substi- tuted in the evening. On the third day the laxatives mentioned may be administered again, and repeated on the fifth or seventh day (Heubner). Two grains of nitrate of silver to four ounces of water are recommended as an enema. Pulv. ipecac, in full closes forms the mainstay of English treatment. In the very severe forms the object is to prevent collapse, hence alcohol, interdicted in the milder varie- ties, must be given, and strong soups at frequent inter- vals. When the dysenteric attack has reached an advanced stage, vegetable astringents, such as tannin, rhatany, etc., are necessary. Above all, in chronic dysentery, change of air must be tried if practicable. Epidemic Cholera. The authentic history of cholera dates back only to 1817, when it made its first appearance in India. After a series of destructive epidemics in the East, it reached Europe, and was imported from Hamburg to Sunderland on October 26th, 1831, from thence spread- ing to the great centres of population in this country. This epidemic lasted during 1831-32, when there was EPIDEMIC CHOLERA. 185 a lull, the next epidemic being in 1848-49, the third during 1853-54, and the last during 1865-66, when it was chiefly confined to London. Cholera seems, according to the views of most recent authorities, to owe its existence to one single ultimate cause, a cholera germ, which again is supposed to be of a parasitic nature, and develops in the gastrointes- tinal tract, in the interior of the follicles, of the small lymph and bloodvessels, and of the submucous con- nective tissue. If the parasitic origin of cholera is granted, it can be understood how in different degrees of vitality these germs can be carried by the air in viewless numbers, and impregnate the water supply, or be drawn directly into the mouth, the different de- grees of vitality accounting, to some extent, for the choleraic diarrhoea, which, as will be seen, always ac- companies the true disease. Experience testifies that nurses and hospital physicians exposed to the concen- trated miasma from the dejections, or washerwomen who wash the linen soiled with cholera dejections, rarely escape taking the disease when it is epidemic ; while the fact of outdoor physicians attached to hos- pitals passing safely from bed to bed, and again out into the open air, seems to indicate that cholera is not contagious. Cholera is more common in hot than in cold weather. Males are more apt to be attacked than females. Although common in child and adult life, it is pre- eminently a disease of between twenty and thirty. Excesses of every kind, whether of food, wine, or fruit, during the continuance of the epidemic, predispose to 186 EPIDEMIC CHOLERA. it. The average incubatory period is from twelve to twenty-four hours, rarely exceeding one week. About one-fifth of those attacked survive. Symptoms.— Diarrhoea always accompanies the chol- era epidemic, coming on suddenly, the stools being fluid, painless, yellowish-brown, and in number aver- aging from two to four in the twenty-four hours. This diarrhoea rarely fails to precede the real attack. The attach proper commences during the night. The patient awakes chilly and dizzy, and this is rapidly followed by a tempestuous diarrhoea, the early stools being black and pappy, but as the bile-pigment quickly disappears, they exhibit the characteristic rice-water appearance. They are passed involuntarily and pain- lessly, and in number vary from three to fifteen. After the diarrhoea has lasted one or two hoars, vomiting, attended with no pain, sets in, at first of the food which may have been taken, and latterly assuming a color- less whey appearance. Intense thirst and suppression of urine are now prominent symptoms. The tongue is, as a rule, white. After a few hours distressing cramps supervene, especially of the calves and feet — rarely of the hands. Sometimes these are entirely absent, and the patient sinks without a struggle. There is also a considerable fall of temperature, com- mencing in the hands and feet, and most marked on the face, nose, and tongue. Should there be a tendency to recovery, the temperature approaches the normal ; if it does not, the features become more pinched, the extremities more cold, livid, and collapsed ; the eyes dry, the cornea cloudy, and the voice assumes a hoarse EPIDEMIC CHOUEKA. 187 and raveny character, or it may sink into an inaudible whisper. This peculiar character has led to its being called " vox choleraica." This stage has been termed the algid or cold stao-e, and either terminates in death or passes into what is called the stage of reaction. The earliest sign of improvement, preceding even the abatement of the diarrhoea and vomiting, is the return of the pulse at the wrist. Heat follows, the blueness disappears, the temperature becomes normal, and con- valescence may be regarded as perfect in from ten to fourteen days. Sometimes the improvement is only transient, being followed by uraemia, or inflammation of the kidneys or intestines. During the attack proper the patient may die in from six to eight hours ; even in bad cases the usual time is, however, twenty-four hours. Morbid Anatomy. — Cholera has no distinctive le- sions ; the cadaveric rigidity is, however, marked. In the digestive tract the isolated and agminated glands are swollen and prominent, more especially the latter. At the ileo-esecal valve, a whitish-gray fluid, with fine granules and cell-nuclei, exudes if the follicles are pierced. These changes are seen during the first forty- eight hours. Afterwards the swelling diminishes, and the glands are shrivelled up, collapsed, and of a yel- lowish or slaty-gray color. The brain, heart, lungs, and liver are usually found healthy, while the kidneys are larger than usual, and congested. Treatment is of two kinds — prophylactic and thera- peutic. During a cholera epidemic all unnecessary meetings, fairs, and pilgrimages should be abandoned. 188 EPIDEMIC CHOLERA. Wells ought to be inspected, defective sanitary arrange- ments remedied, dirt of every kind cleared away, the sale of unripe fruits and vegetables prevented, soup- kitchens established, and the stamina of the poor built up. The prodromic diarrhoea should, if cholera ap- pears, be checked as early and speedily as possible " by the sole and only agent," which, Lebert says, " has a real protective character " — viz., opium. R. Acid, sulph. dil., .... giiss. Tinct. opii, ...... ^iss. Sp. chloroform., ..... ^ij. Aq. menth. pip., . . . .-'§▼}.. M. A tablespoonful after every motion. If the diarrhoea is more obstinate, a powder every four hours of Pulv. opii, . . . Tannin, Bismuth subnit., .... Sacch. alb., ..... Also inject every twenty-four hours, Argent, nit., .... Tinct. opii, .... In starch water, .... If these remedies fail we must now fall back on, or, as some authorities say, commence with a teaspoon- ful of castor oil or tincture of rhubarb. If the diarrhoea resists our efforts, and true cholera with violent discharges begins, astringents are of no avail, and in fact do harm. Ice should be placed on the tongue every few minutes, and carbonic acid gr. ss. gr. "J- gr. V1 J gr. "J- gr. y. T^XV. Z"i- INTESTINAL WORMS. 189 water drank. Morphia may be injected subcutane- ouslv to allay the pain and cramps, and sinapisms ap- plied over the abdomen, while the legs are rubbed with some stimulating liniment. Should the tempera- ture begin to fall, enveloping the patient in a blanket wrung out of hot water and sprinkled with turpentine, together with the internal administration of the same drug, was, in my experience, successful during the last London epidemic. In rapidly sinking cases brandy or champagne may be given (F. 72). When reaction sets in, a large spoonful of good beef tea may be taken every three hours, and later on tea or coffee with milk several times a day. From this we may pass to a more increased and solid diet. " The best treatment of cholera," says Lebert, " therefore, in the state of existing knowledge, is a carefully regulated hygienic and a correctly interpreted symptomatic treatment, with avoidance of all pertur- batory efforts, in the last degree inutile if not even injurious/' Intestinal Worms. Of the different intestinal worms which inhabit the human body there are two great varieties, — the hollow worms and the solid worms. In the first class we find three species of tenia, the most common being the Tcenia solium. Its length varies from two to ten yards or more, and its habitat is the small intestine. It consists essentially of a head and segments. The head is about as large as a small pin's head flattened, 190 INTESTINAL WORMS. with a double circle of hooks, around which are four suckers or mouths by which it attaches itself to the intestine. The segments, joints, or proglottides, are rectangular, and possess male and female organs opening into a common aperture retaining the ova, which, when ripe, contain a six-hooked embryo. The joints are at first more broad than long, but as they diminish in distance from the head they become smaller and smaller, and the length exceeds the breadth. The Cysticercus cellulosce, a parasite chiefly resident in pigs, seems to be the parent of the Taenia solium in man, and from uncooked or improperly cooked pork the tapeworm is developed in the human body. Symptoms. — The only phenomenon which seems to indicate the presence of the parasite is the appearance of segments in the feces. Sometimes the victims of tenia also complain of pain in the belly, unsatisfied appetite, thirst, great depression of spirits, with itch- ing of the anus and nose. Varieties. — Tcenia mediocanellata resembles very much the former variety, but it has only a sucking apparatus in the head, no hooks. It appears to result from the further development of a cysticercus infecting cattle, and owes its introduction into the system to the eating of improperly cooked beef. The Bothriocephalus latus, peculiar to Switzerland, Russia, and Poland, is the largest of all the tapeworms, sometimes attaining a length of twenty-five feet and upwards, each foot containing a hundred and fifty segments and joints, and each joint having its own male and female organs. The head is club-shaped, .ROUND-WORMS. 191 with a longitudinal slit by which it attaches itself, but no suckers. Treatment. — When the presence of the worm has been discovered, the best way to expel it is to tell the patient to take no food for eight hours, then to ad- minister in the evening 30 TT£. of the ext. of male fern in a draught of peppermint water. Follow this up in the morning with a dose of castor oil, and about midday by a large plate of mashed potatoes. The head and segments will probably be thus forced away ; if not, let the same treatment be adopted on a subse-. quent occasion (F. 29). The bark of the pomegranate root, or kousso, or oil of turpentine, are well-known anthelmintics, but in- ferior to the male fern. Round-worms Possess a distinct integument and an alimentary canal, with a mouth at one end and an anus at the other. The sexes are always separate. In the male the genital pore is near the anus, in the female about the middle of the belly. 1st. Ascaris lumbricoides, the common round-worm, resembles much the common earthworm. The female is nearly twice as large as the male. Its habitat is the small intestine, generally of badly fed children, but from this it may creep upwards to the stomach or to the colon, and it has also been found in the nose, hepatic or pancreatic ducts. Authentic records indi- cate that a large number of lumbricoides may be in 192 KOUND-WORMS. the body at the same time. As a rule, however, they rarely exceed five or six. They may penetrate the intestinal wall to the peritoneum, causing an abscess near the umbilicus. The symptoms are obscure and various. Generally speaking, there is thirst, dis- turbed sleep, fever, and depraved appetite, with itch- ing of the nose and anus. Treatment, — The best remedy is santonin given in one to three grains twice daily to a child, or double that quantity to an adult. Turpentine may also be given if preferred (F. 30). 2d. The common threadworm ( Oxyuris vermicularis) is small, white, and threadlike, the female being about the third of an inch long, the male about half that length. They exist in the colon or rectum, generally in great numbers at a time, and infest children who are badly fed or in indifferent health. The chief symptom is itching at the anus or at the nose, with bad breath and generally indifferent health. The diagnosis can easily be confirmed by observing them in the fseces. Treatment — Enemata of cold water, of infusion of quassia, of tea, or liq. calcis, repeated daily, are suffi- cient to kill the oxyures, with occasional doses of hydrarg. c. cret. For adults, perchloride of iron, half an ounce to a pint of water, is recommended. The whipworm (Triehocephalus dispar) and the Sclerostoma duodenale are rarely seen in this country, although the former is sometimes observed in people who have died of typhus or enteric fever. trichina spiralis — trichinosis. 193 Trichina Spiralis — Trichinosis. The Trichina spiralis is met with in the muscular tissue in the form of a minute worm, which lies coiled up in the interior of an oval cyst, giving to the naked eve an appearance like minute white grains. These trichinae are discovered chiefly in the flesh of pigs, and it is from the use of trichinous pork that man has become affected. The trichinae cysts are dissolved by the gastric juice, and the parasites set free. Sex- ual maturity is developed, the ova and the living em- brvos at once commence active migration, findings their way into the small vessels or lymphatics of the bowels, and from thence they are conveyed over the body. In this way they penetrate the intestine, irri- tating it in their passage, getting to the intermuscular tissue of the trunk and limbs, and thence penetrating the muscular tissue and destroying it. Symptoms. — These first consist of intestinal disturb- ance, not unlike that of typhoid fever, with coated tongue, diarrhoea, and great prostration. Secondly, muscular inflammation, pain, and tenderness, not un- like rheumatism, with stiffness and rigidity over the voluntary muscles. Then dropsy commences in the face, goes to extremities, and even involves serous cavities. The duration and severity of trichinosis vary ac- cording to the number of the animals; in some cases recovery taking place in a month, in others in three or four. In some outbreaks the mortality is small, 194 PERITONITIS. in others as much as twenty-five per cent., and it may result from peritonitis, pneumonia, or debility. Treatment. — We can only treat symptoms, as we know of no remedy specially adapted to kill the para- sites. Prophylactically, avoid raw or undone pork or German sausages. Peritonitis. The peritoneum or serous membrane lining the ab- dominal and pelvic cavities, and investing the viscera, may suffer from acute or chronic inflammation. The inflammation is precisely similar to what occurs in all serous membranes, viz., capillary congestion, redness, more or less loss of polish, exudation resulting in a thin grayish lamina, which ultimately becomes thicker, and ribbed or villous according to position. The sur- face of the intestine is injected, the intestines are slightly glued together with soft yellow-gray lymph shifting from one fold of the peritoneum to another. In the pelvic cavity turbid fluid floats, with flakes of lymph. The fluid effused is chiefly observed in chronic cases, and tends naturally to gravitate to the lower and more dependent parts, e.g., into the pelvis and lum- bar regions, where it may escape observation ; or, if excessive, distend the abdominal walls. This fluid may be clear or bloody, or become rapidly or slowly purulent. Peritonitis, even though of local origin, tends to spread until the whole of the peritoneal surface is involved; and convalesce nee, should it occur, is at- tended with absorption of the fluid, organization of PERITONITIS. 195 the false membrane, and thickening of the peritoneal surface, with adhesions of adjacent organs. Should the fluid be purulent, it may form an external abscess, or escape into the intestines. Causation. — Peritonitis is occasioned by injuries, hernia, perforations, and extension of disease from neighboring parts ; it is also the result of various blood diseases, as puerperal fever, tubercle, Bright's disease ; sometimes it is acute aud idiopathic, and due to expo- sure or wet. Symptoms. — In the acute form, however occasioned, the symptoms are marked by fever, and w T ith the fever there is pain in the abdomen, increased on pres- sure or by the slightest movement. The patient lies in bed with the legs drawn up. The face is anxious and pinched, and the abdomen is tympanitic, tense, and hot. Vomiting is often present, and when so naturally aggravates the pain. The urine is scanty and high-colored, the pulse is rapid, hard, and wiry, the tongue parched, and the respiration quick and shallow. Should the disease take a favorable turn, the gravity of the symptoms abates, the fever dimin- ishes, and the pulse becomes normal. If, on the other hand, a fatal issue is to result, the abdomen becomes distended, the pulse thready, the extremities cold, and collapse sets in, with or without loss of consciousness. Death may occur as earlv as the second or third dav, or it may be delayed for a week. Treatment. — This consists in enforcing absolute rest, and maintaining the position which is instinctively assumed, at the same time guarding the patient from 196 CHRONIC PERITONITIS. the unnecessary weight of the bedclothes by means of a cradle. Should the disease be idiopathic and seen early, leeches should be applied to the abdomen, and the bleeding encouraged by hot fomentations. Opium should also be given by the mouth or by rectum, or morphia injected subcutaneously in such quantities as will insure relief from the pain. The strength must also be sustained by liquid nourishment, beef tea, eggs, and milk. In very acute cases an ice-bag over the abdomen, with two or three layers of flannel between, is very useful. If perfora- tion is suspected, abstinence from food or stimulants, and nourishment by enemata are indicated. Ice to suck is very grateful, and mitigates vomiting. Treat- ment by blisters has been advocated, but the inflam- mation is too general for such treatment. Chronic Peritonitis Sometimes follows the acute affection; generally, however, it is an independent affection, associated with the strumous diathesis. Numerous miliary gran- ules lie within or immediately beneath the membrane, especially in the folds of the peritoneum which com- pose the omentum. When there are symptoms of chronic peritonitis, with evidences of a strumous con- stitution and no history of a previous acute attack, Louis seems to think that these granules will always be found. Symptoms. — These are obscure, and steal on the patient in a very insidious manner. Usually pricking TYPHLITIS AND PERITYPHLITIS. 197 pain is experienced in the abdomen, and the belly gets full and tense. The pain is increased on pressure. There are also loss of appetite, nausea, fever, and pro- gressive emaciation, with diarrhoea. After a time the effusion of fluid takes place, the abdomen enlarges, and fluctuation is felt. With this tubercular peri- tonitis there is often combined disease of the mesen- teric glands, phthisis, etc. The fluid does not gravi- tate so freely on account of adhesions, and this fact, with the thickening of the peritoneum, serves to dis- tinguish this affection from ascites. Another useful sign is friction-sound, heard by the ear or stethoscope, and produced by respiration or movement of the ab- dominal wall. Treatment. — Mild nutritious diet — milk, beef tea, etc.; iodine ointment applied externally; while in- ternally syr. iod. ferri and cod-liver oil must be ad- ministered. These cases are very unpromising, and unless chronic peritonitis is the consequence of the acute attack, not much benefit will ensue from any form of treatment. Opium fomentations, or even blistering, may be used if the severity of the symptoms indicates them. Typhlitis and Perityphlitis. In the right iliac fossa lies the caecum and its appendix, only anteriorly and laterally covered by peritoneum. Inflammation not unfrequently attacks this particular part of the intestine, and if the inflam- mation affects the mucous surface and the coats of the 17 198 TYPHLITIS AND PERITYPHLITIS. caecum, it is termed typhlitis (rocpXoq, blind ; terminal itis) ; while if the areolar tissue connecting the caecum to the psoas and iliacus muscles is also involved, the term perityphlitis is employed. Various causes may originate the inflammation. Thus concretions may accumulate in the vermiform appendix, or bits of bone, pins, bristles, etc., may stick there, or any of the intestinal ulcers may perfo- rate the bowel at the place mentioned. Should the perforation occur where the bowel is free from peri- toneal covering, fecal matter escapes directly into the surrounding tissues, leading to inflammation and ab- scess, which may take a varied course; at one time opening into the rectum, or forming a swelling in the groin, or passing downwards along the psoas and ilia- cus muscles to point at the upper part of the thigh. In the majority of cases it presents itself in the iliac region in the position which the caecum usually oc- cupies, from whence it may be discharged either by one of the w T ays previously alluded to, or it may again enter the caecum by its original orifice ; or a series of sinuses may be formed, which never entirely close. Should perforation take place directly into the peritoneal cavity, fatal peritonitis will of course result. Symptoms and Progress. — The early symptoms are pain and tenderness in the iliac region, with rigors and fever. The patient lies on the right side, with legs drawn up. If the abscess forms and extends downwards, the symptoms are obscure ; if it tends to point anteriorly, the fulness and hardness become more pronounced, and the contents may be discharged into DISEASES OF THE LIVER. 199 the bowel, or externally by an artificial anus. Should the discharge be into the peritoneum, the local symp- toms of pain and tenderness will not be confined to one particular spot, but be general over the abdomen, occasioning great suffering and death in a few hours. The duration of typhlitis is uncertain, sometimes ending in speedy recovery, or in death from a linger- ing and obscure illness. Treatment, — Locally, leech and apply hot fomenta- tions or poultices. Internally, avoid giving drastic purgatives. Keep the bowels quiet with opium in any of its forms. Give only liquid food, and allow wine or brandy should exhaustion or suppuration appear. Should the bowels not open naturally, castor oil may be taken if enemata fail. DISEASES OF THE LIVER. The ordinary extent of hepatic dulness in an adult of average size is 4 inches in the right mammary line, i. e., a line descending perpendicularly from the right nipple ; 4 J or 5 inches in the right axillary line, 4 inches in the right dorsal line, i. e., from lines drawn respec- tively from the centre of the axilla, and from the lower angle of the scapula; 3 or 4 inches in the median line anteriorly,/. e., corresponding to the base of the ensiform cartilage. Its position is somewhat arched. Commencing pos- 200 DISEASES OF THE LIVER. teriorly about the tenth or twelfth dorsal vertebra, it ascends gradually towards the axilla and the nipple, and then again descends slightly towards the median line in front. The liver may become enlarged from the normal dimensions given, and as this enlargement is a char- acter common to many diseases of the organ, it has been happily suggested by Dr. Murchison to divide these, for the purposes of diagnosis, into painless and painful enlargements. Painless enlargements are further characterized by an absence of jaundice and by a very chronic course ; but in the painful enlarge- ments jaundice is a very common symptom, and the progress is more rapid. Among painless enlargements we have the so-called amyloid liver, the fatty liver, hydatid tumor of the liver, and simple hypertrophy. Among painful enlargements we have congestion, catarrh of the bile-ducts, obstruction of the common duct, and retention of bile, cancer, pysemic and trop- ical abscesses. Painless Enlargements of Liter. Waxy, Lardaceous, or Amyloid Liver. — The liver may attain, under this disease, a great and uniform size, with a rounded, well-defined lower margin. The growth is slow and imperceptible, extending over many years, with constitutional symptoms of anaemia, and frequently with evidences of a similar disease in kid- neys, stomach, and spleen, the latter being often en- 7 /E N ! A E C H I -N C C C U S , FROM HYDATID CYST OF LIVER. PAINLESS ENLARGEMENTS OF LIVER. 201 larged as well as the liver. The conditions favoring this degeneration are, as in the kidney, constitutional syphilis or other exhausting diseases. From the nature of the disease it may be expected that it can hardly result in recovery, although its progress may be some- what arrested. Fatty Liver. — The enlargement is considerable, but not so great as in the previous form. To the feel, if the abdominal walls are thin, it seems soft and doughy, and can easily be pushed aside by the finger without causing any pain. Many and opposite conditions of the system may give rise to fatty liver. Among these may be specially mentioned alcoholism, phthisis, and general obesity, so that it may rather be considered as an adjunct to other constitutional states than a disease per se. Dr. Addison considered a greasy velvety con- dition of the skin characteristic of fatty liver. On post-mortem examination the liver is found to be pale, staining the knife with grease on cutting into it. The disease is most marked round the lobules, the cells being enlarged and containing fatty globules. Hydatid tumor depends on the development in the liver of the taenia echinococcus, which inhabits the in- testines of the dog. The taenia is supposed to be voided with the feces of the animal, and to enter the human system by means of food and drink, finding its way to the liver or other organs in an unexplained manner. Hydatid tumors of the liver, unlike those previously considered, are not uniform in their direction, but usually follow one direction in particular, either up- wards, downwards, or laterally; hence the tumor 202 DISEASES OF THE LIVER. formed may burst into the peritoneum, stomach, intes- tine, or lung. Sometimes it may suppurate, or it may dry up. The commencement is usually insidious, and the tumor may attain a great size without the patient being aware of its existence. Occasionally, if near to the surface, there is a sign elicited by percussion, known as " hydatid vibration," characterized by a peculiar trembling sensation being imparted to the three fingers of the left hand when they are laid flat on the tumor, and the back of the left middle finger is struck ab- ruptly with the point of the middle finger of the right hand. In simple hypertrophy the enlargement is not great, and is not attended with any prominent symptoms. It has been chiefly observed in some cases of diabetes and leucocythsemia. Treatment — The treatment of these painless affec- tions of the liver is unsatisfactory. In waxy liver the diet ought to be nutritious, with a moderate allow- ance of stimulants. The tincture of iodine may be given, in doses of fifteen minims diluted, thrice daily. Complications, such as diarrhoea, vomiting, etc., must be treated as they arise. In fatty liver, if dependent on indolent habits, an anti-saccharine or Banting diet- ary with exercise must be enforced. If due to alcohol, withdraw the stimulants. In both cases, alkalies with taraxacum are useful, and if circumstances permit, the waters of Carlsbad, Marienbad, or Homburg can be strongly recommended. Iodide of potassium and common salt were at one time considered serviceable in hydatids of the liver, but subsequent experience PAINFUL ENLARGEMENTS OF LIVER. 203 has not confirmed the hopes held forth, and it is now deemed advisable, if the tumor is increasing, to punc- ture and remove the liquid contents of the cyst by a fine trocar and can u la. This being done, both the parent hydatids and offspring die. Out of forty-six cases reported by Dr. Murchison, thirty-five appear to have been perfectly successful. It is necessary only to withdraw a portion of the fluid to cause the death of the hydatid. Painful Enlargements of Liver. Congestion. — The phrase congestion of the liver is too often used vaguely and applied to cases of indi- gestion, when, probably, there is little amiss with the organ. In true congestion there is uniform though not very great enlargement of the organ — probably to the extent of an inch — which disappears after a time, the surface projecting below the ribs being per- fectly smooth, tender on pressure, and accompanied by an uneasy feeling rather than acute pain, radiating from the liver up to the right shoulder. This feeling is increased to actual pain sometimes after meals, or when the patient lies on the left side. Jaundice, rarely intense, is present after two or three days, with nausea, loss of appetite, headache, scanty high-colored urine, and other symptoms of indigestion. There may also be in acute cases evidences of obstructed circulation in splenic enlargement or ascites. Hepatic Congestion may be due to mechanical causes, e. g., consequent on disease of the mitral or 204 DISEASES OF THE LIVER. tricuspid valve, or it may be dependent on errors of diet, excessive tippling, sedentary life, malarious or other poisons, or upon suppression of habitual dis- charges — the catamenia or bleeding from piles — or habitual constipation. Treatment will vary with the cause, but in all cases attended with any severity hot poultices should be ap- plied, with, in some instances, the application of leeches to the anus. The diet should be unirritating and non- alcoholic. Purgatives of sulphate of soda or magnesia, aided by blue pill or podophyllin, should be given at first, followed by the mineral acids, with taraxacum and gentian. When wine requires to be taken, dry sherry and claret are to be preferred. Catarrh of the Bile-Ducts is associated with the same clinical characters as those of congestion, yet with more marked tenderness over the gall-bladder, which sometimes can be felt as a pyriform tumor, while obstruction of the common duct has the further addition of jaundice. Cancer of Liver, in fully three-fourths of the cases, is secondary to cancer in other organs, as the stomach, uterus, or female breast. It runs a rapid course, being rarely prolonged beyond twelve months. It is attended with great pain and nodulated enlarge- ment, generally with jaundice and ascites, and with other evidences of malignant disease. Treatment can only be palliative. Pyemic and Tropical Abscesses differ in this, that the former are many in number and small, while the latter is usually single, and may attain a large size. PAINFUL ENLARGEMENTS OF LIVER. 205 The former are simply the evidence of the constitu- tional state termed pyaemia ; while the latter, though rare in this country, may follow the acute hepatic in- flammation of tropical climates. This inflammation has the symptoms detailed in congestion in an aggra- vated form, with the addition of high fever, and fre- quently troublesome hiccough. Should the inflamma- tion end in the formation of an abscess, this will be sig- nalized by chills and hectic fever, and by fluctuation more or less distinct, according to the distance of the abscess from the surface. The abscess, which is not generally very rapid in its progress, may burst into the peritoneum, giving rise to fatal peritonitis, or open into the biliary ducts and be discharged by the duo- denum. More frequently, however, when the matter gets near the surface of the gland, adhesive inflamma- tion is set up in the portion of the peritoneum imme- diately above it, and lymph is poured out which glues the organ to adjacent parts — to the abdominal parietes, the diaphragm, stomach, or some part of the intestine, the pus being then discharged externally, or into the lung, pleura, or stomach. (Tanner.) Tropical Abscess is often associated with, and some consider it the result of, dysentery. Treatment is similar to that mentioned, under con- gestion, in addition to the employment of chloride of ammonium and ipecacuanha in large doses. After suppuration has been established, the diet must be generous, and wine or brandy allowed. Operative in- terference seems advisable when there is a visible fluc- tuating tumor, when a distinct tumor projects from 18 206 DISEASES OF THE LIVER* the normal contour of the liver even should there be no fluctuation, and when constitutional symptoms in- dicate its presence though there should be no local signs. It is inadvisable when, from jaundice or other symptoms, there is reason to fear the existence of nu- merous abscesses. The operation should be performed with antiseptic precautions, or, if the abscess is large, by means of Bowditch's syringe or Dieulafoy's as- pirator. Contractions of the Liver. The area of hepatic dulness may be diminished in- stead of increased, and under the head of hepatic con- traction we have — 1, simple atrophy ; 2, acute atrophy ; 3, cirrhosis. In simple atrophy there is simply a dimi- nution of the size and no alteration in the structure of the organ. The liver may be reduced to one-half its normal weight and bulk. The circumstances under which it occurs are two, viz., old age and inanition, the latter being dependent on either an insufficient supply of food from actual want, or on a defective as- similation arising from other diseases, as cancer of the stomach. In acute atrophy, not merely is the liver rapidly diminished in size, but the structure of the gland is altered. The secreting cells are broken up into granu- lar matter and oil-globules, and the whole organ is found after death to be soft and yellow. The disease is rare and caused by unknown conditions, though it is most common in pregnant females. It results almost CONTRACTIONS OF THE LIVER. 207 invariably in death by coma, preceded by gastric ca- tarrh, bilious vomiting, jaundice, and cerebral symp- toms of a typhoid character, with low muttering de- lirium and albuminous urine. Treatment is unsatisfactory, though temporary im- provement sometimes follows smart purgation by sul- phate and carbonate of magnesia. Cirrhosis, the so-called gin-drinker's or hobnailed liver, derives its name from xippoq, yellow, the color being due to the large amount of yellow pigment found in the secretins; cells. The liver becomes re- duced in size in consequence of destruction of its se- creting tissue, this destruction again being due to hy- pertrophy of the connective tissue. The organ is thus dense and preternaturally hard, its outer surface being granular and nodulated, and on section it presents firm fibrous bands, including the remains of vessels and bile-ducts and surrounding islets of yellow secret- ing tissue. The disease is chronic, usually extending over several years, with an insidious commencement, and probably increase of size, but latterly by diminished bulk of the liver. In its early stages it is attended with symp- toms of what may be termed alcoholic dyspepsia, sick- ness and retching in the morning, loathing for solid food, and a strong desire for stimulants, with slight pain or tenderness over the hepatic region. In late stages, when the portal circulation has become ob- structed, its hobnailed character may be felt exter- nally — ascites appears and gradually increases, the 208 DISEASES OF THE LIVER. spleen enlarges, and haemorrhoids and hemorrhages from the stomach and bowels occasionally occur. The disease is marked by progressive emaciation and de- bility, by a persistent sallow complexion, though actual jaundice is rare, by increasing dyspeptic derangements, and results fatally, sometimes by exhaustion, attended with coma or oedema and inflammation of the lungs. It is chiefly met with in adults between 35 and 60, in males more than females, and is almost invariably connected with a previous history of undiluted spirit- drinking on an empty stomach. Treatment — In the early stages the essential thing is to stop drinking habits. Spirits should be for- bidden, although a little claret or hock may be allowed. The diet should consist of milk, eggs, plainly cooked white fish, game, and meat, with an avoidance of all hot spiced or greasy food. Regular exercise should be enjoined, and the action of the bowels facilitated by occasional saline or mineral water aperients, and the use of nitro-muriatic acid. In the second stage, though curative treatment is impossible, yet the same dietary must be enjoined. Purgatives and diuretics should be given for the ascites, and these failing^ tapping must be had recourse to (F. 27, 35). Jaundice. The term jaundice is derived from the French jaune, yellow. Icterus, the Greek word for the golden thrush, another synonym, originated in the ancient idea that a sight of this bird by a jaundiced person JAUNDICE, 209 was death to the bird but recovery to the patient. The affection has also been termed u regius morbus/' from the royal and pleasant regimen prescribed for those who had it. Jaundice may be considered as a yellowness of the skin and conjunctivae, and the tissues and secretions generally, from impregnation with bile pigment. It is not, as this and preceding remarks indicate, a disease _per se, but a symptom accompany- ing many complaints, and its existence lias given rise to much controversy and many conflicting statements. All cases of jaundice may be referred to two great causes, 1st, when it results from obstruction to the common bile-duct; 2d, when it is independent of any obstruction. With regard to the first and most com- mon origin there is not much dispute, as it is obviously then dependent on the bile which has been secreted being reabsorbed into the system. On the second point Frerichs's explanation, adopted by Dr. Murchi- son, seems to be the most feasible. It proceeds on the supposition that even in health bile to a greater or less extent is reabsorbed into the system (in addition to what also passes away by the faeces), and is at once transformed so that neither bile-acids nor bile-pig- ment can be discovered in the blood or in the urine, and consequently there is no jaundice. But in certain morbid states this transformation does not occur, and hence it circulates in the blood and stains the skin and other tissues, and jaundice is produced. These mor- bid states are the results of certain poisons, yellow fever, relapsing fever, snake-bites, nervous influences, fear, rage, deficient supply of oxygen, or an excessive 210 JAUNDICE. secretion of bile with great constipation. The ob- structive causes, on the contrary, are from within, as gallstones,* foreign bodies from the intestines ; or from without by pressure, as cancer of the liver or pancreas, loaded intestine, pregnant uterus, ovarian tumors, etc. Symptoms. — The skin and conjunctivae are of a yellow color, the urine stains linen yellow, while on a few drops of nitric acid being added to it on a white plate, a play of colors, green, violet, pink, and yellow, is developed ; the faeces are whitish or of a light clay appearance. The skin is often itchy, the temper irri- table, the taste bitter, with a sleepy, drowsy sensation at all times. The function of digestion is uninter- fered with, except in regard to fatty articles. Cerebral derangements may supervene if jaundice continues long, with stupor and delirium and a ten- dency to hemorrhages. If the obstruction is due to an impacted gallstone, the suffering may be intense, and the pain is known as biliary colic. Vomiting and hiccough frequently accompany. Fatal exhaustion may ensue should the concretion not pass through the duct. Treatment. — This must vary with the cause, but if due to obstruction, as from gallstones, hot poultices should be applied, or a few leeches if the attack has been long and severe, with the subcutaneous injection * Gallstones consist of thickened bile, which in some in- stances has formed round a nucleus of solid biliary matter. They may exist in great numbers. DISEASES OF THE PANCREAS AND SPLEEN. 211 of morphia. Immediate relief is sometimes afforded by large draughts of hot water with one to two drachms of bicarbonate of soda to the pint. Chloro- form is sometimes necessary. To prevent a refor- mation of gallstones the waters of Vichy and Carls- bad are useful. " In other cases of jaundice," says Dr. Tanner, " as we shall be merely working in the dark, it will be better to rest contented with resorting to gentle saline purgatives, diaphoretics, baths, rest, and regulated diet." DISEASES OF THE PAXCREAS. Clinically we know little of the diseases of the pancreas, as the organ is rarely affected primarily. Lying deep in the epigastric region, behind the stomach, and in front of the aorta, it must be remem- bered that if a tumor exists in connection with it, it will be discovered in this region, and that pain will be referred either to the front or to the back at the junction of the lumbar and dorsal vertebrae. The principal diseases to which the pancreas appears liable are morbid growths (chiefly scirrhus), calculi (of phos- phate of lime) of varying size, obstructing the chief duct, and leading to enlargement of the organ and the formation of cysts; catarrhal inflammation of the same duct, probably in the same connection ; and in- flammation of the chief duct. 212 DISEASES OF THE SPLEEN. The symptoms of any of these affections daring life are obscure, and attended with debility and malnutri- tion. As one of the principal functions of the pan- creas is to assist the digestion of fatty compounds in the food, the presence -of fat in the stools has been de- tected in diseases of this organ. Treatment — All special treatment of affections so difficult to diagnose during life seems out of the question. DISEASES OF THE SPLEEN. The spleen, situated in the left hypochondrium, weighs about six ounces; its length being six inches, and its breadth rather more than three inches. Its external surface is convex; its internal border, which is concave, is in relation with the cardiac end of the stomach, and has a vertical fissure — the hilus — at which apertures are found for the entrance and exit of vessels and nerves. It has no excretory duct, and its exact purpose in the system is as yet undetermined. Composed essentially of an elastic fibrous frame- work (trabecular tissue), of Malpighian corpuscles, and of spleen pulp, it may become distended with blood from slight causes, especially from those which inter- fere with the action of the skin, the liver, or the kid- neys. These causes continuing, its elastic power may be lost, and it thus becomes unable to send the accu- mulated blood onward. It may thus suffer from con- DISEASES OF THE SPLEEN, 213 gestion leading to inflammation, abscess, and gangrene; or it may be the seat of malignant disease, of fibrinous deposits, or serous and hydatid cysts may form with- in it. Splenic diseases of any of the above-mentioned forms may occur at any age, especially if the indi- vidual is resident in tropical climates. The most common of these is enlargement, commonly known as ague cake. The history of the case, as associated with intermittent fever or ague, or residence in the tropics even without having contracted fever, and the marked increase in the size of the organ, form clues to diag- nosis. In addition, there are signs of anaemia, debil- ity, a sallow unhealthy complexion, and various diges- tive derangements. Tenderness on pressure is evinced, but this does not occur to any great extent unless the peritoneal covering is involved. In protracted cases general dropsy sets in, with a murmur following the first sound of the heart. Sometimes the spleen may be greatly enlarged without any marked disorder of the general health, with the exception of debility. Treatment. — When the enlargement is the result of ague, change of climate and quinine are essential. In other cases steel and the bromide of potassium are serviceable. Arsenic is recommended in cases where there is no fever or periodicity. It can be con- veniently given in the form of the iodide in T ^ gr. doses, accompanied or followed by iodide or bromide of potass, or both (F. 5). 214 leucocythjemia. Leucocyth^mia. Dr. Hughes Bennett, of Edinburgh, first directed attention to this affection in 1848/ and six weeks afterwards Professor Virchow detailed another case where similar phenomena were observed in the blood. Dr. Bennett called the disease leukaemia or white blood, and imagined it was due "to suppuration of the blood without inflammation." He subsequently modified this view and called the disease leucocyt- hsemia (huxos white, xuroq a cell, and ai/ia blood), white-cell blood. Pathology. — The pathology of the disease to a cer- tain extent is expressed by the name, as there is a great increase of the white corpuscles of the blood, while the red ones are diminished. If an ounce of leucocythsemic blood, freed from fibrin, is placed in a glass, the red corpuscles sink to the bottom, while the colorless constitute the white milky upper stratum. Microscopically the excess mentioned is confirmed, and is more marked w T hen the red corpuscles accumulate in rouleaux, leaving clear spaces filled with the color- less ones. The specific gravity is reduced. The dis- ease is always associated with hypertrophy of one or more of the lymphatic glands, or of the spleen, or of both together. It is also sometimes associated with changes in the medulla of bone. Symptoms. — Great pallor evidences leucocythsemia, and with the pallor there are weakness and emaciation, gradually increasing until death occurs. Ascites from the enlargement of the liver, spleen, or both, accom- BR0NCH0CELE, GOITRE. 215 panics diarrhoea; epistaxis, urine loaded with uric acid, nausea, and jaundice, have also been noticed in cases which have come under observation. There may also be haemorrhages from the bowels and urinary passages. Treatment. — No remedy seems of any special avail in this disease. Of tonics, iron and quinine have ap- peared most serviceable (F. 77, 75). Good nourish- ing food should also be given. Diarrhoea and haem- orrhage should be treated as they arise, by appro- priate remedies. Bronchocele, Goitre, Consists essentially in hypertrophy of the normal constituents of the thyroid gland, viz., the blood- vessels, the connective tissue, and the groups of inter- communicating vesicles. Sometimes these are all in- creased in proportion; the enlargement is, however, generally at the expense of the connective tissue and the vessels. The size varies from mere fulness to that of a cocoanut. It is peculiar to certain localities, and constitutes the goitre of the Swiss and the Derbyshire neck of England. It is also found in Nottinghamshire, Sus- sex, Yorkshire, and seems in all cases to depend on the water supply being greatly impregnated with the sulphate and carbonate of lime, with the addition also, according to Virchow, of some endemic malarial in- fluence not dependent on any of the causes mentioned. A peculiar enlargement of the thyroid body, occur- ring chiefly in young women, and associated with pal- 216 addison's disease. pitation of the heart, uterine and menstrual derange- ments, and prominence of the eyeballs (exophthalmos), is termed Graves's or Basedow's disease. Symptoms. — The enlargement is characterized by no pain. It is simply inconvenient by its bulk, which, however, may be attended with serious symptoms if there is pressure on the large veins, sympathetic, pneu- mogastric, or recurrent laryngeal nerves, or if the oesophagus or trachea is compressed. Treatment — In the endemic form the patient should be removed to another situation, and iodine and its preparations externally and internally should be given. Tincture of digitalis is useful for the excessive palpita- tion, in the exophthalmic form, or belladonna com- bined with iron. In very severe cases operative measures, as passing a seton through or even extirpation of the gland, have been recommended. Disease of the Suprarenal Capsules, Addison's Disease. The function of the suprarenal capsules is a subject of great interest and obscurity. Their purpose in the economy of nature is as yet undetermined. They seem, like the spleen, the thymus, and the thyroid glands, to be essential in a -healthy state to the proper elaboration of the blood, and when diseased they lead, according to the investigations of the late Dr. Addi- son, to a peculiar series of phenomena. The convic- tion seems to have grown on Dr. Addison, that the DISEASES OF KIDNEY. 217 suprarenal capsules were implicated, by observing that a peculiar form of anaemia with discoloration of the skin was not connected with disease of other organs usually associated with anaemia. The symptoms ob- served by him were great and increasing debility, a feeble pulse, faintness on the slightest exertion, loss of appetite, a pain in the epigastrium, shooting through also between the scapulas, and progressive emaciation. With these general symptoms the skin became gradu- ally discolored ; this discoloration being most marked in the face, neck, superior extremities, penis, scrotum, and round the navel. The skin in the regions men- tioned, and also in the hands, assumed a dingy, smoky hue, which in advanced cases deepened into a "bronzed" color. So marked was this in one case recorded by Dr. Addison, "that, but for the features, the patient might have been mistaken for a mulatto." Cases of Addison's disease progress to an unfavor- able termination, and the " bronzing" of the skin in- creases with the general debility. Treatment. — Xo treatment seems of any avail. DISEASES OF THE KIDNEYS. The quantity of urine passed in twenty-four hours in health is two pints and a half, or from forty to fifty ounces ; in color it is pale yellow, in reaction acid. The specific gravity is from 1020 to 1025, and is de- termined by an instrument termed the urinometer. 218 DISEASES OF KIDNEY. What is meant by specific gravity is at once seen by placing the urinometer in distilled water, and after- wards in healthy urine. It will be observed in the one case that the instrument floats at zero, while in the other at the figures mentioned before. The taking of the specific gravity is an important and essential step in determining the nature of diseases of the kid- ney; for if below the figures mentioned, there is probably albumen, if above possibly sugar. Healthy urine freshly passed and examined with the microscope is absolutely structureless ; allowed to stand for twelve hours a slight cloudy precipitate may be observed, which, on microscopic examination, re- veals a few epithelial scales from the bladder, amor- phous urates, or a few crystals of triple phosphate. The appearances presented by the various deposits under the microscope are delineated in the e'ngrav- ings. 1st. Epithelial scales. 2d. Amorphous urates. 3d. Triple phosphates. The amorphous urates consist of salts of potash, soda, and ammonia, in varying proportions. The triple phosphate is a combination of phosphate of ammonia and magnesia. Sometimes these deposits are present in what may be termed detectable excess, and it is necessary to as- certain the effect of reagents upon them, which may be summarized thus : Urine containing a superabundance of urates has DISEASES OF KIDNEY. 219 a very acid reaction, and a pinkish-red deposit, which heat at once dissolves, leaving the urine clear. Urine containing phosphates has an alkaline re- action and a white deposit, which heat does not dis- solve, but on the contrary makes the urine examined cloudy; this cloudiness disappearing on the addition of a drop of nitric acid. The other crystalline deposits observed in urine are uric acid and oxalate of lime. The appearances presented by the former vary (see engravings), but they may be remembered by the fact that they are always colored either red or orange- yellow. Oxalate of lime crystals present an octahedral form (see engravings) sometimes of various sizes ; but rarely a dumb-bell appearance. Heat has no effect upon either of these deposits, but liq. potassse dissolves uric acid, not the oxalates, which require a mineral acid. All these deposits indicate no structural kidney dis- ease, but it is different when what are termed tube- casts are observed under the microscope. Of these there are five distinct kinds: 1st. Blood-casts or exu- dative; 2d. Desquamative or epithelial; 3d. Granular; 4th. Fatty ; 5th. Waxy or hyaline casts. 1. Exudative casts. These consist of the coagulated exudation or fibrin, and present a mould of the uriniferous tubes. The fibrin is poured into the tubes as the result of inflam- mation ; hence these casts are only seen in acute dis- eases of the kidney. 2. Desquamative or epithelial casts consist of a 220 DISEASES OF KIDNEY. cylinder of coagulable matter studded over with epithe- lial cells. 3. Granular casts are usually small, and consist of the usual cylinder studded with small masses of fat, epithelium, oxalates, etc., giving a granular appear- ance, and being characteristic of the most chronic forms of Bright's disease. 4. Fatty casts are the same as the preceding in their origin, only the cells have undergone fatty transfor- mation, and the casts have the appearance of being studded over with oil-globules. 5. Waxy casts are clear glassy cylinders, present- ing the appearance of a structureless substance. It must be remembered that these three last forms of tube-casts are significant of chronic disease of the kidney, and may be seen in varying proportions on the same microscopical slide. Unhealthy urine may also contain pus and blood, detected by their respective appearances under the microscope. Urine containing pus also becomes, on the addition of liq. potass, thick, sticky, ropy, which is evident on attempting to pour it from one vessel to another; while urine having blood in any but the smallest quantity has a smoky or red appearance, and coagulates on being heated. The most important abnormal constituent in the urine is albumen, and it is essential that the tests for its presence there should be familiarly and practically known. For this purpose there are two great tests* heat and nitric acid. A test-tube should be filled to the depth of about an inch with the suspected urine, DISEASES OF KIDNEY. 221 and heat applied by means of a spirit-lamp to its upper stratum until it boils, when, if albumen be present, it becomes turbid and cloudy in various de- grees. This cloudiness persists after the addition of nitric acid, and is thus distinguished from the phos- phatic cloudiness which is also occasioned by heat, but disappears on the addition of the acid. It is im- portant also to remember that if the urine is alkaline, heat will not affect the albumen and make it coagulate until a few drops of acetic acid have been added. The preliminary test for the acidity of the urine is essential, and also the addition of nitric acid after boiling, to distinguish between phosphatic and albu- minous cloudiness. Nitric acid alone is also an excellent test for albu- men. A test-tube being filled as before, and inclined, a little nitric acid is poured in so as to trickle slowly down the side to the bottom. If albumen is present three strata will be observed, one perfectly colorless of nitric acid at the bottom, another above this, coag- ulated albumen, and at the top the unaltered urine. Albumen having been detected in the urine leads to the inquiry, What significance has it, and with what diseases is it associated ? The answer to this is Acute and chronic Bright's disease of the kidneys, although it may also be found accompanying preg- nancy, any of the febrile diseases, heart or lung affec- tions, or cirrhosis of liver. 19 222 DISEASES OF KIDNEY. Nephritis. Previous to entering on Bright's disease, it is nec- essary to mention that the kidney, like other organs of the body, may be the seat of congestion, which may terminate at that stage, or go on to inflammation, and constitute what is termed nephritis. Nephritis is, however, rare. Congestion may be the result of ex- posure to cold, of overdoses of special drugs, such as cantharides or turpentine, or it may appear during the various febrile and inflammatory diseases. It may be then considered active congestion ; while if it results in consequence of cardiac or pulmonary disease interfering with the general venous circulation, or from pregnancy, or tumors pressing on the renal veins, or inferior vena cava above, then it is consid- ered a passive congestion. Following from some of the above causes, or from the direct irritation of a renal calculus or embolus, or from inflammation of the bladder creeping along the ureter to the pelvis, infundibula, and calyces, the condition termed pyelitis, or inflammation of the lining membrane of the kid- ney, may be excited. The mucous membrane thus becomes congested, thickened, softened, and from its free surface is discharged mucus containing epithelium, pus-corpuscles, and sometimes blood. If this affection is persistent, suppuration may be established, false membranes formed, and ulceration take place, not merely in the mucous membrane but also in the sub- stance of the kidney. This may be designated " sup- purative nephritis." Supposing that the pus can DISEASES OF KIDNEY. 223 escape easily by the ureter, and that one kidney is alone affected, the mischief may continue for years with little except local uneasiness, and it may ulti- mately become quiescent. In other cases, and whether or not the ureter is obstructed, an abscess may form, enlarging and burrowing in all directions, sometimes penetrating the diaphragm, pointing in the loins, bursting into the peritoneum, or descending along the psoas muscle and pointing under Poupart's ligament. Symptoms. — Pain and tenderness in the loins, in- creased by pressure or movement, irritability of the bladder, with the passage of urine clouded from the presence of blood, mucus, or albumen, characterize active congestion of the kidneys, — these phenomena being preceded by sickness and feverishness and thirst. These symptoms are intensified in pyelitis, and pus is also present in the urine; while if suppurative ne- phritis is established the local pain will be greatly in- creased, and rigor and hectic fever will accompany, with, in most cases, a typhoid condition, suppression of the urine, and death by exhaustion. Treatment. — In active congestion, if of independent origin, it is advisable to leech or cup the loins, and to follow this up by fomentations or the hot bath. The bowels should be kept freely open by a hydragogue cathartic, such as pulv. jalaps co., if the urine is slight in quantity. If the pain is great, opium may in some cases be given. The treatment of pyelitis or suppura- tive nephritis is based very much on ascertaining the cause, and endeavoring to support the strength. 224 DISEASES OF KIDNEY. In chronic cases, astringents and mineral acids may> be given (F. 78). B right's Disease. The kidney has a thin translucent lightly-adhering capsule, and beneath this capsule is the kidney proper, containing a complicated and convoluted series of tubes lined with epithelium, and lying between the tubes, supporting and binding them, is a thin delicate web of fibrous tissue, and an abundant supply of bloodvessels to enable it to perform its secreting function. Each and all of these various parts may be affected with disease, but, as can be conceived from the intimate union existing between them, one cannot be affected without the other sympathizing, from whatever may be the original starting-point. Diseases implicating the tubes, fibrous tissue, and bloodvessels, thus merge into one another. The name Bright's disease is deservedly given in honor of the illustrious physician of Guy's Hospital, who, in 1827, threw the segis of his name round all kidney affections associated w T ith albumen in the urine. Bright's disease may be considered to be either acute or chronic. Acute Bright's Disease, under which term may be comprehended acute desquamative nephritis (John- son), acute tubal nephritis (Dickinson). The kidney is always enlarged, sometimes to twice its natural size, its capsule easily stripped off, its color usually deep red, at times mottled red and white, and, ACUTE BRIGHT'S DISEASE. 225 .jcaoon thoro io hypcitmphy of the left " on being cut into, it drips with blood ; under the microscope there is observed an immense increase of the epithelial cells of the convoluted tubes, which are thus choked up to a greater or less extent, and com- press the renal capillaries, while the intertubular stroma is unaffected. From this condition it may pass on to recovery, or remain what will be afterwards described as the large white kidney; or the disease may terminate in death by dropsy and other intercur- rent affections, as pneumonia, pleurisy, and pericarditis. Causes and Symptoms. — It may be the direct result of cold or intemperance, or occur during convalescence from scarlet fever or other blood-poisons. Fever, pain in the loins, marked diminution of urine, which is albuminous, smoky colored, or dark brown from the admixture of blood, and of high specific gravity from disproportionate decrease of water to increase of solid constituents, characterize the early stages of this affection.* Dropsy supervenes. If a favorable ter- mination ensues, the urine becomes more abundant, the skin moist, blood, albumen, and tube-casts dis- appear, and convalescence and recovery are estab- lished in a varying interval of weeks or months. A large proportion — Frerichs says two-thirds — recover. Treatment is based on obvious principles to induce perspiration and to relieve the overloaded tubes. Hence a warm blanket bath may be employed, the blanket being wrung out of warm water and wrapped round the patient, while an abundance of water should be drunk, and a mixture of acetate of potass, 226 DISEASES OF KIDNEY. citrate of potash, and infusion of digitalis, ordered (F. 37). The bowels should also be freely acted on by jalap or elateriura (F. 27). Locally, dry-cup the loins and apply hot linseed- meal poultices. The diet should consist of milk, beef tea, or nourishing soups. During convalescence all exposure to cold should be avoided, the wearing of flannel insisted on, and a mild preparation of iron, by preference the ammonio-citrate, given (F. 90). Change of air is also beneficial. Chronic Bright's Disease. — Three chief types are recognized as post-mortem appearances of those dying of chronic Bright's disease: A. — Kidney smooth, white, and enlarged, as re- sulting from previous disease. The cortical substance is increased, capsule easily stripped off, while on the white or mottled surface " conspicuous stellate patches of bloodvessels are seen." Microscopically, the epithe- lial lining of the tubes is swollen, the tubes distended, and the cells opaque and granular, and often loaded with oily particles. The intertubular stroma is un- altered. B. — Kidney granular, brown or brownish-red, small and contracted. The capsule is adherent, requiring force to peel it off; the fibrous stroma is increased, and cysts are frequently developed, most probably through obstruction to the uriniferous tubes. Dr. Bright's original description of this kidney is as fol- lows: "The kidney is rough and hard and gives re- sistance to the knife in attempting to cut into it. Numerous projections are seen to rise on the surface THE LARGE WHITE KIDNEY. 227 not much exceeding a pin's head. The tabular por- tions appear to be drawn near the surface. It ap- pears to be, in short, like a contraction of every part of the organ, with less interstitial deposit than in the last variety." Further, he indicates his belief that this second variety is but a modification of the first, an advanced stage of one and the same disease — an opinion enter- tained by most German pathologists, but not yet ac- cepted by English authorities. C. — Waxy or lardaceous kidney, amyloid degen- eration. In well-marked cases the kidney is enlarged and smooth, and on section the cortex is bloodless, of a white or yellowish color, with a waxy smooth ap- pearance like bacon rind or w T hite beeswax. In other cases the organ may be small. The degeneration seems to affect first the Malpighian bodies and small arteries, and to be follow-ed by transudation of fibrin into the tubules, w r ith subsequently, in some cases, atrophy. The proper test for this degeneration is iodine, which imparts when applied a deep mahogany- brown color to the parts affected, while it merely stains yellow 7 the portions unimplicated. The clinical history, course, and symptoms of these three forms vary. The Large White Kidney, Following on the acute form or having a latent un- detected origin, is attended with dropsy, the counte- 228 DISEASES OF KIDNEY. nance being puffy and pasty. The urine is scanty, containing casts, epithelial, fatty, or hyaline ; and the specific gravity normal or rather high, with albumen always present. The average age of the patient is twenty-eight years. Recoveries and relapses are frequent. In fatal cases the ordinary duration of the disease is under six months, and in exceptional cases it may extend over some years. The Granular Contracting Kidney Is associated with middle age, not youth, being most common about fifty years, and more frequently ob- served in males than females in the proportion of two to one. Its commencement is insidious, the early symptoms slight, the progress slow, and the disease may run a latent course for months or years. Fre- quent micturition and some slight puffiness of the ankles lead to an examination of the urine, which is found to be copious in quantity (three to four pints), of low sp. gr., and with a comparatively small quan- tity of albumen. In later stages the urine becomes scanty and the albumen more abundant. The gen- eral health gives way, the pallor becomes pronounced, chest and stomach derangements increase, and death ensues through exhaustion, or with symptoms of oedema of the lungs, uraemia, or other intercurrent affection. How the chronic nature of the disease gives rise to increase in the heart's structure is as yet an undetermined question ; still in nearly fifty per THE WAXY KIDNEY. 229 cent of the cases there is hypertrophy of the left ventricle, and also a peculiar form of retinitis. Tube- casts are few in number, being either hyaline or finely granular. The Waxy Kidney Is associated usually with amyloid disease of other organs, as liver or spleen, and with a previous history of syphilis, caries, phthisis, long-continued suppura- tion, or other exhausting condition. It is character- ized by a large flow of urine, 100 to 200 ounces being passed in a day. The urine has a low sp. gr., with few tube-casts, generally hyaline in character. The albumen is at first slight, but as the disease advances, the urine, as in the previous form described, becomes of higher sp. gr., and the albumen more abundant. Dropsy does not, until the late stages have been reached, form a prominent feature of the disease. The disease may not be recognized at first, and hence may extend over a series of years. Indeed, it seems to form a part of various constitutional states, and upon these its ultimate issue depends. Treatment of the various forms of chronic Bright's disease requires careful management, though based on certain obvious principles, hygienic, dietetic, and medicinal. All exposure to cold should be avoided, and, if circumstances permit, a residence selected in a mild and sheltered spot, or, what is still better in the more chronic forms, a sea voyage should be made. The 20 230 DISEASES OF KIDNEY. patient should be habitually clothed in flannel, moder- ate exercise insisted on, and an occasional use of warm baths and frictions to the skin. Milk agrees well, and may be taken ad libitum. All spirits should be forbidden, but two or three glasses of claret or beer are permissible daily. The constant draining away from the blood of one of its most important constituents necessitates the ad- ministration of strengthening medicines, and expe- rience has shown iron to be the best of these. The tincture often causes headache, and hence the citrate of iron and quinine, or the syrups of the phosphate or iodide of iron, are recommended, and should be steadily persevered in (F. 76). No medicine seems as yet discovered to have any effect in diminishing directly the quantity of albumen, and hence other treatment must be symptomatic. Dropsy is the chief symptom, and the most effectual way to combat the dropsical effusions is by means of hydragogue cathar- tics and warm baths ; the patient entering the bath at a temperature of 98°, which is gradually raised to 108°, and remaining in it for half an hour, when he returns to bed and is enveloped in blankets. Com- pound jalap powder and bitartrate of potash may be ordered twice or thrice a week, or Friedrichshall or Hunyadi Janos water. More active means of the same nature are found in gamboge and elaterium (F. 27). Opinions vary greatly as to the value of diuretics, but Christison recommends digitalis, and Rayer horse- radish tea. UREMIA. 231 In extreme dropsy punctures or incisions may be made into the skin of the legs or scrotum. Mercury, in any of its forms, is contraindicated by most authorities. It rapidly produces salivation and most untoward consequences. Ukjemia. In the course of Bright's disease, or any other state attended with albumen in the urine, a group of phe- nomena termed unemic, are sometimes presented, owing, it is supposed, to a poisoned state of the blood. Generally they begin insidiously with headache and dimness of vision, followed by convulsive paroxysms, profound insensibility, stertorous breathing, pale face, and dilated pupils. In exceptional cases conscious- ness is not wholly lost, and the patient can be roused from the deep drowsiness by being spoken to or shaken. In these cases there may be some chance of recovery, but in others, when the coma is complete, a fatal issue is almost certain. Much controversy and many theories have been ex- cited by uraemia. The original idea of Willis was that the special poison in the blood was urea. Frerichs supposed that urea is harmless, and that its conversion into carbonate of ammonia occasioned the ursemic phenomena. The more recent experiments of Oppler and Zalesky indicate that neither of these theories is correct, but that the chief poisonous agents are the accumulation in the blood of the first products of tis- sue-change, creatin, creatinin, and other extractives, 232 DISEASES OF KIDNEY. which are converted in the kidneys into urea and uric acid. The question is as yet not satisfactorily determined; for, though the phenomena observed dur- ing life are plain enough, yet the absence of anatomi- cal changes in the chief nervous centres must render the explanation of these a matter of theory and un- certainty. Treatment — All that we can do is to try and in- crease the flow of urine by diuretics, and awaken the action of the skin by diaphoretics (F. 35, 31). Inha- lation of chloroform may modify the severity of the convulsions; an injection of chloral may also be tried. Should the attack be sudden, and the blood not greatly impoverished, as sometimes happens in pregnant wo- men, free venesection has much to recommend it, and should not be dismissed as absurd simply because it was the panacea of our forefathers. Chylous Ueine Was first recognized and described by Dr. Prout, and has since been investigated by other observers. The urine is milky when voided; then coagulates into a tremulous mass like blanc-mange; then liquefies into a creamy scum with a brownish sediment. The urine, in fact, presents those characteristics which would re- sult from the admixture of normal urine and normal chyle. It contains fibrin, albumen, fat in a molecular form like the fat of chyle, and occasionally a small proportion of red corpuscles. HEMATURIA. 233 No casts have, however, been detected; and the fat chiefly characterizes the urine passed after meals. Chylous urine is more common to tropical than temperate climates, to adults than to children, to fe- males than to males. Its presence is not inconsistent with good health. Intermissions are frequent. After lasting some time, it may disappear for years,' or even for life. Pathology. — Dr. Prout imagined it to be due to a faulty assimilation, by which the chyle was permitted to mingle with the blood; and combined with this was some renal disorder, by which the kidneys per- mitted the chyle to transude and mingle with the urine. The blood examined, however, presents no signs of chyle, and post-mortem examination reveals no disease of the kidneys. Dr. Roberts says it is due to vesicular dilatation, and rupture of portions of the lymphatic vessels situated on the mucous surface of the bladder or urinary tract. • Treatment. — Numerous remedies have been sug- gested, and have failed in doing good, as can easily be imagined if Dr. Roberts's explanation is the cor- rect one. Rest and local astringents are advisable, with tonics to combat the anaemia (F. 78). HEMATURIA, As its name implies, means the admixture of blood with the urine ; and this mixture is easily recognized by the color it imparts to the secretion, unless the 234 DISEASES OF KIDNEY. quantity is very small, when it may require the aid of the microscope to detect it. Blood in the urine may originate from different sources, which, as a general rule, can be recognized from the following considera- tions. If from the kidneys it is found equally dif- fused, giving to the urine a smoky-reddish tint, and after standing awhile a grumous-colored deposit sub- sides. If from some other part of the urinary tract — e. g. y if it comes from the ureter, bladder, or urethra — the color is more bloody, more red, and frequently distinct clots are observed in the deposit. All urine containing blood is necessarily more or less albu- minous. By far the most common cause is congestion, due to some blow or injury in the renal region. It may also arise from acute Bright's disease, from malignant dis- ease of the kidney or bladder, from the presence of a calculus either in kidney, ureter, or bladder ; or from the taking of irritating medicines, as turpentine or cantharides. Sometimes it is symptomatic, and de- pendent on other than urinary diseases. Thus it is seen in purpura and scurvy; or it may be found in yellow fever, cholera, or any of the eruptive fevers ; and when detected in the course of these diseases the prognosis is most unfavorable. At other times it is supplementary to a normal state or diseased condition, e. g., it may accompany menstruation in a woman, or a hemorrhoidal flux in either sex. The endemic hematuria of the Mauritius and Brazil is dependent on the presence of a small parasite which infests the H^IMATINURIA. 235 mucous membrane of the pelvis of the kidney or bladder. Haemorrhage from the bladder, due to acute cystitis, fungoid growth, or calculi, is usually recognized by symptoms referred to that organ, viz., very frequent micturition and pain in the hypogastrium. Urethral haemorrhage is known by the escape of blood during the intervals of micturition. Treatment will vary with the causes and circum- stances of the haemorrhage, but when our object is to treat the hematuria for itself — to stay the loss of blood — perfect rest is absolutely necessary, and the application of ice to the seat of the haemorrhage. Thus if the kidneys are the seat, put ice poultices to the loins ; if the bladder, to the epigastrium and perineum. With the local application of ice give astringents internally, e.g., acetate of lead, gr. iij, pulv. opii, gr. J, in a pill every two hours, until six or eight doses have been administered ; or ergotin may be in- jected subcutaneously. In severe vesical haemorrhage a solution of alum, 20 grains to the pint of water, may be injected into the bladder. Hjemattnuma Is a curious disorder, to which attention was first drawn by Dr. George Harley in 1865. The peculiar feature of the disease is the paroxysmal passing of dark-colored urine, containing not blood, but merely the coloring-matter of the blood — haematin. A sense of shivering or cold about the loins precedes the par- 236 DISEASES OF KIDNEY. oxysm. The intervals between these are irregular, and there is no certainty about their occurrence; for sometimes the urine at one micturition is clear, at another porter and bloody-colored. Microscopically, the urine presents chiefly an immense mass of amor- phous granular matter, with dark granular-colored tube-casts. The prognosis is favorable, though the duration of the disease cannot be defined. Treatment — During the cold stage send the patient to bed, and administer warm stimulating drinks. Tonics, as iron and quinine, are also indicated (F. 76). Gravel, Kenal Calculus, or Colic. Sometimes concretions of crystalline or amorphous sediments form in the pelvis of the kidney, and are accompanied with severe pain in their passage along the ureter to the bladder. There is also a frequent desire to micturate, retraction of the testicle, nausea, and vomiting, intense relief being obtained whenever the substance reaches the bladder. This may be termed a "fit of the gravel." When there is merely gritty matter or sand, no pain whatever may be experienced. The most common forms of gravel are the urates of ammonia, uric acid, the triple phosphates of ammonia and magnesia, or oxalates of lime. Treatment varies with the nature of the deposit. Vichy or Carlsbad waters and alkalies are useful when the urates predominate. If phosphates, the nitro- muriatic acid and a generous diet. If oxalates, dilute the urine by drinking plenty of cold water, which DIABETES. 237 must not contain much lime, and avoid all saccha- rine substances. During the passage of a calculus employ a warm bath, afterwards poultices or fomentations to the loins, also give barley-water to drink, along with spiritus setheris nit. and vin. ipecac. To relieve the pain, morphia subcutaneously ; sometimes chloroform is necessary (F. 39, 40). In addition to the diseases mentioned, it mav also be stated in general terms that the kidney or kidneys may be attacked by cancer, either primary or second- ary, usually of the encephaloid form, and that the leading symptoms of the former are a tumor in the abdomen, sometimes very large, and hematuria ; that tubercle or hydatids may also originate in the organ, exhibiting in neither case very well-defined symptoms, though resulting fatallv in both; that when anv im- pediment exists to the flow of urine from the kidney, dropsy of the kidney, or hydronephrosis, may ensue, through dilatation of the pelvis, with atrophy of the cones or whole substance of the organ; and that, finally, one or both kidneys may be shifted from their original position, occasioning the condition known as movable kidneys. To enter, however, further into details would be foreign to the object of this handbook. Diabetes. The word diabetes, derived from the two Greek words, dia fiatvto^ literally means that the water is con- stant in running through the patient's system. Used literally diabetes may thus have a wide significance, 238 DISEASES OF KIDNEY. but it is now employed as representing two distinct kinds of disease. In both there is an increased flow of urine; but in the one, diabetes mellitus, there is sugar in the urine, in the other, diabetes insipidus, this is absent. Diabetes insipidus seems to depend on unknown causes attacking by preference the male sex, usually between the ages of five and thirty. It has certain permanent and characteristic features, viz., an excessive flow of uncolored urine of low sp. gr., containing neither sugar nor albumen, and attended with a dry skin and great thirst. Its course is uncertain, and its treatment empirical. Diabetes mellitus, although it seems to have been' known in some measure to the ancient physicians, was practically unrecognized until Dr. Willis, in 1674, described it as a distinct disease; "for in it the urine differed from all other fluids of the body, as if it had been mixed with honey or sugar, and having a power- fully sweet taste. " Passing over subsequent years, it may be mentioned that Dr. McGregor, of Glasgow, in 1837, discovered sugar in the blood as well as the urine, and that the stomachy formed saccharine matter instead of healthy chyle, which entered into the blood, and instead of forming fat, bone, and muscle, was passed into the system as sugar, and thence eliminated by the kidney. Claude Bernard, in 1848, opened up a new era in diabetes, when he pointed out that sugar was a normal secretion of the liver; and further, if the eighth pair of nerves are irritated at their origin in the fourth ventricle, sugar is produced in an abnormal DIABETES. 239 quantity by the liver. Sugar could also be produced in various other artificial ways. It was supposed that the sugar thus formed in health was carried by the hepatic veins and inferior vena cava into the heart, and thence by the pulmonary arteries to the lungs where, combustion ensued, and the sugar was consumed. If, however, the quantity of sugar were considerably increased, either by faulty digestion or nervous irritation, the lungs were unable to perform their functions, sugar passed into the blood, and from thence found its way to the kidneys. Dr. Pavy's experiments led him to believe that the liver did not secrete sugar in health, but a substance termed hepatin; that the detection of sugar in the blood leaving the liver was a post-mortem, not a living reality; that if the hepatin were converted into sugar in diabetes, it was due to the curb being withdrawn from the liver, which was thus allowed, as after death, to run riot with its saccharine tendencies. Dr. Pavy thus disturbed the belief in Bernard's theory, as Bernard had engendered skepticism in McGregor's. Dr. Dickenson's theory supposes a dilatation of the arteries in the brain, followed by degeneration and excavation of the nervous substance in the neighbor- hood. He thus argues that diabetes has a nervous, not a digestive origin. It will thus be seen that no correct theory of dia- betes has yet been obtained; and this is not at all to be wondered at when post-mortem appearances are negative as to the special organ or organs at fault. In i 240 DISEASES OF KIDNEY. a case of death from diabetes, which occurred lately in the Glasgow Royal Infirmary, there was no con- firmation of Dr. Dickenson's views; the only note- worthy fact in the examination being an unnatural softness and friability of all the organs of the body. Diabetes is best recognized by its symptoms, which are as patent as its pathology is obscure. The earliest symptoms which attract the patient's attention are thirst and hunger and the passage of a great quantity of urine. To these may be added a dry skin, a faulty digestion, a parched or often a red, flabby, or inordi- nately clean and wrinkled tongue, and progressive emaciation and loss of strength : the latter fact being in some cases rendered obvious by an inability or dis- inclination for sexual intercourse. The temperature is also low, and there is sometimes impaired vision. To this may be added the less important symptoms of constipated bowels, and change of temper, going on to a general gloominess. The urine passed may rise to 15, 20, 30 pints, or more, in the course of twenty-four hours, and it presents to the eye a pale color, while its odor is sweet like that of newmown hay, or that detected in a chamber containing apples. Its specific gravity is high, in all cases being above 1030, w T hile in some it rises to 1050. There are three distinctive tests for detecting sugar in diabetic urine : Moore 's Test — Add half the volume of liq. potass, to the urine. Boil in a test-tube, when the mixture assumes a dark- brown color. Healthy urine is only slightly darkened by the same proceeding. DIABETES. 241 Trommers Test. — Place some of the urine in a test- tube, add a drop or two of solution of sulphate of copper, when a pale- blue tint is produced. Add to this liq. potass, in a portion equal to half the volume of urine, when a pale-blue precipitate of the hydrated oxide of copper is thrown down. Boil, and the result will be — 1st. The dissolving of the first precipitate; 2d. The throwing down of a yellowish-brown pre- cipitate of suboxide of copper. If there is no sugar there will be merely a black precipitate of common oxide of copper. Fehling's Solution. — A more delicate test consists in what is termed Fehling's solution — consisting of sulphate of copper, tartrate of potash, and caustic soda (F. 92). Boil a small quantity of the solution, then add a few drops of the urine, when, if sugar is abun-' dant, the same yellowish-brown precipitate as in the former case will result. If equal quantities of urine and of the test are used, and no change ensues, then there is not ^ of a grain of sugar present. Fermentation Test. — Take some German yeast and place it in a test-tube containing urine. Now invert the tube and place it upright in a saucer also contain- ing some of the urine. Placed at the side of the fire, or in a temperature of 80° Fahr., fermentation en- sues, carbonic acid is liberated, and collects in bubbles at the top of the tube. Xo change takes place in healthy urine. The average duration of diabetes, after its detection, is from one to three years in the young; in the old, it 242 DISEASES OF KIDNEY. may be prolonged from five to twenty years. The prognosis is more grave in young subjects than in those after thirty. Various diseases may complicate dia- betes and hasten a fatal issue, as phthisis, pneumonia, bronchitis, carbuncles, abscess, gangrene, phagedenic ulcers, dropsy. Cataract, which is sometimes associ- ated with diabetes, seems due to the direct action of sugar on the crystalline lens. Lastly, inflammation of serous membranes of an asthenic type is a not unfre- quent complication. Treatment. — No drug seems to have any influence on diabetes. The diet must be carefully regulated. All substances containing sugar, or likely to produce sugar, should be avoided. A milk diet is by far the best, with animal food, fish, or eggs, and biscuits con- taining little or no starchy matter. Walker's Glas- gow, or Camplin's London, are best for this purpose. Of vegetables, cabbage and cauliflower may be occa- sionally allowed. Whisky or brandy, to the extent of two glasses daily, are the most suitable stimulants. The parched state of the mouth may be relieved, and perspiration induced, by wearing a respirator night and day, over which may be placed a knitted woollen cloth. Of medicines which are recommended, only one or two require mention. Opium and some opium alka- loids, codeia being best, are frequently prescribed, but require care from the tendencies to coma in some cases of diabetes. Alkaline and mineral springs, as Vichy, have been advocated, but these probably are only use- ful as diaphoretics, and thus merely temporary. DISEASES OF THE NERVOUS SYSTEM. 243 DISEASES OF THE NERVOUS SYSTEM. We shall now attempt a brief description of dis- eases of the brain, and afterwards proceed to take up other affections connected with the nervous system. Insanity will not be spoken of except incidentally, as the subject is too special and complicated to be dealt with in a handbook such as this. The student must remember that our investigations of diseases connected with the nervous system are necessarily obscure dur- ing life, and that this obscurity is often not removed by post-mortem revelations. These so often clash, that any accurate classification seems at present du- bious. The following synopsis of diseases of the brain may be found serviceable : 1. Cerebral amemia, from discharges of blood, and also from poor living. 2. Cerebral congestion, active or passive, as in dis- eases which obstruct the circulation, as tricuspid in- sufficiency, etc., etc. 3. Embolism and thrombosis, occluding the vessels at a point beyond the circle of Willis. The area sup- plied by the occluded vessels is at first pale, and then tinged, from the back flow of blood into if leading to red softening, and the subsequent degenerations of the tissue in the area. 4. Diseases in which the vessels burst, and which result in bleeding; e.g., fatty degeneration of the walls of the vessels, miliary or larger aneurisms; diseased states of the blood, as purpura, etc. 244 DISEASES OF THE NERVOUS SYSTEM. 5. Inflammation of the membranes. Meningitis may be — 1. Simple acute; 2. Simple chronic; 3. Tubercular. 6. Inflammation of the brain- substance, or ence- phalitis, or local inflammation, often followed by- abscess. 7. Tumors, especially syphilitic. 8. Gray degeneration of the nerve-tissue of the brain and spinal cord, with increase of the interstitial tissue in areas here and there. 9. Dropsy of the brain and membranes, hydroceph- alus, etc., etc. Cerebral Anemia. In cases of death from cerebral anaemia, a pale color of the brain is observed, most marked in the gray substance, but also making the white matter look more pale than normal. There is also an absence of the usual red points, combined with a diminished quantity of blood in the vessels. Symptoms. — -Giddiness, ringing and buzzing in the ear, paleness of the face, faintness and loss of con- sciousness, characterize the lighter forms of cerebral anaemia, as in the faintness which attacks the student on his first sight of an operation. The graver forms may be due to sudden haemorrhage, and may be at- tended with convulsions and coma. The state of the pupils is first contraction, next dilatation, and, finally, the normal condition if the issue is to be favorable. By many authorities, death from sudden shock is con- sidered as due to cerebral anaemia. CEREBRAL CONGESTION. 245 Cerebral Congestion May be cither active or passive, and certain appear- ances, which may, however, be all or in part absent, are observed on post-mortem examination. In the active form the capillaries and large bloodvessels of the brain and pia mater are increased in size, hence the blood-points are observed to be larger and more numerous than usual, while the pia mater has a red or rose-colored appearance, in spots, or throughout its whole extent. The gray matter is red or violet in hue, the choroid plexuses are enlarged, and the ventricles contain an excessive amount of fluid. In the passive form, when the quantity of venous blood is augmented, the veins generally are distended. Symptoms. — In the active form there is pain, dizzi- ness, and confusion of the intellect, which may last from half an hour to two or three days; sleeplessness, irritability of temper, and inability to do any mental work, with a sense of flying heat shooting over the head and neck, and redness of the face, are also prom- inent symptoms. In the passive form there is the same confusion of ideas, but with mental torpor in- stead of irritability, and drowsiness instead of sleep- lessness. In the very severe forms there may be loss of consciousness, or delirium, or convulsions. The slight forms are rarely dangerous in themselves, and may be recovered from under treatment. In the severe forms the prognosis is grave, and when death occurs it is during coma. Treatment. — General bloodletting, once so common 21 246 DISEASES OF THE NERVOUS SYSTEM. in cerebral congestion, is now abandoned, except in cases attended with delirium. Local leeching behind the ears is in some cases advisable. The object of treatment is to draw blood away from the head, hence quickly acting purgatives, such as croton oil, or calo- mel and jalap, are employed; while, at the same time, mustard and vinegar should be rubbed on the legs and arms, or the feet may be placed in a warm bath. In the lighter cases ice should be applied to the head. The diet should be light, and all alcoholic stimulants forbidden. Bromide of potassium and ergot are recom- mended by Hammond, followed by strychnia (F. 7 1 a). In cerebral anaemia a horizontal position is indi- cated, with nourishing soups and wine, and the avoid- ance of all mental disturbance. Tonics containing quinine and iron are also useful. Cerebral Embolism and Thrombosis. If the occlusion, the shutting up of a vessel in the cerebral circulation, is due to a something being carried away from a distant part of the system and lodged at the point of occlusion, we say it is due to embolism. If, on the other hand, a clot is formed locally at the spot occluded, we consider it is the result of throm- bosis. The result in either case will be the same to the substance of the brain unless the obstruction be removed. It must lead to deficient supply of nourish- ment in that particular place, to softening, and to the loss of functional power in the parts thus deprived of their nutriment. The symptoms which, however, CEREBRAL HAEMORRHAGE. 247 characterize the first step of the occlusion — the wedg- ing in — vary somewhat. In embolism the onset is sudden ; there are no premonitory warnings, but rapid giddiness, or an involuntary cry, or immediate loss of consciousness. In thrombosis the symptoms are slowly developed, preceded by pains in the head, general confusion, loss of memory, perhaps numbness, and these show the occlusion is complete, that the vessel is fairly dammed up. The further symptoms between the two must be the same, being dependent on the same circumstances. Hemiplegia may follow, or the paralysis may only affect the tongue, or there may be simply a loss of the faculty of speech. Further, it may be mentioned that thrombosis is usually asso- ciated with advanced age and feebleness of the heart's action ; while in embolism there is valvular disease of the heart, which, of course, may occur at any age. Cerebral Hemorrhage. Cerebral hcemorrhage, by which is meant extrava- sation of blood in the substance of the brain, depends essentially, according to recent authorities, on miliary aneurisms, which appear as little globular masses in the small intracranial vessels, and are due to a diffuse arteritis proceeding from without inwards. Although this statement may in the main be true, yet haemor- rhage may also arise from softening of the cerebral tis- sue, from atrophy of the brain-substance, and from tension of the bloodvessels, the result of mental and physical causes. In the majority of cases the seat of cerebral haemorrhage is the corpora striata, the optic 248 DISEASES OF THE NERVOUS SYSTEM. thalami, the crura cerebri, and the medulla oblongata, on the right side more frequently than the left. The blood poured forth, varying according to the causes, dislodges part of the brain-substance and a cavity is produced. If death does not occur, the further be- havior of the extravasated blood is the absorption of the serum, the contraction and hardening of the red corpuscles and the fibrin, the contraction of the cavity, and eventually the formation of a cicatrix which in- closes the remains of the clot. At other times the cavity does not contract, but remains distended with blood, and forms the nidus for secondary lesions, fresh haemorrhage, or abscess. Symptoms. — Often previous to the attack a group of symptoms may forewarn the patient, as sudden diffi- culty of speech, defects of vision, dizziness, faintness, sickness. There may, however, be none of these pro- dromata, the patient being struck down abruptly, as if shot, and rendered thoroughly unconscious, with loss of sensibility and power of motion ; the breathing stertorous, lips and cheeks puffed out with expiration, the pupils * largely dilated and insensible to light. After a time, if death does not occur, consciousness returns, the patient attempts to turn in bed, and en- deavors to speak. He finds, however, that articula- tion is indistinct, that the muscles of one side of the face are paralyzed, and the power of motion of the limbs and body of the opposite side is lost. The temperature is found at first to be low, 96.8°, next normal, 98.5°, so continuing if recovery is to be CEREBRAL HEMORRHAGE. 249 complete; but if a fatal result is to ensue, it will rise markedly to 104° or 106°. There is another form of cerebral haemorrhage un- attended with unconsciousness, and in which the patient is sensible of his condition but unable to avert the hemiplegia which ensues. Causes. — A long list of exciting causes may be made out. It will suffice simply to mention drunken- ness, excessive venery in old people, extreme joy or anger, and straining at stool. It is also found that winter is more favorable to the occurrence of cerebral haemorrhage than summer, and that neither a thin nor plethoric frame, neither poverty nor riches, specially provoke it. The chief predisposing causes are diseases of the heart and vessels, and an occupation necessitat- ing great exertion. Prognosis. — In the severe seizures death may occur within a few hours, in the less severe about one-third of those attacked die; while in the mild form the prog- nosis is generally favorable, although the patient can- not be considered free from danger until after the eighth day. Treatment. — If there are any forewarnings the bow T els should be opened by a brisk purgative, the head kept cool and well raised, every mental strain avoided, and the bromide of potassium given in thirty-grain doses. During the attack, symptoms should be met as they arise. If the bowels have not been recently opened, place two drops of croton oil on the tongue; if the urine is not passed naturally, draw it off with a catheter ; if haemorrhage is still supposed to be going 250 DISEASES OF THE NERVOUS SYSTEM. on, inject ergotin subeutaneously. The patient should also be kept quiet, with the head well raised, and in a well-ventilated room of an even temperature. After the eighth day remedial measures may be put in force to restore the power of motion and prevent contraction. The agents best suited for this purpose are passive motion, strychnia, phosphorus, and elec- tricity (F. 85). Apoplexy Is a term significant chiefly of a prominent symptom in the last three affections of the brain described — embolism, thrombosis, and cerebral haemorrhage. It denotes a clinical fact, a stroke, a beating down sud- denly ; and as this was accompanied by loss of con- sciousness and motor power, with stertorous breathing and peculiar countenance, older writers attempted to establish, and did name as a disease what is in truth only a symptom. They distinguish between several varieties, as sanguineous, nervous, and serous apoplexy. This nomenclature has now been abandoned, and the various clinical phenomena are classified under the term " an apoplectic attack." The question may be asked, Is it possible to distinguish between the causes which may produce this ? The answer to this question is simply a matter of conjecture, although the following consid- erations bear somewhat pertinently on the point. Haemorrhage is much more frequent than thrombosis, and may be said to be rare under forty. The attack may be supposed to be due to embolism if occurring below that age, especially if there be evidence of valv- APOPLEXY. 251 alar disease of the heart, and if the well-marked hemiplegia at first accompanying it disappear within a few days. A person may, however, be discovered in an un- conscious state, resembling an apoplectic seizure, and it is of great importance that a diagnosis should, if possible, be clearly established, as serious mistakes may otherwise occur. This unconsciousness may be due to drunkenness, to uraemia, to narcotic poisoning, to epilepsy, or to concussion from a fall or blow. In all cases the history will form a marked determining dis- tinction, and especially is this true in the two last; for if dependent on epilepsy, the attack will not be long, and there will be an account of former seizures; if from concussion, there may be injuries or bruises on other parts of the body, probably bleeding from the ears or nose, and other circumstances tending to the supposition that the insensibility is due to wilfulness or accident. In drunkenness the patient can be aroused to some extent, the insensibility not being complete; there is no hemiplegia, and the smell of the breath will betray alcohol ; yet as drunkenness and an apoplectic seizure may exist together, the diagnosis should be guarded, and if a doubt exists it is better to err on the safe side and act as if they were com- bined. In uraemia there is no hemiplegia, the urine, if drawn off by a catheter, will be found to be albu- minous, and there will in all probability be indica- tions of dropsy in other parts of the body. In narcotic poisoning the pupils are contracted, with 252 DISEASES OF THE NERVOUS SYSTEM. no hemiplegia, no remissions in the insensibility, but on the contrary deepening coma. In all doubtful cases it is advisable to use the stomach-pump. Cerebral Softening. Cerebral softening may be caused either by anaemia or inflammation, and is a result of some of the lesions already described, or it may proceed without any of them, as, for instance, from long-continued intellectual exertion or mental emotion. It is most apt to occur between fifty and eighty. Cerebral softening, the re- sult of anaemia and due to imperfect nutrition of the part affected, is designated white, yellow, or non-inflam- matory softening, and seems to be dependent on the brain-cells being turned into fat — the color being due to the fat-granules being mixed with the coloring- matter of the blood. In advanced cases the softened brain-matter is white and cream-like, and so soft that a weak stream of water washes it away. In the soft- ening due to inflammation the broken-down nervous substance, with the albuminous exudation and blood- corpuscles, causes the centre of the softening to pre- sent the appearance of a red pulpy mass, and hence the term red or inflammatory softening. The symptoms vary according to. the cause which produced them, but, generally speaking, are loss of intelligence and memory, affection of the speech, delu- sions, drowsiness, headache, and slowly advancing paralysis. SCLEROSIS. 253 Sclerosis. In contradistinction to softening of the brain, it is convenient here to consider an affection which of late years has attracted considerable attention. In order to understand what is meant it is well to remember that in the nervous tissue of the brain or spinal cord there is another element present, which binds the cells and fibres together, and gives the whole substance its nor- mal degree of consistence. It fulfils to all intents the purposes of connective tissue in other organs of the body, and has been termed neuroglia or nerve-cement. In sclerosis this tissue is increased or hypertrophied, the proper nervous substance being in consequence compressed and atrophied; the result is increased hardness and density over a greater or less extent of the nervous system. Hence different names are given. Thus, if it involves both the brain and spinal cord it is called "multiple cerebro-spinal sclerosis," if brain alone, "multiple sclerosis" — the sclerotic or hardened parts in these two cases being diffused through the respective areas mentioned as plates or nodules of varying size, and to a certain extent circumscribed ; while in a third form affecting the brain, and termed "diffuse sclerosis," there are no such boundary lines, the hardness affecting one lobe, or even a whole hem- isphere. Without entering further into a subject which may be said to be still in its infancy, it may be useful for the student to recollect that diffuse sclerosis commences in infancy, and terminates always in im- becility, and often in idiocy ; multiple cerebral scle- 22 254 - DISEASES OF THE NERVOUS SYSTEM. rosis is a disease of male advanced life, with pain and trembling of individual or combined muscles, of arms and hands, or other parts, followed by paralysis, which ultimately extends to the trunk; in multiple cerebro- spinal sclerosis paralysis is noticed before trembling, the latter being only evidenced when a voluntary movement is made. These two latter affections were at one time de- scribed under their most prominent symptom, " paraly- sis agitans," particular attention being also drawn to the fact that the victims would run or plunge eagerly forward in a jog-trot style to any tangible object, while they were unable to walk slowly. This mode of pro- gression is now termed " festination." Aphasia. By aphasia is meant not merely loss of voice or aphonia, proceeding from the larynx, not merely im- pairment of articulation, as in the outbreak of hem- iplegia from paralysis of the muscles employed in speaking, but an impairment or loss of the intellectual, as distinguished from the mechanical, element of speech. It is an attack on that peculiar gift of man — articulate speech — the power by which he expresses his ideas, and clothes them in words. Although it is most frequently a combination of loss of power of speech, loss or impairment of the power of writing, and of gestures (pantomimic gestures), yet in its simplest form it appears to be a sudden rup- ture between the formation of the idea in the mind APHASIA. 255 and the expression of it in words, without being neces- sarily accompanied by any loss of muscular power. Hence the division into — 1. Amnesic aphasia (forget- ting or confusing words); and 2. Ataxic aphasia (de- fective action of the muscles of articulation — inability to form even those words which are remembered). Etiology. — The cause of aphasia is obscure. It may occur during convalescence from fever, and is tem- porary, or from cerebral softening or haemorrhage, and is then often permanent. Symptoms. — The patient has an amount of words sometimes at his disposal, but not the right words. Speech is then conducted in a Malaprop fashion, or simply questions are answered in monosyllables, as by yes or no. The face is intelligent. Remembering faces and events, the patient is unable, either by writing or speaking, to find words to express ideas. Nouns are substituted, for nouns, verbs for verbs, numerals for numerals, and proper names for proper names. Examples are given where patients forget their own names, or at least are unable to express them. Yet an aphasic patient may be able to play at cards correctly, and even to read, without, how- ever, being able to recollect what has been read. Though attacks of temporary aphasia are recovered from perfectly, yet, if they are in any way permanent, the prognosis is very doubtful. Pathology. — Aphasia is most commonly associated with hemiplegia of the right side, and M. Broea has at- tempted to prove that this is due to the fact that the power of language is situated in the posterior portion 256 DISEASES OF THE NERVOUS SYSTEM. of the third left frontal convolution of the brain. Post-mortem and clinical experience has not, however, borne out this idea, or shown any very definite dis- tinction. Ingenious theories have been founded on this supposition, the most practical result being, if it is true, that on the right side the same part has also latent power of language, and that we should not de- spair but that this may, in the course of time, be evoked, and a moderately intelligent life be the result. Treatment. — Rest, bodily and mental, is all we can do for an aphasic patient. All excitement should be avoided, the bowels attended to, and the digestion carefully regulated. Blistering or drugging seems of little avail in aphasia with hemiplegia. Yet if there is any syphi- litic history, iodide of potassium should be given (F. 5). Acute Meningitis. By this is understood acute inflammation of two membranes of the brain — the pia mater and the arach- noid. It is generally the result of injuries to the head, exposure to great heat, spirit-drinking, mental anx- iety, or retrocession of an exanthematous eruption. Symptoms. — Headache, vomiting, and rigors usher in the disease, followed by fever, flushed face, and red eyes, contracted pupils, and intolerance of light or noise. Delirium of a furious character is an early and pretty constant symptom. The tongue is coated, and the bowels are confined. If the disease is to ter- minate fatally, muscular twitchings ensue, sometimes TUBERCULAR MENINGITIS. 257 convulsions, and the delirium merges into coma and collapse. Treatment. — Local bloodletting in the early stages, with an active cathartic, is useful (F. 23). The head should be shaved, ice applied to it, and light excluded from the room. Beef tea may be given at regular intervals. Calomel is recommended by some to be given every two hours until salivation is produced. Should mercury not be decided on, the bromide of potass may be ordered in large doses, with or without the iodide. In cases where the patient cannot swal- low, fluid nourishment may be administered by means of a tube passed through the nose. Tubercular Meningitis Is a disease not uncommon in children under five years. Gray tubercular granulations are found de- posited at the base of the brain, along the course of the middle meningeal artery and its branches. The ventricles are found distended with serum, and this characteristic appearance in post-mortem examina- tions led to its being called acute hydrocephalus, be- fore it was understood that the essential cause of the disease was the tubercles and subsequent inflamma- tion. The disease always terminates fatally. Symptoms. — Tubercular meningitis is preceded by signs of failing health for some weeks or months be- fore the attack sets in, which it does generally with obstinate vomiting and intense pain in the head. The child screams, and there is great intolerance of light 258 DISEASES OF THE NERVOUS SYSTEM. and sound. The temperature varies from 101° to 103°. This may be called the stage of excitement, which lasts from seven to fourteen days, and is suc- ceeded by a stage of depression, with a strong tendency to sleep. The child lies quietly on its back, and takes no notice of external objects. Occasionally there is a peculiar scream, called the " hydrocephalic cry." Respiration is irregular and sighing, pulse low, bowels constipated. This stage may last from two or three days to as many weeks, and is followed by a further stage characterized by frequent and violent convulsions, squinting, eyes dull and heavy, paralysis and, coma. Treatment — The line of treatment is indicated under "Tuberculosis," and is simply prophylactic. When the disease has become established, it seems ob- vious, from the nature of it, that little improvement can be obtained. Niemyer advocates iodide of potass, and Hammond advises to refrain from all leeching and mercurial purgatives, as only tending to make existence more intolerable. Chronic Hydrocephalus Can scarcely be mistaken for any other disease, as it consists essentially of an accumulation of fluid in the ventricles, or in and beneath the arachnoid. The head is in consequence altered in form, enlarged in size, the fontanelles open, the forehead prominent, and the face and body thin and wasted. In many cases it is congenital, or the result of chronic inflammatory disease of the membranes, ap- TUMORS OF BRAIN. 259 pearing generally about the sixth month, and lasting for a varying term of months or years, with a fatal termination either from exhaustion or coma. Treatment. — Compression, by means of adhesive plaster applied over the whole cranium, seems service- able ; and if that fails, puncturing and drawing off the fluid may be tried. Cases have been recorded where mercury was beneficial, followed by iron. Any tendency to this disease should be met by fresh air, regulated strengthening diet, and cod-liver oil. All attempts to exercise the brain should be discouraged. Encephalitis Is a local inflammation often followed by abscess. The part most frequently involved is the gray matter of the cerebrum or cerebellum, and the size of the af- fected part varies from that of a walnut to that of the closed fist. It is caused by injuries, or from extension of inflammation from the ear, and is said always to terminate in death. The symptoms during life are increase and after- wards decrease of the sensibility, with headache, con- vulsions, paralysis, or coma. Tumors of Brain May be of various kinds, vascular, parasitic, can- cerous, tubercular, or syphilitic, etc , etc. The growth of a tumor is at the expense of the brain, which in health nearly fills the cranial cavity ; hence pain, usually fixed and severe, is in the majority 260 DISEASES OF THE NERVOUS SYSTEM. of cases a prominent symptom, with disordered sight, hearing, and taste. Convulsions, local paralysis, and giddiness are frequent concomitants. If the pain in the head is severe, fixed, and intense, and there is also a history of syphilis, there is every probabilty of the tumor being of syphilitic origin, and this is strength- ened by finding nodes on the surface of the body. Paralysis. Paralysis or palsy denotes loss of motor power and sensibility in one or more parts of the body. The loss of motor power in the parts affected, the most striking characteristic, may vary from the slightest feebleness to the most complete inability of movement. The former, the incomplete, is now often termed " paresis," while " paralysis" is reserved for the complete or nearly complete. Paralysis may be general or partial, as the whole or only a part of the body is affected, and various names indicate when the paralysis is only par- tial. Thus when it is limited to one side it is termed " hemiplegia ; " if confined to the lower half of the body, "paraplegia;" if only affecting a small portion of the body, as face, foot, or leg, it is designated " local paralysis ; " and if the nerve specially implicated in causing this is 'known, it can be fitly designated accord- ingly, e. g., " facial paralysis," " paralysis motor oculi." Again, paralysis may be due to certain occupations, hence the names " mercurial paralysis," " lead paraly- sis;" or if associated with certain symptoms, it is known by these, hence " wasting paralysis," " paraly- sis agitans." PARALYSIS 261 The more prominent of these affections will now be briefly considered. General Paralysis. — In the course of some forms of mental derangement a gradually advancing paralysis sooner or later involves nearly every mus- cle of the body, and hence it has been called " general paralysis." Paralysis of the lips and tongue leads to defective, blurred articulation, and the invasion also of the facial muscles gives the face a sad or blank look. As the disease progresses to its almost invari- ably fatal termination, the physical powers diminish, and the patient, unable to walk, stand, or sit, is con- fined to bed for the rest of his existence; death occur- ring; either from difficult deglutition, leading to chok- ing, or from sheer exhaustion, or other intercurrent affection. Atrophy of the optic nerve can often be detected by the ophthalmoscope. Hemiplegia. — This is generally spoken of as a paralytic stroke, and though it may be associated with many of the affections previously mentioned, it is most commonly due to cerebral haemorrhage. As the result of this or of some of the other cerebral diseases, the left side of the body is most commonly found paralyzed, although the actual seat of the lesion in the brain is on the right side in the great majority of cases. The decussation of the pyramids accounts for this phenomenon. Owing to the affection of the facial nerve, the cheek hangs loosely, with the angle of the mouth slightly drawn upwards to the sound side, and the tip of the tongue, when protruded, by the implica- tion of the hypoglossal, is pushed to the sound side, owing to the counterbalancing power of the corre- 262 DISEASES OF THE NERVOUS SYSTEM. sponding muscles being lost. The articulation is im- perfect, and if the third nerve is also involved, the upper eyelid drops, the pupil is dilated, and there is a divergent squint. The loss of motion may be com- plete in the arm and leg, and the patient lies in bed helpless. If it is partial, or if the original attack is being recovered from, the gait is peculiar, the affected leg being drawn after the sound one in a shuffling way, with, if the patient is able to lift the foot so far, the toes pointed -to the ground. In most cases there is loss of sensibility as well as motion. Hemiplegia may be permanent, or it may tend to recovery, which commences in the leg. Treatment — Two weeks after the original seizure, but not sooner, it is by some recommended daily to use friction over the paralyzed parts, with flexion and extension of the joints. Subsequently the subcutane- ous injection of strychnia is recommended, or prepara- tions of phosphorus (F. 85) may be taken internally. The most valuable agent is, however, the application of the constant current. Paraplegia has usually an insidious commence- ment; the feet and legs feeling weak, cold, or ting- ling. As the disease advances, the weakness increases, sensibility and power of motion are gone, and the patient is obliged to remain in a horizontal position, having lost also control over the bladder and rectum. Rest is frequently disturbed by involuntary move- ments of the limbs. Paraplegia may be due to caries of the vertebrae, to concussion or compression, congestion, inflammation, PARALYSIS. 263 or softening of the spinal cord or its membranes. It may also accompany other affections, as hysteria, preg- nancy, worms, or urinary diseases. The history must be the chief guide to the diagnosis as to whether the paraplegia is primary or secondary, dependent on con- gestion or diminished nutrition. Treatment. — If from the nature of the symptoms it is considered that congestion, or too much blood being sent to the cord, originates the paraplegia, it is desira- ble to administer the ergot of rye internally, and bella- donna externally. Both these remedies contract the vessels of the cord and membranes. If, on the other hand, there are evidences of malnutrition or of reflex paraplegia, strychnia is to be preferred, combined, if there is much restlessness, with opium and a generous diet. In addition to this, if the paraplegia seems of reflex origin, the cause should, if possible, be removed. Thus worms must be expelled, the bladder relieved, and hysteria obviated. Facial Paralysis, or Bellas Paealysis, is an affection of the portio dura or facial portion of the seventh pair of nerves, either at its origin or in its course, or as the result of pressure. The appearances are characteristic, as there is paralysis of motion, more or less complete, of the muscles supplied by the nerve. Hence the face has a blank unmeaning expression. The eye of the side affected cannot be closed, tears run over the cheek, the mouth cannot be pursed up to whistle, nor expanded to smile. In accordance with the anatomy of the facial nerve, it will be found that if the morbid process originates above the origin of 264 DISEASES OF THE NERVOUS SYSTEM. the chorda tympani nerve, there will be a diminution of the sense of taste in the corresponding side of the tongue; if behind the gangliform enlargement of the petrosal nerves, there will be, in addition to the other symptoms, paralysis of the parts supplied by these — the uvula will be drawn to the sound side, and the palatine arch will fall down and become straight in- stead of curved. By the tongue being unparalyzed and deglutition unimpaired it is distinguished from glosso-labial pa- ralysis, and by the fact that the patient cannot close the eye, from the facial paralysis of hemiplegia. Facial paralysis is often the result of cold or debility or syphilis, and tends to recovery in from six to ten weeks. If dependent on cerebral or intracranial lesion, the prospect of cure is remote. Treatment — The persistent use of electricity is of great importance, one pole of the induced current being placed over the point of exit of the nerve, while the other is applied in succession over the various muscles supplied by it. The healthy nutrition of the system should be secured by hygiene and tonics, es- pecially strychnia. If there is reason to suspect a syphilitic taint, give potash and mercury (F. 1). Paralysis of the Third Nerve, Motor Oculi. — The paralysis of this nerve depends upon tumors or exudations pressing on it, or cold, or reflex irrita- tion, such as worms or indigestible food. The upper eyelid in consequence falls down, occasioning the con- dition termed ptosis, and if of intracranial origin the eyeball is turned outward and the pupil is dilated. PARALYSIS. 265 If due to cold and not dependent on cerebral causes, recovery is the rule. Glosso-labio-laryngeal Paralysis. — The es- sential lesion here is found in the medulla oblongata and upper part of the spinal cord, and consists of atrophy of nerve-cells connected with the origin of the hypoglossal, spinal accessory, and pneumogastric nerves. As 'a consequence there is a slow yet steady loss of power of the muscles of the tongue, soft palate, pharynx, and larynx, and also of the orbicularis. The disease, dependent on unknown causes, invariably results in death from asphyxia or cessation of the heart's action through implication of the cells of the pneumogastric. Mercurial Palsy or Tremor is caused by long- continued exposure to the fumes of mercury, and is characterized by tremors and jerkings of the voluntary muscles, beginning in the arms, but extending some- times to the legs, tongue, and jaws. These move- ments are increased by the mind being brought to bear upon them or by attempts at exertion. Permanent bad health is often the result. Treatment. — This consists in withdrawal from the cause to a fresh, pure atmosphere, and giving iodide of potassium. Lead Paralysis has been considered under " Colic," page 176. Wasting Palsy, Progressive Muscular Atro- phy. — In this peculiar disease loss of strength in cer- tain muscles of the body, particularly the shoulder, arms, and hands, attracts first the patient's attention, 266 DISEASES OF THE NEKVOUS SYSTEM. and this is followed by atrophy of the muscular tissue, not merely of the parts primarily affected, but pro- gressing until every voluntary muscle of the body may be involved, with the exception of the muscles of the eyeball or the levator palpebrse superioris. The affection seems peculiar to males from twenty-five to thirty-five years, and in some instances to be hered- itary. The cells of the anterior tract of* gray matter of the spinal cord appear to be destroyed by a slow chronic inflammation; and the presumption is, since the disease is unaccompanied by paralysis, that the cells involved are not motor cells, but those which are supposed to govern the nutrition of muscles — trophic cells. The prognosis is very unfavorable, especially if the disease is hereditary. Treatment. — This must be based on the steady em- ployment of the continuous and interrupted currents, with tonics or iodide of potassium if there is any sus- picion of syphilis. Writer's Cramp is a form of nervous disorder at- tacking those who are engaged in writing a great deal. It is first attended with fatigue and inability to hold the pen firmly, and ultimalely, if it progresses, by spasmodic irregular movements of the fingers and thumb when any attempt at writing is made. Half-measures are of little avail in writer's cramp, and complete abstinence from work is necessary to restore nervous vigor. Infantile Spinal Paralysis is generally ushered in with fever, convulsions, and pain in the back, marking the seat of the disease as being in the spinal NEURALGIA. 267 cord. Then it is noticed that the child does not use one hand or kick with one leg, or the paralysis ob- served may be restricted to a group of muscles, or em- brace the four limbs. The temperature of the affected limbs is lower than the corresponding sound ones. This loss of power may last a month or six months, and is succeeded by atrophy, with loss of the electric contractility of the affected muscles, and in some cases even by arrest of development and degeneration of the bones. The essential lesion appears to be situated in the anterior horns of gray matter, consisting of an inflammatory softening leading to degeneration and atrophy of the part affected. Treatment. — This is local and general. The induced current should be applied directly to the skin over the paralyzed muscles, and afterwards friction with a dry towel or flesh-brush should be practiced several times in the course of a day. Ergot should also be given in ten-drop doses of the fluid extract thrice daily, and may be increased up to half a drachm. If the stage of atrophy is reached, ergot is useless, and strychnia must be administered (F. 80), with the persevering use of the induced current, should the muscular con- tractility still continue. "If this is lost to the in- duced current, the cure will be difficult and the treat- ment protracted; if the primary current is also power- less, a cure is impossible." (Hammond.) Neuralgia. Under this head should be included affections which, so far as can be ascertained, are not due to diseases of 268 DISEASES OF THE NERVOUS SYSTEM. the brain or spinal cord, but the seat of which is in the nerves themselves. Different names are given, according to the site or the nerves affected. Thus we have facial neuralgia, or tic douloureux, sciatica, and lumbago. Facial Neuralgia is more apt to attack females than males during adult life, and seems often to have some connection with menstruation, lactation, mental excitement, or exposure to cold. The pain is fre- quently excruciating, coming on and disappearing at fixed hours of the day. It may attack the nerve at any or all of its divisions. Sciatica. — The pain is referred to the course of the sciatic nerve or its branches, and may be restricted to the gluteal region or upper part of the thigh, or it may extend to the soles of the feet. It generally lasts from two to three months, but is apt to recur. It is often associated with a lowered physical stamina, and sometimes there is a previous history of gout, rheumatism, or syphilis. Lumbago and Pleurodynia. — The dorsal and intercostal nerves are here the seat of pain, which is continuous in character and much increased by exer- tion. The mere act of straightening the back in lum- bago often causes great agony. Treatment — In facial neuralgia quinine and arsenic are efficacious, with the addition of colchicum if there is a history of gout, or liquor potass if rheumatism. Locally, to arrest the paroxysms, morphia may be sub- cutaneously injected. A fresh pure air is indispens- EPILEPSY. 269 able to any treatment. Cod-liver oil, iron, and strychnia are often useful (F. 4, 75, 78). In sciatica one injection or two daily of morphia into the tissue of the nerve, or as near to it as possi- ble, seems not only palliative, but even curative. Among other remedies which may be mentioned, stand strychnia, phosphorus, and iron, acupuncture, repeated blisters, Turkish baths, or the local applica- tion of aconite and veratria in the form of an oint- ment. The induced current, continued for half an hour, is sometimes singularly beneficial in this as in the other forms of neuralgia (F. 63). Epilepsy, Sometimes also termed falling sickness, and popu- larly, fits. No definition can be given of epilepsy, because no definition would embrace all its phenomena. Yet it may be stated generally to be a disease characterized by certain leading features, viz., sudden loss of con- sciousness and sensation, with clonic spasms of the voluntary muscles, usually followed by exhaustion and coma. The essential element of epileptic paroxysms is loss of consciousness. Etiology. — The tendency to epilepsy is often hered- itary, but various other causes may be mentioned. Occurring often at puberty, it is justly considered in many cases to be a lamentable corollary of masturba- tion, of too early and frequent sexual intercourse, of malformations of the head, of the scrofulous diathesis, 23 270 DISEASES OF THE NERVOUS SYSTEM. or it may be the direct result, either to himself or children, of a habitual drunkard's habits. These are centric causes ; while as eccentric sympa- thetic causes may be mentioned, uterine derangements, irritation of teething, and a disordered state of the stomach and intestines. Fright is a prominent excit- ing cause in a person predisposed to epilepsy. The first seizure occurs usually betwixt the tenth and twentieth year. Symptoms. — These are best divided into what occurs before, during, and after a fit. Warnings of various kinds may precede the attack. Spectral illusions, confusions of thought or speech, headache, dimness of vision, or what the patient de- scribes as the indescribable sensation of an inward working. The most curious forerunner of a fit is what is termed the " epileptic aura or vapor." It seems to come from some distant part of the body, and patients describe it creeping along, as water may trickle or a serpent crawl, until it reaches the head or stomach, when consciousness is lost in the fit; or there may be what is termed a "motor aura" in contradistinction to this, the sensory aura, recognized by twitching or palsy of some part of the body. With or without these precursors the fit is ushered in by a shrill cry, and the patient falls down uncon- scious, and struggles hard in convulsions. Unable to select a convenient place, the fall in itself may seriously hurt him. The patient gnashes his teeth, pushes out and often bites his tongue, foam gathers at the mouth, forehead and eyebrows twitch, eyes are partly open EPILEPSY. 271 and partly shut, and the pupils are insensible to light, and dilated. The body writhes in convulsions, or is jerked from side to side, and what is popularly thought to be characteristic of the disease may be observed, viz., "the flexing of the fingers, and more especially the flexing of the thumb into the palm of the hand." The urine and feces are often passed involuntarily. The fierceness and alarming nature of the attack renders minutes hours to the bystanders, as a fit averages only five to eight minutes in its duration, although it may last half an hour or more. After perhaps a more sharp convulsive movement, there is deep sleep, from which the patient awakens with utter unconsciousness of what had occurred; with headache, red eyes, dilated pupils, and a peculiar stupid expression of countenance. This is succeeded by seemingly restored health, but ultimately by other seizures, the interval between the occurrence of which varies. Usually an interval of four or five weeks elapses, and this is followed by a series of fits, occur- ring at short intervals. Although epileptic attacks are not primarily fatal, yet gradually the constitution is sapped, the mental and bodily vigor impaired, and not unfrequently the unhappy victim of epilepsy ends his days in an asylum. Such is a description of what is termed the "grand mal," and from which a sliding scale can be traced to what is known as the "petit mal." Here unconsciousness may be as complete as in the severer forms, but the fits may last only a second or two, as, for instance, the person stopping in 272 DISEASES OP THE NERVOUS SYSTEM. the middle of a conversation for a few moments, to re- sume talking where he left off, quite unconscious of the fit. Pathology. — Should death occur during a paroxysm, the brain is found more or less congested, while, in long-standing cases, it may be softened or indurated, and increased in weight. The researches of Schroeder van der Kolk point to the medulla oblongata as the seat of the disease, which is supposed to be more ex- citable and sensible, by an increased afflux of arterial blood, or from the accumulation in the system of some materies morbi^ which leads to an explosion as seen by the epileptic fit. Hughlings Jackson and Ferrier have given rise to epileptiform fits in animals by stimulating (galvanic) certain convolutions of the brain, which if removed do not cause paralysis, but yet when stimulated give rise to these convulsions. Hence, epilepsy seems to have an explosive lesion, like the discharge of a battery, although we cannot say that an excess of energy is manifested, for we must take into account the energy required for constraint, which is taken away, and thus all energy is concen- trated in the abnormal convulsion. Treatment — This consists of two points : 1st. What to do during, and 2d, after a fit. 1. Chloroform may stop a fit, but it leaves the per- son more stupid and afflicted afterwards, and is thus inadvisable. Certain obvious duties are necessary. If the head is hot, apply wet cloths, if feet cold, warmth. The necktie should be unloosened, and the patient placed in such a way, with head somewhat elevated, EPILEPSY. 273 as to prevent him doing himself injury against articles of furniture. If possible a piece of wood, cork, or india-rubber should be placed between the teeth to prevent the tongue being bitten. 2. It is impossible to get rid of certain predisposi- tions, such as a strumous diathesis, a misshapen head, or organic lesion of the brain or spinal cord. At the same time some eccentric causes are remediable. If due to worms, give a vermifuge. If a syphilitic history is told, iodide of potass and the bichloride of mercury are serviceable. If dependent on vicious habits, the patient must be warned against these." The system should also be braced up by good air, cheerful society, and the shower-bath, if it produces after using it a genial glow of warmth. With regard to other remedies, the following are the most noteworthy. Counter-irritation to the nape of the neck, either by cupping, leeching, setons, or blisters. Atropia, gr. ij ; spt. vin. rect., 5ij. Begin with one drop and increase to 20 daily, continuing this for months, and gradually diminishing the dose. Nitrate of silver and acetate of zinc have also been recom- mended. Latterly the favorite and most useful drug seems to be bromide of potassium, given in 10, 20, or 30 grains thrice daily, and continued for some time. Numerous other supposed specifics might be men- tioned, the fact being, as Esquirol remarks, " that epileptics are apt to improve for a time under every new form of treatment.'' Careful watching is important in epilepsy, so that 274 DISEASES OF THE NERVOUS SYSTEM. patients may not be in a dangerous position when a fit occurs. Chorea Literally means a dancing or jumping, being de- rived from the Greek word yopzia. It is the " Saint "Vitus's dance " of this country, the "St. Weit" of Germany, and "St. Guy" of France. It may be defined as a disease most commonly affecting girls between the sixth and the sixteenth years, and char- acterized by irregular action and restlessness of the voluntary muscles of the face and limbs. It some- times attacks boys. As a rule it is confined, in either sex, to the left side. Etiology. — The exciting cause is usually fright, by which the stability of the nervous system is disturbed. Sometimes it is due to worms and to carious teeth; and, as it is often associated with a previous history of rheumatism, and with a systolic murmur at the apex of the heart, it is by many considered due to this disease, or to embolism in some part of the cerebral circulation. The general health is usually below par at the time of the attack. Symptoms. — Twitching of the muscles of the face is generally first observed. This is followed by a halt- ing or unsteady movement of the leg, which the patient drags. Then the hand of the same side is affected, and the patient is unable to keep it in the same posi- tion for any length of time. It is jerked away from any position in which it is placed, and it is unable to retain anything within its grasp. Patient has power, CHOREA. 275 but not control. The articulation is impeded, and in severe cases the tongue, when protruded, is drawn back again with a sudden snap; but consciousness is not affected. Looking at, or drawing attention to, the patient increases the irregular movements. It may be unilateral or bilateral, — in the former case being called hemichorea. During sleep the movements usually cease. The duration of the disease may be stated to be from five to six weeks, although it sometimes becomes chronic and lasts several months. The disease seldom terminates fatally, except when, as rarely happens, it is very acute, and complicated with other affections, as cholera or acute rheumatism. In such cases it is attended with fever, the spasms being of excessive in- tensity; not painful, but still prohibiting sleep, and thus exhausting the system. Pathology. — The post-mortem appearances in those cases which do prove fetal give little insight into the nature of the malady. In some the brain seemed per- fectly healthy, in others there has been noted a serious effusion beneath the arachnoid and into the ventricles. In one case, related by Dr. Aitken, the specific gravity of the corpus striatum of the right side was increased. Treatment. — After a brisk cathartic, combined, if there is any suspicion of worms, with an anthelmintic, the patient should have a carefully regulated easily digested diet; and, if unable to feed herself, should be assisted to do so. Various remedies have been recommended, a^ steel, oxide of zinc, sulphate of copper, nitrate of silver, 276 DISEASES OF THE NERVOUS SYSTEM. bromide of potass, and chloral. None of these has been in my hands nearly as useful as arsenic, given in the form of liq. arsenicalis thrice daily. Sometimes I have combined the arsenic with iron, as in the following formula: R. Vin. Ferri, gij. Liq, Arsen., rr^v. Ft. haust. — To be taken thriee daily. In the very acute cases, where a fatal issue may be feared from sheer exhaustion, it would be proper to keep the patient under the influence of chloroform for protracted periods. It may here not be inappropriate to state that a peculiar affection of the nervous system, characterized by inability to retain the fingers and toes in any posi- tion in which they may be placed, and by their con- tinual motion, has been termed by Hammond athetosis (aOero<:, without fixed position). The conditions which occasion it are as yet unknown. It seems, however, to resist all therapeutic efforts. Delirium Tremens May be defined as alcoholic poisoning, attended with a delirium in which there are great restlessness, suspicion, trembling, and various delusions. Etiology.— The cause is drink. Distilled spirits more surely than wine; wine than beer. The man, it may be added, who, with a highly- wrought nervous organism, drinks to excess to drown the consciousness that he is drinking, is more likely to be affected, with DELIRIUM TREMENS. 277 delirium than the habitual swiller, who may drink to excess, but is able to sleep it off'. Symjrtoms. — Sleeplessness is the most characteristic symptom, and this sleeplessness is associated with busy restlessness, a chattering tongue, fidgety hands, and imaginary spectra. The tongue is protruded in a tremulous way, as in fever, but it is not brown and parched, but moist and creamy. The pulse is soft and compressible; the skin often bathed in perspiration. The patient may coherently reply to a question or two, but soon after relapses into the fancies character- istic of the disease. These fancies are not pleasant, but associated with the low r est and most repulsive forms. Thus rats, mice, serpents, and imaginary de- mons are crawling about him, and, in endeavoring to escape or destroy these, his mind is sorely tried. Often he peeps suspiciously behind the curtain, draws the bedclothes over him, or attempts to leave his bed. Cowardice rather than violence is exhibited both with regard to himself and his actions towards others. The disease tends to recovery, on the third or fourth day, by a sleep from which the patient awakes re- freshed. In fatal cases the symptoms are aggravated, and attended with intense watchfulness, low 7 mutter- ing delirium, subsultus tendinum, and great exhaus- tion. Pathology. — In fatal cases the subarachnoid tissue has been found so infiltrated with fluid as to raise the arachnoid to the level of the convolutions. The cere- bral arachnoid exhibited considerable opacity all over the hemisphere, and the ventricles contained a small 24 278 DISEASES OF THE NERVOUS SYSTEM. amount of fluid; while the cerebral arteries and other parts of the brain were perfectly healthy. Treatment. — The objects in treatment are, to prevent the further introduction of the poison into the system, to quiet the nervous excitement, and to sustain the strength while the accumulation of alcohol is being thus eliminated from the system. To fulfil these indications all stimulants should be forbidden if the patient is young and strong. If there is a history of previous attacks, and the patient is weak, it is advisable to taper off their withdrawal. If the patient can be persuaded to take some beef tea; or chicken soup, there is not much danger in the disease nor necessity for medicinal treatment. If, as often happens, there is loathing of food, it seems ad- visable to place six grains of calomel on the back of the tongue. The liver is thus stimulated to action. Opium must also be given afterwards, combined with antimonial wine, or, if the stomach cannot retain these, morphia must be injected hypodermically until sleep is induced. If the pupils are contracted under its use without sleep, it has been pushed far enough and should not be continued. Bromide of potass and chloral are sometimes substituted for opium benefi- cially. Nourishment as indicated should be given often and cautiously (F. 69, 70). All force, as in the form of strait-jackets, should be discountenanced. The services of well-skilled attend- ants, combined with kindness and humoring of the fancies, seem to be sufficient, even in the most violent cases. It is well not to restrict the patient from SUNSTROKE — HYSTERIA. 279 reasonable muscular exercise, as this conduces to sleep and appetite. Sunstroke. Coup de soleil and heat apoplexy are synonyms ap- plied to a disease peculiar to warm climates, but oc- curring also in this country. Two forms are observed, one in which the disease is due to the direct influence of the sun's rays, the person being struck down sud- denly, with stertorous breathing, slow, full pulse, un- consciousness, and marked heat of head. In the other form excessive heat without exposure to the sun may produce, by some blood-change, phenomena similar to syncope, with weak pulse, and no stertor of the breathing. Nothing characteristic is detected after death in the brain. Treatment. — Apply ice or iced water freely to the head, which should be raised. Afterwards leech or cup behind the ears, and administer a purgative enema for the first form, the true coup de soleil. For the second, cool the body by means of cold douches, after- wards apply sinapisms to the spine, epigastrium, and limbs; administer also stimulants. Hysteria. Hysteria is best known by its clinical history, as evidenced by its affecting the mind, the sensibility, motor or visceral action, or as it counterfeits other disorders. 280 DISEASES OF THE NERVOUS SYSTEM. Mental Symptoms. — These may be of the most varied character. There may be extreme talkativeness or utter silence ; depression of spirits to the shedding of tears succeeded by immoderate laughter, from one and the same cause. Emotions exactly opposite to the proper ones for the occasion may be excited. A tale of grief directly af- fecting the patient may be greeted with every sem- blance of joy. Good fortune may awaken a wringing of the hands, and a shedding of tears. The news that burglars have entered the house may induce stoical indifference. Illusions are common, — a ball rolling over the floor is mistaken for a rat; rain on the roof for burglars entering the room. Hallucinations are equally frequent. " One patient sees angels, another demons, another animals of various kinds." That these disordered mental emotions, illusions, hallucinations, and other allied phenomena, are not due to insanity, is evidenced by the fact that they do not last long, nor color much the conduct of life. Sensibility may be increased or diminished. Pain is felt in varying situations, rarely fixed to one place, and generally described as excessively acute. Pain in the joints, especially the knee, is a common hysterical affection ; though this may be accompanied with swelling, there is no accumulation of fluid in the synovial membrane. The pain in this, as in other parts, also ceases at night; is increased by handling rather than by a severe pressure ; and may be HYSTERIA. 281 cured spontaneously by prayer, by sudden movements, or other causes. The organs of the special senses may be sensibly exalted, vision more keen, hearing more acute, and smell morbidly sensitive. Anaesthesia, though not so common as hyperesthesia, may yet be a phenomenon of hysteria. Its most com- mon seat is the skin, and to such an extent may this be the case that no irritation of the particular part affected is of any avail, not even the wire-twist of the electric coil. It is to be noted that the attacks are not preceded or accompanied by numbness. Alterations of motion, as evinced by paralysis, or clonic or tonic spasm. Thus there may be loss of voice, suddenly appearing and disappearing, or partial or complete paraplegia. Spasm, fixed (tonic), frequently affects the pharynx, giving rise to the sensation of a ball in the throat, " globus hystericus." Spasms (clonic), simulating chorea and epilepsy, are the frequent outcome of attendance on spiritualistic or revival meetings. Digestive Symptoms are various and not uncommon ; the urine is usually increased in quantity, of a low specific gravity and light color. It is frequently voided unconsciously during a paroxysm. Causes. — The affection is peculiar to females, espe- cially between the ages of sixteen and twenty-five. Above all causes may be mentioned lack of aim in life, thus throwing the mind and the emotions back upon self. Hysteria is unknown in savage countries, 282 DISEASES OF THE NERVOUS SYSTEM. and it seems to be a direct attendant frequently of luxurious habits and perhaps ungratified desires. It is frequently met with in patients suffering from uterine or menstrual affections. It is often hereditary. Morbid anatomy and pathology contribute nothing to elucidate the mystery of hysteria. Brain, spinal cord, and sympathetic nerve give no evidence of its former presence ; neither do the generative organs, the stomach or intestines. It seems essentially to consist in the predominance of the emotions over the intellect, and especially over the will; the intensified character of this interfering with the sensibility of various parts of the body, and sometimes deranging the contractility of the muscles. Treatment, — Gain the confidence of the patient, and thus treatment, medicinal, moral, or dietetic, will be more apt to produce the desired effect. During the paroxysms nothing equals chloroform, though some- times dashing water on the face and moral suasion may be sufficient. During the period between the paroxysms the treat- ment must be mainly directed against symptoms, If hyperesthesia, a full course of bromides is essential; if anaesthesia, the induced current over the affected region. For hysterical paralysis, strychnia and phosphorus, together with the use of electricity both of the primary and induced forms, should be tried. In hysterical vomiting, bismuth or hydrocyanic acid (F. 9). DISEASES OF THE SPINAL CORD. 283 Finally, valerian, or valerianate of zinc, is a favor- ite remedy; and careful attention to any menstrual disorder is necessary, should such exist (F. 14). DISEASES OF THE SPINAL CORD. Spinal Meningitis. — Inflammation of the mem- branes of the cord may be either acute or chronic. It is generally caused by exposure to cold or moisture, or injuries. It is characterized in both forms by pain in the back, which is increased by movement, and follows the course of the nerves proceeding from the diseased region ; by spasms in the muscles of the back, reflex motion unaffected, and paralysis, varying in extent and intensity, but generally progressive to a fatal termination. Pathology. — The lesions found after death are gen- erally restricted to the pia mater and subarachnoid space, and consist in thickening of the membrane, turgid ity of the vessels, and the effusion of a large quantity of spinal fluid. Myelitis. — Inflammation of the spinal cord may either be general, affecting the whole extent of the cord, or partial, restricted to a limited portion. It is more frequently the result of an injury than anything else. The symptoms vary with the seat of the dis- 284 DISEASES OP THE SPINAL CORD. ease. The most prominent, however, are pain in the back, a feeling as of a tight cord tied round the body, rapid and complete paralysis, alkaline urine, a marked tendency to sloughing of the skin, speedy loss of elec- tric contractility, and depression of temperature in the paralyzed parts. The termination of acute general myelitis is in death, sooner or later. In the partial variety life may be prolonged, but at the expense of loss of motion and sensibility below the diseased portions. Hemorrhages into Spinal, Cord. — Extravasa- tion of blood may occur into and around the cord through disease of the vessels with increased blood- pressure. It is characterized by a sudden onset, local pain, reflex and motor paralysis of varying amount, and occasional jerkings of the muscles. The bladder and rectum are frequently paralyzed. Recovery often occurs if the haemorrhage is not very extensive. Congestion. — As the result of cold or over-exer- tion, congestion of the spinal cord may ensue, the chief symptoms of which are some pain in the spine, with tingling of the extremities, and paraplegia, which is, however, rarely complete. Paralysis of the bladder, with constipation, is common, but there is no tendency to sloughing or wasting of the muscles. The result is sometimes recovery, sometimes permanent paraplegia. Softening of the Cord is the common termina- tion of acute myelitis, but it may originate primarily, DISEASES OF THE SPINAL CORD. 285 without any evidence of inflammation, hence it has been termed " non-inflammatory softening." The first symptom observed is numbness of those parts of the body below the seat of lesion ; this is followed by want of motor power, and the two advancing together afterwards become more and more marked. The dis- ease progresses to utter helplessness. The functions of the bladder and bowels are interfered with, and there is a marked tendency to sloughing of the skin. . The nerve-cells in the gray substance are destroyed, and the nerve-tubules of the white substance have their place taken by oil-globules and granule- masses, the constituents of which are fat. Spinal, Irritation. — The term spinal irritation seems first to have been used by Dr. C. Brown of Glasgow, in 1828. Its existence as a distinct disease has given rise to much controversy. Hammond, while retaining the term, thinks that it is due to anaemia of the posterior columns. It is specially recognized by the occurrence of tender spots in the skin or deeper tissues over one or more parts of the spine, and by neuralgic pains shooting over different regions of the back. It is peculiar to females of a weak habit of body between the ages of fifteen and twenty-five. " In general terms, it may be stated that any cause capable of reducing the system may produce spinal irritation." In doubtful cases, where it may be confounded with myelitis, meningitis, or congestion, it is said that a hypodermic injection of one-thirtieth of a grain of strychnia will settle the difference. This invariably 286 DISEASES OF THE SPINAL CORD. aggravates the symptoms of the other diseases, while it is the efficient means of cure in spinal irritation. Locomotor Ataxy Is a peculiar form of paralysis, due to disturbed co- ordination of muscular movements. In health the muscles must contract and relax together, in unison with the movements we may desire. If one muscle contracts too soon, and another relaxes too quickly, then there is disturbed co-ordination of muscular movements. Etiology. — The cause of locomotor ataxy is obscure, yet undue exposure to cold or damp after a long journey, venereal excesses, mental exhaustion, and syphilis, seem in some cases to lead to its occurrence. Symptoms. — The origin is insidious. The first sus- picion of there being anything wrong is frequently awakened by an inability to run, through a feeling of the legs being too heavy. This is followed by fatigue after any exertion, and by increased micturition. The desire for sexual intercourse is at this stage of the disease increased. The disease progresses often slowly, and months and years may intervene before the patient presents the well-marked symptoms of locomotor ataxy, viz., a straddling gait in movement, the foot being lifted high in the air and planted down heel first. To support his balance the patient grasps at anything that may be near, as a friend's arm or a convenient chair. He is unable to walk in the dark, or with his eyes shut. A feeling of constriction round the waist LOCOMOTOR ATAXY. 287 is also complained of, as if a cord were drawn tightly round it. In severe cases the patient cannot stand stead) 7 , cer- tainly not with eves shut, nor can he walk on a nar- row board, the breadth required being a gauge of the severity of the affection. Usually there is diminished tactile and muscular sensibility of the lower extrem- ities, with numbness or formication. These symp- toms may be preceded by transitory pains, as well as fleeting phenomena, referable to the cerebrum, or am- aurosis, difficult deglutition, etc. Electro-muscular contractility remains intact to the last. There is no palsy or wasting of the muscles, and, if the patient is placed on a chair, you cannot bend his legs against his will. As the disease progresses it does not stop at the legs, but creeps upwards. Arms, hands, and fingers, are involved. The coat cannot be buttoned, the pin put into the cravat, or the spoon carried to the mouth. The urine is passed involuntarily in bed, and now the sexual power and appetite are diminished. Thus the patient may remain for years. Ultimately the lower extremities become thinner, emaciation attacks the whole body, and death results from general weakness, consumption, or other intercurrent disease. It is especially a disease of males, and is rarely met with in youth, usually occurring between the ages of thirty and fifty years. Pathology. — Locomotor ataxy depends on disease of the posterior columns of the spinal cord and posterior roots of the spinal nerves. There is atrophy and de- 288 DISEASES OF THE SPINAL CORD. generation of the nerve-fibres to a greater or less ex- tent, and they become ultimately thin, translucent connective tissue cords. The anterior roots of all the nerves are normal, and there is also a healthy condition of other parts of the nervous system. Treatment — The patient should carefully avoid overstraining his limbs. Medicinal treatment is essen- tially tonic and strengthening. The metallic tonics, especially silver, are frequently prescribed. Probably the best chance will be afforded by a prolonged and careful application of the constant current to the back and limbs, which often at least gives relief to the neuralgic pains which are frequently so troublesome. Cerebro-Spinal Fever, Epidemic Cerebro- spinal Meningitis. This peculiar disease appears to consist in an inflam- mation of the membranes, and sometimes also of the substance of the brain and spinal cord. Its origin is unknown, its epidemic character undoubted; but its contagiousness is questioned. It affects chiefly the male sex between fifteen and thirty, if crowded together during cold weather, as in barracks or workhouses. Symptoms. — The attack is sudden and characterized by intense pain in the head, prostration, with spasm and rigidity of the muscles of the back of the neck, and great sensitiveness of the whole surface of the body. The temperature of the body is abnormally low at first, and never reaches any great height. A peculiar petechial eruption is often present on the HYDROPHOBIA. 289 neck, breast, or limbs, of a red, purple, or black color, and varying in size from a pin's head to three-quarters of an inch in diameter. The course of the disease is rapid, as some die within a few hours, many within twelve or twenty-four. The first four days are most dangerous; after that time there appears to be a fair prospect of recovery. About half of those attacked die. Treatment is unsatisfactory. Stimulants are recom- mended from the outset, with the application of leeches behind the ears to relieve the headache, and ice to the spine and head to mitigate the spasm. The hypo- dermic injection of morphia; chloral and bromide of potassium have been strongly urged; and its resem- blance to malarial fever has suggested the use of quinine. Hydrophobia. The term hydrophobia was first used by Celsus 200 B.C., and simply expressed one prominent feature of an affection, the pathology of which has ever remained obscure, viz., dread of water, or, it may be added, of liquids in any form. It is the result of the implanta- tion of a specific virus; this inoculation taking place most frequently from the bite of a rabid animal, especially the dog. The skin must be wounded, and its spontaneous development is never known. Wounds so occasioned are more dangerous on the hands and face than on the lower extremities, probably because the clothing worn intercepts the virus. After the infliction "of the wound there is a sta^e of 290 DISEASES OF THE SPINAL CORD. incubation, varying from six weeks to as many months, daring which time the wound heals perfectly. After this a peculiar pricking sensation is felt over the site of the cicatrix, accompanied with general symptoms of restlessness, depression, and disturbed sleep. On these supervene the terribly significant phenomenon of dread of liquids and intense thirst. As the disease progresses all attempts to drink are avoided. The sight even of a drinking vessel containing water is intolera- ble, and the patient turns away his face, shrieking out at the slightest touch or breath of air. The muscles of the neck and trunk, and even the whole muscular system, contract spasmodically with convulsive trem- bling of the limbs; at times, during the frenzical fits, snapping motions are made with the jaws, like biting. Although during convulsions mental hallucinations occur, yet in the temporary cessation from these the patient responds correctly to questions, begs friends not to leave him, and with a consciousness of impend- ing death, may ask them to pray for him. The saliva is now greatly increased in quantity, and, as it cannot be swallowed, is ejected in all directions. The respi- ration is hurried, and accompanied with a sighing sob. This state may continue from one and a half to three days, and is succeeded by a stage of paralysis lasting two to eighteen hours, with an abatement of the dis- tressing symptoms, but greatly increased weakness, which deepens into death. The skin is covered with a clammy sweat, pulse small and irregular, saliva running from the mouth, and accelerated breathing. TETANUS. 291 The duration of the disease in hydrophobia is only from two to four days. It always terminates fatally. Treatment. — This is of no avail, although many remedies have been tried ; yet humanity dictates the removal of every cause of excitement, the separation of the patient from everything calculated to disturb or render him anxious, and the maintenance ~of the strength by nutritious enemata during the temporary abatement of the spasms, or while under the influence of chloroform. Tetanus. Tetanus may be either idiopathic or traumatic, and speaking generally, in both cases seems essentially to consist in an inflammatory affection of the spinal cord. It is one of the most fatal of maladies, and in its idiopathic form appears to be induced by exposure to cold or damp, especially in those who have suffered from wounds ; it has also apparently been caused by worms, by abortion, and by diseases of the womb. The first symptom is pain in the epigastric region, extending backwards to the spinal column, and due to spasm of the diaphragm. Succeeding this are stiff- ness of the throat, fixedness of the jaws, and diffi- culty of swallowing. Sooner or later there follows tonic, i. e., continuous, spasms of the neck, back, and loins, causing the body to assume the form of an arch (opisthotonos). The skin is hot, the temperature high, from 105° Fahr. to 110° Fahr.; wakefulness, thirst, and constipation are also prominent symptoms. Strychnia poisoning may be mistaken for tetanus, but 292 DISEASES OF THE SKIN. it is distinguished from it by this, that there is no epi- gastric pain, spasms are more rapidly developed, and do not commence in the jaw. The average duration of the disease is from three to five days. Hopes of recovery may be entertained if it extends over a week. Death results from apnoea or exhaustion. Treatment — This is very unsatisfactory. The favor- ite remedies, however, are Calabar bean, aconite, chlo- ral, bromide of potassium, opium, and chloroform. DISEASES OF THE SKIN. A few general observations on terms used in skin nomenclature will prepare the student for understand- ing the classification adopted, and the descriptions, necessarily brief, of the various diseases. A series of interrogatories may more fully bring out what is meant. What is the essential character of an exan- thematous affection, apart from the fever which some- times accompanies it? It is superficial and red, the eruption not being uniform but occurring in patches, varying in size and severity, and disappearing under pressure. How does it terminate? In resolution, the whole exanthem dying away ; or in desquamation, scales forming where the eruption formerly was. Thus the exanthemata are said to consist of superficial red patches, varying in size and severity, disappearing un- der pressure and terminating in resolution or desqua- GENERAL REMARKS. 293 mation. Included under this division are erythema, 'urticaria, and' roseola. The former, speaking generally, terminating in resolution ; the latter, as in syphilitic roseola, in desquamation. What is a vesicle? is it large or small? Small, and consisting of a slight elevation of the epidermis. But it is more than a slight elevation. It is not solid. Prick it and fluid exudes, which is generally trans- parent, but sometimes cloudy or sero-purulent. Cover one or more rain-drops with skin, and an idea may be formed of a vesicular eruption, if you suppose further that it may be placed upon skin uninflamed, not red, at other times on a red patch. Sometimes the vesicles are single, at other times in clusters; sometimes they come out at once, sometimes irregularly. With these irregularities in situation and in appearance they also combine an irregularity in their mode of termination. There is fluid in the vesicle. How is it got rid of? By absorption or resolution in some instances, the re- sult of this being probably a scale where the vesicle was ; or it may burst externally, causing excoriation of the neighboring parts, and where the vesicle was a scab may form, under whose protecting influence the new skin is produced. The definition of a vesicle is thus seen to be a raising of the epidermis, containing fluid, generally serous and transparent, sometimes cloudy and sero-purulent. The class vesiculse com- prises sudamina, herpes, eczema. Bullae may be considered as a sub-order of the vesicula?, differing from these as a large umbrella does from a small parasol. The bullae or blebs form blad- 25 294 DISEASES OF THE SKIN. der-like prominences, coming out rapidly, and con- taining at first serous fluid, which becomes purulent or sero-purulent. The blebs burst, and on the seat of the former elevation large black crusts form. The rapid formation, the larger size, the more distinct, black, crusty scab, and the bad health usually associ- ated with them, alone distinguish bullse from vesiculse. Under this class are rupia and pemphigus. In what way do pustules differ from vesicles? The difference seems only one of degree. They are situ- ated on a hard, indurated, inflamed base, and the true pustule is by Willan said to differ from a vesicle in this, that it contains pus from the first moment of its formation. Pus cannot be absorbed, and so it seeks the surface naturally, aided, as in the case of boils, by the lancet, and is followed by scabs or a permanent cicatrix on its former site. Pustules are therefore defined to be the formation between the cuticle and the cutis vera of small tumors containing purulent fluid, and terminating by a scab or a permanent cicatrix. To this order belong ecthyma and impetigo. What is a papule or pimple? It is solid; it rs small ; it is pointed ; it is raised somewhat above the surrounding skin, and as such it can be felt and rec- ognized. Retaining its elevated character, in color either white or red, attended, as a rule, with itching, how does it terminate? Generally by resolution, at other times by slight desquamation, and occasionally by ulceration. In addition to these characteristics, it may be stated that papular diseases are chronic in GENERAL REMARKS. 295 their course, non-contagious, and attended sometimes with itching. The diseases under this order are lichen and prurigo. A scale, in skin nomenclature, means an altered epithelial cell, and it may either be primary or sec- ondary, i.e., the product of the original disease, or coming on as the termination of another skin com- plaint. Scales may be produced either by increased formation or hypertrophic growth, and may be large or small, thick or thin, clear or opaque, crowded together in patches or separate. The term squamae is applied to scales of degener- ated, thickened, dry epidermis, easily detached and easily produced. Psoriasis, pityriasis, and ichthyosis belong to this order. The term tubercle, in skin diseases, must be associ- ated with degeneration, this degeneration assuming the form of a tumor, which may be small or large, more or less prominent, circumscribed in form, and persistent, and may lead either to ulceration or sup- puration at the summits of the tubercles. The tuber- culse are chronic, sometimes hereditary, and in their graver forms are peculiar to tropical climates. Under the tuberculse are elephantiasis, acne, lupus, mollus- cum, frambcesia, keloid. The following classification of skin diseases is that of Willan considerably modified : Order 1. Exanthemata : Erythema, Roseola, Urticaria. " 2. Vesiculse: Sudamina, Herpes, Eczema. 296 DISEASES OF THE SKIN. Order 3. Bullae : Pemphigus, Rupia. " 4. Pustular : Ecthyma, Impetigo. " 5. Parasitici : Tinea tonsurans, Tinea favosa, Tinea decalvans, Tinea sycosis, Chloasma, Scabies. " 6. Papulse : Lichen, Prurigo. " 7. Squamse: Psoriasis, Pityriasis, Ichthyosis. u 8. Tuberculse: Elephantiasis, Molluscum, Acne, Lupus, Framboesia, Keloid. Erythema. — There are three chief varieties of erythema — 1. Simple erythema, of which a general description has been given in the preceding remarks. It has a sub-variety, " erythema fugas," so called from its shifting character, and its appearing and disappear- ing at intervals on different parts of the body. Some- times it is observed in fevers on the face, trunk, and upper extremities,'and its appearance on such occasions forms an element in determining an unfavorable prog- nosis. 2. Erythema papulatum is often seen 'in young persons at the age of puberty, and is usually associa- ted with some disorder of the menstrual or digestive functions. Small papules may appear on any part of the body, but, as a rule, the sites selected are the back of the hands, neck, or face. These papules spread and coalesce with one another until the parts affected are covered with a red blush, which lasts for a few days and then disappears, with some itching. 3. Erythema nodosum has a knotty appearance, the knots or patches being about one or two inches in diameter, and attacks the surface of the legs between the knee and the ankle. ROSEOLA — URTICARIA. 297 The constitutional disturbance is considerable. It is peculiar to females between fourteen and twenty, and sometimes occurs in an epidemic form. Treatment. — Mild saline aperients are serviceable for simple erythema (F. 24). Rest in bed and a low diet are recommended for "erythema nodosum/' Greasy applications in all the varieties mentioned ag- gravate the disease. Cloths soaked in whisky and water are especially useful in the simple or papular form. Roseola. — Rose-colored, bright spots, small and of various shapes, not much elevated above the surround- ing skin, distributed more or less over the body, and accompanied by some fever, characterize this affection. The roseola seen in infants might be mistaken for measles, but it has no regular site for its eruption, at times being on the neck or buttocks, and it is unac- companied by catarrhal symptoms and attended with some itching. Treatment. — Alteratives, laxatives, and tonics may be required according to the state of the system at the time of the roseolar eruption (F. 8). Urticaria, or nettlerash, bears, as its name indi- cates, more or less resemblance to the eruption pro- duced by the application of a common nettle to the skin. Hence, wheals or raised elevations are observed, of irregular form and uncertain duration, with a white centre and red margin, and accompanied by more or less tingling and itching, Urticaria may be either 298 DISEASES OF THE SKIN. acute or chronic. In the former the disease runs a rapid course and is attended with a smart fever; in the latter it is slow, obstinate, persistent, or tending to come and go. Both forms seem to be due to errors of diet, as eating shellfish, cucumbers, almonds, or indigestion and uterine derangements of various kinds. Treatment. — In the acute form give an emetic, and follow it up by a purgative. In the chronic form at- tend carefully to the digestion by ordering a simple diet without wine, beer, or spirits, and administer laxatives or antacids, with occasional tepid baths. A lotion containing prussic acid or perchloride of mer- cury is useful in relieving the local irritation (F. 55). Sudamhsta are often seen in the form of round, pearly vesicles, like drops of water, in the course of rheumatic or typhoid fever, phthisis, or any other dis- ease with excessive perspiration. Herpes. — Groups of vesicles, varying in size from a millet seed to that of a pea, are formed on inflamed skin. Herpes, in its simplest form, is seen on the lip, sometimes in acute pneumonia, or during the progress of a common cold, or on the prepuce as the result of connection. A more complicated variety is known as shingles or herpes zoster. The vesicles in this case form a band half encircling the body, and following in nineteen cases out of twenty the course of the inter- costal nerves on the right side, in the position that would be occupied by a sword-belt. The disease lasts ECZEMA. 299 from fourteen to twenty days, and is succeeded by scabs. Treatment. — Regulate the diet and attend to the . bowels. Employ locally the prussic acid lotion, or dust the part with starch, three parts, and oxide of zinc, one part. If pain be severe, as it sometimes is in shingles, it may be necessary to use aconite oint- ment, or to inject morphia in the course of the nerve. Protecting the part by means of cotton-wool is fre- quently very beneficial. Eczema consists of an eruption of very minute vesicles on various parts of the skin, crowded together, and often running into one another in such a manner as to present a combination of the various appearances of vesicles, pustules, fissures, on an inflamed patch of skin. The most distinctive feature of this affection is that the vesicles burst, discharging a thin fluid, which dries up into yellow crusts. The irritation produced by the itching occasions restlessness, and sometimes a considerable amount of fever. Various names have been given to different varieties. Thus it is termed eczema simplex if the vesicles are placed on different parts of the skin without any inflammation ; eczema rubrum if the skin is inflamed, with heat and swell- ing; if engendered by the heat of the sun it is termed eczema solare; if by mercury, eczema mercuriale. Treatment. — For the eczema which occurs in infants, Dr. Erasmus Wilson considers small doses of calomel at moderate intervals a specific, followed by Fowler's solution, in doses proportionate to the age of the child, 300 DISEASES OF THE SKIN. while the oxide of zinc ointment should be applied externally. In the other varieties general measures must be trusted to ; saline laxatives, mineral acids, sarsaparilla, cod-liver oil. In severe and chronic cases the iodide of potassa or Fowler's solution should be tried. Locally, employ glycerin, carron oil, or oint- ments of oxide of zinc, with prussic acid, or if chronic and scaly, the oil of cade may be used. Iodide of sul- phur ointment has been recommended, but Dr. McCall Anderson prefers soothing applications, of which the ungt. diachyli, composed of lead plaster and olive oil, is to be preferred. In any case the* patient should be strictly enjoined never to bring water in contact with the affected part (F. 59, 60, 61, 4). Pemphigus. — The eruption, consisting of large bullae, is usually preceded by fever and constitutional disturbance, and locally by irritation and itching. The bullae may be two or three inches in diameter, and are either separate or run into one another, and when they burst are succeeded by large brown crusts. The disease is one of debility, favored by intemperance, bad diet, or cold, or it may be due to syphilis. The course is chronic. Rupia is generally syphilitic in its origin. Small flat bullae arise, containing serous fluid at first, which degenerates into blood and pus. A thick black scab is formed, and beneath it unhealthy ulceration pro- gresses, as evidenced by a nasty-smelling discharge. The margins of the surrounding skin inflame, more IMPETIGO — ECTHYMA. 301 serum is poured out, and the incrustation takes on a stratified appearance, resembling a limpet shell. Its duration may vary from two or three weeks to several months. Treatment. — Both these diseases being attended with debility, a generous diet, and fresh air, with wine and tonics, are essential. If of syphilitic origin, iodide of potassium, with Plummer's pill or the perchloride of mercury, may be administered. Locally, poultice, and use antiseptic dressings (F. 3, 5). Impetigo. — The pustules characteristic of this dis- ease are sometimes crowded together, at other times distinct, — hence the division into impetigo figurata and sparse. In both divisions the pustules break, and are succeeded by scabs, with a peculiar candy- sugar appearance, if observed on the face. The crusta lactea of young children is simply an impetiginous eruptive mask. The variety "sparsa" is sometimes distributed over a wide area, as the limbs, the body, or buttocks. Impetigo generally attacks young, scrofulous, ill- fed children, or elderly debilitated people. Ecthyma may be confounded with impetigo, as both diseases are pustular and attended with scabs ; but in ecthyma the inflammation is of a more severe type and there is more constitutional disturbance. The pustules are usually separate, with a hard in- flamed base, and terminate with a dark-colored scab. The latter leaves superficial ulcers, followed by cica- 26 302 DISEASES OF THE SKIN. trices. Ecthyma may occur spontaneously, or follow the application of some irritant to the skin. Treatment. — This is similar to what was mentioned in the previous disease, viz., cleanliness, good living, and good air, with wine and bark. If the scabs are large, apply a charcoal poultice and a sedative oint- ment of acetate of lead and lard, or (F. 61). Lichen. — -There are two great varieties of lichen, "simplex" and "agrius." In the former, papules about the size of a millet seed are thickly crowded together. In the latter the papules are situated on red inflamed skin, and there is pain, itching, and tingling, with sometimes fever, nausea, and vomiting. The inflammation subsides, the papule scales and heals; or by scratching, the point of the elevation is torn off, and in consequence there is a thin serous discharge, and the skin is left fissured with deep and painful cracks. The eruption of lichen sometimes subsides in a fortnight, in other instances it may extend over some months. It is seen most frequently on the hands, arms, and body, and constitutes the grocers', bakers', and bricklayers' itch. Peurigo is a chronic papular affection associated with old age and uncleanliness, accompanied with in- tense itching, as the result of which the tops of the papulesare torn off to the effusion of blood, and the blood hardens on the top of the pimple. The appear- ance presented by the skin is thus somewhat piebald — the bloody-topped papules being situated on dirty PSORIASIS — PITYRIASIS RUBRA. 303 flaccid skin. Prurigo may be mistaken for fleabites, but the history of the case will guide to a proper de- cision. Treatment. — This in lichen is similar to' what has been mentioned in the other forms of skin disease, and consists in the allaying of irritation by baths, oint- ments, etc., etc.; while the digestion is aided by mild laxatives and a simple diet. In prurigo, cleanliness must be insisted on by means of baths, to which the addition of four ounces of carbonate of soda is useful. In obstinate cases arsenic or strychnia may be given (F. 57, 55). Psoriasis is a common chronic skin eruption char- acterized by thickened patches of skin varying in size, covered by silvery scales, and with a red base. Heal- ing commences from the centre to the circumference, and there is no tendency to suppuration or ulceration. There are two great varieties of psoriasis, syphilitic and non-syphilitic — the former occurring most frequently on the hands or soles of the feet, the latter on the outer aspect of the elbows or knees. A further division has also been made into guttata and aggregata, according as the patches or scales are put down in a drop form or crowded together. Pityriasis Rubra. — In the only case I ever saw the man stated that his body commenced to itch, and he observed in the morning that it was red all over. This was followed by thin branny scales, which were situated on erythematous skin. The epidermis des- 804 DISEASES OF THE SKIN. quamates in large pieces, so much so that it may sep- arate from the foot in the form of a slipper. Another variety of pityriasis, called dandriff, is characterized by the production of minute white scales, especially on the scalp, or parts covered with hair. Another form of scaly skin affections is termed ichthyosis, or the fish-skin disease, in which the scales are large, hard, and dry, resting on an uninflamed surface, and unattended with itching or pain. Treatment — In psoriasis, non-syphilitic, arsenic should be given. In the syphilitic variety the triple compound of iodine, arsenic, and mercury (Donovan's solution) is requisite. Locally apply, after the scales have been removed by poulticing, the oil of cade or tar ointment. Tar capsules have also been given with advantage. In dandriff, citrine ointment, glyc- erin, or (F. 64), does much good. Ichthyosis is con- sidered a congenital disease, and hence treatment, by means of simple warm and alkaline baths, can only be employed in a palliative manner. Of the forms of tubercular skin diseases two are seen in this country, acne and lupus. Acne. — -Acne simplex and acne indurata are com- mon at puberty, on the forehead or cheeks. Acne rosacea is most frequently associated with good living, or with stomach or liver disease. It is sometimes the signal-flag of the intemperate. Lupus. — Two varieties are lupus exedens and lupus non-exedens. The disease in both instances consists lupus. 305 in nodular elevations, which ulcerate in the one case, but not in the other. In the non-ulcerative form the nodules, which are small, softish, and red, and at- tended with no pain, become covered with little white scales, then a sort of fatty degeneration occurs, the nodules shrink and die away, leaving a loss of sub- stance in the form of a depression. In the other form, instead of absorption, ulceration sets in, the neighbor- ing tissues are invaded, and the edges are thick and red. It sometimes destroys the whole nose, including the mucous membrane and bones. In both varieties it appears to be connected with scrofula, to be most common between the ages of fifteen and twenty-five, and to affect the face, especially the nose. Treatment. — In acne rosacea, if a cure is attempted, it is obvious that the diet must be attended to and drinking habits stopped ; while in the other varieties of acne, friction and gentle stimulation are useful, which in the severer forms may be combined with the iodide of sulphur ointment (F. 65). In ordinary acne the evacuation of the follicles by pressure, succeeded by the application of acetic acid lotion, will be fol- lowed by good results. The scrofulous nature of lupus necessitates tonics, especially cod-liver oil combined with acids and bitters. In the severe form, if there is any history of syphilis, use Donovan's solution or iodide of potass, with sarsapariila. Locally, for the non-ulcerating form, Mr. Wilson recommends the acetum cantharidis; while for the ulcerating type caustic applications are called for, such as chloride of 306 PARASITICA zinc, nitric acid, and potassa fusa, or the surface may be scraped by means of a curette. PARASITICA. Parasitic diseases may either be of animal or vege- table origin, and all are contagious, provided the para- site is implanted on a suitable soil. Scabies depends on the presence of a parasite of animal origin, viz., the "acarus scabiei." It most fre- quently attacks the flexures of joints; notably it is first observed between the fingers, and from thence may extend over the whole body with the exception of the face, where it is rarely, if ever, seen. The dep- osition of the acarus acts as an irritant; a vesicular eruption is formed, and this is attended with much itching and is specially increased by warmth. Practi- cally few people go in for the scientific hunt of the acarus, which is the only true evidence of the disease, and it is sufficient proof of it if small pointed vesicles are observed between the fingers, on the anterior as- pect of the forearm, and a pruriginous eruption on the inner part of the thigh, attended with much itching. A valuable diagnostic sign is the existence of a marked eruption at the ulnar side of the wrist and around the ankles in children. The presence of furrows with fol- liculi (being the female insect covered by epidermis) PARASITICA. 307 at their extremities is of considerable diagnostic im- portance. Treatment. — The acarus is most easily destroyed by the application of sulphur ointment to which a little bero;amot has been added to disguise the smell. Two or three applications will be sufficient. The clothes should afterwards be fumigated by sulphurous acid gas, or destroyed. The generic term given to the parasites of vegetable origin is tinea. Tinea favosa commonly affects the scalp in the form of a small cup-shaped yellow crust, giving it a honeycombed appearance. Each crust contains a hair in its centre, and the spores of the fungus are im- planted within the follicle. The odor detected is said to be like that of cats or mice. Tinea Tkicophytixa. — The parasite may attack the scalp, hairy part of the face, or general surface of the body. "When it affects the scalp (tinea tonsurans) it is characterized by the appearance of round or oval patches of baldness, brittleness or dryness of the dis- eased hairs, and round which there are diffused fine scales ; when it attacks the hairy parts of the face (sycosis menti), by pustular inflammation of the hair- follicles in round patches; when it affects the general surface of the body (tinea circinata), by rings spread- ing from a centre, reddened and raised, and preferring those parts of the body which are most exposed. 308 PARASITICA Tinea decalvans, Alopecia areata, commences with slight itching and redness. Scales are observed, and then the hair falls away, leaving little circular bald shining patches, which, however, may so extend as to cover a large surface. It affects the beard and scalp, and the fungus is not easily detected. Tinea versicolor, Chloasma, characterized by the appearance of fawn-colored patches on the chest and abdomen, which are rough to the touch and cov- ered with fine branny scales. Treatment. — This must be local and general — local to destroy the parasite, general to strengthen the sys- tem and prevent the skin forming a suitable soil for its development. Thus, poultice to remove scabs, then pull out the hair in and around the patches ; sub- sequently employ a parasiticide ointment (creasote) or sulphurous acid lotion. " Pass a stream of the gas through water to saturation; two ounces of this satu- rated solution are then added to six ounces of water to make the lotion." For tinea versicolor a lotion com- posed of two grains of the perchloride of mercury to six ounces of water is very serviceable (F. 58). If the parasite has thus been destroyed, it is necessary to soothe the local irritation by hot cloths, and after- wards stimulate by some compound of cantharides, vinegar, or rose-water. The general treatment con- sists in cleanliness, good hygienic conditions, nourish- ing food, cod-liver oil, and iron. In tinea decalvans nux vomica and phosphoric acid are recommended. APPENDIX. FORMULAE. The doses in the following prescriptions are intended for adults, and it is well for the student to remember that, if used for children, the rule suffices to divide the dose for an adult, in proportion to the number of years of the child's age, increased by 12. Thus, for a child of two years, it will be 2 + 12 = 14, and this divided by 2 (e. g., T \ths) will make the dose ^th of that of an adult. If for a child of three years, 3 + 12 = 15 (/-ths), or |th, etc. Opium and its preparations act powerfully on children, and hence the dose must be reduced to a greater extent. Principal Preparations containing Opium, Mercury, Arsenic, etc., with the j^roportions. Tinct. Opii contains gr. j in min. xiv. Tinct. Camph. Co. contains gr. j in gss. Pil. Plumbi c. Opio contains gr. j in gr. viij. Pulv. Ipecac. Co. contains gr. j in gr. x. Pulv. Kino Co. contains gr. j in gr. xx. Enema Opii contains min. xv tinct., or gr. j in gj. Liniment. Opii contains two fl. ounces of tincture in ^iv. Morph. Acet. Liquor contains gr. iv in one fl. ounce. Morph. Hydrochlor. Liq. contains gr. iv in one fl. ounce. Inject. Morph. Hypodermica contains gr. j in min. xij. 310 APPENDIX. Mercury. Hydrarg. c. Creta contains gr. j in gr. iij. Pil. Hydrarg. contains gr. j in gr. iij. Liq. Hydrarg. Perchlor. contains gr. -^ in ^j. Arsenic. (Fowler's Solution.) Liquor Arsenicalis contains gr. ^ in min. v. Liquor Sodse Arseniat. contains gr. iv in gj. Liquor Arsenici Hydrochlor. contains gr. Jj in min. v. Strychnia. Liquor Strychniaa contains gr. fa in min. v. (Donovan's Solution.) A fluid drachm contains fa of a grain of arsenic, gr. £ mer- cury, and gr. f of iodine. Dose min. x to xxx. I.— ALTEKATIVES AND KESOLVENTS. Mercury and Iodide of Potassium. 1. R. Hydrarg. Perchlorid., gr. j ; Potass. Iod., ^iij ; Decoct. Sarsaa. Co., ^vj. M. A tablespoonful thrice daily after food. Mercury and Gentian. 2. R. Hydrarg. Perchlor., gr. j; Ext. Gentian, £ss. Misce. Divide in twelve pills ; one thrice daily. Useful in secondary syphilis. Donovan } s Triple Solution. 3. R. Liquoris Hydriodatis Arsenici et Hydrarg., giij ; Tinct. Zingib., giij ; Aqua3 ad gvj. Misce. A tablespoonful thrice daily after food. Useful in secondary syphilis and some skin eruptions. APPENDIX. 311 Arsenic and Cinchona. 4. R. Liquor. Soda? Arseniatis, gj ; Tinct. Cardamom Co., ^iij ; Decoct. Cinchon. ad §vj. Misce. A table- spoonful thrice daily after food. Useful in various skin affections. Iodide of Potassium and Calumba. 5. R. Potass. Iodid , gij ; Infus. Calumbae ad gvj. Misce. A dessertspoonful thrice daily. Useful in various diseases, syphilitic or otherwise. Guaiacum Mixture. 6. R. Tinct. Guaiaci Co., giij ; Tinct. Aconiti, rn?xx ; Mist.' /£>£» Cam ph. ad gvj. Misce. Two tablespoonfuls thrice daily. Recommended in cynanche tonsillaris and some skin affections. Chlorate of Potash. 7. R. Potass. Chlorat., gij ; Syrupi Simplicis, giij ; Aquae/£t/ Camph. ad gviij. M. A tablespoonful every four hours. Recommended in inflammatory affections of the mouth, etc. Mercury, Rhubarb, and Soda. a 8. R. Hydrarg. c. Creta, gr. ij ; Pulv. Rhei, gr. ij ; Sodse Bi- carb., gr. iij. M. Make a powder. One at bedtime. Recommended in various infantile or children's diseases. II.— ANTACIDS. Bismuth, Hydrocyanic Acid, etc. 9. R. Liq. Bismuth. (Scht.), gss* ; Acid. Hydrocyanic. dil. r /4y f "n^xl ; Tinct. Card. Co., giij ; Spt. Chloroform., giss. ; Aquae ad §yj. Misce. A tablespoonfCil thrice daily before food. Recommended in dyspepsia for vomiting and pain. 312 APPENDIX. Ammonia, Potash, and Chiretta. 10. R. Aramon. Sesquicarb., gj ; Potass. Bicarb., 31SS. ; Inf/ f Chirettae ad gvj. Misce. A tablespoonful thrice daily before food. Useful for the acid eructations of dyspepsia and debility. Magnesia and Soda. 11. R. Magnes. Levis, gss. ; Sodae Carb., gr. xx ; Tinct. Au- ILH rantii, £ss. ; Aquae Menth. Pip., 3>ijs8. Misce. The draught to be taken in heartburn, etc. III.— ANTISPASMODICS. Lobelia, Ether. 12. R. Tinct. Lobel., gij ; Spt. Ether. Sulph.,giij; Tinct. Co-/ 4> J nii, gij ; Mist. Amygdalae ad £vj. M. A tablespoon- ful every three hours. In asthma and paroxysmal coughs. Cardamoms and Ammonia. 13. R. Tinct. Card. Co., £iv ; Acid. Hydrocyan. dil., ^xl;/ 4*7-1 Spt. Ammon. Arom , gij ; Tinct. Zingib., giij ; Spt. Chloroform., 31 j ; Aquae Carui ad gvj. M. A table- spoonful taken occasionally. For flatulence or colic. Valerian and Asajoetida. 14. R. Tinct. Valerian., Tinct. Asafoet, aa Jjij ; Spt. Lavand. Co., ^iss. ; Aquae ad §vj. M. A tablespoonful every three hours. For hysteria, etc. • APPENDIX. 313 Gibb's Nitric Acid Mixture, 15. R. Acid. Nit. dil., ^xij ; Tinct. Card. Co., giij ; Syrup. Simplicis ; giiiss. ; Aquae, §j. M. A teaspoonful every two hours. For hooping-cough. IV.—ASTRINGENTS. Sulphuric Acid and Opium. 16. R. Acid. Sulph. dil., ^iiss. ; Tinct. Opii, £j ; Spt. Chloro- form., gij ; Aquae Menth. Pip. ad gvj. M A table- spoonful after every liquid stool of adults. For diarrhoea. Catechu, Opium, and Chalk. 17. R. Tinct. Catechu, giij ; Tinct. Opii, £j ; Pulv. Aromat., ^iss. ; Mist. Cretae pd §vj. M. A tahlespoonful after every liquid stool of adults. For excessive diarrhoea of typhoid fever. Chalk Mixture, Cinnamon, and Opium. 18. R. Tinct. Opii, tr^x ; Pulv. Aromat., 33 ; Mist. Cretae, gvj ; Aquae Cinnamomi, giiiss. M. A teaspoonful may be given every hour. For diarrhoea of children. Gcdlic Acid. 19. R. Acid. Gallici, gr. x; Aquae, giss. M. To be taken every four hours. Useful in haemoptysis and various haemorrhages. Bismuth Mixture. 20. R. .Bismuth. Subnitrat., 3J : Mucilag. Acaciae, gvj. M. A tahlespoonful every three hours. Useful in the diarrhoea of phthisis. L&0J1 !y-o 314 APPENDIX. Cascarilla, Squills, Dilute Sulphuric Acid, 21. R. Tinct. Scillse, giss. ; Acid. Sulph. dil., £iss. ; Tinct. Opii, gss. ; Inf. Cascarilla? ad Jvj. M. A tablespoonful every three hours. Useful in chronic bronchitis to check excessive expectoration. Starch and Laudanum Enema. 22. R. Tinct. Opii, £ss.; 01. Terebinth., v% x ; Mucilag. Amyli, gij. M. It may be employed to check the diarrhoea of typhoid fever when excessive. V.— CATHARTICS AND ANTHELMINTICS. Calomel and Jalap. 23. R. Calomel, gr. v; Pulv. Jalapae, gr. xv. M. An active purgative. Sulphate of Magnesia and Sulphuric Acid. L« •: 24. R. Magnes. Sulph., gij ; Acid. Sulph. dil., giss. ; Tine Card. Co., giss. ; Aqua? Menth. Pip. ad gvj. M. A wineglassful every half hour until bowels act freely. Aloes , Senna, and Jalap. 25. R. Tinct. Senna?, Tinct. Jalapse, aa gij ; Decoct. Aloes Co. ad gvj. M. An ounce night and morning. Useful in bilious headache and constipation. Rhubarb, Soda, and Aloes. 26. R. Extract Rhei, gr. x ; Soda? Phosphat., gj ; Decoct. Aloes Co., gss. ; Aqua? Menth. Pip., gj. M. A warm aperient, useful in the early stage of gout. APPENDIX. 315 Elaterium and Coloeynth. 27. R. Extract Elaterii, gr. j ; Ext. Coloeynth. Co., *iiss. ; Ext. Hyoseyam., gr. xij. Misce, and divide into twelve pills, one night and morning. Useful in cardiac or other forms of dropsy. Antimony, Sulphate of Magnesia, Citrate of Ammonia, 28. R. Vin. Antimon., £j ; Magnes. Sulph , gss. ; Liquor Am- mon.Cit1at.5iss.; Aquae ad gvj. M. Two table- spoonfuls twice or thrice daily. Useful as an aperient in the early stages of various disorders. 29. R. Extracti Filicis Liquidi, ti£xxx ; Pulv. Gum. Acacia?, 3J ; Aqua? Menth. Pip., §j. Make emulsion. Considered a specific in tapeworm. 30. R. Santonin., gr. ij ; Pulv. Scammon., gr. iij. M. Very effectual in expelling the roundworm or thread- worm in children. YL— DIAPHOKETICS. Acetate of Ammonia c. Ether. 31. R. Liquor. Amnion. Acetat.,gj; Spt. Ether. Nit., gss. ; Tinct. Hyoseyam., giij ; Aqua? Camph. ad j|vj. M. A tablespoonful every three hours. L T seful in febricular and some inflammatory disorders. Dover's Powder and Antimony. 32. R. Pulv. Ipecacuanha? Com., gr. vj ; Antimon. Tartrat., gr. J. M. One powder every six hours. Guaiacum and Xitre. 33. R. Pulv. Guaiac, gss. ; Pulv. Potass. Nitrat., Jjj. M. To be taken at bedtime (some warm gruel to be taken after it). Useful in chronic rheumatism. 316 APPENDIX. Ipecac, c. Citrate of Ammonia. 34. R. Vini Ipecac, giss. ; Syrupi, t ^ss. ; Tinct. Camph. Co., giij ; Liquor. Amnion. Cit., §ss. ; Aquae ad gij. M. A teaspoonful every two hours. Useful in catarrhal and febrile affections of children. VII.— DIURETICS. Squills, Broom, and Acetate of Ammonia. 35. R. Tinct. Scillae, gij ; Liq. Amnion, Acetat., gij ; Decoct. Scoparii ad ^vj. M. Two tablespoonfuls thrice daily. Useful in dropsy dependent on heart, liver, etc. Mercury, Squills, and Digitalis. 36. R. Pil. Hydrarg., £ss ; Pulv. Scillse, gr. vj ; Pulv. Digitalis, gr. xij. M. Divide into twelve pills. One twice daily. Useful in pleurisy or pericarditis to remove effusion. Acetate of Potass, Squills, and Digitalis. 37. R. Potass. Acet.,£ss. ; Acet. Scillae, ^ss. ; Spt. Ether. Nit., Tt£xx ; Tinct. Digitalis, njjv ; Decoct. Scoparii, giss. M. The draught thrice daily. 37a. R. Potass. Acetat., giij ; Potass. Citrat., spij ; Inf. Digi- talis ad gvj. M. A teaspoonful every three hours. Bitartrate of Potass and Buclxu. 38. R. Potass. Bitart., giij ; Inf. Buchu ad gvj. M. Two tablespoonfuls thrice daily. Useful as a diuretic, and where there is very acid urine with an excessive secretion of uric acid. APPENDIX. 317 Oil of Juniper, Nitric Ether, and Digitalis. 39. R. Olei Juniperi, £ss. j Spt. iEtheris Nit., Yini Ipecac, Tinct. Digitalis, aa ^iij. M. Twenty-five drops every three hours. Diuretic, and in some cases also useful as an emmenagogue. Nitrate of Potass and Barley Water. 40. R. Potass. Nitrat., gij ; Acid. Nit. dil., 33. To be put into a pint of barley water and drunk daily. Useful in the early stages of fever. YIIL— EMETICS AND EXPECTORANTS. Antimonial or Jpecacuan Emetic. 41. R. Antimon. Tartratis, gr. j ; Yin. Ipecac, gj ; Aquae ad giss. M. vel 42. R. Yin. Ipecac, gj. Either of these draughts w 7 ill relieve the stomach. They are sometimes recommended in the early stages of fevers, etc Toln, Ammoniacum, and Opium. 43. R. Syrupi Tolutani, ^ss. ; Mist. Ammoniaci, §ij; Tinct. Camph. Co., ^iij ; Aquae ad £vj. M. A tablespoon- ful three times a day. Useful in chronic bronchitis. Ammonia, Squills, and Senega. 44. R. Ammonia? Carbonatis, £j ; Tinct. Scillae, ^iij ; Tinct. Camph Co., gss. ; Decoct. Senegae ad gvj. M. A tablespoonful every four hours. A stimulating expectorant in various chest affections. 27 318 APPENDIX. Ipecac, Tolu, and Acacia. 45. R. Yin. Ipecac, gij ; Syrup. Tolutani, ^iv; Mucilag. Acaciae ad §ij. M. A teaspoonful every hour or every second hour. Useful in acute bronchitis or measles with chest symptoms. Lobelia, Spirit Chloroform, and Conium. 46. R. Tinct. Lobelia, gij ; Spt. Chloroform., giij ; Tinct. Conii, giij ; Mist. Amygdalae ad gvj. M. A table- spoonful three times a day. Useful in asthma, etc. IX.— GAKGLES AND INHALATIONS. Tannin Gargle. 47. R. Tannin, gj ; Aquae Camph.,gvj. M. The gargle to be used frequently. 48. R. Tinct. Myrrbae, ^iij ; Aluminis, ^j ; Infusi Kosae Acidi ad gvj. M. To be used frequently in mercurial sali- vation, or scarlatinous or aphthous ulceration of the throat. Tannin and Glycerin. 49. R. Tannin, gss. ; Glycerini, giv. M. The throat to be touched witfr this twice or thrice daily in scarlet fever, etc. Borax and Glycerin. 50. R. Sodae Biborat., 3J ; Glycerini, gij. M. Useful in ulceration of mouth and throat. Nitrate of Potash. 51. R. Potass. Nitrat., gj ; Aquae, gj- Saturate white blotting- paper in this solution, and dry it; cut the paper into pieces 3 inches long, J inch broad. One piece may be lighted, and the smoke inhaled. One to six papers may be used in succession for each inhalation. Recommended as an antispasmodic in asthma. APPENDIX. 319 Hop Inhalation. 52. R. 01. Humuli, gss. ; Magnesiae Carb. Pond., gj. M. Aquae ad !§iij. M. A teaspoonful to be put into a pint of boiling water, afterwards used by Maw's inhale*. Useful in phthisis, where cough is irritable, and in various chest affections. Creosote and Carbolic Acid Inhalation. 53. R. Creasot., giij ; Magnes. Carb. Pond., giss. ; Aquae ad giij. M. ; or, 53a. R. Acid. Carbolici, gj ; Aquae, gvij. M. • A teaspoonful in a pint of water at 150° F. for each inhalation. Useful in chronic congestion of the larynx. Pine Inhalation. 54. R. 01. Pini Sylvestris, spj ; Carb. Magnes. Pond., gj ; Aquae ad 3 iij . M. A teaspoonful in a pint of water at 150° F. for each inhalation. X.— LOTIONS, LINIMENTS, Etc. Prussic Acid and Perchloride of Mercury. 55. R. Hydrarg. Perchlor., gr. ij ; Acid. Hydrocyanici dil., gj ; Mist. Amygdalae ad gvj. M. Useful in prurigo, and various skin affections attended with itching. Prussic Acid and Potass. 56. R. Liquoris Potassae, gij.j Acid. Hydrocyanici dil., £j ; 2?f Aquae ad gvj. M. Useful in pityriasis. 5Ga. R. Acid. Carbolic i, gr. viij ; Glycerini, gss. ; Aqua? ad Applied to pustules in small-pox. 320 APPENDIX. Soda and Glycerin. 57. R. Sodse Bicarb., gj ; Glycerini, giss. M. Useful in the itching of cutaneous diseases. Perchloride of Mercury. 58. R. Hydrarg. Perchlor., gr. j ; Aquae ad §ijss. Useful in tinea favosa in children, or in chloasma in adults. XI.— OINTMENTS. 59. R. 01. OlivEe, §xij : Litharg., giij. M. S. A., and add 01. Lavand., gij. Apply on linen twice daily in eczema. 60. R. 01. Cadini, Spt. Vini Kect., Sapon. Mollis, aa gj ; Spt. Lavand., giiss. M. Kecommended by Dr. McCall Anderson in eczema. Bismuth, Zinc, Prussic Acid. 61. R. Bismuthi Trisnitrat., 3 j ; Ungt. Zinc. Ox., gj ; Acid. Hydrocyanici dil., gj. M. Useful in various skin affections. 62. R. Balsami Tolutani, ^ij ; Olei Eosmarini, tr^xx ; Tinct. Cantharid., Jj ; Olei Kicini, gss. ; Adipis Prep., ^iss. M. To be rubbed on night and morning to roots of hair in cases of baldness, after syphilis, fevers, etc. Aconitia and Iodine. 63. R. Aeonitise, gr. ij ; Ungt. Iodi, gj. M. To be painted ^' over part in severe neuralgia (tic douloureux). Citrine Ointment 64. R. Ungt. Hydrarg. Nit., £j ; Adipis, §j. M. Used in vesicular, squamous, and some parasitic affections. APPENDIX. 321 Iodide of Sulphur Ointment. 65. R. Iod. Sulpb., gr. x ; Sulph. Sublim., gr. x ; Acid. Hydro- cyan, dil., ™£x ; Adipis, §j. M. Used in acne and other skin affections. XII.— SALINES. 66. R. Spt. Ammon. Aromat., giij ; Liq. Ammon. Cit., §fv; /^ Syrup. Limon., gj ; Aquae ad ^viij. M. A table- spoonful every three or four hours. Useful in early stages of tonsillitis, diphtheria, or in febricula. Chlorate of Potash {Fever Drink). 67. R. Potass. Chlorat.. 3J ; Aquae ad Oj. M. Recommended as a daily drink in scarlet or other fevers. Colchicum and Magnesia. 68. R. Yini Colchici, gjss. ; Magnes. Carb., 31 j ; Aquae ad Jvj. M. A tablespoonful every three hours. Useful in gout. Or, 68a. R. Yini Colchici, g?s. ; Magnes.,gr. xv ; Magnes. Sulphat., 3J ; Aquae Cinnamom. ad 3 i j . M. This draught is recommended by Sir Charles Scudamore during the paroxysms of gout. XIII.— SEDATIYES. Bromide of Potash and Chloral. R. Potass. Bromid , Jiij ; Chloral Hydrate, gj ; Aquae ad §vjsa — A tablespoonful every two hours. Useful in delirium tremens, and also in fevers with great restlessness. 322 APPENDIX. Opium and Antimony. 70. R. Tinct. Opii, 31 j ; Antimonii Tartar., gr. iv ; Aquae Camph. ad §vj. M. A tablespoonful every two hours until sleep is produced. Useful in delirium tremens. Morphia and Hydrocyanic Acid. 71. R. Morphise Hydrochlor., gr. j; Acid. Hydrochlor. dil., tt£v; Acid. Hydrocyan. dil., gss. ; Syrup. Scillse, gj ; Aquae, §j. M. One teaspoonful to be taken when cough is very severe, as in advanced cases of phthisis. Bromide of Potass and Ergot. 71a. R. Potass. Bromide, jjiij ; Extract. Ergotae Liquid., 31J ; Z? Aquae ad §vj. M. A tablespoonful three times a day. Useful in cerebral congestion, and also in infantile spinal paralysis in earty stage. XIV.— STIMULANTS. Spirit of Chloroform and Brandy Mixture. 72. R. Spt. Chloroform., gij ; Mist. Spt. Vini Gallici ad gvj. M. A tablespoonful every two hours in the low stages of fevers or other exhausting diseases. Ammonia, Potash, and Rhubarb. 73. R. Spt. Amnion. Arom., Liquor. Potass., Tinct. Ehei, aa gj. M. A teaspoonful twice a day in water, as an antacid stimulant and stomachic. Soda and Calumba. 74. R. Sodae Bicarb., 3J ; Tinct. Calumb., gvj ; Aquae Anethi ad gvj. M. A tablespoonful every three hours. Useful to relieve heartburn and nausea. APPENDIX. 323 XV.— TONICS. Quinine Mixture. 75. R. Quiniae Sulphatis, gj ; Acid. Sulph. dil., giss. ; Syrup. Aurant., Tinct. Aurant., aa giv; Aquae ad gvj. M. A tablespoonful three times a day. Quinine and Ammonia. 76. R. Ferri et Quiniae Citratis, giss. ; Amnion. Carbonatis, gij ; Tinct. Aurantii, Jij ; Aquae, Jij. M. A tablespoon- ful three times a day. Quinine and Gentian. 77. R. Ferriet Quiniae Citratis, Ext. Gentian., aagss. M. To be divided into twelve pills. One to be taken twice a day. Iron and Hydrochloric Acid. 78. R. Tinct. Ferri Perchlor., giss. ; Acid. Hydrochlor. dil., g j ; Tinct. Hyoscyam., g j ; Inf. Calumb. ad gvj. M. A tablespoonful three times a day. Iron, Calumba, and Glycerin. 79. R. Tinct. Ferri Perchlor., gij ; Tinct. Calumbae, giij ; Glyc- erini, gij ; Aquae ad gvj. M. A tablespoonful three times a day. Useful in anaemia, and sometimes also in phthisis. Strychnia and Nitric Acid. 80. R. Liquor. Strychnia?, gj ; Acid. Nitric, dil., giss. ; Acid. Hydrochlor. dil., giss.; Tinct. Zingiber., giiiss. ; Syrup. Croci, giij ; Aquae ad gvj. M. A table- spoonful three times a day. Useful in some special affections. 324 APPENDIX. Syrup of Iodide of Iron and Cod-liver Oil. 81. R. Syrupi Ferri Iodidi, giij ; Mucilag. Acaciae, gj ; 01. Morrhuao, givss. M. A tablespoonful three times a day. Hypophosphite of Lime and Glycerin. 82. R. Calcis Hypophosphitis, ^j ; Glycerini ad gvj. M. A tablespoonful three times a day. Iron and Gentian. 83. R. Ferri Sulphatis, Ext. Gentian., aa Jss. M. Divide into twelve pills ; one twice daily. Citric Acid, Citrate of Iron, Bismuth, and Prussic Acid. 84. R. Ferri Citratis, ^iss. ; Acid. Citrici, gvj ; Aquae ad gvj. M. Acid. Hydrocyanici dil., fl^lxxij ; Potass. Bicarb., gvj j Liq. Bismuth., Syrup. Aurantii, aa giij. M. A dessertspoonful of the contents of each in a glass of water thrice daily. Recommended in dropsy from granular kidney. 85. R. Strychnias, gr. j ; Ferri Pyrophosphatis, Qniniae Sulph., aa ^j ; Acid. Phos. dilut., Syrup. Zingiber, aa §ij. M. A teaspoon ful three times a day in a little water. Recommended in some nervous affections when strychnia is required. 86. R. 01 ei Phosphorat., gs's. ; Mucilag. Acaciae, gj ; Olei Ber- gamot., gtt. xl. M. Twenty-five drops three times a day. Useful in nervous affections requiring phosphorus. APPENDIX. 325 Salicylic Acid Mixture. R. Acid. Salicylici, gij ; Potass. Acetat., ^iss. ; Aquse ad gvj. M. A tablespoonful every three hours. Recommended in rheumatic fever. R. Salicin, gr. xx. One every three hours. Digitalis and Iron. 3. R. Tinct. Ferri Perchlor., ^ij ; Inf. Digital, ad gvj. M. A dessertspoonful thrice daily. Ammonia, Citrate of Iron, and Calumba. 90. R. Ferri Ammon. Citrat, £j ; Tinct. Calumbae, giij ; Aquas Camph. ad gvj. M. A tablespoonful thrice daily. Useful tonic in kidney disease, etc. Rhubarb and Pepsin. 91. R. Pulv. Rhei, gr. iv ; Pepsin, gr. iij. M. Useful in dyspepsia with flatulence. To be taken after meals. Test for Diabetic Urine. 92. Fehling's Standard Solution is prepared according to the following prescription : Sulphate of Copper, 90J grains ; Neutral Tartrate of Potash, 364 grains ; Solu- tion of Caustic Soda, sp. gr. 1.2, 4 fluid ounces; add water to make up exactly 6 fluid ounces. 200 grains of this solution are exactly decomposed by one grain of sugar. 28 INDEX. Abdominal aorta, aneurism of, 161 Abdominal diseases, physical diag- nosis of, 16 Abscess of brain, 259 of kidney, 223 of liver, 205 of lung, 124 of spleen, 34 Acarus scabiei, 306 Acne, 304 Acute atrophy of liver. 206 desquamative nephritis, 224 tubal nephritis, 224 Addison's disease, 216 Adherent pericardium, 149 ^Egophony, 125. 131 Ague, 35 Ague spleen or cake, 37, 213 Albumen in urine, 220 Alopecia areata, 308 Alteratives, 310 Amphoric respiration, 139 Amyloid liver, 200 kidney, 229 Anaemia, 85 cerebral, 244 Anaemic murmur, 86 Anaesthesia, hysterical, 281 Anasarca, 58 scarlatinal, 50 Aneurism, abdominal. 161 miliary, 247 thoracic, 159 Angina pectoris, 142 Anginosa scarlatina, 50 Antacids, 311 Anthelmintics, 314 [ Antiscorbutics, 82 Antispasmodics, 312 Aorta, aneurism of, 159, lfil Aortic valves, disease of, 156 Aphasia, 255 Aphonia, 255 Aphthae of the mouth, 164 Apoplexy, 250 diagnosis of, 251 meaning of, 250 Apoplectic seizure, 251 Arsenic, preparations containing, 310 Articular rheumatism, 72 Ascaris lumbricoides, 191 Ascites, 59 diagnosis of, 60 Asthma, 121 idiopathic or spasmodic, 121 symptomatic or organic, 121 Astringents, 313 Athetosis, 276 Atrophy of heart, 147 of liver, acute and simple, 206 Aura epileptica, 270 Auscultation, 15, 91 Bakers' itch, 302 Basedow's disease, 216 Baths, use of, in fevers, 27, 33, 38, 40, 52 Bell's paralysis, 263 Bengal fever, 38 Biliary calculi, 209 colic, 210 ducts, catarrh of, 204 Bilious fever, 22 remittent fever, 23 328 INDEX. Black measles, 55 vomit, 41 Bladder, haemorrhage from, 234 Bleeding from kidney, 234 from lung, 137 from stomach. 137, 170 Blood, excess of white cells in, 214 in urine, 220, 234 poverty of, 85 spitting of, 136 vomiting of, 137, 170 Bothriocephalus latus, 190 Bowels, obstruction of, 176 perforation of, 198 Brain, abscess of, 259 anaemia of, 244 congestion of, 245 diseases of, 243 fever, 22 haemorrhage into, 247 inflammation of, 259 sclerosis of, 253 softening of, 252 syphilitic tumors of, 68 tumors of, 259 Bricklayers' itch, 302 Bright's disease, 224 acute, 224 chronic, 226 morbid anatomy of, 226 treatment of, 229 Bronchial dilatation, 116 fistula, 130 respiration, 92 Bronchiectasis, 116 Bronchitis, 112 acute, 112 chronic. 116 varieties of, 112 Bronchocele, 215 Bronchophony, 92 Bruit, aneurismal, 161 de diable, 86 de pot fele, 139 Bullae, 293, 300 Calculus, biliary, 210 in kidney, 236 urinary, 236 Cancer of brain, 259 of kidney, 237 of liver, 204 of lung, 142 Cancer of oesophagus, 166 of stomach, 172 Cancrum oris, 164 Capillary bronchitis, 112 Cardiac dropsy, 60 murmurs, 152 diagnosis of, 155 functional and organic, 157 treatment of, 158 Cardialgia, 168 Carpopedal spasms, 106 Case-taking, 14 Cataract in diabetes, 242 Catarrh, 95 of bile-ducts, 204 Catarrhal fever, 22 pneumonia, 126 Cathartics, 314 Cavernous respiration, 91 Cerebral anaemia, 244 congestion, 245 embolism and thrombosis, 246 haemorrhage, 247 meningitis, 256 paralysis, 260 Cerebral sclerosis, 253 softening, 252 Cerebro-spinal fever, 288 meningitis, 288 Chalkstones, 76 Chicken-pox, 48 Chloasma, 308 Chlorosis, 85 Cholera, English, 180 epidemic, 184 Chorea, 274 Chronic atrophy of liver, 206 bronchitis, 116 gout, 76 hydrocephalus, 258 peritonitis, 196 pleurisy, 134 rheumatism, 71 Chylous urine, 232 Cirrhosis of the liver, 207 Classification of disease, 13 Coecum, disease of, 197 Coffee-grounds, vomiting, 173 Colic, 175 biliary, 210 lead, 176 renal, 236 Condylomata, treatment of, 70 INDEX. 329 Congestion of liver. 203 of spinal cord, 284 Constipation, 1 74- Consuinption, 136 Continued fever, 21 Contracting or granular kidney, 22S Convulsions, uremic, 231 Corvza, 95 Coup de Boleil, 279 Cow-pox. 47 Crepitatio redux, 125 Crepitation. 93 Croup, diagnosis of, 103 false. 106 true, 102 Croupous inflammation, 103 Crusta lactea, 301 Cutaneous affections, ^syphilitic, 69 Cynanche parotidea, 165 tonsillaris, 165 Cysticercus cellulosse, 190 Dandriff, 304 Dandy fever, 42 Delirium tremens, 276 Dengue. 42 Derbyshire neck, 215 Diabetes, 237 cataract in, 242 insipidus, 238 mellitus. 238 Diagnosis, general remarks on, 13 physical, 14, 91 Diaphoretics. 315 Diaphragmatic pleuris} 7 , 132 Diarrhoea., simple, 180 typhoid, 29 Diathesis, gouty, 77 scrofulous, 65 tubercular, 62 Diffuse sclerosis, 253 Digestive organs, diseases of, 166 Dilatation of heart, 145 Diphtheria, 98 diagnosis of, 103 Diphtheritic inflammation, 99 Disease, meaning of term, 13 Diseases, general. 13 of circulatory system, 14, 143 of digestive system, 14, 166 of genito-urinary system, 14, 218 Diseases of integumentary system, 14, 292 of nervous system, 14, 243 of respiratory system, 14, 91 Diuretics, 316 Donovan's solution, 310 Dropsy. 58 active, 59 acute, 59 cardiac. 60 chronic. 59 diagnosis of, 60 hepatic. 60 of the kidney, 237 passive. 59 renal, 60 scarlatinal, 50 treatment of, 61 Dropsical fluid, characters of, 61 Drop wrist, 176 Dysentery. 181 Dyspepsia, 166 strumous, 65 Echinococci, 201 Ecthyma. 301 Eczema, 299 Embolism and thrombosis, cere- bral, 246 Emetics. 317 Emphysema, 118 interlobular, 119 lobular. 119 senile, 120 Empyema, 130 Encephalitis, 259 Endemic disease, meaning of, 19 Endocarditis, 151 rheumatic, 72 English cholera, 180 Enteric fever, 27 ulcer, 29 Epidemic catarrh, 110 cholera, 184 meaning of, 19 Epilepsy, 269 Eruptive fevers, 43 Erysipelas, 87 diagnosis of, S9 Erythema, 296 Etiology, 20 Exanthemata, 292, 295 Exophthalmic goitre, 216 330 INDEX. Expectorants, 317 Facial neuralgia, 268 paralysis, 263 Falling sickness, 269 False croup, 106 Famine fever, 33 Fatty degeneration of heart, 147 of kidney, 227 of liver, 201 growth of heart, 148 stools, 212 Favus, 307 Febricula, 21 Fever, cerebro-spinal, 288 continued, 21 generally, 21 dengue or dandy, 42 intermittent or ague, 35 relapsing, 33 remittent, 38 scarlet, 49 simple, 21 typhoid, 27 typhus, 23 yellow, 40 Fevers, eruptive, 43 Fibroid pneumonia, 127 Fish-skin disease, 304 Fistula, bronchial, 130 Fits, apoplectic, 251 epileptic, 270 hysteric, 281 Flatulence, 167 Follicular stomatitis, 164 Formula, 309 Friction-sound, cardiac, 150 pulmonary, 130 Gallstones, 210 Gangrene of the lung, 126 Gangrenous stomatitis, 164 Gargles, 318 Gastralgia, 167 Gastric fever, 27 ulcer, 169 Gastrodynia, 168 Gastrotomy, 180 General diseases, 14, 18 paralysis of insane, 261 remarks on diagnosis. 14 Gin-drinker's liver, 207 Globus hystericus, 281 Glosso-labio-laryngeal paralysis, 265 Glottis, oedema of the, 96 Glycosuria, 238 Goitre, 215 Gout, 74 diagnosis of, 78 retrocedent, 77 Gouty asthma, 77 diathesis, 77 kidney, 77, 228 Granular or contracting kidney. 228 Gravedo, 95 Gravel, 236 Graves's disease, 216 Gray hepatization of lung, 124 tubercle, 63 Gummata, 68 Haematemesis, 137, 170 treatment of, 171 Haematinuria, 235 Haematuria, 234 Haemoptysis, J 37 Haemorrhage, cerebral, 247 from kidney, 234 from lungs, 137 from stomach, 137 into spinal cord, 284 Heart, angina pectoris, 142 atrophy of, 147 dilatation of, 145 diseases of, 142 fatty degeneration of. 147 fatty growth of, 148 hypertrophy of, 144 murmurs, 152 palpitation of, 159 valvular diseases of, 152, 155 Heartburn, 168 Heat apoplexy, 279 Hemichorea, 275 Hemiplegia, 261 Hepatic abscess, 205 congestion, 203 diseases, 199 dropsy, 60 Hepatitis, 205 Hepatization of lung, 124 Herpes, 298 zoster, 298 Hobnailed liver, 207 INDEX. 331 Hollow worms, 189 Hooping-cough, 107 Hydatid vibration, 202 Hydatids of kidney, 237 of liver, 201 Hydrocephalus, 59 acute. 257 chronic. 258 Hydronephrosis, 237 Hydropericardium, 59 Hydrophobia, 289 Hydropneumothorax, 130, 136 Hydrothorax, 59. 136 Hypertrophy of heart. 144 simple, of liver, 202 Hysteria, 279 Ichthyosis, 304 Icterus, 208 Idiopathic asthma, 121 Ileum, typhoid ulceration of. 29 Ileus. 177 Impetigo, 301 Incubation, periods of, 44 Indigestion, 167 Infantile paralysis, 266 Inflammation of bile-ducts, 204 of brain, 259 of bronchial tubes, 112 of ccecum, 198 of endocardium, 151 of kidney, 222 of larynx, 96 of liver, 205 of lungs, 122 of meninges of brain, 256 of mouth, 164 of parotid, 165 of pericardium, 148 of peritoneum, 194 of pleura, 129 of spinal cord, 283 of tonsil, 165 Inflammatory croup, 102 softening of brain, 252 Influenza, 110 Inhalations, 318 Insane, general paralysis of, 261 Insolatio, 279 Interlobular emphysema, 119 Intermittent fever, 35 Internal gout, 77 Interstitial pneumonia, 127 Intestinal obstruction, 176 worms, 189 Intussusception, 177 Inunction of mercury, 69 Itch, 306 Jaundice, 208 Jungle fever, 38 Kidney, Bright's disease of. 224 Bright's disease of, acute. 224 Bright's disease of,chronic, 226 calculus of, 236 cancer of, 237 congestion of, 222 contracting, 228 dilatation of. 237 diseases of, 217 dropsy of, 237 granular disease of, 228 hematuria from, 233 hydatids. 237 inflammation of, 222 lardaceous or waxy, 227 large, white, 227 movable, 237 tubercular disease of, 237 Lardaceous liver, 200 Large white kidney, 227 Laryngismus stridulus, 106 Laryngitis, acute and chronic, 96 Larynx, diseases of, 96 Latent pleurisy, 132 Lead colic, 176 palsy, 176 Leucocythaemia, 214 Leukaemia, 214 Lichen, 302 Liniments, 319 Liver, abscess of, 205 amyloid, lardaceous, or waxy, 200 atrophy, simple and acute, 206 cancer of. 204 catarrh of bile-ducts, 204 cirrhosis of, 207 congestion of, 203 contractions of, 206 diseases, 199 fatty, 201 hydatid tumor of, 201 hypertrophy, simple, of, 202 332 INDEX. Liver, inflammation of, 205 painful enlargements of, 203 painless enlargements of, 200 pysernic and tropical abscess of, 204 syphilitic tumors of, 68 Lobular emphysema, 119 Local paralysis, 260 Locked jaw, 291 Locomotor ataxy, 286 Lotions, 319 Lumbago, 268 Lungs, cancer of, 142 diseases of, 112 emphysema of, 118 gangrene of, 126 inflammation of, 122 tubercular disease of, 63, 136 Lung-tissue, detection of, in spu- tum, 140 Lupus, 304 Malaria, 36 Marsh miasm, 36 Measles, German, 56 true, 55 Meningitis, acute, 256 cerebro-spinal, 288 chronic, 258 spinal, 283 tubercular, 257 Mensuration, 16, 94 Mercurial palsy, 265 Mercury, preparations containing, 310 Mesenteric fever, 22 Miliary aneurisms, 247 tubercle, 63 Mitral valve, disease of, 155 Morbilli, 53 Morbus Addisonii, 216 Brightii, 224 regius, 209 Morphia, preparations containing, 309 Motor oculi, paralysis of, 264 Mouth, diseases of, 164 Movable kidney, 237 Muco-crepitant rales, 95 Multiple cerebro-spinal sclerosis, 253 Multiple sclerosis, 253 Mumps, the, 165 Myelitis. 283 Nausea, 167 Nephralgia, 236 Nephritis, 222 acute desquamative, 224 acute tubal, 224 suppurative, 222 Nervous system, diseases of, 243 Nettlerash, 297 Neuralgia, 267 Non-inflammatory croup, 106 softening of brain, 252 softening of spinal cord, 285 Nummular sputum, 138 Obstruction of the bowels, 176 (Edema, 58 glottidis, 96 (Esophagus, diseases of, 166 Oidium albicans, 164 Ointments, 320 Opisthotonos, 291 Opium, preparations containing, 309 Organic asthma, 121 Oxalate of lime in urine, 219 Oxyuris vermicularis, 192 Painters- colic, 176 Palpation, 16 Palpitation of the heart, 159 Palsy, wasting, 265 Pancreas, diseases of the, 211 Papular eruptions, 302 Papule, description of, 294 Paracentesis thoracis, 135 Paralysis, 260 agitans, 254 diphtheritic, 102 facial or Bell's, 263 glosso-labio-laryngeal, 265 infantile spinal, 266 lead, 176 mercurial, 265 of the insane, 261 of the third nerve, 264 varieties of, 260 wasting, 265 Paraplegia, 262 Parasitic eruptions, 306 plants, 307 Paresis, 260 INDEX. 333 Parotid, inflammation of the, 165 Passive dropsy, 59 Pectoriloquy, 92 Pemphigus, 300 Percussion of chest, 16, 95 Perforation of bowels, 198 of stomach, 170 Pericarditis, 148 Peritonitis, 194 acute, 195 chronic. 196 tubercular, 197 Perityphlitis, 197 Petechia;, 82 Peyer's patches, typhoid ulcers of, 30 Phthisis, 136 acute, 140 Physical diagnosis, 14, 91 Pityriasis, 303 Plague, 43 Pleurisy, 129 acute, 129 chronic, 134 diagnosis. 132 diaphragmatic, 132 latent, 132 Pleurodynia, 268 Pleuropneumonia, 126 Pneumonia, 122 catarrhal, 127 fibroid, 127 interstitial, 127 Pneumothorax, 130, 136 Podagra, 97 Polypi of larynx, 97 Preparations containing opium, mercury, etc, 309 Prognosis, 20 Purpura ha>raorrhagica, 83 simple, 83 Pus in urine, 220 Pustular eruptions, 301 Pustule, definition of, 294 Pj-gemic abscess of liver, 204 Pyelitis, 222 Pylorus, stricture of, 170 Pyrosis, 168 Pythogenic fever, 27 Quartan ague, 36 Quinsy, 165 Quotidian ague, 36 Rabies, 289 Rales, 93 crepitant, 93 moist, 93 muco-crepitant, 95 subcrepitant, 95 Rash, typhoid, 28 typhus, 23 Red hepatization of lung, 124 softening of brain, 252 Relapsing fever, 33 Remittent fever, 38 Renal calculus, 236 colic, 236 dropsy, 60 Resolvents, 310 Respiration, amphoric, 139 bronchial, 92 cavernous, 91 puerile, 126, 132 tracheal. 91 tubular, 92 Respiratory organs, diseases of, 91 Retrocedent gout, 77 Progressive muscular atrophy, 265 Rheumatism, 70 Progressive paralysis of the insane, j Rhonchi, sibilant and sonorous, 93 261 Prurigo, 302 Psoriasis, 303 Ptosis, 264 Puerile breathing, 133 Pulmonary cancer, 142 consumption, 136 emphysema, 1 18 valves, disease of, 157 Purgatives, 314 Purpura, 82 diagnosis of, 84 Roseola, 297 Rotheln, 56 Roundworms, 191 Rubeola, 56 Rupia, 300 Rusty sputum of pneumonia, 123 Saint Vitus's dance, 274 Salicin in rheumatism, 74 Salines, 321 Sarcinae ventriculi, 168 Scabies, 306 29 334 INDEX. Scale, description of, 295 Scarlatina, 49 anginosa, 50 maligna, 50 simplex, 49 Scarlatinal dropsy, 51 Scarlet fever, 49 Sciatica, 268 Sclerosis, cerebral, 252 Selerostoma duodenale, 192 Scorbutus, 79 Scrofula, 62 Scrofulous diathesis, 65 Scurvy, 79 diagnosis of, 84 Sedatives, 321 Senile emphysema, 120 Shingles, 298 Sibilant rhonchi, 93 Simple atrophy of heart. 147 of liver, 206 erysipelas, 87 fever, 21 hypertrophy of heart, 144 of liver, 202 scarlatina, 49 Skin, diseases of, 292 classification of, 295 syphilitic, 69 Small-pox, 44 confluent, 45 Softening of the brain, 252 spinal cord, 284 Sonorous rhonchi, 93 Spasm of the glottis, 106 Spasmodic asthma, 121 croup, 106 Specific gravity of urine, 218 Spinal cord, congestion of, 284 diseases of, 283 haemorrhage into, 284 inflammation of, 283 softening of, 284 Spinal irritation, 285 meningitis, 283 Spleen, ague cake of, 37, 213 diseases of, 212 relapsing abscess of, 34 Spurious croup, 106 Sputa, lung-tissue in, 140 Squamous eruptions, 303 Stimulants, 322 Stomach, cancer of, 172 diseases of, 166 perforation of, 170, 171 ulcer of, 169 Stomatitis, 164 Stricture of intestine, 176 of oesophagus, 166 of pylorus, 170, 173 Stroke, paralytic, 261 Strumous diathesis. 65 dyspepsia, 65 Strychnia, preparations contain- ing, 310 Subcrepitant rales, 95 Sudamina, 298 Sugar in urine, 240 Sunstroke, 279 Suppurative nephritis, 222 Suprarenal capsule, disease of, 216 Sycosis menti, 307 Symptomatic asthma, 121 Syphilis, 67 of brain, 259 of liver, 68 Syphilitic ulcer on tongue, 163 Tabes mesenterica, 66 Taenia, 189 echinococcus, 201 mediocanellata, 190 solium, 189 Tapeworm, 189 Temperature in apoplectic seiz- ures, 248 in fevers, 21, 24, 28, 34,50, 54 normal, 21 in phthisis, 138 in pneumonia, 123 in rheumatism, 72 Tenesmus, 182 Tertian ague, 36 Testicle, syphilitic tumors of, 68 Tests for albumen in urine, 220 pus in urine, 220 sugar in urine, 240 Tetanus, 291 Thermometer, mode of using, 21 Third nerve, paralysis of, 264 Thoracic aorta, aneurism of, 159 Threadworms, 192 INDEX. 335 Thrombosis and embolism, cere- bral, 246 Thrush, the 164 Tic douloureux, 268 Tinea cireinata, 307 decalvans, 308 favosa, 307 sycosis. 307 tonsurans, 307 tricophytina, 307 versicolor, 308 Tongue, diseases of, 163 Tonics. 323 Tonsillitis, 165 Tophi. 76 Tracheal respiration, 91 Tracheotomy, 97, 105 Traumatic erysipelas, 87 tetanus, 291 Treatment, general and prophy- lactic, 20 Trichina spiralis, 193 Trichinosis, 193 Tricocephalus dispar, 192 Tricuspid valves, diseases of. 157 Tropical abscess of liver, 204 True croup, 102 Tube-casts in urine, 219 Tubercle, 63 calcification of, 64 degeneration of, 64 gray, 63 miliary, 63 of brain. 257 of kidneys, 237 of lungs, 63, 136 yellow, 63 Tubercular eruptions, 296, 304 meningitis, 257 mesenteric disease, 66 peritonitis, 196 Tuberculosis, 62 symptoms of, 64 treatment of, 66 Tubular breathing. 92 Tumors of brain, 259 of larynx, 97 Tympanitis. 60 Typhlitis, 197 Typhoid fever, 27 diagnosis of, 30 ulcer, 29 Typhus fever, 23 diagnosis of, 26 Ulceration of stomach, 169 syphilitic, 68 Ulcers of the intestine, dysenteric, 181 typhoid, 29 of the larynx, 97 of the tongue, 163 Uraemia, 231 Uric acid in urine, 218 Urinary calculus, 236 deposits, 218 Urine, albumen in, 220 amorphous urates in, 218 blood in, 220. 234 casts in 219 chylous, 233 epithelium in, 218 mucus in. 223 oxalate of lime in, 219 pus in, 220 specific gravity of, 218 sugar in, 240 triple phosphates in, 218 uric acid in, 219 Urinometer, 218 Urticaria, 297 Vaccination, 48 Varicella, 48 Variola, 44 confluens, 45 discreta, 45 Valves of heart, diseases cf, 152, 155 Vegetable parasites, 307 Vesicle, definition of, 293 Vesicular eruptions, 298 murmur, 92 Vibices, 82 Vocal fremitus. 95 resonance, 92 Vomiting, 167 of blood, 137, 170 Vox choleraica, 187 Walcheren fever, 38 Walls of abdomen, 17, 18 of chest, 15, 16 -r 336 INM1X. Wasting palsy, 265 Water in the head, 258 Waxy kidney, 229 liver, 200 White softening of the brain, 252 Worms, intestinal, 189 Writer's cramp, 266 Yellow atrophy of liver, 206 fever, 40 softening of brain, 252 tubercle, 63 Zoster, herpes, 298 i Zymotic diseases, 19 L'< tfr'33 LIBRARY OF CONGRESS 021 067 404 4j